Oral vancomycin prophylaxis for the prevention of recurrent Clostridioides difficile infection during re-exposure to systemic antibiotics: A systematic review and meta-analysis

• Published in: CMI Communications 2024-12, Vol.1 (2), Article 105041
• Main Authors: Prosty, Connor, Bortolussi-Courval, Émilie, Dubé, Laurie-Rose, Lee, Todd C., McDonald, Emily G.
• Format: Article
• Language: English
• Subjects: C. difficile; Prevention; Prophylaxis; Recurrence; Systemic antibiotic
• ISSN: 2950-5909; 2950-5909
• DOI: 10.1016/j.cmicom.2024.105041

Patients who have had Clostridioides difficile infection (CDI) are at high risk of recurrence following antibiotic re-exposure. Secondary oral vancomycin prophylaxis during antibiotic re-exposure may mitigate this risk. We conducted a systematic review and meta-analysis on the effectiveness and safety of vancomycin prophylaxis versus placebo/no prophylaxis for the prevention of recurrent CDI (rCDI) during antibiotic re-exposure.   Data Sources: Embase, MEDLINE, and CENTRAL. Study Eligibility Criteria: Randomized controlled trials (RCT) or comparative observational studies. Participants: Adults with recent (as defined in the studies) CDI who were re-exposed to systemic antibiotics. Interventions: Vancomycin prophylaxis (of variable doses) versus placebo/no prophylaxis. Assessment of Risk of Bias: Cochrane's ROBINS-I and RoB2 tools for comparative observational studies and RCTs, respectively. Methods of Data Synthesis: Recurrent CDI, all-cause mortality, and safety outcomes were pooled by random-effects meta-analysis and reported as odds ratios (OR). Eight observational studies were included in the systematic review and meta-analysis. All were at high risk of bias. The total population comprised 2156 patients, including 656 who received vancomycin prophylaxis and 1500 who did not; antibiotic re-exposure occurred within a median of 1 to 12 months after a qualifying episode of CDI. Vancomycin prophylaxis (125–1000 mg daily) was associated with a significantly reduced odds of rCDI compared to no prophylaxis (OR=0.41, 95 % Confidence Interval [95 %CI]=0.20–0.87). All-cause mortality was comparable between the two groups (OR=0.93, 95 %CI=0.62–1.40). None of the included studies reported on adverse events. The existing evidence base, consisting entirely of low quality observational studies, suggests that vancomycin prophylaxis could be effective in reducing the risk of rCDI with antibiotic re-exposure. These findings support a definitive RCT to firmly establish the efficacy and safety of vancomycin prophylaxis. [Display omitted]