Impact of Oral Metronidazole, Vancomycin, and Fidaxomicin on Host Shedding and Environmental Contamination with Clostridioides difficile

European Practice for CDI Treatment

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.

Risk factors for Recurrent Clostridioides Difficile Infection in Children

OBJECTIVE

The aims of this study were to determine the epidemiologic and treatment factors associated with recurrent C. difficile infection in children.

METHODS

We conducted a 13-year retrospective review of pediatric C. difficile infections at our institution focusing on the epidemiologic, clinical, and treatment factors associated with recurrent disease. Repeat episodes occurring between 4 weeks and 2 months after initial infection were defined as early recurrences, whereas repeat episodes between 2 and 12 months after initial infection were defined as late recurrences.

RESULTS

We identified 303 children with C. difficile infection. Recurrent infections were limited to children with chronic conditions, affecting 27.4% (68 of 248) of this cohort. Early and late recurrences occurred in 36.8 and 63.2% of children, respectively. Among children with a chronic condition, female sex and initial use of metronidazole (as opposed to vancomycin) were associated with recurrent disease in bivariate and multivariate analyses. Overall, there was a high treatment failure rate (34 of 102, 33.3%) once children had developed recurrent disease.

CONCLUSIONS

Findings from this study demonstrate the importance of underlying chronic conditions in the development of recurrent C. difficile disease and the shortcomings of current treatment options for recurrent cases. Additionally, our findings indicate that initial treatment selection may impact the likelihood of future disease, with metronidazole usage being associated with higher recurrence rates than vancomycin. These findings highlight the need for additional studies to better understand the implications of C. difficile treatment strategies.

Retrospective Cohort Analysis of Outpatient Antibiotic Use for Clostridioides difficile-Indicated Agents in British Columbia, from 2000 to 2018

Background

Clostridioides difficile (CDI) is the most common cause of nosocomial diarrheal infections. Historically, metronidazole was the first-line treatment, but guidelines now indicate oral vancomycin and fidaxomicin as primary antibiotics for initial episodes. A provincial stewardship program has operated in British Columbia (BC), since 2005. Since the program's inception, surveillance of antibiotic use has been ongoing. However, this is the first study to review community-acquired CDI-indicated antibiotic use. Moreover, this study offers the first interpretation of fidaxomicin use in BC since its addition to the provincial formulary.

Methods

A retrospective cohort analysis included all outpatient dispensations for CDI-related antibiotics from January 1, 2000, to December 31, 2018. Antibiotic dispensations were extracted for metronidazole, vancomycin, and fidaxomicin. Consumption rates were calculated as prescriptions per 1000 population. Rates were examined overall and then stratified by medication, age, and sex. Secondary outcomes of interest included an examination of adherence to provincial special authority criteria; and proportions of outpatient antibiotic use attributable to administrative health records for CDI.

Results

The average annual rate of prescribing was 18.5 per 1000 population for all CDI-indicated antibiotics. The rate of prescribing increased (15%) over the 19-year study period, from 17.2 to 19.8 dispensations per 1000 population. Metronidazole accounted for the most antibiotics dispensed in every study year; however, by 2018 it demonstrated the most modest increase in use (15%). In comparison, fidaxomicin increased by 226% by 2018. Vancomycin had the highest percentage increase (621%), with the greatest change occurring from 2014 to 2015, correlating to the dissemination of new clinical practice guidelines.

Conclusion

This is the first study to evaluate outpatient prescribing for CDI-indicated antibiotics, and one of the few studies to examine fidaxomicin since its introduction to Canadian formularies. Although causation cannot be inferred from study results, oral vancomycin, and fidaxomicin use has increased in line with, or in advance-of guidelines.

An Enhanced Strategy for Daily Disinfection in Acute Care Hospital Rooms: A Randomized Clinical Trial

IMPORTANCE

Environmental contamination is a source of transmission between patients, health care practitioners, and other stakeholders in the acute care setting.

OBJECTIVE

To compare the efficacy of an enhanced daily disinfection strategy vs standard disinfection in acute care hospital rooms.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial (RCT) was conducted in acute care hospital rooms at Duke University Hospital in Durham, North Carolina, from November 2021 to March 2022. Rooms were occupied by patients with contact precautions. Room surfaces (bed rails, overbed table, and in-room sink) were divided into 2 sides (right vs left), allowing each room to serve as its own control. Each side was randomized 1:1 to the intervention group or control group.

INTERVENTIONS

The intervention was a quaternary ammonium, salt-based, 24-hour continuously active germicidal wipe. It was applied in addition to routine disinfection for the intervention group. The control group received no intervention beyond routine disinfection.

MAIN OUTCOMES AND MEASURES

The primary outcome was the total contamination, measured in colony-forming units (CFUs) on the bed rails, overbed table, and sink on study day 1. The secondary outcomes were the proportion of sample areas with positive test results for clinically important pathogens, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and carbapenem-resistant Enterobacteriaceae; the similarity in baseline contamination between sample area sides on study day 0 before application of the intervention, and the proportion of sample areas with removed UV luminescent gel on study day 1.

RESULTS

A total of 50 study rooms occupied by 50 unique patients (median [IQR] age, 61 [45-69] years; 26 men [52%]) with contact precautions were enrolled. Of these patients, 41 (82%) were actively receiving antibiotics, 39 (78%) were bedridden, and 28 (56%) had active infections with study-defined clinically important pathogens. On study day 1, the median (IQR) total CFUs for the intervention group was lower than that for the control group (3561 [1292-7602] CFUs vs 5219 [1540-12 364] CFUs; P = .002). On study day 1, the intervention side was less frequently contaminated with patient-associated clinically important pathogens compared with the control side of the room (4 [14%] vs 11 [39%]; P = .04).

CONCLUSIONS AND RELEVANCE

Results of this RCT demonstrated that a quaternary ammonium, salt-based, 24-hour continuously active germicidal wipe decreased the environmental bioburden in acute care hospital rooms compared with routine disinfection. The findings warrant large-scale RCTs to determine whether enhanced daily disinfection strategies can decrease patient acquisition and adverse patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05560321.