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Sauvat L, Verhoeven PO, Gagnaire J, Berthelot P, Paul S, Botelho-Nevers E, Gagneux-Brunon A. Vaccines and monoclonal antibodies to prevent healthcare-associated bacterial infections. Clin Microbiol Rev 2024:e0016022. [PMID: 39120140 DOI: 10.1128/cmr.00160-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
SUMMARYHealthcare-associated infections (HAIs) represent a burden for public health with a high prevalence and high death rates associated with them. Pathogens with a high potential for antimicrobial resistance, such as ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) and Clostridioides difficile, are responsible for most HAIs. Despite the implementation of infection prevention and control intervention, globally, HAIs prevalence is stable and they are mainly due to endogenous pathogens. It is undeniable that complementary to infection prevention and control measures, prophylactic approaches by active or passive immunization are needed. Specific groups at-risk (elderly people, chronic condition as immunocompromised) and also healthcare workers are key targets. Medical procedures and specific interventions are known to be at risk of HAIs, in addition to hospital environmental exposure. Vaccines or monoclonal antibodies can be seen as attractive preventive approaches for HAIs. In this review, we present an overview of the vaccines and monoclonal antibodies in clinical development for prevention of the major bacterial HAIs pathogens. Based on the current state of knowledge, we look at the challenges and future perspectives to improve prevention by these means.
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Affiliation(s)
- Léo Sauvat
- CIRI - Centre International de Recherche en Infectiologie, GIMAP team, Inserm, U1111, CNRS, UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Faculty of Medicine, Université Jean Monnet St-Etienne, St-Etienne, France
- Infection Control Unit, University Hospital of Saint-Etienne, Saint-Etienne, France
- Department of Infectious Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Paul O Verhoeven
- CIRI - Centre International de Recherche en Infectiologie, GIMAP team, Inserm, U1111, CNRS, UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Faculty of Medicine, Université Jean Monnet St-Etienne, St-Etienne, France
- Department of Infectious Agents and Hygiene, University-Hospital of Saint-Etienne, Saint-Etienne, France
| | - Julie Gagnaire
- Infection Control Unit, University Hospital of Saint-Etienne, Saint-Etienne, France
- Department of Infectious Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Philippe Berthelot
- CIRI - Centre International de Recherche en Infectiologie, GIMAP team, Inserm, U1111, CNRS, UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Faculty of Medicine, Université Jean Monnet St-Etienne, St-Etienne, France
- Infection Control Unit, University Hospital of Saint-Etienne, Saint-Etienne, France
- Department of Infectious Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Stéphane Paul
- CIRI - Centre International de Recherche en Infectiologie, GIMAP team, Inserm, U1111, CNRS, UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Faculty of Medicine, Université Jean Monnet St-Etienne, St-Etienne, France
- CIC 1408 Inserm, Axe vaccinologie, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Elisabeth Botelho-Nevers
- CIRI - Centre International de Recherche en Infectiologie, GIMAP team, Inserm, U1111, CNRS, UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Faculty of Medicine, Université Jean Monnet St-Etienne, St-Etienne, France
- Department of Infectious Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France
- CIC 1408 Inserm, Axe vaccinologie, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Amandine Gagneux-Brunon
- CIRI - Centre International de Recherche en Infectiologie, GIMAP team, Inserm, U1111, CNRS, UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Faculty of Medicine, Université Jean Monnet St-Etienne, St-Etienne, France
- Department of Infectious Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France
- CIC 1408 Inserm, Axe vaccinologie, University Hospital of Saint-Etienne, Saint-Etienne, France
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2
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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 PMCID: PMC11324037 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Gianfranco Sanson
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Jacopo Monticelli
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Verena Zerbato
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Luigi Principe
- Microbiology and
Virology Unit, Great Metropolitan Hospital
“Bianchi-Melacrino-Morelli”,
Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
- Department of Internal
Medicine (Digestive Diseases), Yale School of Medicine, Yale
University, New Haven,
Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases
Unit, ARNAS Civico-Di Cristina
Hospital, Palermo,
Italy
| | - Roberto Luzzati
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
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3
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Ágreda Fernández M, Origüen J, Rodriguez-Goncer I, San Juan R, López-Medrano F, Parra P, Ruiz-Merlo T, Redondo N, Orellana MÁ, Aguado JM, Fernández-Ruiz M. Predictive value of fecal calprotectin and lactoferrin levels for negative outcomes in Clostridioides difficile infection. Eur J Clin Microbiol Infect Dis 2024; 43:313-324. [PMID: 38072880 DOI: 10.1007/s10096-023-04729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/28/2023] [Indexed: 01/28/2024]
Abstract
PURPOSE We investigated the role of fecal calprotectin (FC) and lactoferrin (FL) as predictive biomarkers in Clostridioides difficile infection (CDI). METHODS We assembled a prospective cohort including all patients with a laboratory-confirmed CDI diagnosis between January and December 2017. FL and FC levels were measured at diagnosis by commercial ELISA and EIA kits. We investigated the diagnostic accuracy of FC and FL to predict CDI recurrence and severity (study outcomes) and explored optimal cut-off values in addition to those proposed by the manufacturers (200 µg/g and 7.2 µg/mL, respectively). RESULTS We included 170 CDI cases (152 first episodes and 18 recurrences). The rates of recurrence (first episodes only) and severity (entire cohort) were 9.2% (14/152) and 46.5% (79/170). Both FL and FC levels were significantly higher in patients who developed study outcomes. Optimal cut-off values for FC and FL to predict CDI recurrence were 1052 µg/g and 6.0 µg/mL. The optimal cut-off value for FC yielded higher specificity (60.9%) and positive predictive value (PPV) (16.9%) than that proposed by the manufacturer. Regarding CDI severity, the optimal cut-off value for FC (439 µg/g) also provided higher specificity (43.9%) and PPV (54.1%) than that of the manufacturer, whereas the optimal cut-off value for FL (4.6 µg/mL) resulted in an improvement of PPV (57.5%). CONCLUSION By modifying the thresholds for assay positivity, the measurement of FC and FL at diagnosis is useful to predict recurrence and severity in CDI. Adding these biomarkers to current clinical scores may help to individualize CDI management.
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Affiliation(s)
- Mario Ágreda Fernández
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain.
| | - Julia Origüen
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Isabel Rodriguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Natalia Redondo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - María Ángeles Orellana
- Department of Microbiology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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Fitzpatrick F, Brennan R, van Prehn J, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:57-84. [PMID: 38175471 DOI: 10.1007/978-3-031-42108-2_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) management guidance for CDI were updated in 2021. This guidance document outlines the treatment options for a variety of CDI clinical scenarios and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). One of the main changes is that metronidazole is no longer recommended as first-line CDI treatment. Rather, fidaxomicin is preferred on the basis of reduced recurrence rates with vancomycin as an acceptable alternative. Recommended options for recurrent CDI now include bezlotoxumab as well as FMT.A 2017 survey of 20 European countries highlighted variation internationally in CDI management strategies. A variety of restrictions were in place in 65% countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. This survey was repeated in November 2022 to assess the current landscape of CDI management practices in Europe. Of 64 respondents from 17 countries, national CDI guidelines existed in 14 countries, and 11 have already/plan to incorporate the ESCMID 2021 CDI guidance, though implementation has not been surveyed in 6. Vancomycin is the most commonly used first-line agent for the treatment of CDI (n = 42, 66%), followed by fidaxomicin (n = 30, 47%). Six (9%) respondents use metronidazole as first-line agent for CDI treatment, whereas 22 (34%) only in selected low-risk patient groups. Fidaxomicin is more likely to be used in high-risk patient groups. Availability of anti-CDI therapy influenced prescribing in six respondents (9%). Approval pre-prescription was required before vancomycin (n = 3, 5%), fidaxomicin (n = 10, 6%), bezlotoxumab (n = 11, 17%) and FMT (n = 10, 6%). Implementation of CDI guidelines is rarely audited.Novel anti-CDI agents are being evaluated; it is not yet clear what will be the roles of these agents. The treatment of recurrent CDI is particularly troublesome, and several different live biotherapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Robert Brennan
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mairead Skally
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Health Protection Surveillance Centre (HPSC), Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals, Leeds, UK
- University of Leeds, Leeds, UK
| | - Mark H Wilcox
- University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and Leeds Regional Public Health Laboratory, UK Health Security Agency (UKHSA), Leeds, UK.
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5
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Bratkovič T, Zahirović A, Bizjak M, Rupnik M, Štrukelj B, Berlec A. New treatment approaches for Clostridioides difficile infections: alternatives to antibiotics and fecal microbiota transplantation. Gut Microbes 2024; 16:2337312. [PMID: 38591915 PMCID: PMC11005816 DOI: 10.1080/19490976.2024.2337312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/27/2024] [Indexed: 04/10/2024] Open
Abstract
Clostridioides difficile causes a range of debilitating intestinal symptoms that may be fatal. It is particularly problematic as a hospital-acquired infection, causing significant costs to the health care system. Antibiotics, such as vancomycin and fidaxomicin, are still the drugs of choice for C. difficile infections, but their effectiveness is limited, and microbial interventions are emerging as a new treatment option. This paper focuses on alternative treatment approaches, which are currently in various stages of development and can be divided into four therapeutic strategies. Direct killing of C. difficile (i) includes beside established antibiotics, less studied bacteriophages, and their derivatives, such as endolysins and tailocins. Restoration of microbiota composition and function (ii) is achieved with fecal microbiota transplantation, which has recently been approved, with standardized defined microbial mixtures, and with probiotics, which have been administered with moderate success. Prevention of deleterious effects of antibiotics on microbiota is achieved with agents for the neutralization of antibiotics that act in the gut and are nearing regulatory approval. Neutralization of C. difficile toxins (iii) which are crucial virulence factors is achieved with antibodies/antibody fragments or alternative binding proteins. Of these, the monoclonal antibody bezlotoxumab is already in clinical use. Immunomodulation (iv) can help eliminate or prevent C. difficile infection by interfering with cytokine signaling. Small-molecule agents without bacteriolytic activity are usually selected by drug repurposing and can act via a variety of mechanisms. The multiple treatment options described in this article provide optimism for the future treatment of C. difficile infection.
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Affiliation(s)
- Tomaž Bratkovič
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Abida Zahirović
- Department of Biotechnology, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Maruša Bizjak
- Department of Biotechnology, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Maja Rupnik
- National Laboratory for Health, Environment and Food, Prvomajska 1, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Borut Štrukelj
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Department of Biotechnology, Jožef Stefan Institute, Ljubljana, Slovenia
| | - Aleš Berlec
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Department of Biotechnology, Jožef Stefan Institute, Ljubljana, Slovenia
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6
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Coia JE, Kuijper EJ, Fitzpatrick F. The ESCMID Study Group for Clostridioides difficile: History, Role, and Perspectives. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:351-362. [PMID: 38175483 DOI: 10.1007/978-3-031-42108-2_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides difficile (C. difficile) is a major nosocomial pathogen but is also increasingly recognised as an important diarrhoeal pathogen in the community, not always associated with antibiotics. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for C. difficile (ESGCD) is a group of clinicians, scientists, and others from many European countries and further afield, who share a common interest in C. difficile. The aims of the Study Group are centred around raising the profile of C. difficile infection (CDI) in humans and animals, fostering collaboration amongst centres in different European countries and providing a forum for discussing and disseminating information. One of the principal aims of the Study Group is to raise awareness of C. difficile infections in Europe. ESGCD has a particular interest in the development and dissemination of European guidance on prevention, diagnosis, and treatment of CDI. This chapter will discuss the organisation of ESGCD within the ESCMID Study Group structure, the origins of the Study Group, the aims, and objectives of the group, and will highlight some of the past and present activities of ESGCD in relation to these.
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Affiliation(s)
- John E Coia
- Institute for Regional Health Research (IRS), University of Southern Denmark (SDU), Esbjerg, Denmark.
- ESCMID Study Group for C. difficile (ESGCD), Basel, Switzerland.
- ESCMID Study Group for Nosocomial Infections (ESGNI), Basel, Switzerland.
| | - Ed J Kuijper
- ESCMID Study Group for C. difficile (ESGCD), Basel, Switzerland
- Department of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- ESCMID Study Group for Host and Microbiota Interaction (ESGHAMI), Basel, Switzerland
| | - Fidelma Fitzpatrick
- ESCMID Study Group for C. difficile (ESGCD), Basel, Switzerland
- ESCMID Study Group for Host and Microbiota Interaction (ESGHAMI), Basel, Switzerland
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland
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7
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Christensen S, Bouguermouh S, Ilangovan K, Pride MW, Webber C, Lockhart SP, Shah R, Kitchin N, Lamberth E, Zhang H, Gao Q, Brock L, Anderson AS, Gruber WC. A phase 3 study evaluating the lot consistency, immunogenicity, safety, and tolerability of a Clostridioides difficile vaccine in healthy adults 65 to 85 years of age. Vaccine 2023; 41:7548-7559. [PMID: 37977942 DOI: 10.1016/j.vaccine.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND A toxoid-based Clostridioides difficile vaccine is currently in development. Here, we report lot-to-lot consistency, immunogenicity, safety, and tolerability of 3 C difficile vaccine doses in healthy older adults. METHODS This phase 3, placebo-controlled study randomized (1:1:1:1) healthy adults 65 to 85 years of age to 1 of 3 C difficile vaccine lots or placebo. Participants received C difficile vaccine (200 μg total toxoid) or placebo (Months 0, 1, 6). The primary immunogenicity objective was lot-to-lot consistency (2-sided 95 % CIs within 0.5 and 2 for comparisons of geometric mean concentration [GMC] ratios) for toxins A- and B-specific neutralizing antibody levels 1 month after Dose 3. Safety outcomes included local reactions and systemic events ≤7 days after vaccination, adverse events (AEs), and serious AEs (SAEs). RESULTS Of 1317 enrolled participants, 1218 completed the study. C difficile vaccine immunogenicity was consistent across lots, with neutralizing antibody responses 1 month after Dose 3 for both toxin A (GMC [95 % CI]: lot 1, 878.8 [786.3, 982.2]; lot 2, 873.0 [779.2, 978.1]; lot 3, 872.9 [782.6, 973.5]) and toxin B (lot 1, 5823.9 [5041.0, 6728.4]; lot 2, 5462.8 [4733.4, 6304.7]; lot 3, 5426.0 [4724.4, 6231.8]). Two-sided 95 % CIs for GMC ratios were within 0.5 and 2 for toxins A and B, indicating lot-to-lot consistency was achieved. C difficile vaccine was well tolerated, with similar rates of local reactions and systemic events among vaccine lots. AE and SAE rates were similar across C difficile vaccine (36.5 % and 4.5 %, respectively) and placebo (35.3 % and 6 %). CONCLUSIONS Three doses (Months 0,1,6) of toxoid-based C difficile vaccine induced robust neutralizing antibody responses and were well tolerated in healthy participants 65 to 85 years of age. Lot-to-lot consistency was excellent, indicating the manufacturing process for this C difficile vaccine formulation was well controlled. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03579459.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Qi Gao
- Pfizer Inc, Collegeville, PA, USA
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8
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Pal R, Athamneh AI, Deshpande R, Ramirez JAR, Adu KT, Muthuirulan P, Pawar S, Biazzo M, Apidianakis Y, Sundekilde UK, de la Fuente-Nunez C, Martens MG, Tegos GP, Seleem MN. Probiotics: insights and new opportunities for Clostridioides difficile intervention. Crit Rev Microbiol 2023; 49:414-434. [PMID: 35574602 PMCID: PMC9743071 DOI: 10.1080/1040841x.2022.2072705] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/17/2022] [Accepted: 04/28/2022] [Indexed: 02/08/2023]
Abstract
Clostridioides difficile infection (CDI) is a life-threatening disease caused by the Gram-positive, opportunistic intestinal pathogen C. difficile. Despite the availability of antimicrobial drugs to treat CDI, such as vancomycin, metronidazole, and fidaxomicin, recurrence of infection remains a significant clinical challenge. The use of live commensal microorganisms, or probiotics, is one of the most investigated non-antibiotic therapeutic options to balance gastrointestinal (GI) microbiota and subsequently tackle dysbiosis. In this review, we will discuss major commensal probiotic strains that have the potential to prevent and/or treat CDI and its recurrence, reassess the efficacy of probiotics supplementation as a CDI intervention, delve into lessons learned from probiotic modulation of the immune system, explore avenues like genome-scale metabolic network reconstructions, genome sequencing, and multi-omics to identify novel strains and understand their functionality, and discuss the current regulatory framework, challenges, and future directions.
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Affiliation(s)
- Rusha Pal
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA
| | - Ahmad I.M. Athamneh
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47907, USA
| | | | - Jose A. R Ramirez
- ProbioWorld Consulting Group, James Cook University, 4811, Queensland, Australia
| | - Kayode T. Adu
- ProbioWorld Consulting Group, James Cook University, 4811, Queensland, Australia
- Cann Group, Walter and Eliza Hall Institute, La Trobe University, Victoria 3083, Australia
| | | | - Shrikant Pawar
- The Anlyan Center Yale Center for Genomic Analysis, Yale School of Medicine, New Haven CT USA
| | - Manuele Biazzo
- The Bioarte Ltd Laboratories at Life Science Park, San Gwann, Malta
| | | | | | - Cesar de la Fuente-Nunez
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Mark G. Martens
- Reading Hospital, Tower Health, West Reading, PA 19611, USA
- Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - George P. Tegos
- Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Mohamed N. Seleem
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA
- Center for Emerging, Zoonotic and Arthropod-borne Pathogens, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
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9
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Wingen-Heimann SM, Davies K, Viprey VF, Davis G, Wilcox MH, Vehreschild MJGT, Lurienne L, Bandinelli PA, Cornely OA, Vilken T, Hopff SM, Vehreschild JJ, Webber C, Rupnik M, Wilcox M. Clostridioides difficile infection (CDI): A pan-European multi-center cost and resource utilization study, results from the Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI). Clin Microbiol Infect 2022; 29:651.e1-651.e8. [PMID: 36586512 DOI: 10.1016/j.cmi.2022.12.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI) is one of the leading nosocomial infections worldwide, resulting in a significantly increasing burden on the healthcare systems. However, Pan-European data about cost and resource utilization of CDI treatment do not exist. METHODS A retrospective analysis within the Combatting Bacterial Resistance in Europe CDI project was conducted based on resource costs for inpatient treatment and productivity costs. Country-specific cost values were converted to EURO referred to 1 January, 2019 values. Differences in price levels for healthcare services among the participating countries were adjusted by using an international approach of the Organisation for Economic Co-operation and Development. As the study focused on patients with recurrent CDI, the observed study population was categorized into (a) patients with CDI but without CDI recurrence (case group), (b) patients with CDI recurrence (recurrence group), and (c) patients without CDI (control group). RESULTS Overall, 430 hospitalized patients from 12 European countries were included into the analysis between July 2018 and November 2018. Distribution of mean hospital length of stay and mean overall costs per patient between the case group, recurrence group, and control group were as follows: 22 days (95% CI 17-27 days) vs. 55 days (95% CI 17-94 days) vs. 26 days (95% CI 22-31 days; p 0.008) and € 15 242 (95% CI 10 593-19 891) vs. € 52 024 (95% CI 715-103 334) vs. € 21 759 (95% CI 16 484-27 035; p 0.010), respectively. The CDI recurrence rate during the observational period was 18%. Change escalation in CDI medication (OR 3.735) and treatment in an intensive care unit (OR 5.454) were found to be the most important variables associated with increased overall costs of patients with CDI. CONCLUSIONS Treatment of patients with recurrent CDI results in a significant burden. Prevention of CDI recurrences should be in focus of daily patient care to identify the most cost-effective treatment strategy.
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Affiliation(s)
- Sebastian M Wingen-Heimann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; University of Applied Sciences for Economics and Management (FOM), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn-Cologne Duesseldorf, Cologne, Germany.
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom; The European Study Group for C. difficile, European Society of Clinical Microbiology and Infectious Disease
| | - Virginie F Viprey
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Georgina Davis
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn-Cologne Duesseldorf, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Molecular Medicine Cologne, Cologne, Germany
| | - Tuba Vilken
- University of Antwerp, Vaccine & Infectious Disease Institute, Laboratory of Medical Microbiology, Antwerp, Belgium
| | - Sina M Hopff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn-Cologne Duesseldorf, Cologne, Germany
| | - Jörg Janne Vehreschild
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department II of Internal Medicine, Hematology/Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany
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10
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Fitzpatrick F, Safdar N, van Prehn J, Tschudin-Sutter S. How can patients with Clostridioides difficile infection on concomitant antibiotic treatment be best managed? THE LANCET. INFECTIOUS DISEASES 2022; 22:e336-e340. [PMID: 35617982 DOI: 10.1016/s1473-3099(22)00274-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/16/2022] [Accepted: 04/20/2022] [Indexed: 06/15/2023]
Abstract
Antibiotics are modifiable risk factors for Clostridioides difficile infection (CDI), driving pathogenesis via gut microbiome disruption. The management of patients with CDI prescribed concomitant non-CDI antibiotics is problematic and influences CDI outcome and recurrence risk. Though an assessment of the ongoing requirement for concomitant antibiotics is essential, discontinuation is often not possible. Antibiotics for other reasons might also need to be commenced during CDI therapy. Attempts to minimise the number and duration of antibiotics with a change to a low-risk class are recommended. Fidaxomicin might be preferable to vancomycin due to it having less effect on the gut microbiome; however, vancomycin is also acceptable. Metronidazole should be avoided and proton pump inhibitors discontinued. Access to fidaxomicin might be limited; hence, it should be prioritised for patients at high risk of recurrence. There is insufficient evidence to support extending anti-CDI therapy duration and concerns regarding microbiome effect remain. The addition of bezlotoxumab might be considered if multiple additional risk factors for recurrent CDI exist, though the amount of evidence is low. Investigational approaches to reduce the effect of concomitant antibiotics on the gut microbiome could further optimise CDI treatment in the presence of concomitant antibiotic use in the future.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Microbiology, Beaumont Hospital, Dublin, Ireland; ESCMID (European Society of Clinical Microbiology and Infectious Diseases), Basel, Switzerland
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin-Madison and the William S Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands; ESCMID (European Society of Clinical Microbiology and Infectious Diseases), Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; Department of Acute Medicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; ESCMID (European Society of Clinical Microbiology and Infectious Diseases), Basel, Switzerland.
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11
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Diluted Fecal Community Transplant Restores Clostridioides difficile Colonization Resistance to Antibiotic-Perturbed Murine Communities. mBio 2022; 13:e0136422. [PMID: 35913161 PMCID: PMC9426422 DOI: 10.1128/mbio.01364-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Fecal communities transplanted into individuals can eliminate recurrent Clostridioides difficile infection (CDI) with high efficacy. However, this treatment is only used once CDI becomes resistant to antibiotics or has recurred multiple times. We sought to investigate whether a fecal community transplant (FCT) pretreatment could be used to prevent CDI altogether. We treated male C57BL/6 mice with either clindamycin, cefoperazone, or streptomycin and then inoculated them with the microbial community from untreated mice before challenge with C. difficile. We measured colonization and sequenced the V4 region of the 16S rRNA gene to understand the dynamics of the murine fecal community in response to the FCT and C. difficile challenge. Clindamycin-treated mice became colonized with C. difficile but cleared it naturally and did not benefit from the FCT. Cefoperazone-treated mice became colonized by C. difficile, but the FCT enabled clearance of C. difficile. In streptomycin-treated mice, the FCT was able to prevent C. difficile from colonizing. We then diluted the FCT and repeated the experiments. Cefoperazone-treated mice no longer cleared C. difficile. However, streptomycin-treated mice colonized with 1:102 dilutions resisted C. difficile colonization. Streptomycin-treated mice that received an FCT diluted 1:103 became colonized with C. difficile but later cleared the infection. In streptomycin-treated mice, inhibition of C. difficile was associated with increased relative abundance of a group of bacteria related to Porphyromonadaceae and Lachnospiraceae. These data demonstrate that C. difficile colonization resistance can be restored to a susceptible community with an FCT as long as it complements the missing populations.
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12
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Amandine GB, Gagnaire J, Pelissier C, Philippe B, Elisabeth BN. Vaccines for healthcare associated infections without vaccine prevention to date. Vaccine X 2022; 11:100168. [PMID: 35600984 PMCID: PMC9118472 DOI: 10.1016/j.jvacx.2022.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022] Open
Abstract
In spite of the widespread implementation of preventive strategies, the prevalence of healthcare-associated infections (HAIs) remains high. The prevalence of multidrug resistant organisms is high in HAIs. In 2019, the World Health Organization retained antimicrobial resistance as one of the ten issues for global health. The development of vaccines may contribute to the fight against antimicrobial resistance to reduce the burden of HAIs. Staphylococcus aureus, Gram negative bacteria and Clostridium difficile are the most frequent pathogens reported in HAIs. Consequently, the development of vaccines against these pathogens is crucial. At this stage, the goal of obtaining effective vaccines against S.aureus and Gram negative bacteria has not yet been achieved. However, we can expect in the near future availability of a vaccine against C. difficile. In addition, identifying populations who may benefit from these vaccines is complex, as at-risk patients are not great responders to vaccines, or as vaccination may occur too late, when they are already confronted to the risk. Vaccinating healthcare workers (HCWs) against these pathogens may have an impact only if HCWs play a role in the transmission and in the pathogens acquisition in patients, if the vaccine is effective to reduce pathogens carriage and if vaccine coverage is sufficient to protect patients. Acceptance of these potential vaccines should be evaluated and addressed in patients and in HCWs.
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Affiliation(s)
- Gagneux-Brunon Amandine
- Inserm, CIC 1408, I-REIVAC, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France.,CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France.,Department of Infectious Diseases, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France
| | - Julie Gagnaire
- Department of Infectious Diseases, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France.,Infection Control Unit, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France
| | - Carole Pelissier
- Occupational Health Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France
| | - Berthelot Philippe
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France.,Department of Infectious Diseases, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France.,Infection Control Unit, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France
| | - Botelho-Nevers Elisabeth
- Inserm, CIC 1408, I-REIVAC, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France.,CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Univ Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France.,Department of Infectious Diseases, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France
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13
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Berger RE. Does Prophylaxis Prevent Recurrent Clostridioides difficile Infection? NEJM EVIDENCE 2022; 1:EVIDtt2200026. [PMID: 38319213 DOI: 10.1056/evidtt2200026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Prophylaxis and Recurrent Clostridioides difficileA 68-year-old woman is admitted with pyelonephritis. Two months earlier, she had been treated for pneumonia and subsequently developed Clostridioides difficile colitis, which resolved with 10 days of oral vancomycin. When you start treatment with intravenous ceftriaxone, should you also prescribe prophylaxis to prevent recurrent C. difficile infection?
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14
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Oral Vancomycin Prophylaxis for Primary and Secondary Prevention of Clostridioides difficile Infection in Patients Treated with Systemic Antibiotic Therapy: A Systematic Review, Meta-Analysis and Trial Sequential Analysis. Antibiotics (Basel) 2022; 11:antibiotics11020183. [PMID: 35203786 PMCID: PMC8868369 DOI: 10.3390/antibiotics11020183] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality as well as high propensity of recurrence. Systemic antibiotic therapy (SAT) represents the top inciting factor of CDI, both primary and recurrent (rCDI). Among the many strategies aimed to prevent CDI in high-risk subjects undergoing SAT, oral vancomycin prophylaxis (OVP) appears promising under a cost-effectiveness perspective. Methods: A systematic review with meta-analysis and trial sequential analysis (TSA) of studies assessing the efficacy and the safety of OVP to prevent primary CDI and rCDI in persons undergoing SAT was carried out. PubMed and EMBASE were searched until 30 September 2021. The protocol was pre-registered on PROSPERO (CRD42019145543). Results: Eleven studies met the inclusion criteria, only one being a randomized controlled trial (RCT). Overall, 929 subjects received OVP and 2011 represented the comparator group (no active prophylaxis). OVP exerted a strong protective effect for CDI occurrence: odds ratio 0.14, 95% confidence interval 0.04–0.38. Moderate heterogeneity was observed: I2 54%. This effect was confirmed throughout several subgroup analyses, including prevention of primary CDI versus rCDI. TSA results pointed at the conclusive nature of the evidence. Results were robust to a variety of sensitivity and quantitative bias analyses, although the underlying evidence was deemed as low quality. No differences between the two groups were highlighted regarding the onset of vancomycin-resistant Enterococcus infections. Conclusions: OVP appears to be an efficacious option for prevention of CDI in high-risk subjects undergoing SAT. Nevertheless, additional data from RCTs are needed to establish OVP as good clinical practice and define optimal dosage and duration.
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