Date Published: January 19, 2017
Publisher: Public Library of Science
Author(s): Emilie Baro, Tatiana Galperine, Fanette Denies, Damien Lannoy, Xavier Lenne, Pascal Odou, Benoit Guery, Benoit Dervaux, John Green.
Clostridium difficile infection (CDI) is characterized by high rates of recurrence, resulting in substantial health care costs. The aim of this study was to analyze the cost-effectiveness of treatments for the management of second recurrence of community-onset CDI in France.
We developed a decision-analytic simulation model to compare 5 treatments for the management of second recurrence of community-onset CDI: pulsed-tapered vancomycin, fidaxomicin, fecal microbiota transplantation (FMT) via colonoscopy, FMT via duodenal infusion, and FMT via enema. The model outcome was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) among the 5 treatments. ICERs were interpreted using a willingness-to-pay threshold of €32,000/QALY. Uncertainty was evaluated through deterministic and probabilistic sensitivity analyses.
Three strategies were on the efficiency frontier: pulsed-tapered vancomycin, FMT via enema, and FMT via colonoscopy, in order of increasing effectiveness. FMT via duodenal infusion and fidaxomicin were dominated (i.e. less effective and costlier) by FMT via colonoscopy and FMT via enema. FMT via enema compared with pulsed-tapered vancomycin had an ICER of €18,092/QALY. The ICER for FMT via colonoscopy versus FMT via enema was €73,653/QALY. Probabilistic sensitivity analysis with 10,000 Monte Carlo simulations showed that FMT via enema was the most cost-effective strategy in 58% of simulations and FMT via colonoscopy was favored in 19% at a willingness-to-pay threshold of €32,000/QALY.
FMT via enema is the most cost-effective initial strategy for the management of second recurrence of community-onset CDI at a willingness-to-pay threshold of €32,000/QALY.
Clostridium difficile infection (CDI) is the leading cause of healthcare associated diarrhea, presenting a significant burden to global healthcare systems . In recent years, there has been an increase of incidence and severity of CDI in North America and Europe. Rates of community-acquired CDI have also increased and community-associated CDI is estimated to be responsible for more than one third of all CDI cases [2,3]. The main problem in CDI is symptomatic relapse after antimicrobial therapy completion. Moreover, the risk of recurrent CDI is increased in patients who have already had one recurrence, rising from 25% after an initial episode to 45% after a first recurrence and to 65% after two recurrences . Recurrent CDI is associated with a diminished quality of life and increased morbidity. In addition, recurrent CDI also increases the risk of person-to-person transmission . A recent study focusing on the economic consequences of recurrent CDI compared to patients with CDI who did not experience a recurrence showed that there were substantially higher pharmacological and hospitalization costs among the patients with recurrent CDI .
Our decision model indicated that the current standard approach using pulsed-tapered vancomycin is less costly than FMT, but FMT is more effective regardless of mode of delivery. The extra cost associated with FMT via enema for this increased effectiveness compared with vancomycin was €18,092/QALY. Thus, FMT via enema appears to be the most cost-effective strategy at a willingness-to-pay threshold of €32,000/QALY. The base case analysis showed that FMT via duodenal infusion and fidaxomicin were dominated by FMT via colonoscopy and FMT via enema. Fidaxomicin was on the efficiency frontier if common costs of FMT increased by 81%. However, such an increase in FMT costs is unlikely to occur.