PGY2 infectious Diseases Pharmacy Residency

Extended Duration Vancomycin (EDV) Versus Standard of Care for initial Clostridioides Difficile Episode in Solid Organ Transplant (SOT) Recipients

Melissa P. O’Neal, PharmD; William L. Musick, PharmD, BCIDP; Kevin Grimes, MD, MPH, FIDSA

PURPOSE C. difficile infection (CDI) occurs up to 5-times more frequently among solid organ transplant (SOT) recipients compared to the general population and is associated with significant graft loss and mortality. Current treatment recommendations come primarily from studies in immunocompetent individuals, there remains a lack of evidence specifically in SOT patients. The objective of this review is to evaluate the use of extended duration vancomycin (EDV) as a primary treatment for index CDI to reduce recurrent CDI in SOT patients.

RESULTS

Overall 103 patients were included; 47 and 56 patients in the EDV and non-EDV cohorts, respectively. Median duration of treatment was 25 days in the EDV group and 14 days in the non-EDV group. The primary endpoint was significantly lower in the EDV cohort (2.1 vs 12.5%, p=0.050). Ninety-day recurrence was similar between groups (17.0% vs 19.6%). The overall recurrence rate was 32.0% and similar between groups. Median time to recurrence was numerically longer in the EDV cohort (81.5 days vs 49 days).

METHODS

This was a retrospective chart review of all SOT recipients across the Houston Methodist system from February 15, 2018 to June 30, 2021 who were diagnosed with, and treated for, index C. difficile episode. Diagnosis of C. difficile included a positive PCR test and documentation of diarrhea preceding the test. EDV was defined as at least 21 days of oral vancomycin; non-EDV was defined as no more than 20 days of either oral vancomycin or fidaxomicin. The primary endpoint was recurrence at 30 days from end of treatment. The secondary endpoints were recurrence at 90 days from end of treatment, incidence of recurrence, and overall time to recurrence.

CONCLUSION

Solid organ transplant patients have a myriad of risk factors that predispose them to C. difficile infection and recurrence. in order to reduce CDI in this population, it is imperative to reduce or mitigate risk factors wherever possible. Best available treatment for CDI in these patients has not yet been fully elucidated. Vancomycin remains a mainstay of therapy for these patients and extended-duration vancomycin may present a viable initial option to reduce recurrence. Further studies comparing primary treatments and durations in SOT recipients are needed to validate these findings.

PGY2 INFECTIOUS DISEASES PHARMACY RESIDENCY

Melissa O’Neal, PharmD

Melissa earned her PharmD from the University of South Carolina College of Pharmacy in 2020. She completed her PGY1 residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Melissa has accepted an ID Specialist position at Tampa General Hospital. Primary project preceptor: William L. Musick, PharmD, BCIDP

Presented at 2021 Virtual Vizient Pharmacy Network and 2022 Midwest Pharmacy Residents Conference.