Evaluation of Addition of Intravenous Metronidazole to Oral Vancomycin Therapy in Critically Ill Patients with Non‐Fulminant Severe Clostridioides difficile Infection

2020 ◽  
Vol 40 (5) ◽  
pp. 398-407 ◽  
Author(s):  
Ana D. Vega ◽  
Emily L. Heil ◽  
Alison L. Blackman ◽  
Mary Banoub ◽  
Jennifer Kristie Johnson ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Oral Vancomycin ◽  
Vancomycin Therapy ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

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

2020 ◽  
Vol 8 ◽  
pp. 205031212093089
Author(s):  
Kathryn A Connor ◽  
Kelly M Conn
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Low Dose ◽  
Secondary Prophylaxis ◽  
Infection Prophylaxis ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Critically Ill Adults ◽  
Ill Adults ◽  
Infection Recurrence

Introduction: Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non- Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. Objectives: To determine whether critically ill adults receiving low-dose per os vancomycin for secondary Clostridioides difficile infection prophylaxis have fewer recurrences of Clostridioides difficile infection in 90 days compared with patients receiving metronidazole for secondary Clostridioides difficile infection prophylaxis or control (no secondary prophylaxis). Methods: This was a retrospective, two-center, observational study in a large academic medical center and affiliated community hospital. Included patients had a history of Clostridioides difficile infection within 1 year of receiving antibiotics for clinical care. We compared patients receiving secondary prophylaxis with vancomycin or metronidazole and control patients; in addition, an unplanned fourth group (vancomycin/metronidazole combination) was identified and analyzed. The primary outcome was Clostridioides difficile infection recurrence within 90 days of a course of broad-spectrum antibiotic therapy. Fisher’s exact, analysis of variance, and Kruskal–Wallis tests were used to compare Clostridioides difficile infection recurrence with prophylaxis group and additional contributing factors. Results: Eighty-two patients were included: 38 control (46.3%), 20 metronidazole (24.4%), 17 vancomycin (20.7%), and 7 combination (8.5%). Ten of 82 patients (12.2%) had at least one Clostridioides difficile infection recurrence; 8/38 patients in the control group (21.1%), 1/7 patients in the combination group (14.3%), 1/17 patients in the per os vancomycin group (5.9%), and 0/20 in the metronidazole group (0%; p = 0.073). As a post hoc secondary analysis, the three prophylaxis groups were coalesced into one group and compared with control (4.5% vs 21%; p = 0.039). Additional factors (e.g. age, obesity, immunosuppression, acid suppression) were not significantly associated with Clostridioides difficile infection recurrence or with prophylaxis group. Conclusion: There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.

scholarly journals Initial therapy affects duration of diarrhoea in critically ill patients with Clostridioides difficile infection (CDI)

Critical Care ◽  
2019 ◽  
Vol 23 (1) ◽  
Author(s):  
Carolin F. Manthey ◽  
Darja Dranova ◽  
Martin Christner ◽  
Andreas Drolz ◽  
Stefan Kluge ◽  
...  
Keyword(s):  
Risk Factors ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Multivariate Regression ◽  
Initial Therapy ◽  
Clostridioides Difficile ◽  
Standardized Treatment ◽  
Clostridioides Difficile Infection ◽  
Associated Risk Factors ◽  
Specific Agent

Abstract Background Critically ill patients in the intensive care unit (ICU) are at high risk for developing Clostridioides difficile infections (CDI). Risk factors predicting their mortality or standardized treatment recommendations have not been defined for this cohort. Our goal is to determine outcome and mortality associated risk factors for patients at the ICU with CDI by evaluating clinical characteristics and therapy regimens. Methods A retrospective single-centre cohort study. One hundred forty-four patients (0.4%) with CDI-associated diarrhoea were included (total 36.477 patients admitted to 12 ICUs from January 2010 to September 2015). Eight patients without specific antibiotic therapy were excluded, so 132 patients were analysed regarding mortality, associated risk factors and therapy regimens using univariate and multivariate regression. Results Twenty-eight-day mortality was high in patients diagnosed with CDI (27.3%) compared to non-infected ICU patients (9%). Patients with non CDI-related sepsis (n = 40/132; 30.3%) showed further increase in 28-day mortality (45%; p = 0.003). Initially, most patients were treated with a single CDI-specific agent (n = 120/132; 90.9%), either metronidazole (orally, 35.6%; or IV, 37.1%) or vancomycin (18.2%), or with a combination of antibiotics (n = 12/132; 9.1%). Patients treated with metronidazole IV showed significantly longer duration of diarrhoea > 5 days (p = 0.006). In a multivariate regression model, metronidazole IV as initial therapy was an independent risk factor for delayed clinical cure. Immunosuppressants (p = 0.007) during ICU stay lead to increased 28-day mortality. Conclusion Treatment of CDI with solely metronidazole IV leads to a prolonged disease course in critically ill patients.

scholarly journals Prevalence of Clostridioides difficile Infection in Critically Ill Patients with Extreme Leukocytosis and Diarrhea

2021 ◽  
Vol 13 (1) ◽  
pp. 18-22
Author(s):  
Bijan Teja ◽  
Nafeesa Alibhai ◽  
Gordon D. Rubenfeld ◽  
Linda R. Taggart ◽  
Naheed Jivraj ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Clostridium Difficile ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Empiric Antibiotic Therapy ◽  
Empiric Treatment ◽  
Clostridioides Difficile ◽  
Empiric Antibiotic ◽  
Clostridioides Difficile Infection

While early empiric antibiotic therapy is beneficial for patients presenting with sepsis, the presentation of sepsis from Clostridioides difficile (formerly Clostridium difficile) infection (CDI) has not been well studied in large cohorts. We sought to determine whether the combination of extreme leukocytosis and diarrhea was strongly predictive of CDI in a cohort of 8659 patients admitted to the intensive care unit. We found that CDI was present in 15.0% (95% CI, 12.1–18.3%) of patients with extreme leukocytosis and diarrhea and that mortality for those with CDI, diarrhea, and extreme leukocytosis was 33.8% (95% CI, 23.2–44.3%). These data support consideration of empiric treatment for CDI in unstable critically ill patients with extreme leukocytosis and diarrhea, along with treatment of other possible sources of sepsis as appropriate. Empiric treatment for CDI can usually be discontinued promptly, along with narrowing of other broad-spectrum antimicrobial coverage, if a sensitive C. difficile test is negative.

scholarly journals 2433. Oral Vancomycin Plus Intravenous Metronidazole for Severe Clostridioides difficile Infection in Critically Ill Patients

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S841-S841
Author(s):  
Ana D Vega ◽  
J Kristie Johnson ◽  
Emily Heil ◽  
Alison L Blackman ◽  
Mary Banoub ◽  
...  
Keyword(s):  
Combination Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Clinical Success ◽  
Apache Ii ◽  
High Morbidity ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
The Impact ◽  
To Receive

Abstract Background Molecular strain 027/NAP1/BI (NAP1) is a common cause of Clostridioides difficile infections (CDI). Despite high morbidity and mortality, optimal therapy remains elusive. There is also a paucity of data regarding optimal treatment of critically ill patients with severe CDI. We aimed to determine the impact of combination therapy (intravenous metronidazole [IV MTZ] plus oral vancomycin [PO VAN]) on clinical outcomes in critically ill patients with severe CDI, including those with NAP1 CDI. Methods Retrospective cohort of adult patients admitted to an intensive care unit (ICU) from April 2016 to October 2018 with a positive C. difficile PCR and an order for PO VAN. Patients with an order for IV MTZ for at least 72 hours formed the combination therapy group. A subset of patients had stool samples collected for NAP1 identification via GeneXpert C. difficile Epi molecular assay. The primary outcome was 30-day in-hospital mortality. A subgroup was matched using Acute Physiology and Chronic Health Evaluation (APACHE) II Scores. Cox regression was conducted to identify variables associated with time to mortality. Results 138 patients were included; 60 (43.5%) received IV MTZ. Patients with IV MTZ had a higher median WBC count at diagnosis (20.9 vs 15.9, P = 0.0002) and were more likely to receive a higher dose of PO VAN (31.7% vs 12.9%, P = 0.008). 42 patients had NAP1 testing, 11 were positive (26.2%). There was no difference in probability of receiving IV MTZ based on APACHE II, however, NAP1+ were more likely to receive IV MTZ (50% vs 16.7%, P = 0.049). Clinical success was higher in the monotherapy group (46.8% vs 16.7%, P = 0.002). There was no difference in mortality (20% vs 14.1%, P = 0.368). In a subgroup of patients matched by APACHE II (n = 96), mortality remained non-significantly different (18.8% vs 14.6%, P = 0.785). Adjusted for IV MTZ, APACHE II (aHR = 1.06, 95% CI 1–1.12) and number of severity criteria (aHR = 2.08, 95% CI 1.40 – 2.97) were associated with mortality. There was no difference in mortality (9.1% vs 3.2% P = 0.459) or clinical success (18.2% vs 33.7%, P = 0.283) among NAP1+ vs. NAP- patients. Conclusion Our data questions the utility of IV MTZ with PO VAN for ICU patients with severe CDI, including NAP1 infections. There remains a possibility for confounding by indication in our analysis. Disclosures All authors: No reported disclosures.

scholarly journals 1376. Oral Vancomycin as Secondary Prophylaxis Against Clostridioides difficile Infection in Pediatric Patients

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S698-S698
Author(s):  
Hongkai Bao ◽  
Yanina Dubrovskaya ◽  
John Papadopoulos ◽  
Justin Siegfried ◽  
Cristian Merchan ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Odds Ratio ◽  
Protective Factor ◽  
Pediatric Patients ◽  
Antibiotic Exposure ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
History Of ◽  
Systemic Antibiotics

Abstract Background Secondary oral vancomycin prophylaxis (OVP) has been utilized in adults with a history of Clostridioides difficile infection (CDI) while receiving systemic antibiotics to prevent CDI recurrence. However, this practice is poorly described in pediatric patients. Rates of CDI recurrence in pediatric patients range from 10-40% and is associated with morbidity and mortality. This study assessed the efficacy and safety of secondary OVP in pediatric patients with subsequent antibiotic exposure. Methods This retrospective study evaluated pediatric patients ≤18 years with any history of clinical CDI and receiving systemic antibiotics in a subsequent encounter during the time period of 2013-2019. Patients who received OVP 10 mg/kg (up to 125 mg per dose) every 12 hours during concomitant antibiotics were compared to those who did not. The primary outcome was CDI recurrence within 8 weeks following antibiotic exposure. Secondary outcomes included time to recurrence, severity of recurrence, and isolation of vancomycin-resistant enterococci (VRE) from any site. Risk factors for CDI recurrence were assessed using logistic regression. Results A total of 153 patients were screened for inclusion, of which 32 and 47 patients were assigned to the OVP and no OVP group, respectively. Median age was 8.6 years and the most common comorbidities were malignancy (47%) and immunosuppression (46%). Median time since last CDI to study inclusion was 64.5 days in the OVP group and 90 days in the no OVP group, P=0.320. Compared to the no OVP group, OVP patients had longer hospital stays (5 vs 14 days, P=0.001) and more concomitant antibiotic exposure (8 vs 12.5 days, P=0.001). Median duration of OVP was 12 days. CDI recurrence occurred in 12 patients and was significantly lower in the OVP vs no OVP group (3.1% vs 23.4%; odds ratio, 0.106; 95% confidence interval, 0.013-0.864; P=0.022). VRE was not isolated in any patients. After adjustment in a multivariate analysis, only secondary OVP remained as a protective factor against recurrence (odds ratio, 0.082; 95% confidence interval, 0.009-0.748; P=0.027). Conclusion Secondary OVP effectively reduces the risk of recurrent CDI in pediatric patients with a history of CDI while receiving systemic antibiotics. Future prospective studies should validate these findings. Disclosures Cristian Merchan, PharMD, BCCCP, abbive (Speaker’s Bureau)

scholarly journals Vancomycin therapy in critically ill patients on continuous renal replacement therapy; are we doing enough?

2015 ◽  
Vol 23 (3) ◽  
pp. 327-329 ◽  
Author(s):  
Ali S. Omrani ◽  
Alaa Mously ◽  
Marylie P. Cabaluna ◽  
John Kawas ◽  
Mohammed M. Albarrak ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Vancomycin Therapy

scholarly journals The Addition of Intravenous Metronidazole to Oral Vancomycin is Associated With Improved Mortality in Critically Ill Patients WithClostridium difficileInfection

2015 ◽  
Vol 61 (6) ◽  
pp. 934-941 ◽  
Author(s):  
Kristina E. E. Rokas ◽  
James W. Johnson ◽  
James R. Beardsley ◽  
Christopher A. Ohl ◽  
Vera P. Luther ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Oral Vancomycin

scholarly journals 785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S437-S437
Author(s):  
Kerui Xu ◽  
Andrea L Benin ◽  
Hsiu Wu ◽  
Jonathan R Edwards ◽  
Qunna Li ◽  
...  
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Antibiotic Use ◽  
Prevalence Rates ◽  
Hospital Level ◽  
First Line ◽  
Oral Vancomycin ◽  
Patient Admissions ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Methods We matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs. Results Among the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63). Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018 Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs Conclusion The moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs. Disclosures All Authors: No reported disclosures

Sign in / Sign up

Export Citation Format

Share Document