Saccharomyces boulardii prophylaxis for targeted antibiotics and infectious indications to reduce healthcare facility-onset Clostridioides difficile infection

Background: Probiotic prophylaxis for Clostridioides difficile infection (CDI) is controversial stemming from deficits in strain and disease specificity considerations and concern for adverse effects. Here risk for healthcare facility-onset CDI (HO-CDI) dependent on concomitant antibiotic and infectious indication is assessed to identify opportunities for targeted prophylaxis. Methods: Retrospective matched-cohort study from January 2016 through March 2019. Patientadmissions administered high risk antibiotics were categorized by Saccharomyces boulardii administration and matched 1:1 to non-recipients. Unadjusted and adjusted HO-CDI risk estimated using Cox proportional hazards regression. Results: S. boulardii administration was associated with 48% risk reduction for HO-CDI compared to nonrecipients (aHR 0.52, 95% CI: 0.31-0.87). Patient-admissions administered antibiotics and S. boulardii for a pneumonia indication exhibited a 57% reduction in risk for HO-CDI (aHR 0.43, 95% CI: 0.19-0.95). Administration of S. boulardii with ceftriaxone was associated with a 76% reduced risk of HO-CDI (aHR 0.24, 95% CI: 0.11-0.53) compared to ceftriaxone without S. boulardii, number needed to treat of 100. Conclusions: S. boulardii administration is associated with a significant HO-CDI risk reduction for inpatients receiving antibiotics associated with CDI. Institutions interested in targeted use of S. boulardii to limit potential adverse effects may consider prophylaxis for inpatients with pneumonia or receiving ceftriaxone.