Efficacy of Oral Vancomycin, Oral Metronidazole, or IV Metronidazole Prophylaxis at Reducing the Risk of Clostridium difficile Recurrence

Abstract

BackgroundSecondary prophylaxis (SP) for Clostridium difficile infection (CDI) with oral vancomycin or oral/IV metronidazole when initiating antibiotics is common, though few studies are available to support this practice. The purpose of this study was to assess the efficacy of prophylaxis within a year of index CDI.MethodsThis retrospective chart review looks at subsequent courses of antibiotics and CDI in patients with initial positive CDI testing in 2013–16. A positive CDI test within 90 days of antibiotics was a recurrence. The use of antibiotics for SP was noted, along with other factors associated with CDI relapse. Non-parametric and exact tests were used for univariate analysis. These variables were included in a multivariate proportional hazards model.ResultsWe found 597 antibiotic episodes in 230 patients. 130 episodes (21.8%) received SP. The difference of recurrence rates with and without antibiotics, 9.2 % vs 10.7%, was not statistically significant. No difference was seen when metronidazole was used, but vancomycin SP reduced the rate to 7.5% (6/80, P = 0.45). Probiotics were associated with a higher rate of recurrence (16.7 vs. 8.9%, P = 0.025). Proton pump inhibitors were also associated with a slightly higher rate of CDI recurrence (13.0% vs. 8.4%). The rate of relapse fell significantly with increasing time since the index case of CDI by logistic regression (P = 0.011). In multivariate regression, relapse was associated with shorter time from index CDI, shorter durations of antibiotics, and the use of probiotics.ConclusionThis retrospective study does not support the routine use of metronidazole in subsequent antibiotic courses following CDI. The use of probiotics paradoxically increased the rate of CDI relapse in this study. The limitations of this retrospective study do not eliminate the possibility of utility of vancomycin as prophylaxis, but this requires further evaluation.Disclosures All authors: No reported disclosures.

Efficacy of oral vancomycin prophylaxis for prevention of Clostridioides difficile infection: a systematic review and meta-analysis

“…A total of seven studies had follow up of more than 60 days. 10 , 16 , 17 , 19 , 21 , 25 , 26 Among those studies, the rate of future CDI in patients on OVP was 16.4% (85/518 compared with 21.9% (1810/8244). Meta-analysis revealed a significant decreased risk of future CDI with OVP (OR, 0.41; 95% CI, 0.22–0.77; p = 0.0005, I 2 = 61%) ( Supplemental Figure S3a ).…”

“…Meta-analysis revealed no statistically significant decreased risk of future CDI with OVP (OR, 0.29; 95% CI, 0.06-1.38; p = 0.12, I 2 = 11%) (Supplemental Figure S2b) Follow up duration A total of seven studies had follow up of more than 60 days. 10,16,17,19,21,25,26 Among those studies, the rate of future CDI in patients on OVP was 16.4% (85/518 compared with 21.9% (1810/8244). Meta-analysis revealed a significant decreased risk of future CDI with OVP (OR, 0.41; 95% CI, 0.22-0.77; p = 0.0005, I 2 = 61%) (Supplemental Figure S3a).…”

“…Of the 14 studies included, 10 , 11 , 16 – 27 9 assessed secondary prophylaxis only, 4 assessed primary prophylaxis only, and 1 evaluated both primary and secondary prophylaxis; 8 studies included any adult hospitalized patient receiving antibiotics, 3 included hospitalized hematopoietic stem cell transplant recipients, 2 included hospitalized solid organ transplant recipients, and 1 included hospitalized patients >65 years of age. A total of 13 studies were retrospective observational studies and 1 was an open-label prospective trial.…”

“…Ten observational studies comprising a total of 9258 CDI patients evaluated OVP for secondary prevention. 10,16,17,19,[21][22][23][24][25][26] Among these, the rate of future CDI in patients on OVP was 13.3% (95/713) compared with 21.9% (1875/8545) in patients that did not receive OVP. Meta-analysis using a random effects model revealed a statistically significant decreased risk of recurrent CDI (OR, 0.34; 95% CI, 0.20-0.59; p = 0.00001).…”

“…All hospitalized patients A total of seven studies, including all hospitalized patients, evaluated the efficacy of OVP for secondary prophylaxis. 10,16,17,19,21,[23][24][25] Among these, the rate of future CDI in patients on OVP was 13.7% (92/668) compared with 21.9% (1862/8485) in patients that did not receive OVP. Meta-analysis revealed a statistically significant decreased risk of future CDI with OVP (OR, 0.35; 95% CI, 0.19-0.63; p = 0.0005, I 2 = 69%) (Supplemental Figure S2a)…”