132 Oral Vancomycin 6-week Taper Regimen is Superior to Metronidazole and Short Course Oral Vancomycin as Treatment for Both Initial and Recurrent Clostridium difficile Infection (CDI)

Friday, March 19, 2010
Grand Hall (Hyatt Regency Atlanta)
Dale Lieu, MD , Kaiser Permanente, San Diego, CA
Leia Skol, PharmD , Kaiser Permanente, San Diego, CA
Corinne Lieu, BS , Kaiser Permanente, San Diego, CA
Susan Cheng, BS , Kaiser Permanente, San Diego, CA
Background:

CDI is a severe health-care associated infection. Relapse rates of > 20% have been reported when metronidazole or vancomycin is discontinued. Observational studies suggest prolonged, tapering, and pulsed-dosed regimens of vancomycin reduce relapse. Prolonged regimens as initial therapy have not been previously studied. We initiated vancomycin 6-week taper as treatment of choice for first CDI diagnosis in patients ≥ 60 years, patients < 60 years with co-morbidities, and as treatment of choice for patients with a previous history of CDI.

Objective: Compare vancomycin 6-week taper to metronidazole and to short course (≤14 days) vancomycin as treatment for both initial and recurrent CDI.

Methods: We studied all patients in our service area treated for positive C. difficile toxin from June 2007 through September 2009.  In October 2008, our treatment guidelines changed. Vancomycin 6-week taper is now recommended as treatment for first CDI diagnosis in patients age ≥ 60 years and in younger patients with significant co-morbidities.  In addition, vancomycin 6-week taper is now recommended as treatment for any patient with a previous history of CDI, including relapse (defined as recurrence of disease within 3 months).

Results: 1.  In the 16 months prior to change in treatment guidelines, 747 patients were treated for first time CDI.  Relapse occurred in 62/396 (15.7%) treated with metronidazole and in 44/351 (12.5%) treated with short course vancomycin.  An additional 134 patients with a previous history of CDI were treated.  Relapse occurred in 5/19 (26.3%) treated with metronidazole, 7/39 (17.9%) treated with short course vancomycin, and 7/76 (9.2%) treated with vancomycin 6-week taper.

 2.  In the subsequent 12 months after treatment guidelines changed, 471 patients were treated for first time CDI.  Relapse occurred in 7/63 (11.1%) treated with metronidazole, 11/89 (12.4%) treated with short course vancomycin, and in 26/319 (8.2%) treated with vancomycin 6-week taper.  An additional 130 patients with a previous history of CDI were treated.  Relapse occurred in 6/118 (5.9%) treated with vancomycin 6-week taper.

Conclusions: Oral vancomycin 6-week taper regimen outperformed metronidazole and short course vancomycin for both initial and recurrent Clostridium difficile infection.  Oral vancomycin 6-week taper is now our standard of practice.  Only a few patients, typically younger, outpatients, and without co-morbidities, are still treated with other regimens.