Long-Duration Vancomycin Linked to Lower Rates of C. Diff Recurrence in IBD

By Marilynn Larkin

December 06, 2019

NEW YORK (Reuters Health) - In patients with inflammatory bowel disease (IBD), a long course of oral vancomycin is associated with lower odds of Clostridioides difficile infection recurrence than a short course, a retrospective chart review reveals.

"In IBD, having C diff is associated with worse outcomes - e.g., greater likelihood for hospitalization or surgery, lower likelihood to respond to medical therapy and, as we showed previously (http://bit.ly/2LpkC3k), increased risk for J pouch complications if a patient had C diff before their colectomy," Dr. David Rubin of University of Chicago Medicine told Reuters Health by email. "We also know that having one C diff infection increases the likelihood of having another, and having two increases the likelihood of a third substantially."

"There are no good data on optimized treatment for C diff in IBD, and lots of empiric tapering schedules and a mishmash of other unproven approaches," he noted.

Dr. Rubin started treating all of his IBD patients with C. difficile infection with long-duration vancomycin (a 28-day course) after discussions with infectious diseases specialists.

"After a while, it seemed to me that my patients had lower recurrence and reinfection rates than my colleagues' patients," he said.

"Our study did in fact demonstrate significantly reduced rates of recurrence (testing positive within 8 weeks after antibiotic cessation) and although reinfection rates (testing positive more than 8 weeks after antibiotics) were also lower, this finding was not statistically significant," he said. "The latter was mainly a statistical power issue."

The study included 134 patients who had at least one positive C. difficile toxin assay by polymerase chain reaction between 2010 and 2016. Long-duration (LD) vancomycin was defined as 21-42 days, and short-duration (SD) as 10-14 days.

As reported in the American Journal of Gastroenterology, 57 patients were treated with LD vancomycin and 77 with SD. The groups were similar in mean age at C. difficile infection (about 36), gender (about half male), and IBD diagnosis and disease location.

Those taking LD vancomycin had a 1.8% incidence of C. difficile infection recurrence, compared with 11.7% in the SD group (odds ratio, 0.13). As Dr. Rubin noted, C. difficile reinfection rates and time to reinfection were not significantly different between the groups. However, multivariate logistic regression models showed that treatment with LD vancomycin had lower odds for recurrence than SD vancomycin (odds ratio, 0.03).

Dr. Rubin said, "There is no downside to LD vancomycin treatment, other than the short-term cost of it. But if you calculate the cost of recurrence and other outcomes, I think it is very likely a cost-effective approach to managing these complicated patients."

"I believe that this (approach) should be considered in our future guidelines, and as well by the Infectious Disease Society of America," he said.

A prospective study is now in development.

Dr. Niket Sonpal, a New York City-based internist and gastroenterologist and adjunct professor at Touro College, called the findings "very important."

"Though C diff is difficult to eradicate in all populations, using vancomycin for a longer duration in a population at high risk makes good sense," he said in a phone interview. "The most difficult aspect is ensuring the medication is covered by the patient's insurance for the duration of therapy, as most insurance companies are hard to work with when attempting to get coverage (outside of the) conventional duration."

"C diff is harder to eradicate in patients with active inflammation, and is a common cause of flares in IBD," he added. "These data are a good start to solving a more long-term issue."

SOURCE: http://bit.ly/2DLvfJt American Journal of Gastroenterology, online November 7, 2019.

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