Oral Vancomycin Lowers Risk for Recurrent C Difficile

Nicole M. Bohm, PharmD, BCPS

Oral vancomycin prophylaxis can reduce the risk for recurrent Clostridium difficile (C difficile) infections, according to a recent meta-analysis.

Researchers from the Medical University of South Carolina conducted a literature review in order to summarize and evaluate the evidence for oral vancomycin prophylaxis in preventing recurrent C difficile infections. They also examined the potential consequences of this practice and any future implications.

In order to answer their questions, the team searched for published papers between 1947 and 2018 from the Medline database using search terms for “vancomycin” and “C difficile” and “prophylaxis.”

“Given the challenge of treating and the burden of C difficile infection and its propensity to recur, the focus on prevention is increasing in prominence,” study author Nicole M. Bohm, PharmD, BCPS, told MD Magazine®. “Currently, the data for secondary prevention by treating high-risk patients (history of recurrent C difficile infection and receiving broad spectrum antibiotics) with oral vancomycin is limited by the small number of study subjects, variable dosing regimens, and inconsistent surveillance in the follow-up period.”

The investigators ultimately identified 3 applicable studies that tested oral vancomycin prophylaxis or secondary prophylaxis of C difficile. However, they said other papers were included as references or for background discussion in their analysis. They wrote that while oral vancomycin for secondary prophylaxis is not recommended, it is nevertheless becoming an emerging strategy without any prospective data and only limited retrospective data currently existing.

While the study authors did not evaluate the long-term risks, they did determine that oral vancomycin prophylaxis appears to be effective based on the papers’ definitions.

“Clinicians can consider using oral vancomycin in selected high-risk patients when they believe the benefits outweigh potential risks,” Bohm added.

One study showed that in patients with 1 previous C difficile infection, oral vancomycin prophylaxis had no effect on recurrence compared to matched healthy controls who did not receive prophylaxis. But in patients with a history of C difficile infections, 54% of those who received oral vancomycin prophylaxis experienced recurrence compared to 70% of those who did not receive prophylaxis and experienced recurrence.

A second study gave 71 patients with a history of C difficile infection doses of either 125 mg or 250 mg twice daily oral vancomycin prophylaxis. Recurrent infection occurred in 4% of the intervention group compared to 27% in the control group.

Another study retrospectively examined the effectiveness of secondary oral vancomycin prophylaxis on renal transplant patients. Among a group of 29 different patients, there were 36 total systemic antibiotic courses; there were 12 uses of oral vancomycin prophylaxis. There were no reported instances of recurrent C difficile in the oral vancomycin prophylaxis group, and there were 2 in the control group. The researchers did not find this statistically significant and did not include follow up information after the oral vancomycin prophylaxis intervention.

The authors of the meta-analysis wrote that the retrospective nature of the study, small sample sizes, and heterogeneity of these 3 studies “leave many clinical questions unanswered.” One main factor they pointed out was that because these were single-center studies, it is unknown whether patients did in fact develop recurrent C difficile but were treated at another facility.

“I believe the implications/impact on practice are that hopefully this review will highlight that oral vancomycin prophylaxis may offer benefits for some patients and provide clinicians with greater insight into the data limitations and potential risks associated with oral vancomycin prophylaxis for secondary prophylaxis,” Bohm said.

The study authors concluded that clinicians can consider using vancomycin 125 mg daily or twice daily in patients at a high risk for recurrent C difficile infection who complete their course of broad-spectrum antibiotics.

The study, titled “Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection,” was published in the Annals of Pharmacotherapy.