Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection

Abstract

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.

Epidemiology, Risk Factors, and Outcomes After Early Posttransplant Clostridiodes difficile Infection in Renal Transplant Recipients

“…15 However, the risks associated with this therapy are not completely understood. 16 Given the relatively low incidence of CDI and the possible but unclear impact on long-term graft outcomes found in our study and others, universal prophylaxis with oral vancomycin likely would not be favored from a risk or cost standpoint. 6 However, targeted prophylaxis provided to those of highest risk may be warranted.…”

Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults

“…Other strategies that have been explored to reduce CDI recurrences, such as probiotics, fecal microbiota transplant, and bezlotoxumab, are also not employed routinely in our critically ill patients. 4,15 When weighing the decision of whether to initiate secondary CDI prophylaxis, clinicians should assess factors such as the length of time from previous CDI treatment, the number and severity of previous CDI episodes, and the health status of the patient (e.g. underlying frailty).…”

Treatment of Recurrent Clostridium difficile Infection

“…The effectiveness of oral vancomycin prophylaxis (OVP) has been examined in retrospective studies. A recently published review of three studies found a reduced risk of recurrent CDI with OVP however the data is not convincing as all of them were retrospective and lack randomization [52]. In one of these studies, OVP did not affect recurrence in patients with a single previous episode of CDI (P = 0.69).…”