Oral Vancomycin Linked to Lower Clostridioides difficile Recurrence but Raises VRE Concerns: JAMA

Key Findings

• Of the 81 participants enrolled (median age 59 years, IQR 50–67 years), 39 were treated with oral vancomycin and 42 with placebo.

• Recurrent CDI developed in 17 participants (43.6%) in the vancomycin arm versus 24 participants (57.1%) in the placebo arm.

This created an absolute difference of -13.5% (95% CI, -35.1% to 8.0%), which was not statistically significant. 60 participants (74.1%) completed the 8-week follow-up:

• 31 from the vancomycin group and 29 from the placebo group.

• Adverse effects were frequent and affected 27 members in each group, representing 69.2% for the vancomycin arm and 64.3% for the placebo arm.

• As for antimicrobial resistance, vancomycin-resistant Enterococcus (VRE) stool colonization was found in 15 out of 30 members (50%) in the vancomycin arm but only in 6 out of 25 members (24%) in the placebo group (P = 0.048), which posed a concern about the development of resistance.

Overall, this multicenter randomized clinical trial indicated that oral vancomycin administered as prophylaxis with and after systemic antibiotic treatment might be related to lower recurrence of CDI, although the outcome failed to be statistically significant. Furthermore, vancomycin utilization was associated with greater carriage of vancomycin-resistant Enterococcus, the issue warranting serious consideration prior to routine prophylactic application. Larger, well-powered trials are needed to validate these results and completely determine the risk-benefit ratio of oral vancomycin prophylaxis for prevention of recurrent CDI.

Reference:

Keating JA, Xu T, Graham MB, et al. Oral Vancomycin for Prevention of Recurrent Clostridioides difficile Infection: A Randomized Clinical Trial. JAMA Netw Open. 2025;8(7):e2517834. doi:10.1001/jamanetworkopen.2025.17834