Prevention of C. Diff Recurrence with PO Vanco

I still have several months of new literature to catch up on and post about here, but these articles came across my desk from the most recent Clinical Infectious Diseases and I found them pretty interesting.

Efficacy of Oral Vancomycin in Preventing Recurrent Clostridium Difficile Infection in Patients Treated with Systemic Antimicrobial Agents.
Clinical Infectious Diseases, 2016

• A restrospective cohort study from a single site looking at patients who received Vancomycin prophylaxis for recurrent c-diff between 2010-2014
• Defined recurrence as symptoms + positive PCR within 4 weeks after completion of systemic Abx (in patients who had previously been successfully treated for c-diff)
• Either got 125 mg PO BID or 250mg PO BID concurrently with the systemic abx and for up to 1 week after (average 0.8 days)
• 4.2% recurrence in prophylaxis group, 26.6% in no prophylaxis group
  • only 3 cases in the px group, 2 of which were asymptomatic, just PCR positive

This study is not powerful enough to start consistently applying to practice, and there are a lot more parameters that need to be defined (eg how recent does th previous occurrence need to be to consider routine prophylaxis?) but it gives some credence to when we arbitrarily give vanco Px to pts with several c-diff recurrences in the past. It also gives a bit of guidance as to dosing; we don’t have to use QID.

Editorial Commentary : Potential Risks and Rewards With Prophylaxis for Clostridium difficile Infection
Clinical Infectious Diseases, 2016

The author of this commentary presents some interesting points that I wasn’t aware of. For instance, he references several papers showing that vanco has a terrible effect on protective microbiome and leaves the patient very vulnerable to c-diff recurrence in the period immediately after vanco cessation. It can also make the host more susceptible to colonization with nosocomial MDR bugs. (This doesn’t happen with flagyl). He points out that the lowest dose of vanco possible for Px would be ideal (possibly less than 125 daily) and noticed that 2/3 recurrences in the study occured with the 250mg BID dosing. I also didn’t know that for patients who develop c-diff during a long course of abx (like in osteomyelitis), who will need longer than the 14 days of usual c-diff tx, vanco is recommended for the “extended” portion as flagyl is not found in good concentrations in non-diarrheal feces.