Vancomycin Taper and Pulse Regimen With Careful Follow-up for Patients With Recurrent Clostridium difficile Infection

Sirbu, Benjamin D; Soriano, Melinda M.; Manzo, Carl; Lum, Jessica; Gerding, Dale N.; Johnson, Stuart

doi:10.1093/cid/cix529

Cited by 54 publications

(40 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Administering a relatively long taper could potentially be beneficial to provide sufficient time to eliminate residual spores from the intestinal tract. However, Sirbu et al (15) reported similar cure rates in patients receiving vancomycin taper regimens of Ͻ10 and Ͼ10 weeks in total duration. Efforts to minimize the risk for reexposure to spores after the taper may also be beneficial (e.g., environmental disinfection and patient hand hygiene and bathing).…”

Section: Discussionmentioning

confidence: 96%

“…Although new approaches for management of recurrent CDI are promising, oral vancomycin administered as a tapered and/or pulsed regimen remains the most common treatment strategy for second or greater recurrences of CDI (14)(15)(16). These regimens typically include a 10-to 14-day course of oral vancomycin at a dose of 125 mg four times per day, followed by a tapering dose over 2 weeks, followed by "pulsed" dosing with 125 mg once every 2 or 3 days for 2 to 8 weeks (14)(15)(16). Standard vancomycin regimens achieve persistent high concentrations in stool (1,000 to 2,000 g/g stool) and cause marked disruption of the intestinal microbiota (4)(5)(6)(7)(8)(9)17).…”

mentioning

confidence: 99%

See 1 more Smart Citation

Tapering Courses of Oral Vancomycin Induce Persistent Disruption of the Microbiota That Provide Colonization Resistance to Clostridium difficile and Vancomycin-Resistant Enterococci in Mice

Tomas

Mana²,

Wilson

et al. 2018

Antimicrob Agents Chemother

View full text Add to dashboard Cite

Vancomycin taper regimens are commonly used for the treatment of recurrent infections. One rationale for tapering and pulsing of the dose at the end of therapy is to reduce the selective pressure of vancomycin on the indigenous intestinal microbiota. Here, we used a mouse model to test the hypothesis that the indigenous microbiota that provide colonization resistance against and vancomycin-resistant enterococci (VRE) is repopulated during tapering courses of vancomycin. Mice were treated orally with vancomycin daily for 10 days, vancomycin in a tapering dose for 42 days, fidaxomicin for 10 days, or saline. To assess colonization resistance, subsets of mice were challenged with 10 CFU of or VRE at multiple time points during and after completion of treatment. The impact of the treatments on the microbiome was measured by cultures, real-time PCR for selected anaerobic bacteria, and deep sequencing. Vancomycin taper-treated mice developed alterations of the microbiota and disruption of colonization resistance that was persistent 18 days after treatment. In contrast, mice treated with a 10-day course of vancomycin exhibited recovery of the microbiota and of colonization resistance by 15 days after treatment, and fidaxomicin-treated mice maintained intact colonization resistance. These findings demonstrate that alteration of the indigenous microbiota responsible for colonization resistance to and VRE persist during and after completion of tapering courses of vancomycin.

show abstract

Section: Discussionmentioning

confidence: 96%

mentioning

confidence: 99%

Tapering Courses of Oral Vancomycin Induce Persistent Disruption of the Microbiota That Provide Colonization Resistance to Clostridium difficile and Vancomycin-Resistant Enterococci in Mice

Tomas

Mana²,

Wilson

et al. 2018

Antimicrob Agents Chemother

View full text Add to dashboard Cite

show abstract

“…Retrospective observational data suggest potential efficacy of extended-pulsed vancomycin for recurrent C difficile infection. 24 However, laboratory studies have shown the disruptive effect of vancomycin on gut microbiota, 25 and such an extended regimen could further exacerbate post-treatment gut microbiota dysbiosis.…”

Section: Discussionmentioning

confidence: 99%

Extended-pulsed fidaxomicin versus vancomycin for Clostridium difficile infection in patients 60 years and older (EXTEND): a randomised, controlled, open-label, phase 3b/4 trial

Guery

Menichetti

Anttila

et al. 2018

The Lancet Infectious Diseases

159

143

View full text Add to dashboard Cite

show abstract

“…To optimize vancomycin treatment evaluated in recurrent C difficile infection, it might be possible to use a pulsed or tapered regimen of vancomycin. Evidence for this approach includes observational studies showing recurrence rates ranging from 31% to 6%100101102 and one randomized trial that included 12 patients, where the recurrence rate reached 41.7% 103…”

Section: Treatmentmentioning

confidence: 99%

Clostridioides difficile: diagnosis and treatments

Guery

Galpérine

Barbut

2019

BMJ

View full text Add to dashboard Cite

Clostridioides difficile (formerly Clostridium) is a major cause of healthcare associated diarrhea, and is increasingly present in the community. Historically, C difficile infection was considered easy to diagnose and treat. Over the past two decades, however, diagnostic techniques have changed in line with a greater understanding of the physiopathology of C difficile infection and the use of new therapeutic molecules. The evolution of diagnosis showed there was an important under- and misdiagnosis of C difficile infection, emphasizing the importance of algorithms recommended by European and North American infectious diseases societies to obtain a reliable diagnosis. Previously, metronidazole was considered the reference drug to treat C difficile infection, but more recently vancomycin and other newer drugs are shown to have higher cure rates. Recurrence of infection represents a key parameter in the evaluation of new drugs, and the challenge is to target the right population with the adapted therapeutic molecule. In multiple recurrences, fecal microbiota transplantation is recommended. New approaches, including antibodies, vaccines, and new molecules are already available or in the pipeline, but more data are needed to support the inclusion of these in practice guidelines. This review aims to provide a baseline for clinicians to understand and stratify their choice in the diagnosis and treatment of C difficile infection based on the most recent data available.

show abstract

Vancomycin Taper and Pulse Regimen With Careful Follow-up for Patients With Recurrent Clostridium difficile Infection

Cited by 54 publications

References 11 publications

Tapering Courses of Oral Vancomycin Induce Persistent Disruption of the Microbiota That Provide Colonization Resistance to Clostridium difficile and Vancomycin-Resistant Enterococci in Mice

Tapering Courses of Oral Vancomycin Induce Persistent Disruption of the Microbiota That Provide Colonization Resistance to Clostridium difficile and Vancomycin-Resistant Enterococci in Mice

Extended-pulsed fidaxomicin versus vancomycin for Clostridium difficile infection in patients 60 years and older (EXTEND): a randomised, controlled, open-label, phase 3b/4 trial

Clostridioides difficile: diagnosis and treatments

Contact Info

Product

Resources

About