Journal Club

Oral Vancomycin for C. difficile Prophylaxis: Ready for Prime Time in Stem Cell Patients?

By Erica Kaufman West, MD

Allogenic hematopoietic stem cell transplant (alloHCT) patients carry most of the risk factors for Clostridium difficile infection (CDI): hospitalization, exposure to antibiotics, and advanced age. When you factor in immunosuppression and impaired gut integrity, it’s not surprising that up to 31% of alloHCT patients develop CDI ― and with a higher mortality rate than expected.

A single-center retrospective chart review in Transplant Infectious Disease looked at the effectiveness of CDI prophylaxis with vancomycin 125 mg orally twice daily compared to no prophylaxis in 200 consecutive alloHCT patients. Oral vancomycin was given on the day of inpatient admission for alloHCT and continued until the day of discharge. The primary outcome was the association between CDI prophylaxis and incidence of CDI during alloHCT hospitalization. CDI was defined as three or more unformed stools in one day with a positive PCR for toxin B. All alloHCT patients were screened for vancomycin-resistant Enterococcus (VRE) weekly, and all received levofloxacin for prophylaxis when their absolute neutrophil count fell below 500 cells/μL (or cefuroxime if there was an allergy). Baseline demographics were similar, except that more patients in the vancomycin prophylaxis group received transplants collected from the bone marrow (62%) compared to the preintervention group (36%), due to a program shift in preference. Eleven percent of patients in the preintervention group developed CDI versus 2% in the prophylaxis group (P = .018). Of note, there were no differences in acute graft-versus-host disease, length of stay, or bloodstream infections between the two groups. Interestingly, there were no differences in VRE colonization between the two groups either, despite the length of stay ― and thus of oral vancomycin ― averaging 25 to 26 days.

This article adds to the growing body of literature showing that oral vancomycin for CDI prophylaxis in this high-risk group is both effective and safe. Although a randomized controlled clinical trial is the gold standard, in its absence, studies like these should push the needle toward implementation.

(Altemeier and Konrardy. Transpl Infect Dis. 2022:24(2):e13790.)