CMI Communications (Nov 2024)
Oral vancomycin prophylaxis for the prevention of recurrent Clostridioides difficile infection during re-exposure to systemic antibiotics: A systematic review and meta-analysis
Abstract
Background: 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. Objectives: 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. Methods: 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). Results: 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. Conclusions: 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.
