When Should Oral Vancomycin Prophylaxis be Used to Prevent C. difficile Infection?

Abstract

Purpose of Review: It is unclear if oral vancomycin prophylaxis (OVP) should be used to reduce the risk of Clostridioides difficile infection (CDI) during systemic antibiotic exposure, and which patients benefit most from this approach. This review seeks to evaluate currently available literature on the utility of OVP, discuss clinical controversies, and suggest when OVP may be considered. Recent Findings: To date, 12 unique studies have been published evaluating the utility of OVP for primary and secondary prevention of CDI, with only one of these studies being conducted prospectively. Most studies demonstrate clinical benefit or no significant harm when using OVP. There has been notable heterogeneity in the published studies, namely, differences in the patient populations studied, time from initial CDI episode (when used for secondary prophylaxis), and doses and durations of OVP utilized. Additionally, studies have demonstrated that oral vancomycin has a significant impact on the host microbiota. Summary: The mostly retrospective and heterogeneous nature of the currently available evidence makes it difficult to draw definitive conclusions as to when OVP should be utilized and who may benefit most from its use. High-risk patient populations (elderly, immunocompromised, and those expected to have a prolonged hospitalization) who are receiving parenteral antibiotics may be reasonable to target for OVP. Future large prospective studies are warranted to draw more definitive conclusions on the potential benefit and risk of OVP. Research should also focus on the development of more predictive risk-prediction models to best identify those who may benefit from OVP.