WASHINGTON — Long-term vancomycin suppression appeared to help prevent recurrences of Clostridioides difficile infections (CDI) and did not lead to a substantial increase in vancomycin-resistant Enterococcus (VRE), according to a retrospective cohort study.
Among 324 patients taking suppressive vancomycin, none developed CDI during therapy, while 2.8% developed positive VRE clinical cultures versus 3.7% on a vancomycin taper regimen, reported Samir Memic, a research associate at the Northeast Ohio VA Healthcare System in Cleveland, at the IDWeek annual meeting.
After discontinuation, vancomycin suppression was associated with a lower risk of CDI recurrence compared with vancomycin taper (HR 0.29, 95% CI 0.18-0.46, P<0.0001).
“Overall, our study found that vancomycin suppressive therapy may be an option for select patients suffering from multiply recurrent CDI when other strategies are not feasible,” Memic said during his presentation. “However, more work needs to be done on whether or not to clarify patient selection, and on determining the optimal duration of suppression.”
Up to 30% of patients may develop recurrent CDI after their first episode, with recurrence risk rising after each episode. That recurrence risk may reach 50% after multiple CDI episodes. For multiple CDI recurrences, the most effective treatment is fecal microbiota-based therapy (FMT), with other options including vancomycin taper and pulse approaches, vancomycin followed by rifaximin, and fidaxomicin.
American College of Gastroenterology guidelines suggest considering prolonged, low-dose, suppressive vancomycin in patients with multiple recurrent CDI episodes who aren’t candidates for FMT. That patient pool includes those on ongoing or frequent systemic antibiotics, patients who lack access to FMT, or those who have a limited life expectancy.
For this study, Memic and colleagues used Veterans Health Administration data from 2015 through 2024 on 38,182 patients positive for C. difficile who received oral vancomycin treatment. Those on vancomycin suppression received a continuous daily dose without tapering or pulsing for at least 60 days. Among 2,554 patients who took at least 90 days of vancomycin, 2,230 received vancomycin taper, and 324 received vancomycin suppression.
Median patient age was 77 years, 92% were men, 49% had been hospitalized at least once during suppression, and median vancomycin duration was 510 days. Sixty-eight percent had received systemic antibiotics, and 19% were nursing home residents.
Chart reviews of 113 patients on vancomycin suppression showed that 40.7% weren’t considered to be FMT candidates, given use of systemic antibiotics, short life expectancy, or prior failed FMT. Another 16% were on temporary suppression while awaiting FMT or gastrointestinal surgery, chemotherapy, or immunosuppressive therapy.
The longer patients remained on suppression therapy, the lower their risks were for CDI recurrence, Memic explained. Patients who underwent suppressive therapy for 3 to 6 months were significantly more likely to have a CDI recurrence than those on suppressive therapy for longer than 6 months (P=0.0003).
Most of the patients on vancomycin suppression didn’t have diarrhea during treatment and weren’t tested for C. difficile, study co-author Curtis Donskey, MD, of the Cleveland VA Hospital, noted during the presentation. “But during the chart review, we found five or six patients who developed some form of diarrhea and were tested. They were all negative.”
