Guidelines Impact Use of Fidaxomicin in C diff Treatment

When guidelines are quickly implemented for C diff treatment recommendations, the changes are reflected quickly.

At first, the use of fidaxomicin for the treatment of Clostridioides difficile (C diff) remained low — but after a release of guidelines and relaxing of system restrictions, the use of fidaxomicin increased, according to a poster presented during IDWeek 2019.

The Infectious Diseases Society of America/Society for Healthcare Epidemiology released guidelines in February 2018 that suggested expanding the use of fidaxomicin, recommending oral vancomycin in severe or non-severe initial episodes or for most recurrences. In response, the University of Pittsburgh Medical Center (UPMC) relaxed their system-wide guidelines in April 2018 to allow for fidaxomicin use in the first recurrence of C diff or later, with earlier use allowed by infectious diseases or gastrointestinal specialists or with local pharmacy and therapeutics chair approval. If desired, hospitals in the UPMC system could continue to keep their restrictions in place.

Investigators from the University of Pittsburgh then reviewed changes in fixadomicin, oral vancomycin, and IV/PO metronidazole across 15 hospitals. They classified health care centers as standard (following the new guidelines) or more restrictive (following more restrictive procedures). The investigators further grouped hospitals by local stewardship programs: robust or non-robust, depending on the presence of an infectious disease-trained clinical pharmacist or physician with specific, dedicated time to antibiotic review.

Across all 15 hospital sites, the use of fidaxomicin and oral vancomycin increased after the UPMC guideline change. IV/PO metronidazole use decreased after the guidelines were adopted, the study authors reported.

“I think one of the most surprising findings was how quickly the changes in use of fidaxomicin and oral vancomycin were seen,” study author Ryan Bariola, MD, the director of the UPMC Outreach Antimicrobial Stewardship Program, told Contagion®. “Sometimes there is a delay between release of new guidance and actual changes in practice. At UPMC, I would credit that rapid dissemination of these new guidelines to the local pharmacists at UPMC hospitals, many of whom worked hard to make sure this information was known by the local providers.”

However, Bariola added, the investigators were not surprised to see that more restrictive hospitals used less fidaxomicin and more oral vancomycin compared to the standard hospitals.

When the study authors examined the data through the lens of standard versus more restrictive hospitals, they found that hospitals with less restrictive criteria used more fidaxomicin compared to those with more restrictions following the adoption of the new guidelines. Less oral vancomycin and PO metronidazole was used after April 2018 in standard hospitals compared to more restrictive hospitals. And more restrictive hospitals used more IV metronidazole than standard hospitals following April 2018.

The study authors additionally found similar trends when they compared health care centers based on their stewardship programs. More fidaxomicin was used in non-robust hospitals compared to robust centers following April 2018. Use of oral vancomycin was less in non-robust hospitals compared to robust hospitals after the centers adopted the guidelines. The use of IV metronidazole was less in robust hospitals but PO metronidazole use was less in non-robust hospitals after April 2018.

“The implications of this work are that guidelines can be implemented into clinical practice relatively quickly,” Bariola continued. “It is very important for hospital pharmacists and antimicrobial stewardship programs to make sure front-line providers are made aware of updates and changes to clinical practice regarding antimicrobials.”

The poster, Impact of Updated IDSA Clostridium difficile Guidelines on the use of Fidaxomicin in a Large Health System, was presented on Thursday, October 3, 2019, at IDWeek 2019 in Washington DC.