Objective: To summarize and critically appraise the evidence regarding oral vancomycin prophylaxis (OVP) to prevent recurrent Clostridium difficile infections (RCDIs), identify potential consequences of this emerging practice, and highlight future directions of study. Data Sources: A MEDLINE literature search of English-language publications from 1947 through September 2018 was performed using the search terms vancomycin and C difficile and prophylaxis. Clinical trials were identified on the National Library of Medicine clinical trials registry. Study Selection and Data Extraction: All clinical studies (n = 3) assessing oral vancomycin for secondary prophylaxis of C difficile infection (CDI) were evaluated by all authors. Other search results and references in selected publications were used for background and discussion. Data Synthesis: OVP reduced the risk of RCDI in high-risk patients taking systemic antibiotics. Variable dosing regimens and lack of safety data are limitations. OVP may have an adverse impact on the gastrointestinal microbiome, but this was not examined in the clinical studies. Relevance to Patient Care and Clinical Practice: Although current studies are limited by methodological concerns, clinicians can consider vancomycin 125 mg orally once or twice daily in high-risk patients receiving broad-spectrum antibacterial agents. Results of ongoing trials will define the most appropriate regimen and its impact on outcomes, including collateral damage. Conclusions: OVP reduces the risk of RCDIs and should be considered on a case-by-case basis. Caution is warranted before routine use is implemented because the impact on long-term outcomes has not been assessed and the optimal regimen has not been defined.

Objective: To identify the incidence of and risk factors for hypoglycemia in patients with chronic kidney disease (CKD) stage III-V or end stage renal disease (ESRD) treated with intravenous (IV) insulin for hyperkalemia. Design: Single-center, retrospective, cohort study. Setting: Large academic tertiary care medical center. Patients: Adults with a diagnosis of CKD stage III-V or ESRD who had a serum potassium ≥ 5 mmol/L and were treated with regular insulin for hyperkalemia between October 1, 2015 and August 16, 2016. Measurements and main results: The primary outcome was the incidence of hypoglycemia during the hospitalization after the administration of insulin for hyperkalemia. Key secondary outcomes included incidence of hypoglycemia within 24 hours of insulin administration and identification of risk factors associated with hypoglycemia. Data collected included patient age, sex, race, history of diabetes, stage of CKD, weight, body mass index (BMI), baseline blood glucose, inciting serum potassium concentration, units of regular insulin administered, and grams of dextrose given with insulin. A total of 235 hospitalizations were included in the final analysis. Sixty-six patients (28.1%) experienced a hypoglycemic event during their hospital encounter. Fifty-three patients (22.6%) had hypoglycemia within 24 hours of insulin administration. The average time to onset of hypoglycemia was 21.2 hours in all patients who experienced hypoglycemia and 6.4 hours in the subset of patients who experienced hypoglycemia within 24 hours of insulin administration. Inciting potassium was significantly higher and baseline blood glucose was significantly lower in the group that experienced hypoglycemia (P = 0.01, P = 0.02, respectively). Conclusion: Hypoglycemia following treatment for hyperkalemia with IV regular insulin was common in this patient population. Consideration should be given to the development of a comprehensive order set for insulin use in hyperkalemia to include protocol driven glucose monitoring with dextrose administration tailored to baseline glucose levels.

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