Oral vancomycin prophylaxis during systemic antibiotic exposure to preventClostridiodes difficileinfection relapses

Abstract

Objective:To determine whether oral vancomycin prophylaxis accompanying systemic antibiotics reduces the risk of relapse in patients with history of Clostridioides difficile infection (CDI).Design:Retrospective cohort study.Patients:Adult inpatients with a history of CDI who received systemic antibiotics in either of 2 hospitals between January 2009 and June 2015.Methods:We compared relapse rates in patients who started oral vancomycin concurrently with systemic antibiotics (exposed group) versus those who did not. We assessed for CDI relapse by toxin or nucleic acid testing at 90 days. We used inverse probability weighting and machine learning to adjust for confounders, to estimate propensity for treatment, and to calculate odds ratios for CDI relapse. We performed secondary analyses limited to toxin-positive relapses, patients with 1 versus >1 prior CDI episodes, and patients who received oral vancomycin on each antibiotic day.Results:CDI relapse occurred within 90 days in 19 of 193 exposed patients (9.8%) versus 53 of 567 unexposed patients (9.4%; unadjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.60–1.81; adjusted OR, 0.63; 95% CI, 0.35–1.14). CDI relapses at 90 days were less frequent in exposed patients with only 1 prior episode of CDI (OR, 0.42; 95% CI, 0.19–0.93) but not in those with >1 prior episode (OR, 1.19; 95% CI, 0.42–3.33). Our findings were consistent with a lack of benefit of oral vancomycin when restricting results to toxin-positive relapses and to patients who received vancomycin each antibiotic day.Conclusions:Prophylactic oral vancomycin was not consistently associated with reduced risk of CDI relapse among hospitalized patients receiving systemic antibiotics. However, patients with only 1 prior CDI episode may benefit.

Oral vancomycin prophylaxis for the prevention of Clostridium difficile infection: A systematic review and meta-analysis

“…26,27 Despite clear differences between the populations included in the studies, 7 of 9 studies found OVP use to be associated with lower CDI. Splinter et al 23 and Caroff et al 22 found this reduction to be statistically insignificant. However, the first study was underpowered, including only 29 patients, while in the latter the mean duration of OVP treatment was 2.29 days, which might have been insufficient exposure.…”

“…Moreover, there is no current consensus on the dose of OVP, duration of treatment or long-term outcomes. In this review, we evaluated 8 studies that examined patients with different risk factors for CDI, including previous CDI followed by systemic antibiotic therapy, 19,22,28,29 immunosuppression due to solid organ transplant, 23 or hematopoietic cell transplant, 24,25 and elderly patients. 26,27 Despite clear differences between the populations included in the studies, 7 of 9 studies found OVP use to be associated with lower CDI.…”

“…The studies were further stratified based on immune status of the study population. In 6 studies evaluating immunocompetent patients, OVP was associated with reduced CDI (OR, 0.32; 95% CI, 0.17-0.63; I 2 = 60%) [19][20][21][22]26 compared to (OR, 0.08; 95% CI, 0.02-0.37; I 2 = 0%) [23][24][25] in 3 studies examining immunosuppressed patients (Fig. 2B).…”

“…Of the 8 cohort studies, 4 evaluated patients with a previous CDI episode requiring systemic antibiotics for a different indication. [19][20][21][22] The remaining studies evaluated CDI recurrence in renal transplant patients 23 and CDI occurrence in hematopoietic stem cell transplant recipients 24,25 or in elderly patients. 26,27 The end points of CDI or rCDI were defined as polymerase chain reaction (PCR) assay or toxin-proven CDI within 4 weeks of systemic antibiotic use, 19,23 within 60 days of resolution of previous CDI episode, 25 within 90 days of systemic antibiotic exposure, 22 within 12 months of subsequent hospitalization requiring systemic antibiotics, 21 within 6 months of previous diagnosis, 20 or diarrhea (>3 loose stools in 24 hours) in patients with positive stool PCR for C. difficile >72 hours into hospitalization, 27 or when the attending physician ordered OVP empirically.…”

Does oral vancomycin prophylaxis during systemic antibiotic exposure prevent Clostridioides difficile infection relapses? Still in search of an answer

“…1 Despite the lack of robust supporting evidence, secondary prophylaxis with oral vancomycin in patients on systemic antibiotics for infections other than CDI has become common practice. [2][3][4] We read "Oral vancomycin prophylaxis (OVP) during systemic antibiotic exposure to prevent Clostridioides difficile infection relapses" by Caroff et al 4 with great interest. The authors reported that OVP was effective in reducing CDI relapse in patients with incident CDI (1 previous CDI) but not recurrent CDI (≥2 CDI episodes).…”