When should Vancomycin (vancomycin) be given prophylactically for Clostridioides difficile (C. diff) infection?

From the Guidelines

Vancomycin prophylaxis for C. difficile infection (CDI) should only be considered in very specific high-risk situations, such as during outbreaks in healthcare facilities or for patients with multiple recurrent CDI episodes who require antibiotics for another infection, as recommended by the 2021 focused update guidelines on management of clostridioides difficile infection in adults 1. When used prophylactically, oral vancomycin at 125 mg once daily is typically prescribed during and for several days after completion of the triggering antibiotic course. This approach should be limited to patients with at least 2-3 prior CDI episodes who absolutely require antibiotics known to disrupt gut flora (like fluoroquinolones, clindamycin, or broad-spectrum cephalosporins). Some key points to consider when deciding to use vancomycin prophylactically include:

• The potential risks of promoting antimicrobial resistance, disrupting normal gut microbiota, and potentially selecting for vancomycin-resistant organisms 1
• The importance of standard prevention measures like antimicrobial stewardship, hand hygiene, and contact precautions in CDI prevention 1
• The preference for careful antibiotic selection and minimizing unnecessary antibiotic exposure over vancomycin prophylaxis for most patients, even those with prior CDI 1 It's also worth noting that fidaxomicin is suggested as a preferred treatment option for initial and recurrent CDI episodes, rather than vancomycin, according to the 2021 focused update guidelines 1.

From the Research

Vancomycin Prophylaxis for Cdiff

• Vancomycin prophylaxis may be considered for patients at high risk of developing Clostridium difficile infection (CDI) who are receiving broad-spectrum antibiotics 2.
• The optimal dosing regimen for vancomycin prophylaxis is not well defined, but a dose of 125 mg orally once or twice daily has been suggested 2.
• Studies have shown that oral vancomycin prophylaxis (OVP) can reduce the risk of CDI in high-risk patients, although the evidence is limited by methodological concerns 2, 3.
• A systematic review and meta-analysis found that OVP was associated with decreased CDI, but the results should be interpreted with caution due to considerable heterogeneity between studies 3.
• A randomized, prospective, open-label study found that OVP was effective in preventing healthcare facility-onset CDI in targeted patients during systemic antibiotic exposure 4.
• However, another study found that prophylactic oral vancomycin was not consistently associated with reduced risk of CDI relapse among hospitalized patients receiving systemic antibiotics, although patients with only 1 prior CDI episode may benefit 5.

Patient Selection

• Patients who may benefit from vancomycin prophylaxis include those with a history of CDI, those receiving broad-spectrum antibiotics, and those with underlying medical conditions that increase their risk of developing CDI 2, 4.
• The decision to use vancomycin prophylaxis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 6.

Safety and Efficacy

• The safety and efficacy of vancomycin prophylaxis have not been fully established, and further prospective investigation is warranted 2, 4.
• The use of vancomycin prophylaxis may have an adverse impact on the gastrointestinal microbiome, although this has not been fully studied 2.
• The risk of vancomycin-resistant enterococci (VRE) infection after OVP has been evaluated in several studies, and no significant increase in risk has been found 3, 4.