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Can Enteral Vancomycin C Diff Prophylaxis Improve Outcomes in HSCT Recipients?

If an individual who has undergone autologous and allogenic hematopoietic stem cell transplantation (HSCT) becomes infected with Clostridiodies difficile, the consequences can be severe.

C diff may compromise nutrition following HSCT and can cause complicated gastrointestinal mucositis resulting in mucosal barrier infections or sepsis. The infection can also play into acute gastrointestinal graft versus host disease and reduce survival rates in patients who have undergone allogenic HSCT.

However, using enteral vancomycin for C diff prophylaxis may be the key to reducing morbidity and improving outcomes in recipients of HSCT. A team of investigators from Texas Transplant Institute/Methodist Children’s Hospital presented their research on this topic in a session at the 2020 Transplantation and Cellular Therapy (TCT) Meetings of ASBMT and CIBMTR.

According to the abstract, Methodist Children’s Hospital initiated enteral vancomycin for C diff prophylaxis in all recipients of autologous and allogenic HSCT as a quality improvement initiative in February 2019.

Patients were prescribed 125 mg vancomycin oral/enteral twice daily from the point of HSCT admission through discharge. Patients who were readmitted within the first 100 days following HSCT returned to the enteral vancomycin regimen while hospitalized.

All patients were monitored for C diff and vancomycin-resistant Enterococcus as per institutional policy. For this study, the investigators retrospectively reviewed pre- and post-implementation data. Specifically, the team used Two-sided Fisher’s exact test to compare C diff occurrences.

During the pre-implementation period, January 5, 2018, through February 12, 2019, the rate of C diff was 29% (9 of 31). In the post-implementation period, February 13, 2019, through September 16, 2019, the rate of C diff was 0% (0 of 23).

“Enteral vancomycin resulted in a significant reduction in the number of C diff cases (P = 0.0068),” the authors wrote.

In the pre-implementation period, 26% (7 of 27) of the recipients of allogeneic HSCT developed gastrointestinal acute graft versus host disease. Of these 7 individuals, 6 had a history of C diff.  

In the post-implementation period, 7% (1 of 14) of recipients of allogeneic HSCT recipients developed gastrointestinal acute graft versus host disease.

The study team also reports that there were no vancomycin-resistant Enterococcus positive screens or infections, or adverse events related to enteral vancomycin.

“Enteral vancomycin appears to be safe and effective C diff prophylaxis in pediatric, adolescent, and young adult HSCT recipients,” the authors wrote. “Since institution of enteral vancomycin prophylaxis, there has been a significant reduction of C diff in our HSCT patients.”

The investigators also noted that this quality improvement project is ongoing and that future work will compare gastrointestinal acute graft versus host disease and overall survival with the pre- and post-implementation of enteral vancomycin prophylaxis.

The abstract, Enteral Vancomycin Is Effective Clostridium Difficile prophylaxis in Pediatric, Adolescent, and Young Adult Hematopoietic Stem Cell Transplant Recipients, was presented in a poster session on Wednesday, February 19, 2020, at the 2020 Transplantation and Cellular Therapy (TCT) Meetings of ASBMT and CIBMTR in Orlando, Florida.
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