Oral vancomycin prophylaxis during systemic antibiotic exposure to preventClostridiodes difficileinfection relapses

2019 ◽  
Vol 40 (6) ◽  
pp. 662-667 ◽  
Author(s):  
Daniel A. Caroff ◽  
John T. Menchaca ◽  
Zilu Zhang ◽  
Chanu Rhee ◽  
Michael S. Calderwood ◽  
...  
Keyword(s):  
Group Versus ◽  
Probability Weighting ◽  
Oral Vancomycin ◽  
Unadjusted Odds Ratio ◽  
Inverse Probability ◽  
Clostridioides Difficile ◽  
History Of ◽  
Secondary Analyses ◽  
Systemic Antibiotics ◽  
Relapse Rates

AbstractObjective:To determine whether oral vancomycin prophylaxis accompanying systemic antibiotics reduces the risk of relapse in patients with history ofClostridioides difficileinfection (CDI).Design:Retrospective cohort study.Patients:Adult inpatients with a history of CDI who received systemic antibiotics in either of 2 hospitals between January 2009 and June 2015.Methods:We compared relapse rates in patients who started oral vancomycin concurrently with systemic antibiotics (exposed group) versus those who did not. We assessed for CDI relapse by toxin or nucleic acid testing at 90 days. We used inverse probability weighting and machine learning to adjust for confounders, to estimate propensity for treatment, and to calculate odds ratios for CDI relapse. We performed secondary analyses limited to toxin-positive relapses, patients with 1 versus >1 prior CDI episodes, and patients who received oral vancomycin on each antibiotic day.Results:CDI relapse occurred within 90 days in 19 of 193 exposed patients (9.8%) versus 53 of 567 unexposed patients (9.4%; unadjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.60–1.81; adjusted OR, 0.63; 95% CI, 0.35–1.14). CDI relapses at 90 days were less frequent in exposed patients with only 1 prior episode of CDI (OR, 0.42; 95% CI, 0.19–0.93) but not in those with >1 prior episode (OR, 1.19; 95% CI, 0.42–3.33). Our findings were consistent with a lack of benefit of oral vancomycin when restricting results to toxin-positive relapses and to patients who received vancomycin each antibiotic day.Conclusions:Prophylactic oral vancomycin was not consistently associated with reduced risk of CDI relapse among hospitalized patients receiving systemic antibiotics. However, patients with only 1 prior CDI episode may benefit.

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 800. Oral Vancomycin Prophylaxis Against Clostridioides difficile in Patients Admitted to a Tertiary Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S443-S444
Author(s):  
David B Kopelman ◽  
Sharon B Wright ◽  
Howard Gold ◽  
Preeti Mehrotra ◽  
Preeti Mehrotra
Keyword(s):  
Primary Prevention ◽  
Medical Center ◽  
Acute Infection ◽  
Academic Medical Center ◽  
Nucleic Acid Amplification ◽  
Prior History ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
History Of ◽  
Systemic Antibiotics

Abstract Background In an effort to more accurately diagnose Clostridioides difficile infection (CDI), many hospitals have switched to two-step testing algorithms that rely on nucleic acid amplification testing with reflex enzyme immunoassay for toxin. Additionally, oral vancomycin prophylaxis (OVP) against CDI is increasingly being used; initial studies focused on preventing recurrence in patients with a prior history of CDI, but OVP is also being studied in primary prevention. We hypothesized that following the implementation of two-step testing, clinicians may use OVP for prevention of a patient’s first episode of CDI based on knowledge of prior PCR+/Toxin- testing. Methods We performed a single-center, retrospective cohort study of patients admitted to Beth Israel Deaconess Medical Center. We identified patients who received oral vancomycin once daily or BID for the prevention of CDI following implementation of two-step testing. Patients who received oral vancomycin as part of a taper following acute infection were excluded. We categorized rationale for prophylaxis based on clinical documentation and collected details of patients’ CDI history, antibiotic exposure, and subsequent CDI testing during hospitalization. Results In the 12 months following implementation of two-step testing, there were 80 patients who received OVP during hospitalization (2 daily and 78 BID). The vast majority (73, 91.3%) had a history of CDI and received OVP for secondary prevention while receiving systemic antibiotics. There were only 3 patients (3.8%) without known clinical history of CDI whose clinicians documented prophylaxis based on previous PCR+/Toxin- testing. Patients on OVP received a mean of 4.1 systemic antibiotics during hospitalization. When continuing OVP for a finite period after discontinuation of systemic antibiotics, this was most commonly done for 2-7 days (16 of 26, 61.5%). 22 patients underwent stool testing for CDI while receiving OVP in the hospital and all resulted PCR-negative. OVP Indication OVP Duration Conclusion Following implementation of two-step testing for CDI, use of OVP for primary prevention based solely on knowledge of PCR+/Toxin- testing in patients without a history of CDI was rare. Acute CDI appears unlikely in patients actively receiving OVP. Disclosures All Authors: No reported disclosures

scholarly journals 2414. Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in High-Risk Patients

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S833-S833
Author(s):  
Steven W Johnson ◽  
David H Priest ◽  
Shannon V Brown
Keyword(s):  
High Risk ◽  
Medical Center ◽  
Healthcare Facility ◽  
Oral Vancomycin ◽  
High Risk Patients ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Risk Patients ◽  
Systemic Antibiotics ◽  
The Impact

Abstract Background Studies suggest oral vancomycin prophylaxis may be effective in preventing Clostridioides difficile infection. These studies are limited by their retrospective design, reliance on local clinical practice patterns, lack of intervention standardization, and limited risk stratification. We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility-onset CDI (HCFO-CDI) in high-risk patients. Methods We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina between October 2018 and April 2019. Admitted high-risk patients (defined as: ≥ 60 years of age, hospitalized ≤ 30 days prior to the index hospitalization and received systemic antibiotics during that prior hospitalization and currently receiving systemic antibiotics) were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days post completion of systemic antibiotics [OVP]), or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility-associated CDI (CO-HCFA-CDI), development of VRE colonization after receiving OVP, and adverse effects and cost of OVP. Results A total of 100 patients were evaluated, 50 patients in each group. Baseline and hospitalization characteristics were similar in each group. No incidents of HCFO-CDI were diagnosed in the OVP group compared with 6 (12%) in the no prophylaxis group (P = 0.03). CO-HCFA-CDI was not observed in either group. No patients developed new VRE colonization with only 1 patient reporting mild gastrointestinal side-effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $728.25, $60.69 per patient. Conclusion OVP was highly effective in preventing HCFO-CDI. OVP was well tolerated with no apparent risk for VRE colonization. Further prospective investigation is warranted to determine the impact and cost-effectiveness of routine use of OVP in high-risk patients. Disclosures All authors: No reported disclosures.

Long-Term Efficacy of Oral Vancomycin Prophylaxis for the Prevention of Clostridium difficile Recurrence

2019 ◽  
Vol 33 (5) ◽  
pp. 633-639 ◽  
Author(s):  
Emmanuel M. Knight ◽  
Daryl S. Schiller ◽  
Magda K. Fulman ◽  
Rupangi Rastogi
Keyword(s):  
Clostridium Difficile ◽  
Community Hospital ◽  
Antibiotic Exposure ◽  
Limited Evidence ◽  
Oral Vancomycin ◽  
Term Efficacy ◽  
History Of ◽  
Initial Episode ◽  
Systemic Antibiotics

Background: Limited evidence suggests that prophylactic oral vancomycin may be beneficial in preventing Clostridium difficile infection (CDI) recurrence, but long-term efficacy is unknown. Objective: To evaluate the long-term efficacy of oral vancomycin prophylaxis (OVP) in preventing CDI recurrence in subjects who require subsequent antibiotic exposure. Methods: A retrospective cohort study was conducted at a community hospital. A total of 91 subjects with a history of CDI between January 2013 and December 2015 who had a subsequent hospitalization requiring systemic antibiotics within 12 months were evaluated. Thirty-two subjects who received prophylaxis with oral vancomycin were compared to 59 subjects who did not receive prophylaxis. Results: CDI recurrence within 12 months was significantly lower in subjects receiving OVP compared to those who did not receive OVP (6.3% vs 28.8%; odds ratio [OR]: 0.16; 95% confidence interval [CI]: 0.04-0.77; P = .011) including patients whose previous CDI was an initial episode (3.7% [1/27] vs 28.3% [15/53]; OR: 10.3; 95% CI: 1.28-82.6; P = .009). Conclusion: Use of OVP in subjects with a history of CDI up to 12 months prior to subsequent antibiotic exposure appears to reduce the risk of CDI recurrence for up to 12 months.

scholarly journals 2412. Oral Vancomycin Prophylaxis Against Recurrent Clostridioides difficile Infection: Efficacy and Side-effects: Two Hospitals Experience

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S833-S833
Author(s):  
Ioannis Zacharioudakis ◽  
Fainareti Zervou ◽  
Yanina Dubrovskaya ◽  
Michael Phillips
Keyword(s):  
New York ◽  
Extended Period ◽  
Final Analysis ◽  
Absolute Number ◽  
Infection Prevalence ◽  
Enterococcus Species ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
History Of ◽  
The Absolute

Abstract Background Clostridioides difficile is the most common hospital-acquired pathogen with an unchanged infection prevalence between 2011–2015. The data regarding the effectiveness of chemical prophylaxis to prevent recurrent C. difficile infection (CDI) are conflicting. Methods We conducted a retrospective study of hospitalized patients with CDI history in 2 New York academic hospitals over a 4.5-year period to determine the effectiveness of vancomycin prophylaxis for CDI prevention. The participating hospitals implemented an automated alert to providers recommending oral vancomycin 125 mg twice daily in patients with a history of CDI scheduled to receive any systemic antimicrobials for the duration of therapy and 5 days thereafter. Measured outcomes included the rate of breakthrough and recurrent CDI, defined as CDI during and in the one-month following prophylaxis, respectively. A self-controlled, before and after study design was employed to examine whether the use of oral vancomycin was associated with an increase in the prevalence of vancomycin-resistant Enterococcus species (VRE) both in absolute numbers and in comparison to vancomycin-sensitive Enterococcus species (VSE) in the period following vancomycin prophylaxis. Results 264 patients were included in the final analysis. Breakthrough CDI was identified in 17 (6.4%; 95% CIs 3.8%–10.1%) and recurrent CDI in 22 (8.3%; 95% CIs 5.3%–12.3%) patients. Of the 102 patients with a history of CDI within the 3 months preceding the administration of prophylaxis 4 (3.9%, 95% CIs 1.1%-9.7%) had breakthrough CDI and 9 had recurrent disease (8.3%, 95% CIs 5.3%–12.3%). In the 3 months following vancomycin prophylaxis there was an increase in both the absolute number of VRE and the ratio of VRE to VSE isolates compared with the combined period of 1.5 months preceding and the 3–4.5 months following the administration of prophylaxis. The increase in the absolute number of VRE colonized patients remained in the extended period of 6 months following prophylaxis. Conclusion Prophylactic vancomycin is an effective strategy to prevent CDI recurrence, but is associated with an increase in VRE colonization in the immediate period after administration. The risk of VRE infection should lead to careful selection of patients at the highest risk for CDI recurrence. Disclosures All authors: No reported disclosures.

Oral vancomycin prophylaxis against recurrent Clostridioides difficile infection: Efficacy and side effects in two hospitals

2020 ◽  
Vol 41 (8) ◽  
pp. 908-913
Author(s):  
Ioannis M. Zacharioudakis ◽  
Fainareti N. Zervou ◽  
Yanina Dubrovskaya ◽  
Michael S. Phillips
Keyword(s):  
New York ◽  
Absolute Number ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
History Of ◽  
High Benefit ◽  
To Receive ◽  
Selection Of

AbstractObjective:The data regarding the effectiveness of chemical prophylaxis against recurrent C. difficile infection (CDI) remain conflicting.Design:Retrospective cohort study on the effectiveness of oral vancomycin for prevention of recurrent CDI.Setting:Two academic centers in New York.Methods:Two participating hospitals implemented an automated alert recommending oral vancomycin 125 mg twice daily in patients with CDI history scheduled to receive systemic antimicrobials. Measured outcomes included breakthrough and recurrent CDI rates, defined as CDI during and 1 month after initiation of prophylaxis, respectively. A self-controlled, before-and-after study design was employed to examine the effect of vancomycin prophylaxis on the prevalence of vancomycin-resistant Enterococcus spp (VRE) colonization and infection.Results:We included 264 patients in the analysis. Breakthrough CDI was identified in 17 patients (6.4%; 95% confidence interval [CI], 3.8%–10.1%) and recurrent in 22 patients (8.3%; 95% CI, 5.3%–12.3%). Among the 102 patients with a history of CDI within the 3 months preceding prophylaxis, 4 patients (3.9%; 95% CIs, 1.1%–9.7%) had breakthrough CDI and 9 had recurrent disease (8.8%; 95% CIs, 4.1%–16.1%). In the 3-month period following vancomycin prophylaxis, we detected a statistically significant increase in both the absolute number of VRE (χ2, 0.003) and the ratio of VRE to VSE isolates (χ2, 0.003) compared to the combined period of 1.5 months preceding and the 3–4.5 months following prophylaxis. This effect persisted 6 months following prophylaxis.Conclusions:Prophylactic vancomycin is an effective strategy to prevent CDI recurrence, but it increases the risk of VRE colonization. Thus, a careful selection of patients with high benefit-to-risk ratio is needed for the implementation of this preventive policy.

scholarly journals Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility–Onset Clostridioides difficile Infection in Targeted Patients During Systemic Antibiotic Exposure

2019 ◽  
Vol 71 (5) ◽  
pp. 1133-1139 ◽  
Author(s):  
Steven W Johnson ◽  
Shannon V Brown ◽  
David H Priest
Keyword(s):  
Medical Center ◽  
Healthcare Facility ◽  
Antibiotic Exposure ◽  
Oral Vancomycin ◽  
Open Label ◽  
Systemic Antibiotic ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Gastrointestinal Side Effects ◽  
Systemic Antibiotics

Abstract Background Limited retrospective data suggest prophylactic oral vancomycin may prevent Clostridioides difficile infection (CDI). We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility–onset CDI (HCFO-CDI) in targeted patients. Methods We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina, between October 2018 and April 2019. Included patients were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days postcompletion of systemic antibiotics [OVP]) or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility–associated CDI (CO-HCFA-CDI), incidence of vancomycin-resistant Enterococci (VRE) colonization after receiving OVP, adverse effects, and cost of OVP. Results A total of 100 patients were evaluated, 50 patients in each arm. Baseline and hospitalization characteristics were similar, except antibiotic exposure. No events of HCFO-CDI were noted in the OVP group compared with 6 (12%) in the no-prophylaxis group (P = .03). CO-HCFA-CDI was identified in 2 patients who were previously diagnosed with HCFO-CDI. No patients developed new VRE colonization, with only 1 patient reporting mild gastrointestinal side effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $1302, $26.04 per patient. Conclusion OVP appears to protect against HCFO-CDI during in-patient stay in targeted patients during systemic antibiotic exposure. Further prospective investigation is warranted.

scholarly journals 2421. Efficacy of Secondary Prophylaxis with Oral Vancomycin in Preventing Recurrent Clostridioides difficile Infections in Patients Receiving Systemic Antibiotics

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S836-S836
Author(s):  
Kelly E Pillinger ◽  
Jason K Lew ◽  
Kelly M Conn ◽  
Stephanie Shulder
Keyword(s):  
Risk Factors ◽  
Medical Center ◽  
Secondary Prophylaxis ◽  
Hospital Length Of Stay ◽  
Control Group ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Significant Difference ◽  
Systemic Antibiotics ◽  
The Impact

Abstract Background One of the major challenges in Clostridioides difficile infection (CDI) is preventing recurrence, particularly in the setting of risk factors, such as systemic antibiotics that impact the gut microbiome. There are little data to demonstrate the impact of secondary prophylaxis with oral vancomycin and due to the lack of evidence, the IDSA guidelines do not make a recommendation. Methods This was a multi-site, retrospective cohort study of adult inpatients within the University of Rochester Medical Center who received either a high- or medium-risk systemic antibiotic between July 1, 2013 and September 30, 2018 and had a positive C. difficile test within one year prior to admission. The primary endpoint was incidence of recurrent CDI within 90 days from the start of antibiotics in patients who received oral vancomycin prophylaxis (OVP) vs. those who did not receive prophylaxis (control). Results Of 425 patients screened, 153 patients were included in the control and 78 patients in the OVP group. The OVP group was more likely to be immunosuppressed (P < 0.001), have increased hospital length of stay (P < 0.001), receive a proton pump inhibitor (P = 0.049), have a prior episode of CDI within the previous 90 days (P < 0.001), and have > 1 prior episode of CDI (P = 0.038). The control group was more likely to have received metronidazole for the most recent CDI episode (P < 0.001), likely reflecting mild-moderate severity. Recurrent CDI within 90 days was 10.3% in the OVP group compared with 17.6% in the control (P = 0.175). A subgroup analysis of the patients with recurrent CDI found the time to recurrence from initiation of systemic antibiotics was similar in the OVP group compared with control (43 vs 30 days, P = 0.223). Conclusion While there was not a statistically significant difference in recurrent CDI within 90 days, the OVP group had numerous risk factors that made these patients at higher risk for recurrence compared with the control group. This may be clinically important and certain risk factors, such as timing of previous CDI episode, could be used to guide which patients should receive OVP. Prospective studies are needed to better elucidate the role of OVP and better define the patients that may benefit the most. Disclosures All authors: No reported disclosures.

scholarly journals Clostridioides difficile infections: Epidemiology, correlations and treatment in a Lebanese cohort with use of ATLAS scoring

2020 ◽  
Vol 14 (12) ◽  
pp. 1461-1465
Author(s):  
Jacques Choucair ◽  
Rami Waked ◽  
Elie Haddad ◽  
Marie Chedid ◽  
Nabil Chehata ◽  
...  
Keyword(s):  
Proton Pump Inhibitors ◽  
Proton Pump ◽  
Therapeutic Response ◽  
Tertiary Care ◽  
Dual Therapy ◽  
Care Hospital ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Significant Difference ◽  
History Of

Introduction: The objectives of the present study were to investigate epidemiology, correlations, severity, and therapeutic response of Clostridioides difficile infections in a Lebanese tertiary care hospital. Methodology: In this retrospective cohort study, patients having at least one positive Clostridioides difficile test (antigen glutamate dehydrogenase/GDH with toxins, or PCR) were studied. Results: Among 58 patients, 20 (34.5%) and 53 (91.4%) had positive antigen GDH and toxins, respectively. PCR was performed in 25 (43.1%) patients without any positive ribotype 027. Fifteen (25.9%) patients were immunocompromised, 35 (60.3%) patients received antibiotics prior to the infection and 34 (58.6%) on proton pump inhibitors. Fifty-four (93%) patients had a resolution of their symptoms after a mean period of 4.2 days of treatment. Twenty-two (38%) participants were treated with oral vancomycin, 11 (19%) with intravenous metronidazole and 23 (39.6%) with both antibiotics. Resolution of symptoms was significantly more rapid with monotherapy (p = 0.007) with no significant difference between vancomycin and metronidazole (p = 0.413). A positive correlation was found between ATLAS score and delay to symptoms resolution (r = 0.553; p < 0.001; N = 54), as well as between ATLAS score and prevalence of complications (p = 0.003). Conclusions: History of treatment with antibiotics, proton pump inhibitors, and hospital admission during the previous year were prevalent among our patient cohort. Rates of symptomatic resolution were similar with monotherapy and dual therapy.

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