Revised Clostridioides difficile Practice Guidelines Had Significant Effect on Treatment Decisions

Publication of the revised clinical practice guidelines for Clostridioides difficile infection (CDI) in February 2018 by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) was followed by significant increases in use of oral vancomycin and fidaxomicin, and a significant decrease in use of oral metronidazole in the United States, according to paper published in Clinical Infectious Diseases.

In order to determine if oral formulations of vancomycin, fidaxomicin, and metronidazole use in the United States changed after publication of the revised IDSA/SHEA guidelines, researchers obtained data on dispensed antibiotic prescriptions from IQVIA (Durham, North Carolina) from March 2006 through 2019. Because bezlotoxumab was not included in the revised guidelines, researchers did not include it in their analysis.

Researchers converted numbers of units of different agents into numbers of 10-day treatment courses of the following regimens in order to normalize monthly dispensed prescriptions: vancomycin 125 mg four times a day, vancomycin 500 mg four times daily, fidaxomicin 200 mg twice a day, or metronidazole 500 mg three times a day. Data were expressed as 3-month rolling averages of the numbers of 10-day treatment courses for each drug per month. Courses were combined for the four times a day dosing of vancomycin 125 mg and 500 mg.

Researchers compared linear trends for monthly numbers of treatment courses in different time periods. For oral vancomycin and oral metronidazole, linear trends were compared in 3 time periods: baseline (March 2006 through publication of Polymer Alternative for CDI Treatment [PACT] data in May 2014); post-PACT (June 2014 through publication of revised IDSA/SHEA guidelines in February 2018); and post-revised guidelines (March 2018 through August 2019). For fidaxomicin, linear trends were compared in 2 time periods: pre-revised guidelines (January 2013 through February 2018) and postrevision.

Cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% (n=226,166) and 48% (n=18,518), respectively, during the 18 months immediately after publication of revised CDI guidelines compared with the 18 months immediately before publication. During the same periods, cumulative treatment courses of oral metronidazole decreased by 3% (n=238,372). Researchers noted that the combined increase in vancomycin and fidaxomicin use was “almost perfectly offset by decreased metronidazole use.”

Monthly vancomycin use decreased significantly throughout the baseline period (P =.03), before increasing significantly throughout both the post-PACT (P <.0001) and post-revised guideline (P <.0001) periods. In contrast, monthly metronidazole increased significantly throughout the baseline period (P <.0001) and decreased significantly throughout post-PACT (P =.0001) and post-revised guideline (P <.0001) periods. Monthly fidaxomicin use decreased significantly from 2013 through the post-PACT period (P <0.0001), before increasing significantly throughout the post-revised guideline period (P =.0002).

Researchers noted that changes in vancomycin and metronidazole use after publication of the revised guidelines were greater than those previously observed after publication of the PACT data. Given that “data used to revised CDI treatment recommendations were available for years before changes in practice were endorsed by IDSA and SHEA,” findings from this study “support a new IDSA initiative to develop, disseminate, and adopt more timely guidelines and guidance for managing antimicrobial-resistant and other difficult-to-treat infections, as set forth in the society’s 2019 Strategic Plan,” they concluded.

Disclosure: Cornelius J. Clancy, MD, and M. Hong Nguyen, MD, declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Clancy CJ, Buehrle D, Vu M, Wagener MM, Nguyen MH. Impact of revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America clinical practice guidelines on the treatment of Clostridium difficile infections in the United States [published online April 28, 2020]. Clin Infect Dis. doi:10.1093/cid/ciaa484