Effectiveness of bezlotoxumab for prevention of recurrent Clostridioides difficile infection among transplant recipients

Background Bezlotoxumab significantly reduces the incidence of recurrent Clostridioides difficile infection; however, limited data is available in solid-organ and hematopoietic-cell transplant recipients. Methods We conducted a single-center retrospective analysis comparing recurrent Clostridioides difficile infection in solid-organ and hematopoietic-cell transplant recipients receiving standard of care alone (oral vancomycin, fidaxomicin, or metronidazole) or bezlotoxumab plus standard of care. The primary outcome was 90-day incidence of recurrent Clostridioides difficile infection, and secondary outcomes included 90-day hospital readmission, mortality, and incidence of heart failure exacerbation. Results Overall, 94 patients received bezlotoxumab plus standard of care (n=38) or standard of care alone (n=56). The mean age was 53 years, patients had a median of 3 prior Clostridioides difficile episodes, and 4 risk factors for recurrent infection. Most patients were solid-organ transplant recipients (76%), with median time to index Clostridioides difficile infection occurring 2.7 years post-transplantation. Ninety-day recurrent Clostridioides difficile infection occurred in 16% (6/38) in the bezlotoxumab cohort compared to 29% (16/56) in the standard of care cohort (p=0.13). Multivariable regression revealed bezlotoxumab was associated with significantly lower odds of 90-day recurrent Clostridioides difficile infection (Odds Ratio [95% CI]: 0.28 [0.08-0.91]). There were no differences in secondary outcomes, and no heart failure exacerbations were observed. Conclusions In a cohort of primarily solid-organ transplant recipients, bezlotoxumab was well tolerated and associated with lower odds of recurrent Clostridioides difficile infection at 90-days. Larger, prospective trials are needed to confirm these findings amongst solid-organ and hematopoietic-cell transplant populations.