Targeted Prophylaxis Reduces Hospital-Onset C difficile Infections in High-Risk Patients
The STOP-CDI intervention presented by Matthew J.Ziegler, MD MSCE revealed using prophylactic enteral vancomycin, significantly reduced hospital-onset C difficile infections among immunocompromised patients.
Patients undergoing immunosuppression for cancer treatment and transplantation are at the highest risk for developing hospital-onset C difficile infections (HO-CDI). STOP-CDI investigated a prophylactic enteral vancomycin intervention aimed at reducing HO-CDI rates in high-risk hospitalized patients. The STOP-CDI intervention was found to effectively reduce HO-CDI rates, length of stay, and associated symptoms within this vulnerable population.
Matthew J Ziegler, MD MSCE, assistant professor of medicine at UPenn, presented the STOP-CDI trial results at IDWeek and discussed key findings on screening and targeted prophylaxis for CDI, and whether they challenge and/or support current clinical practices. “The key finding of our research was that among the patients who were screened, there was a very low rate of HO-CDI, less than 1%, compared to our control group, which had roughly 5.6% after waiting for the same diseases. We found that this STOP intervention was very successful at reducing HO-CDI, which contrasts with common clinical and infection control practices.”
From November 2021 to December 2023, 692 patients were screened for C diff, with 11% colonized. The intervention group had lower odds of HO-CDI compared to matched controls, with a number needed to screen 31. Notable reductions in 90-day HO-CDI rates, stool output, and length of stay were observed, while no differences in vancomycin-resistant Enterococcus (VRE) infections or mortality were noted.
Ziegler discussed the implications for specific patient populations at higher risk for CDI, “When we did subgroup analyses of our research and looked at the relative benefit in solid organ transplant versus oncology patients, we saw a pretty stark difference. Our oncology patients historically had roughly a 7.5% rate of HO-CDI, and that went down to 1% in our intervention, showing a large difference and significant benefit from the intervention.”
Patients undergoing solid organ transplants, autologous stem cell transplants, CAR-T therapy, or leukemia treatment were screened for C diff colonization. Those who tested positive received oral vancomycin prophylaxis for 10 days or until discharge. Outcomes were compared to concurrent and historical controls, with the primary outcome being HO-CDI and secondary outcomes including 90-day CDI rates, stool output, length of stay, VRE infections, and mortality.
“On the other hand, our solid organ transplant patients were enrolled during their index admission for organ transplantation, and our historical rate of HO-CDI in that group is only 1%. While that dropped from 1% to zero, that’s a much smaller absolute difference. We thought that would be a group likely to benefit, but it turns out that this group seems to be at lower risk of transitioning from colonization to an infection state during that specific time period,” Ziegler said.
Ziegler discussed the integration of screening and prophylactic measures for CDI evolving in clinical settings, considering emerging guidelines and antibiotic stewardship initiatives: “I think the uptake of this practice, clinically or more broadly, requires some additional research to identify other patient populations that are at high risk. It’s possible that there are other patient populations where this intervention may also be useful, but it’s also possible that this research intervention, or the STOP intervention, may not be beneficial for all hospitalized patients.”
Ziegler concludes, “Many antibiotic stewardship interventions focus on giving antibiotics to patients who will benefit and trying to avoid them in patients who won’t. I think this targeted prophylaxis approach really falls in line with some of these tenets of antibiotic stewardship.” Future research will explore how targeted screening and prophylaxis can reduce C diff transmission in various units and its effectiveness in other patient populations.
