Treating C. Difficile With Vancomycin, When Less Is More

Lower and higher doses of oral vancomycin are similarly effective in the treatment of Clostridium difficile (C. difficile) infection in hospitalized patients, according to researchers at Montefiore Medical Center in New York, New York.

Caregivers at Montefiore used to administer vancomycin doses of 250 mg or higher every 6 hours to patients infected with C. difficile. In 2008, however, the facility’s antimicrobial stewardship team — a group charged with facilitating the appropriate use of antibiotics — recommended reducing the dose to 125 mg every 6 hours, which data showed produced enough concentration to kill C. difficile in the large bowel.

To determine if the lower dose was effective, the researchers analyzed the records of 300 patients hospitalized at Montefiore between 2006 and 2010 who were diagnosed with C. difficile-associated diarrhea. Of the 197 patients prescribed vancomycin 125 mg every 6 hours, 85% showed clinical improvement at 72 hours after the initial dose. Similarly, 86% of the 103 patients prescribed 250 mg every 6 hours showed clinical improvement.

The researchers also noted statistically similar outcomes between the lower dose and higher dose groups in total length of hospital stay, mortality rates during hospitalization, 30-day readmission rates, and clinical improvement at the end of therapy or time of discharge.

“Using a lower dose can potentially reduce medication costs, reduce the potential for adverse outcomes such as vancomycin-resistant colonization in the gastrointestinal tract, or reduce further disturbance of the microbial flora in the tract,” said researcher Dr. Philip Chung, clinical pharmacy manager at Montefiore and assistant professor of infectious diseases at Albert Einstein College of Medicine.

An antimicrobial stewardship program can be a useful platform to implement improved institutional prescribing practices, noted Dr. Chung, who presented the study’s findings at the Annual Interscience Conference on Antimicrobial Agents and Chemotherapy in September.

He said health-system pharmacists play key roles in the daily activities of an effective antimicrobial stewardship program by coordinating and preparing institutional treatment guidelines, furthering prescriber education, and conducting performance evaluations.

“They conduct surveillance of appropriate antibiotic use and educate clinicians on appropriate antibiotic prescribing through in-services, grand rounds, and written guidelines,” said Dr. Chung. “They also conduct research and coordinate with other healthcare providers in special situations, such as an infection outbreak, to optimize treatment outcomes.”

—Dan Cook

Reference:

Chung P. Comparison of high- and low-dose oral vancomycin for treatment of Clostridium difficile infection in hospitalized patients. Presented at presented at the Annual Interscience Conference on Antimicrobial Agents and Chemotherapy.