Prophylactic vancomycin may reduce recurrent Clostridioides difficile infection but increases antimicrobial resistance

1. In this randomized clinical trial, oral vancomycin reduced the risk of recurrent Clostridioides difficile infection (CDI) in participants with previous CDI, although not with a statistically significant difference.

2. The use of oral vancomycin was associated with a higher rate of vancomycin-resistant enterococci (VRE) in the gut 8 weeks after treatment. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Clostridioides difficile infection (CDI) is a leading cause of diarrhea in hospitals, and over one-third of patients experience at least one recurrence. Antibiotic use is the biggest risk factor for recurrence, especially when they are used again for other illnesses. Preventing recurrence is crucial to avoid serious adverse health effects. A randomized clinical trial was conducted to evaluate whether low-dose oral vancomycin prophylaxis can prevent recurrent CDI in patients with a history of CDI who are receiving systemic antibiotics for reasons other than CDI. Along with that, the study aimed to determine whether the use of vancomycin affects gut colonization with vancomycin-resistant enterococci (VRE). The primary outcome of the study was to compare the incidence of recurrent CDI in participants in the intervention group versus the placebo group, during treatment and in the following 8 weeks. Compared to the placebo group, participants in the vancomycin treatment group had decreased rates of CDI recurrence. Although there have been associations between vancomycin and increased VRE in the gut, the results from this study found that VRE levels decreased in the placebo group but stayed the same in the intervention group. Overall, in this randomized clinical trial, patients who received vancomycin prophylaxis had lower rates of recurrent CDI; however, the difference was not significantly significant, likely due to the study being underpowered.  

Click here to read the study in JAMA Network Open 

Relevant Reading: Oral Vancomycin Prophylaxis for Primary and Secondary Prevention of Clostridioides difficile Infection in Patients Treated with Systemic Antibiotic Therapy 

In-Depth [randomized clinical trial]: Individuals were eligible to participate if they received a diagnosis of 1 or more cases of CDI within the past 180 days, completed CDI treatment, and were receiving antibiotics for reasons other than CDI for 2 weeks or less. Participants were ineligible to participate if they had contraindications to vancomycin, were using oral vancomycin during the study for other reasons, or were using other antibiotic therapy, along with other criteria. Participants were then randomized in a 1:1 ratio to either the intervention or placebo group. The intervention group consisted of 125 mg of oral vancomycin (Akorn) while the placebo was 125 mg of lactose formula grade powder. After meeting eligibility and consenting, 81 participants (median age, 59 years [IQR, 50-67 years]) were included and randomized, with 39 assigned to the oral vancomycin group and 42 to the placebo group. However, the secondary analysis only included 60 participants (74.1%), with 29 in the placebo group (69.0%) and 31 in the intervention group (79.5%). In the 8 weeks after treatment completion, 17 patients in the intervention group (43.6%) and 24 in the placebo group (57.1%) experienced a CDI recurrence (absolute percentage difference, -13.5% [95% CI, -35.1% to 8.0%]). In the same timeframe, VRE was reported in 15 (50.0%) participants in the intervention group and 6 (24.0%) participants in the placebo group. Adverse events were reported by 27 participants (69.2%) in the intervention group, and 27 participants (64.3%) in the placebo group. 

Image: PD

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