Dose addition of intravenous metronidazole to oral vancomycin improve outcomes in Clostridioides difficile infection?

2019 ◽  
Author(s):  
Ying Wang ◽  
Aaron Schluger ◽  
Jianhua Li ◽  
Angela Gomez-Simmonds ◽  
Hojjat Salmasian ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Primary Outcome ◽  
Time Window ◽  
Dual Therapy ◽  
Secondary Outcome ◽  
Index Test ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Improved Outcomes ◽  
Clostridioides Difficile Infection

Abstract Background Guidelines recommend adding intravenous (IV) metronidazole to oral vancomycin for fulminant Clostridioides difficile infection (CDI). This study compared dual therapy with IV metronidazole and oral vancomycin versus vancomycin monotherapy. It assessed prevalence of use and effectiveness of dual therapy in non-fulminant and fulminant CDI. Methods This was a two-center retrospective study conducted from 2010 to 2018. Adult inpatients were included if they had a positive C. difficile PCR performed on an unformed stool and received oral vancomycin within two days (either before or after) of testing. Patients were classified as having received dual therapy if IV metronidazole was given within the same time window, and otherwise as having received vancomycin monotherapy. The primary outcome was  death or colectomy within 90 days after the index test. Logistic regression modeling was used to adjust for CDI severity and other established predictors of CDI outcomes. CDI recurrence was examined as a secondary outcome, adjusting for death as a competing risk. Results The study included 2,114 patients (dual therapy: 993; monotherapy: 1,121) of whom 23% met the primary outcome. There was no association between dual therapy and the primary outcome (adjusted OR (aOR) 1.07, 95% CI 0.79-1.45) which remained true when the analysis was restricted to patients with fulminant CDI (aOR 1.17, 95% CI 0.65-2.10). There was also no association between dual therapy and CDI recurrence. Conclusions Dual therapy with IV metronidazole and oral vancomycin was common for non-fulminant and fulminant CDI, but was not associated with improved outcomes compared to vancomycin alone.

Evaluating Adherence to Guideline-Directed C Difficile Infection Management Pre- and Postimplementation of an Electronic Order Set

2020 ◽  
pp. 089719002090385
Author(s):  
Aamer Attaar ◽  
Juanqin Wei ◽  
Luigi Brunetti
Keyword(s):  
Infectious Disease ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Single Center ◽  
Clostridioides Difficile ◽  
Order Sets ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
Electronic Order ◽  
Order Set

Background: After publication of the Clostridioides difficile infection (CDI) guidelines by the Infectious Disease Society of America (IDSA) in early 2018, we identified that many prescribers at our institution continued to practice using the older guidelines. Objective: This study aimed to determine whether the implementation of an electronic order set for CDI would increase prescriber compliance to current IDSA recommendations for CDI management. Methods: This was a single-center, prospective cohort study of adult inpatients with a confirmed CDI. The study was conducted between March 1, 2018, and April 1, 2019. Patients were stratified into a preintervention and postintervention group before and after order set implementation. The primary outcome was a composite of appropriate CDI therapy selection and discontinuation of nonessential antimicrobials and acid-suppressive agents. The secondary outcome evaluated appropriate CDI therapy medications prescribed at hospital discharge. Results: Of the 149 patients included in this study, 96 were included in a preintervention group and 53 included in a postintervention group. The primary outcome was met in 45% of patients in the preintervention group and 66% of patients in the postintervention group ( P = .01). The secondary outcome occurred in 86% of patients in the preintervention group and 100% of patients in the postintervention group ( P = .02). Conclusion: Implementation of a CDI electronic order set and alert bundle was associated with enhanced prescriber adherence to guideline-directed therapy. Our results suggest that order sets not only improve inpatient compliance to guidelines but may also improve medication-related adherence to guideline recommendations upon discharge.

scholarly journals 1376. Oral Vancomycin as Secondary Prophylaxis Against Clostridioides difficile Infection in Pediatric Patients

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S698-S698
Author(s):  
Hongkai Bao ◽  
Yanina Dubrovskaya ◽  
John Papadopoulos ◽  
Justin Siegfried ◽  
Cristian Merchan ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Odds Ratio ◽  
Protective Factor ◽  
Pediatric Patients ◽  
Antibiotic Exposure ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
History Of ◽  
Systemic Antibiotics

Abstract Background Secondary oral vancomycin prophylaxis (OVP) has been utilized in adults with a history of Clostridioides difficile infection (CDI) while receiving systemic antibiotics to prevent CDI recurrence. However, this practice is poorly described in pediatric patients. Rates of CDI recurrence in pediatric patients range from 10-40% and is associated with morbidity and mortality. This study assessed the efficacy and safety of secondary OVP in pediatric patients with subsequent antibiotic exposure. Methods This retrospective study evaluated pediatric patients ≤18 years with any history of clinical CDI and receiving systemic antibiotics in a subsequent encounter during the time period of 2013-2019. Patients who received OVP 10 mg/kg (up to 125 mg per dose) every 12 hours during concomitant antibiotics were compared to those who did not. The primary outcome was CDI recurrence within 8 weeks following antibiotic exposure. Secondary outcomes included time to recurrence, severity of recurrence, and isolation of vancomycin-resistant enterococci (VRE) from any site. Risk factors for CDI recurrence were assessed using logistic regression. Results A total of 153 patients were screened for inclusion, of which 32 and 47 patients were assigned to the OVP and no OVP group, respectively. Median age was 8.6 years and the most common comorbidities were malignancy (47%) and immunosuppression (46%). Median time since last CDI to study inclusion was 64.5 days in the OVP group and 90 days in the no OVP group, P=0.320. Compared to the no OVP group, OVP patients had longer hospital stays (5 vs 14 days, P=0.001) and more concomitant antibiotic exposure (8 vs 12.5 days, P=0.001). Median duration of OVP was 12 days. CDI recurrence occurred in 12 patients and was significantly lower in the OVP vs no OVP group (3.1% vs 23.4%; odds ratio, 0.106; 95% confidence interval, 0.013-0.864; P=0.022). VRE was not isolated in any patients. After adjustment in a multivariate analysis, only secondary OVP remained as a protective factor against recurrence (odds ratio, 0.082; 95% confidence interval, 0.009-0.748; P=0.027). Conclusion Secondary OVP effectively reduces the risk of recurrent CDI in pediatric patients with a history of CDI while receiving systemic antibiotics. Future prospective studies should validate these findings. Disclosures Cristian Merchan, PharMD, BCCCP, abbive (Speaker’s Bureau)

scholarly journals A preliminary study of bowel rest strategy in the management of Clostridioides difficile infection

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Hiroshi Sugimoto ◽  
Ayaka Yoshihara ◽  
Takao Yamamoto ◽  
Keisuke Sugimoto
Keyword(s):  
Secondary Outcome ◽  
Control Group ◽  
Matched Cohort ◽  
Full Cohort ◽  
Clostridioides Difficile ◽  
Significant Difference ◽  
All Cause Mortality ◽  
Clostridioides Difficile Infection ◽  
Bowel Rest ◽  
Preliminary Study

AbstractClostridioides difficile infection (CDI) is an important nosocomial infection and is the leading cause of infectious diarrhea in hospitalized patients. We aimed to assess the effect of bowel rest on the management of CDI. A single-center retrospective cohort study was conducted. The primary outcome was the composite of the all-cause mortality and CDI recurrence within 30 days. The main secondary outcome was switching from metronidazole to vancomycin. Of the 91 patients with CDI enrolled as the full cohort, 63 patients (69%) and 28 patients (31%) constituted the control group and the bowel rest group, respectively. After one-to-one propensity score matching, a total of 46 patients were included as the matched cohort. In the full cohort, the composite outcome occurred in 19.0% and 14.3% of the patients in the control and the bowel rest group, respectively (p = 0.768). In the matched cohort, it was 17.4% in each group. Although there was no statistically significant difference, the trend of switching was lower in the bowel rest group. The bowel rest may not affect the all-cause mortality and CDI recurrence within 30 days. However, in those prescribed bowel rest, switching from metronidazole to vancomycin may reduce.

scholarly journals 785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S437-S437
Author(s):  
Kerui Xu ◽  
Andrea L Benin ◽  
Hsiu Wu ◽  
Jonathan R Edwards ◽  
Qunna Li ◽  
...  
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Antibiotic Use ◽  
Prevalence Rates ◽  
Hospital Level ◽  
First Line ◽  
Oral Vancomycin ◽  
Patient Admissions ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Methods We matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs. Results Among the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63). Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018 Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs Conclusion The moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs. Disclosures All Authors: No reported disclosures

scholarly journals Diagnostic performance of the combined nasal and throat swab in patients admitted to hospital with suspected COVID-19

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kuan Ken Lee ◽  
◽  
Dimitrios Doudesis ◽  
Daniella A. Ross ◽  
Anda Bularga ◽  
...  
Keyword(s):  
Diagnostic Performance ◽  
Primary Outcome ◽  
Clinical Laboratory ◽  
Throat Swab ◽  
Tertiary Care ◽  
Secondary Outcome ◽  
Index Test ◽  
Repeated Testing ◽  
Rt Pcr ◽  
Serial Testing

Abstract Background Accurate diagnosis in patients with suspected coronavirus disease 2019 (COVID-19) is essential to guide treatment and limit spread of the virus. The combined nasal and throat swab is used widely, but its diagnostic performance is uncertain. Methods In a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, we evaluated the combined nasal and throat swab with reverse transcriptase-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in consecutive patients admitted to hospital with suspected COVID-19. Diagnostic performance of the index and serial tests was evaluated for a primary outcome of confirmed or probable COVID-19, and a secondary outcome of confirmed COVID-19 on serial testing. The diagnosis was adjudicated by a panel, who recorded clinical, laboratory and radiological features blinded to the test results. Results We enrolled 1368 consecutive patients (median age 68 [interquartile range, IQR 53–80] years, 47% women) who underwent a total of 3822 tests (median 2 [IQR 1–3] tests per patient). The primary outcome occurred in 36% (496/1368), of whom 65% (323/496) and 35% (173/496) had confirmed and probable COVID-19, respectively. The index test was positive in 255/496 (51%) patients with the primary outcome, giving a sensitivity and specificity of 51.4% (95% confidence interval [CI] 48.8 to 54.1%) and 99.5% (95% CI 99.0 to 99.8%). Sensitivity increased in those undergoing 2, 3 or 4 tests to 60.1% (95% CI 56.7 to 63.4%), 68.3% (95% CI 64.0 to 72.3%) and 77.6% (95% CI 72.7 to 81.9%), respectively. The sensitivity of the index test was 78.9% (95% CI 74.4 to 83.2%) for the secondary outcome of confirmed COVID-19 on serial testing. Conclusions In patients admitted to hospital, a single combined nasal and throat swab with RT-PCR for SARS-CoV-2 has excellent specificity, but limited diagnostic sensitivity for COVID-19. Diagnostic performance is significantly improved by repeated testing.

scholarly journals Clinical Impact of the Revised 2019 CLSI Levofloxacin Breakpoints in Patients with Enterobacterales Bacteremia

2021 ◽  
Author(s):  
Ho-Yin Huang ◽  
Chu-Feng Wang ◽  
Po-Liang Lu ◽  
Sung-Pin Tseng ◽  
Ya-Ling Wang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Clinical Evidence ◽  
Inhibitory Concentration ◽  
Clinical Impact ◽  
Secondary Outcome ◽  
Lower Survival Rate ◽  
Multivariable Logistic Regression ◽  
Kaplan Meier

Background The Clinical and Laboratory Standards Institute (CLSI) revised the fluoroquinolone minimal inhibitory concentration (MIC) breakpoints for Enterobacterales in 2019, based on pharmacokinetic/pharmacodynamic analyses. However, clinical evidence supporting these breakpoints revision is limited. Methods A retrospective cohort was conducted at 3 hospitals in Taiwan between January 2017 and March 2019. Patients treated with levofloxacin for Enterobacterales bacteremia with high-MIC (1 or 2 μg/mL; levofloxacin-susceptible by pre-2019 CLSI breakpoints) were compared with those with low-MIC (≤0.5 μg/mL; levofloxacin-susceptible by 2019 CLSI breakpoints) to assess therapeutic effectiveness in multivariable logistic regression. The primary outcome was 30-day mortality and the secondary outcome was the emergence of levofloxacin-resistant isolates within 90 days after levofloxacin initiation. Results A total of 308 patients were eligible in the study. Kaplan-Meier analysis showed that patients infected with high-MIC isolates (n=63) had a significantly lower survival rate compared with those infected with low-MIC isolates (n=245) (p=0.001). Multivariable logistic regression revealed high levofloxacin MIC was a predictor of 30-day mortality [odds ratio (OR) 6.05, 95% confidence interval (CI) 1.51-24.18, p=0.011]. We consistently found similar result in propensity-score matched cohort (OR 5.38, 95%CI 1.06-27.39, p=0.043). The emergence of levofloxacin-resistant isolates was likely more common in the high-MIC group compared to the low-MIC group (7.5% vs. 25.0%, p=0.065). An estimated AUC/MIC ratio≥ 87 was significantly associated with better survival (p=0.002). Conclusions Patients with high levofloxacin MICs within the pre-2019 CLSI susceptible range of 1 or 2 μg/mL were associated with higher mortality compared to those with MICs ≤0.5 μg/mL.

Oral Vancomycin as Secondary Prophylaxis for Clostridioides difficile Infection

PEDIATRICS ◽  
2021 ◽  
pp. e2020031807
Author(s):  
Hongkai Bao ◽  
Jennifer Lighter ◽  
Yanina Dubrovskaya ◽  
Cristian Merchan ◽  
Justin Siegfried ◽  
...  
Keyword(s):  
Secondary Prophylaxis ◽  
Oral Vancomycin ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Effect of oral vancomycin dose on outcomes in patients with Clostridioides difficile infection

2021 ◽  
pp. 106311
Author(s):  
J.Nicholas O'Donnell ◽  
Gregory M. Novak ◽  
Benjamin R Bratek ◽  
Gurkirat Singh ◽  
Odirichukwu O Duru ◽  
...  
Keyword(s):  
Oral Vancomycin ◽  
Vancomycin Dose ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Evaluating Clostridioides difficile infection (CDI) treatment duration in hematology/oncology patients receiving concurrent non-CDI antibiotics

2021 ◽  
pp. 107815522199873
Author(s):  
Kelli R Keats ◽  
Tia M Stitt ◽  
Daniel B Chastain ◽  
Bhaumik P Jivan ◽  
Elizabeth Matznick ◽  
...  
Keyword(s):  
Treatment Duration ◽  
Primary Outcome ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Oncology Patients ◽  
Clostridioides Difficile ◽  
Standard Duration ◽  
Clostridioides Difficile Infection ◽  
Extended Analysis ◽  
The Impact

Purpose To determine the impact of Clostridioides difficile infection (CDI) treatment duration on CDI recurrence in hematology/oncology patients receiving concurrent non-CDI antibiotics. Patients and methods This multi-site, retrospective study examined hematology/oncology patients age ≥18 years hospitalized with active CDI who received ≥1 dose of concurrent non-CDI antibiotics between September 2013 and June 2019. All patients were classified by two definitions for statistical analysis: standard (10-14 days) versus prolonged (>14 days) duration of CDI treatment and non-extended (≤24 hours after stopping non-CDI antibiotics) versus extended (>24 hours after stopping non-CDI antibiotics) CDI treatment. Primary outcome was CDI recurrence within 180 days of completing CDI treatment. Secondary outcomes included hospital length of stay (LOS) as well as mortality and incidence of vancomycin-resistant enterococcus (VRE) infections at 180 days. Results Of the 198 patients included, 112 were classified as prolonged versus 86 standard duration and 138 were classified as extended versus 60 non-extended duration. After accounting for demographic differences, no difference existed in the primary outcome of CDI recurrence in either prolonged versus standard or extended versus non-extended analysis (all p > 0.05). Patients who received prolonged versus standard CDI treatment had longer LOS (p < 0.0001) while no difference existed in extended versus non-extended (p > 0.05). No difference in mortality existed in prolonged versus standard (p > 0.05) while those who received extended versus non-extended CDI treatment had significantly lower mortality (p = 0.0008). Conclusions Neither prolonging CDI treatment beyond standard duration nor extending duration beyond end of non-CDI antibiotics was associated with decreased CDI recurrence rate.

scholarly journals Diagnostic performance of the combined nasal and throat swab in patients admitted to hospital with suspected COVID-19

2020 ◽  
Author(s):  
Kuan Ken Lee ◽  
Dimitrios Doudesis ◽  
Daniella A. Ross ◽  
Anda Bularga ◽  
Claire L. MacKintosh ◽  
...  
Keyword(s):  
Diagnostic Performance ◽  
Primary Outcome ◽  
Clinical Laboratory ◽  
Throat Swab ◽  
Tertiary Care ◽  
Secondary Outcome ◽  
Index Test ◽  
Repeated Testing ◽  
Rt Pcr ◽  
Serial Testing

AbstractBackgroundAccurate diagnosis in patients with suspected coronavirus disease 2019 (COVID-19) is essential to guide treatment and limit spread of the virus. The combined nasal and throat swab is used widely, but its diagnostic performance is uncertain.MethodsIn a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, we evaluated the combined nasal and throat swab with reverse transcriptase-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in consecutive patients admitted to hospital with suspected COVID-19. Diagnostic performance of the index and serial tests was evaluated for a primary outcome of confirmed or probable COVID-19, and a secondary outcome of confirmed COVID-19 on serial testing. The diagnosis was adjudicated by a panel, who recorded clinical, laboratory and radiological features blinded to the test results.ResultsWe enrolled 1,369 consecutive patients (68 [53-80] years, 47% women) who underwent a total of 3,822 tests (median 2 [1-3] tests per patient). The primary outcome occurred in 36% (496/1,369), of whom 65% (323/496) and 35% (173/496) had confirmed and probable COVID-19, respectively. The index test was positive in 255/496 (51%) patients with the primary outcome, giving a sensitivity and specificity of 51.4% (95% confidence interval [CI] 48.8 to 54.1%) and 99.5% (95% CI 99.0 to 99.8%). Sensitivity increased in those undergoing 2, 3 or 4 tests to 60.1% (95% CI 56.7 to 63.4%), 68.3% (95% CI 64.0 to 72.3%) and 77.6% (95% CI 72.7 to 81.9%), respectively. The sensitivity of the index test was 78.9% (95% CI 74.4 to 83.2%) for the secondary outcome of confirmed COVID-19 on serial testing.ConclusionsIn patients admitted to hospital, a single combined nasal and throat swab with RT-PCR for SARS-CoV-2 has excellent specificity, but limited diagnostic sensitivity for COVID-19. Diagnostic performance is significantly improved by repeated testing.

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