Reduction of in-hospital rate of C difficile infection from 11% to 4%, with no increased risk of infection following treatment.
Michael J Williams, PharmD
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A recent study has shown that oral vancomycin prophylaxis (OVP) significantly reduces the incidence of Clostridioides difficile infection (CDI) during hospitalization in autologous stem cell transplant (ASCT) recipients, without increasing the risk of infection after discharge. The study, conducted at a single institution, evaluated 254 ASCT patients between January 2012 and December 2021. Patients were divided into two groups: those who received OVP (125 mg twice daily) and those who did not. The primary outcome, the incidence of CDI during hospitalization, revealed a significantly lower CDI rate in the OVP group (4%) compared to the non-OVP group (11%), with a p-value of .03.
The secondary outcome, assessing CDI risk up to 180 days after discharge, found no increased risk following OVP discontinuation. The study also identified longer hospital stays as a factor associated with a higher risk of CDI.
In an interview with Contagion, Michael Williams, PharmD, the study’s lead investigator, addressed concerns about the long-term effects of OVP, particularly regarding antibiotic resistance and microbiome disruption. He explained, “Based on the significant reduction of in-hospital CDI incidence, we expect the benefit to occur acutely during the immediate early transplant period, especially prior to cell engraftment. A potential long-term risk remains promotion of vancomycin resistance, however multiple studies have dispelled this concern (Morisette 2019 and Altemeier 2022). Concern for gut microbiome disruption is valid but has yet to be fully elucidated. In our study, the timing of CDI did not exactly correlate with time periods identified as highest risk due to antimicrobial-related microbiota disruption. Given there was no increased risk for CDI post-OVP discontinuation, compared to those who were OVP-naive, we do not have reason to suspect increased OVP-induced risk of CDI development long term. Data surrounding risk of Gram-negative infections are mixed.”
CDI is a serious concern for immunocompromised populations like those undergoing stem cell transplants, and while oral vancomycin has been used prophylactically in other high-risk groups, its role in ASCT patients had not been well studied. This study provided evidence for OVP’s effectiveness in reducing CDI during the acute hospitalization phase without increasing the risk of CDI after treatment ends.
In-hospital CDI rates were significantly lower in the OVP group (4%) compared to the non-OVP group (11%) with a p-value of .03.
There was no increased risk of CDI in the 180 days following discharge for patients who received OVP.
The length of stay in the hospital was identified as a significant factor influencing CDI risk.
Williams also highlighted that OVP could be beneficial for other immunocompromised populations, particularly those with neutropenia, such as stem cell transplant and myelosuppressive chemotherapy patients, “Nearly all (94%) of the CDI cases in our study were neutropenic at the time of CDI detection which is not a factor commonly observed in solid organ transplant patients.” This emphasized that OVP’s benefit in preventing CDI may be most pronounced in populations with neutropenia, particularly since diarrhea is often associated with chemotherapy.
Regarding implications for clinical practice, this suggests that OVP could be a valuable tool in preventing CDI in ASCT recipients. Williams explained, “We aimed to provide a comparison of primary OVP prophylaxis among autologous stem cell transplant patients with a longer follow-up period than previously described. While our findings validated our current practice, we encourage other institutions to evaluate their own CDI incidence and consider prevention strategies if indicated. Ultimately, a randomized controlled trial would best describe the role of OVP in the stem cell transplant population.”
The study's findings provide evidence for the role of OVP in reducing CDI during hospitalization in ASCT patients. As Williams pointed out, further research, including randomized controlled trials, will be necessary to refine treatment protocols and explore the broader applications of OVP for other immunocompromised populations. Given the outcomes of this study, additional trials could help clarify the long-term benefits of OVP and its potential role in reducing CDI in transplant patients.
