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Obaid NA. Alternative treatment of recurrent Clostridioides difficile infection in adults by fecal transplantation: an overview of phase I-IV studies from Clinicaltrials.gov. Front Microbiol 2024; 15:1374774. [PMID: 38784794 PMCID: PMC11111976 DOI: 10.3389/fmicb.2024.1374774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
Background Fecal microbiota transplantation (FMT) is an interventional approach to treat chronic and recurrent Clostridioides difficile infection (CDI). However, there is insufficient evidence regarding its effectiveness and safety. Clinical trials have been conducted to inspect the safety and effectiveness of FMT with and without comparison to pharmacological treatments. Aim This review explored the treatment of CDI in adults using FMT and evaluated the safety of this intervention based on phase I-IV studies registered on Clinicaltrials.gov. Method A comprehensive search of Clinicaltrials.gov was conducted to identify relevant studies that investigated CDI in adults. Data on study type, study design, sample size, intervention details, and outcomes related to FMT were examined and evaluated. Results In total, 13 clinical trials on FMT for CDI published through 17 November 2023 were identified, all of which were interventional studies. The investigation focused on both terminated and completed studies. Basic and advanced outcome measures were examined. Conclusion Some studies were terminated during phase II, and FMT was less effective than antibiotics such as vancomycin and fidaxomicin. However, colonoscopy and oral FMT were explored in several completed studies with promising results, but the evidence remains limited and inconclusive.
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Affiliation(s)
- Najla A. Obaid
- Pharmaceutical Sciences Department, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
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2
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Stallmach A, von Müller L, Storr M, Link A, Konturek PC, Solbach PC, Weiss KH, Wahler S, Vehreschild MJGT. [Fecal Microbiota Transfer (FMT) in Germany - Status and Perspective]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:490-499. [PMID: 37187187 DOI: 10.1055/a-2075-2725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Fecal microbiota transfer (FMT) is a treatment to modulate the gastrointestinal microbiota. Its use in recurrent Clostridioides difficile infection (rCDI) is established throughout Europe and recommended in national and international guidelines. In Germany, the FMT is codeable in the hospital reimbursement system. A comprehensive survey on the frequency of use based on this coding is missing so far. MATERIAL AND METHODOLOGY Reports of the Institute for Hospital Remuneration (InEK), the Federal Statistical Office (DESTATIS), and hospital quality reports 2015-2021 were examined for FMT coding and evaluated in a structured expert consultation. RESULTS Between 2015 and 2021, 1,645 FMT procedures were coded by 175 hospitals. From 2016 to 2018, this was a median of 293 (274-313) FMT annually, followed by a steady decline in subsequent years to 119 FMT in 2021. Patients with FMT were 57.7% female, median age 74 years, and FMT was applied colonoscopically in 72.2%. CDI was the primary diagnosis in 86.8% of cases, followed by ulcerative colitis in 7.6%. DISCUSSION In Germany, FMT is used less frequently than in the European comparison. One application hurdle is the regulatory classification of FMT as a non-approved drug, which leads to significantly higher costs in manufacturing and administration and makes reimbursement difficult. The European Commission recently proposed a regulation to classify FMT as a transplant. This could prospectively change the regulatory situation of FMT in Germany and thus contribute to a nationwide offer of a therapeutic procedure recommended in guidelines.
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Affiliation(s)
- Andreas Stallmach
- Klinik für Innere Medizin IV, Universitätsklinikum Jena, Jena, Deutschland
| | | | | | - Alexander Link
- Gastroenterologie, Hepatologie und Infektiologie, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Deutschland
| | - Peter C Konturek
- Thüringen-Klinik Saalfeld Georgius Agricola GmbH, Saalfeld, Deutschland
| | | | - Karl Heinz Weiss
- Krankenhaus Salem der Evang. Stadtmission Heidelberg gGmbH, Heidelberg, Deutschland
| | | | - Maria J G T Vehreschild
- Medizinische Klinik 2, Infektiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
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Lan KY, Le PH, Chiu CT, Chen CC, Yeh YM, Cheng HT, Kuo CJ, Chen CL, Chen YC, Yeh PJ, Chiu CH, Chang CJ. Fecal microbiota transplantation for treatment of refractory or recurrent Clostridioides difficile infection in Taiwan: a cost-effectiveness analysis. Front Med (Lausanne) 2023; 10:1229148. [PMID: 37849493 PMCID: PMC10577297 DOI: 10.3389/fmed.2023.1229148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
Background Compared to antibiotic treatment, fecal microbiota transplantation (FMT) is a more effective treatment for refractory or recurrent CDI (rCDI). Patients with inflammatory bowel disease (IBD) have a higher incidence of CDI and worse outcomes. There has been no study from Asia to evaluate the cost-effectiveness of FMT for overall rCDI patients and rCDI patients with IBD. Methods We applied a Markov model with deterministic and probabilistic sensitivity analyses to evaluate the cost and effectiveness of different treatments for rCDI patients with a time horizon of 1 year from the payer's perspective. We compared the cost and clinical outcomes of FMT through colonoscopy to two antibiotics (vancomycin and fidaxomicin) using data from Chang Gung Memorial Hospital, Taoyuan, Taiwan. Results Compared to vancomycin, FMT was cost-effective in overall rCDI patients as well as IBD patients with rCDI [USD 39356 (NT$1,101,971.98)/quality-adjusted life year (QALY) gained in overall patients; USD65490 (NT$1,833,719.14)/QALY gained in IBD patients]. Compared to fidaxomicin, FMT was only cost-effective in overall rCDI patients [USD20255 (NT$567,133.45)/QALY gained] but slightly increased QALY (0.0018 QALY gained) in IBD patients with rCDI. Conclusion FMT is cost-effective, compared to vancomycin or fidaxomicin, for the treatment of rCDI in most scenarios from the payers' perspective in Taiwan.
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Affiliation(s)
- Kai-Yen Lan
- Department of Biomedical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chien-Chang Chen
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Yuan-Ming Yeh
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Hao-Tsai Cheng
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chyi-Liang Chen
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Yi-Ching Chen
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Pai-Jui Yeh
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chee-Jen Chang
- Department of Biomedical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Clinical Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memory Hospital, Linko Branch, Taoyuan, Taiwan
- Research Service Center for Health Informatics, Chang Gung University, Taoyuan, Taiwan
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4
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Swart N, Sinha AM, Bentley A, Smethurst H, Spencer G, Ceder S, Wilcox MH. A cost-utility analysis of two Clostridioides difficile infection guideline treatment pathways. Clin Microbiol Infect 2023; 29:1291-1297. [PMID: 37356620 DOI: 10.1016/j.cmi.2023.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Treatment guidelines are key drivers of prescribing practice in the management of Clostridioides difficile infection (CDI), but recommendations on best practice can vary. We conducted a cost-utility analysis to compare the treatment pathway recommended by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline with the pathway proposed by the National Institute for Health and Care Excellence (NICE) guideline, from the perspective of the UK National Health Service. METHODS A decision tree modelling approach was adopted to reflect the treatment pathway for CDI as outlined in ESCMID and NICE guidelines. Patients experiencing a CDI infection received up to three treatments per infection to achieve a response and could subsequently experience up to two recurrences. Data on patient demographics, treatment response, recurrence, utilities, CDI-related mortality, and costs were taken from published literature. RESULTS The ESCMID treatment pathway was cost-effective versus the NICE treatment pathway at a threshold of £20 000 per quality-adjusted life year gained, with an incremental cost-effectiveness ratio of £4931. Cost-effectiveness was driven by differences in index infection recommendations (ESCMID recommends fidaxomicin as first-line treatment whereas NICE recommends vancomycin). The model results were robust to variations in inputs investigated in scenarios and sensitivity analyses, and probabilistic sensitivity analysis demonstrated that the ESCMID guideline treatment strategy had a 100% likelihood of being cost-effective versus the NICE treatment strategy. DISCUSSION Compared with the NICE guideline, the ESCMID guideline recommendations for treating an index CDI represent the most cost-effective use of healthcare resources from the perspective of the UK National Health Service.
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Affiliation(s)
| | | | | | | | | | | | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom.
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Bromilow T, Holmes H, Coote L, Woods S, Pink J. Cost-Effectiveness Analysis of Antimicrobial Prescribing in the Treatment of Clostridioides Difficile Infection in England. PHARMACOECONOMICS - OPEN 2023; 7:739-750. [PMID: 37306930 PMCID: PMC10471526 DOI: 10.1007/s41669-023-00420-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND An economic model was developed with guidance from the National Institute for Health and Care Excellence (NICE) 'Managing Common Infections' (MCI) Committee to evaluate the cost effectiveness of different antibiotic treatment sequences for treating Clostridioides difficile infection (CDI) in England. METHODS The model consisted of a 90-day decision tree followed by a lifetime cohort Markov model. Efficacy data were taken from a network meta-analysis and published literature, while cost, utility and mortality data were taken from published literature. A treatment sequence was defined as a first-line intervention or a different second-line intervention, and used constant third- and fourth-line interventions. The possible first- and second-line interventions were vancomycin, metronidazole, teicoplanin and fidaxomicin (standard and extended regimens). Total costs and quality-adjusted life-years (QALYs) were calculated and were used to run a fully incremental cost-effectiveness analysis. Threshold analysis was conducted around pricing. RESULTS Sequences including teicoplanin, fidaxomicin (extended regimen) and second-line metronidazole were excluded based on recommendations from the committee. The final pairwise comparison was between first-line vancomycin and second-line fidaxomicin (VAN-FID), and the reverse (FID-VAN). The incremental cost-effectiveness ratio for FID-VAN compared with VAN-FID was £156,000 per QALY gained, and FID-VAN had a 0.2% likelihood of being cost effective at a £20,000 threshold. CONCLUSION First-line vancomycin and second-line fidaxomicin was the most cost-effective treatment sequence at the NICE threshold for treating CDI in England. The main limitation of this study was that the initial cure and recurrence rates of each intervention were applied constantly across each line of treatment and each round of recurrence.
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Affiliation(s)
- Tom Bromilow
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK.
| | - Hayden Holmes
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK
| | - Laura Coote
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK
| | - Sam Woods
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK
| | - Joshua Pink
- National Institute of Health and Care Excellence (NICE), Centre for Guidelines, London, UK
- School of Health and Society, University of Salford, Salford, UK
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6
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Tariq A, Lancaster L, Elugunti P, Siebeneck E, Noe K, Borah B, Moriarty J, Banerjee I, Patel BN. Graph convolutional network-based fusion model to predict risk of hospital acquired infections. J Am Med Inform Assoc 2023; 30:1056-1067. [PMID: 37027831 PMCID: PMC10198521 DOI: 10.1093/jamia/ocad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 04/09/2023] Open
Abstract
OBJECTIVE Hospital acquired infections (HAIs) are one of the top 10 leading causes of death within the United States. While current standard of HAI risk prediction utilizes only a narrow set of predefined clinical variables, we propose a graph convolutional neural network (GNN)-based model which incorporates a wide variety of clinical features. MATERIALS AND METHODS Our GNN-based model defines patients' similarity based on comprehensive clinical history and demographics and predicts all types of HAI rather than focusing on a single subtype. An HAI model was trained on 38 327 unique hospitalizations while a distinct model for surgical site infection (SSI) prediction was trained on 18 609 hospitalization. Both models were tested internally and externally on a geographically disparate site with varying infection rates. RESULTS The proposed approach outperformed all baselines (single-modality models and length-of-stay [LoS]) with achieved area under the receiver operating characteristics of 0.86 [0.84-0.88] and 0.79 [0.75-0.83] (HAI), and 0.79 [0.75-0.83] and 0.76 [0.71-0.76] (SSI) for internal and external testing. Cost-effective analysis shows that the GNN modeling dominated the standard LoS model strategy on the basis of lower mean costs ($1651 vs $1915). DISCUSSION The proposed HAI risk prediction model can estimate individualized risk of infection for patient by taking into account not only the patient's clinical features, but also clinical features of similar patients as indicated by edges of the patients' graph. CONCLUSIONS The proposed model could allow prevention or earlier detection of HAI, which in turn could decrease hospital LoS and associated mortality, and ultimately reduce the healthcare cost.
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Affiliation(s)
- Amara Tariq
- Department of Administration, Mayo Clinic, Phoenix, Arizona, USA
| | - Lin Lancaster
- Department of Administration, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Eric Siebeneck
- Department of Administration, Mayo Clinic, Phoenix, Arizona, USA
| | - Katherine Noe
- Department of Neurology, Mayo Clinic, Phoenix, Arizona, USA
| | - Bijan Borah
- Robert D. and Patricia E. Kern Center, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - James Moriarty
- Robert D. and Patricia E. Kern Center, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Imon Banerjee
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
| | - Bhavik N Patel
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
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7
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Aby ES, Rajasingham R, Enns EA, Vaughn BP. Faecal microbiota transplantation for first and second episodes of Clostridioides difficile infection. Lancet Gastroenterol Hepatol 2023; 8:110-111. [PMID: 36620979 DOI: 10.1016/s2468-1253(22)00353-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Eva A Enns
- Division of Health Policy and Management, School of Public Health University of Minnesota, Minneapolis, MN 55455, USA
| | - Byron P Vaughn
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
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Risk Factors, Diagnosis, and Management of Clostridioides difficile Infection in Patients with Inflammatory Bowel Disease. Microorganisms 2022; 10:microorganisms10071315. [PMID: 35889034 PMCID: PMC9319314 DOI: 10.3390/microorganisms10071315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 12/10/2022] Open
Abstract
Clostridioides difficile infection (CDI) and inflammatory bowel disease (IBD) are two pathologies that share a bidirectional causal nexus, as CDI is known to have an aggravating effect on IBD and IBD is a known risk factor for CDI. The colonic involvement in IBD not only renders the host more prone to an initial CDI development but also to further recurrences. Furthermore, IBD flares, which are predominantly set off by a CDI, not only create a need for therapy escalation but also prolong hospital stay. For these reasons, adequate and comprehensive management of CDI is of paramount importance in patients with IBD. Microbiological diagnosis, correct evaluation of clinical status, and consideration of different treatment options (from antibiotics and fecal microbiota transplantation to monoclonal antibodies) carry pivotal importance. Thus, the aim of this article is to review the risk factors, diagnosis, and management of CDI in patients with IBD.
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Sandhu A, Chopra T. Fecal microbiota transplantation for recurrent Clostridioides difficile, safety, and pitfalls. Therap Adv Gastroenterol 2021; 14:17562848211053105. [PMID: 34992678 PMCID: PMC8725027 DOI: 10.1177/17562848211053105] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/20/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile infection (CDI) is one of the leading causes of hospital-acquired infection attributing to substantial morbidity, mortality, and healthcare cost. Recurrent CDI (rCDI) is common and occurs after effective treatment of first episode. Treatment of rCDI is based on accurate diagnoses, due to difficulty in distinguishing between colonization of C. difficile spores or CDI; coronavirus disease 2019 (COVID-19) added to the complexity of diagnoses as both entities can co-occur. It is difficult to eradicate rCDI, and there remains a critical gap regarding treatment of rCDI. The treatment goal of rCDI is to reestablish normal microbiota. Fecal microbiota transplantation (FMT) is suggested as a treatment for second episode of rCDI. Based on the collective evidence of all randomized controlled trials, FMT was reported more efficacious compared with vancomycin or fidaxomicin; however, these trials had limited number of patients and all patients were pre-treated with vancomycin prior to FMT. Furthermore, when comparing various routes of instillation and types of preparation of fecal microbiota, no difference was observed in cure rate. Despite the success rate of FMT, there remains a concern for transmission of infectious agents, such as Gram negative bacteremia or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), adverse events (diarrhea and abdominal pain), and reports of new diagnoses (inflammatory bowel disease, weight gain and irritable bowel syndrome). To lessen the risk of transmissible infections, donor screening should be performed, which includes screening for medical comorbidities and infectious pathogens in blood and feces. Scheduling complexities and reimbursement places an additional roadblock for using FMT. Microbiome-based therapies are being developed to eliminate the logistical challenges related to FMT. Large prospective and placebo-controlled studies are needed to evaluate the efficacy and long-term safety of FMT, so its use can be justified in clinical practice.
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Affiliation(s)
- Avnish Sandhu
- Department of Internal Medicine, Division of Infectious Disease, Wayne State Universit School of Medicine, Detroit Medical Center Detroit, MI, USA
| | - Teena Chopra
- Department of Internal Medicine, Division of Infectious Disease, Wayne State Universit School of Medicine, Detroit Medical Center Detroit, Harper University Hospital, 3990 John R street, Detroit, MI, 48201, USA
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10
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Impact of Clostridioides difficile infection on patient-reported quality of life. Infect Control Hosp Epidemiol 2021; 43:1339-1344. [PMID: 34615561 DOI: 10.1017/ice.2021.413] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We investigated the quality of life (QoL) of patients hospitalized with C. difficile infection (CDI). DESIGN Prospective survey study. SETTING US tertiary-care referral center, acute-care setting. PARTICIPANTS Adults hospitalized with a diagnosis of CDI, defined as ≥3 episodes of unformed stool in 24 hours and a positive laboratory test for C. difficile. METHODS We surveyed patients from July 2019 to March 2020 using the disease-specific Cdiff32 questionnaire and the generic PROMIS GH survey. We compared differences in Cdiff32 scores among demographic and clinical subgroups (including CDI severity, CDI recurrence, and various comorbidities) using 2-sample t tests. We compared PROMIS GH scores to the general population T score of 50 using 1-sample t tests. We performed multivariable linear regression to identify predictors of Cdiff32 scores. RESULTS In total, 100 inpatients (mean age, 58.6 ±17.1 years; 53.0% male; 87.0% white) diagnosed with CDI completed QoL surveys. PROMIS GH physical health summary scores (T = 37.3; P < .001) and mental health summary scores (T = 43.4; P < .001) were significantly lower than those of the general population. In bivariate analysis, recurrent CDI, severe CDI, and number of stools were associated with lower Cdiff32 scores. In multivariable linear regression, recurrent CDI, severe CDI, and each additional stool in the previous 24 hours were associated with significantly decreased Cdiff32 scores. CONCLUSIONS Patients hospitalized with CDI reported low scores on the Cdiff32 and PROMIS GH, demonstrating a negative impact of CDI on QoL in multiple health domains. The Cdiff32 questionnaire is particularly sensitive to QoL changes in patients with recurrent or severe disease.
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11
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Wingen-Heimann SM, van Prehn J, Kuijper EJ, Vehreschild MJGT. The need for a holistic view on management of Clostridioides difficile infection. Clin Microbiol Infect 2021; 27:1383-1385. [PMID: 34311078 DOI: 10.1016/j.cmi.2021.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Sebastian M Wingen-Heimann
- University Hospital of Cologne, Department I of Internal Medicine, Cologne, Germany; FOM University of Applied Sciences, Cologne, Germany.
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Eduard J Kuijper
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands; Centre for Infectious Disease, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
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12
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Khanna S, Tande A, Rubin DT, Khoruts A, Kahn SA, Pardi DS. Fecal Microbiota Transplantation for Recurrent C difficile Infection During the COVID-19 Pandemic: Experience and Recommendations. Mayo Clin Proc 2021; 96:1418-1425. [PMID: 34088413 PMCID: PMC8169126 DOI: 10.1016/j.mayocp.2021.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/23/2021] [Accepted: 04/12/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To report experience with fecal microbiota transplantation (FMT) for recurrent Clostridioides difficile infection (rCDI) and provide recommendations for management of rCDI and donor testing during the COVID-19 pandemic. METHODS A retrospective study of patients with rCDI who underwent FMT from May 26, 2020, to September 30, 2020, with stool from well-screened donors with health and infectious screening and a newly implemented strategy for COVID-19 screening with every 2-week bookend testing with stool quarantine. Patients were followed up for development of rCDI and COVID-19. RESULTS Of the 57 patients who underwent FMT for rCDI, 29 were tested for COVID-19 via nasopharyngeal polymerase chain reaction (PCR) and 22 via serology. All results were negative, except for 1 positive serology. Donor testing every 2 weeks for COVID-19 via serology and nasopharyngeal swab PCR was negative, except for 2 donors at 1 center who were excluded. Three patients had rCDI after FMT, and 1 underwent repeat FMT. One patient developed respiratory symptoms suggestive of COVID-19 and tested negative via nasopharyngeal PCR. Eleven patients who underwent COVID-19 testing for elective procedures or hospitalizations tested negative. No SARS-CoV-2 transmission was noted. CONCLUSIONS With appropriate donor screening, FMT can be performed safely for rCDI during the COVID-19 pandemic. Development of a validated stool assay for SARS-CoV-2 will simplify this process further.
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Affiliation(s)
- Sahil Khanna
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| | - Aaron Tande
- Infectious Diseases, Mayo Clinic, Rochester, MN
| | - David T Rubin
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL
| | - Alexander Khoruts
- Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN
| | - Stacy A Kahn
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
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The effect of a microbial ecosystem therapeutic (MET-2) on recurrent Clostridioides difficile infection: a phase 1, open-label, single-group trial. Lancet Gastroenterol Hepatol 2021; 6:282-291. [PMID: 33631102 DOI: 10.1016/s2468-1253(21)00007-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Faecal microbiota transplantation (FMT) is highly effective for recurrent Clostridioides difficile infection but has inherent risks. Microbial Ecosystem Therapeutic 2 (MET-2) is an oral encapsulated formulation of 40 lyophilised bacterial species initially isolated from stool of a healthy donor, but subsequently manufactured independently of donors, eliminating potential risks introduced by changes in donor health. The aim of this study was to determine MET-2 activity, safety, and tolerability. METHODS This phase 1, open-label, single-group feasibility study was done in Alberta, Canada. The main inclusion criteria were mild to moderate C difficile infection and at least one episode of C difficile infection recurrence (ie, two episodes of C difficile infection) within 12 months. Initial daily treatment was ten oral capsules for 2 days, then three capsules for 8 days. If C difficile infection recurred, a higher dose was offered: 20 capsules for 2 days, then three capsules for 8 days. Patients were followed for adverse events and C difficile infection recurrence up to day 130. The primary outcome was absence of C difficile infection recurrence (fewer than three unformed bowel movements in 24 h persisting for at least 2 days) at day 40 by intention-to-treat analysis. Secondary outcomes were mortality or hospitalisation due to C difficile infection, infections attributed to treatment, nausea, abdominal pain, vomiting, or diarrhoea during treatment, quality of life (C difficile Health Related Quality of Life Questionnaire) before and after treatment, and engrafted MET-2 bacteria in patient stool. Absence of C difficile infection recurrence at day 130 was an exploratory outcome. This study is registered with ClinicalTrials.gov, NCT02865616 FINDINGS: Between Sept 19, 2018, and Feb 28, 2020, we enrolled 19 adult patients with at least two episodes of mild to moderate C difficile infection (median age 65 years [IQR 56-67]; 12 women [63%], seven men [37%]). Recurrent C difficile infection was absent at day 40 in 15 (79%) of 19 patients after initial treatment, increasing to 18 (95%) 40 days after retreatment. No mortality associated with C difficile infection, infections associated with MET-2 treatment, or other serious adverse events were observed. The most common self-limited, mild to moderate symptoms reported during treatment were diarrhoea in 12 (63%) of 19 patients and abdominal cramps in 12 (63%). After MET-2 treatment, quality of life improved significantly, as did alpha diversity in stool microbial composition (p=1·93×10-6). MET-2 associated taxa were found in greater abundance in most patients after treatment compared with baseline. 16 (84%) of 19 patients did not have recurrence of C difficile infection by day 130. INTERPRETATION MET-2 appears to be safe, efficacious, and well tolerated among patients with recurrent C difficile infection. Results must be validated in controlled studies. FUNDING NuBiyota.
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Maul X, Dincer BC, Wu AW, Thamboo AV, Higgins TS, Scangas GA, Oliveira K, Ho AS, Mallen-St Clair J, Walgama E. A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing. Otolaryngol Head Neck Surg 2021; 165:647-654. [PMID: 33588621 DOI: 10.1177/0194599820988740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed. STUDY DESIGN A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given. SETTING Patients with nonabsorbable nasal packing placed. METHODS Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model. RESULTS The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective. CONCLUSIONS Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence. LEVEL OF EVIDENCE 3a.
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Affiliation(s)
- Ximena Maul
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Otolaryngology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Berkay C Dincer
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA.,School of Medicine, Hacettepe University, Ankara, Turkey
| | - Arthur W Wu
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA
| | - Andrew V Thamboo
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas S Higgins
- Department of Otolaryngology-Head and Neck, University of Louisville, Louisville, Kentucky, USA
| | - George A Scangas
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Kristin Oliveira
- Department of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut, USA
| | - Allen S Ho
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA
| | - Jon Mallen-St Clair
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA
| | - Evan Walgama
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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FECAL MICROBIOTES TRANSPLANTATION TECHNOLOGIES: MEDICAL, BIOTECHNOLOGICAL AND REGULATORY ASPECTS. BIOTECHNOLOGIA ACTA 2021. [DOI: 10.15407/biotech14.01.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fecal microbiota transplantation (FMT) is a treatment method based on donor's fecal solution injection into the patient's gastrointestinal tract. FMT is effectively used in the treatment of recurrent Clostridium difficile infection. There is also growing interest in the therapeutic application of the method to treat metabolic, autoimmune and other disorders that was not previously associated with intestinal microbiota. Despite the promising results of FMT use, the organizational and legal matters and that of the safety FMT application have not yet been resolved in the European and Ukrainian medical community. The purpose of this review was to summarize information on the FMT application and the regulatory aspects of its use. The analysis of the practical instructions provisions of for FMT applying in clinical practice was carried out, and the bioethical problems associated with the FMT use were investigated.
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Hammeken LH, Baunwall SMD, Hvas CL, Ehlers LH. Health economic evaluations comparing faecal microbiota transplantation with antibiotics for treatment of recurrent Clostridioides difficile infection: a systematic review. HEALTH ECONOMICS REVIEW 2021; 11:3. [PMID: 33439367 PMCID: PMC7805077 DOI: 10.1186/s13561-021-00301-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/04/2021] [Indexed: 05/10/2023]
Abstract
BACKGROUND Faecal microbiota transplantation (FMT) is increasingly being used in the treatment of recurrent Clostridioides difficile infection (rCDI). Health economic evaluations may support decision-making regarding the implementation of FMT in clinical practice. Previous reviews have highlighted several methodological concerns in published health economic evaluations examining FMT. However, the impact of these concerns on the conclusions of the studies remains unclear. AIMS To present an overview and assess the methodological quality of health economic evaluations that compare FMT with antibiotics for treatment of rCDI. Furthermore, we aimed to evaluate the degree to which any methodological concerns would affect conclusions about the cost-effectiveness of FMT. METHODS We conducted a systematic literature review based on a search in seven medical databases up to 16 July 2020. We included research articles reporting on full health economic evaluations comparing FMT with antibiotic treatment for rCDI. General study characteristics and input estimates for costs, effectiveness and utilities were extracted from the articles. The quality of the studies was assessed by two authors using the Drummonds ten-point checklist. RESULTS We identified seven cost-utility analyses. All studies applied decision-analytic modelling and compared various FMT delivery methods with vancomycin, fidaxomicin, metronidazole or a combination of vancomycin and bezlotoxumab. The time horizons used in the analyses varied from 78 days to lifelong, and the perspectives differed between a societal, a healthcare system or a third-party payer perspective. The applied willingness-to-pay threshold ranged from 20,000 to 68,000 Great Britain pound sterling (GBP) per quality-adjusted life-year (QALY). FMT was considered the most cost-effective alternative in all studies. In five of the health economic evaluations, FMT was both more effective and cost saving than antibiotic treatment alternatives. The quality of the articles varied, and we identified several methodological concerns. CONCLUSIONS Economic evaluations consistently reported that FMT is a cost-effective and potentially cost-saving treatment for rCDI. Based on a comparison with recent evidence within the area, the multiple methodological concerns seem not to change this conclusion. Therefore, implementing FMT for rCDI in clinical practice should be strongly considered.
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Affiliation(s)
- Lianna Hede Hammeken
- Danish Center for Healthcare Improvements, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, DK-9220 Aalborg Ø, Denmark
| | - Simon Mark Dahl Baunwall
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus, Denmark
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus, Denmark
| | - Lars Holger Ehlers
- Danish Center for Healthcare Improvements, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, DK-9220 Aalborg Ø, Denmark
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Gupta A, Ananthakrishnan AN. Economic burden and cost-effectiveness of therapies for Clostridiodes difficile infection: a narrative review. Therap Adv Gastroenterol 2021; 14:17562848211018654. [PMID: 34104214 PMCID: PMC8170348 DOI: 10.1177/17562848211018654] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile is the most common cause of healthcare-associated diarrhea. Disease complications as well as recurrent infections contribute significantly to morbidity and mortality. Over the past decades, there has been a rapid increase in the incidence of C. difficile infection (CDI), with a rise in the number of community-acquired cases. CDI has a profound economic impact on both the healthcare system and patients, secondary to recurrences, hospitalization, prolonged length of stay, cost of treatment, and indirect societal costs. With emergence of newer treatment options, the standard of care is shifting from metronidazole and vancomycin towards fidaxomicin and fecal microbiota transplantation (FMT), which despite being more expensive, are more efficacious in preventing recurrences and hence overall are more beneficial forms of therapy per cost-effectiveness analyses. Data regarding preferred route of FMT, timing of FMT, and non-conventional therapies such as bezlotoxumab is scant. There is a need for further studies to elucidate the true attributable costs of CDI as well as continued cost-effectiveness research to reduce the economic burden associated with the disease and improve clinical practice.
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Affiliation(s)
- Akshita Gupta
- Department of Medicine, Massachusetts General
Hospital, Boston, MA, USA
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18
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Durham SH, Le P, Cassano AT. Navigating changes in Clostridioides difficile prevention and treatment. J Manag Care Spec Pharm 2020; 26:S3-S23. [PMID: 33533699 PMCID: PMC10408425 DOI: 10.18553/jmcp.2020.26.12-a.s3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Clostridioides difficile (C. difficile, previously known as Clostridium difficile) infections are a major health care concern. The Centers for Disease Control and Prevention (CDC) estimates that C. difficile causes almost half a million illnesses in the United States yearly, and approximately 1 in 5 patients with a C. difficile infection (CDI) will experience 1 or more recurrent infections. The incidence of infection has risen dramatically in recent years, and infection severity has increased due to the emergence of hypervirulent strains. There have been noteworthy advances in the development of CDI prevention and treatment, including a growth in the understanding of the role a patient's gut microbiome plays. The 2017 Infectious Diseases Society of America (IDSA) guidelines made a significant change in treatment recommendations for first time CDI episodes by recommending the use of oral vancomycin or fidaxomicin in place of metronidazole as a first-line treatment. The guidelines also included detailed recommendations on the use of fecal microbiota transplant (FMT) in those patients who experience 3 or more recurrent CDI episodes. A number of novel therapies for the treatment of CDI are in various stages of development. Treatments currently in phase 3 trials include the antibiotic ridinilazole, the microbiome products SER-109 and RBX2660, and a vaccine. All of these agents have shown promise in phase 1 and 2 trials. Additionally, several other antibiotic and microbiome candidates are currently in phase 1 or phase 2 trials. A qualitative review and evaluation of the literature on the cost-effectiveness of treatments for CDI in the U.S. setting was conducted, and the summary provided herein. Due to the higher cost of newer agents, cost-effectiveness evaluations will continue to be critical in clinical decision making for CDI. This paper reviews the updated CDI guidelines for prevention and treatment, the role of the microbiome in new and recurrent infections, pipeline medications, and comparative effectiveness research (CER) data on these treatments. DISCLOSURES: Durham and Le have nothing to disclose. Cassano reports consulting fees from Baxter Healthcare. Peer reviewers Drs. Ami Gopalan and Mark Rubin and Ms. Kathleen Jarvis have nothing to disclose. Planners Dr. Christine L. Cooper and Ms. Susan Yarbrough have nothing to disclose.
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Affiliation(s)
- Spencer H Durham
- BCPS, BCIDP, Auburn University Harrison School of Pharmacy, Auburn, AL
| | - Phuc Le
- Lerner College of Medicine, Case Western Reserve University and Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH
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19
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Khurana S, Kahl A, Yu K, DuPont AW. Recent advances in the treatment of Clostridioides difficile infection: the ever-changing guidelines. Fac Rev 2020; 9:13. [PMID: 33659945 PMCID: PMC7886080 DOI: 10.12703/b/9-13] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Clostridioides difficile infection (CDI), formerly known as Clostridium difficile, continues to be the most common healthcare-associated infection worldwide. With the shifting epidemiology towards higher a incidence of community-acquired CDI and the continued burden on the healthcare system posed by high rates of CDI recurrence, there has been an impetus to advance the diagnostic testing and treatment strategies. Recent advancements over the past decade have led to rapidly changing guidelines issued by the Infectious Diseases Society of America and European Society of Clinical Microbiology and Infectious Diseases. With our comprehensive review, we aim to summarize the latest advances in diagnosing and treating CDI and thus attempt to help readers guide best practices for patient care. This article also focusses on cost-effectiveness of various therapies currently available on the market and provides an analysis of the current evidence on a relatively new monoclonal antibody therapy, Bezlotoxumab, to treat recurrent CDI.
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Affiliation(s)
- Shruti Khurana
- Department of Internal Medicine and Pediatrics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alyssa Kahl
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kevin Yu
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Andrew W DuPont
- Associate Professor, Department of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, Houston, TX, USA
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20
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Terra DADA, Vilela EG, Silva ROS, LeÃo LA, Lima KS, Passos RIFÂ, Diniz AN, Coelho LGV. STRUCTURING A FECAL MICROBIOTA TRANSPLANTATION CENTER IN A UNIVERSITY HOSPITAL IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:434-458. [PMID: 33331486 DOI: 10.1590/s0004-2803.202000000-79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fecal microbiota transplantation (FMT) is an important therapeutic option for recurrent or refractory Clostridioides difficile infection, being a safe and effective method. Initial results suggest that FMT also plays an important role in other conditions whose pathogenesis involves alteration of the intestinal microbiota. However, its systematized use is not widespread, especially in Brazil. In the last decade, multiple reports and several cases emerged using different protocols for FMT, without standardization of methods and with variable response rates. In Brazil, few isolated cases of FMT have been reported without the implantation of a Fecal Microbiota Transplantation Center (FMTC). OBJECTIVE The main objective of this study is to describe the process of implanting a FMTC with a stool bank, in a Brazilian university hospital for treatment of recurrent and refractory C. difficile infection. METHODS The center was structured within the criteria required by international organizations such as the Food and Drug Administration, the European Fecal Microbiota Transplant Group and in line with national epidemiological and regulatory aspects. RESULTS A whole platform involved in structuring a transplant center with stool bank was established. The criteria for donor selection, processing and storage of samples, handling of recipients before and after the procedure, routes of administration, short and long-term follow-up of transplant patients were determined. Donor selection was conducted in three stages: pre-screening, clinical evaluation and laboratory screening. Most of the candidates were excluded in the first (75.4%) and second stage (72.7%). The main clinical exclusion criteria were: recent acute diarrhea, overweight (body mass index ≥25 kg/m2) and chronic gastrointestinal disorders. Four of the 134 candidates were selected after full screening, with a donor detection rate of 3%. CONCLUSION The implantation of a transplant center, unprecedented in our country, allows the access of patients with recurrent or refractory C. difficile infection to innovative, safe treatment, with a high success rate and little available in Brazil. Proper selection of qualified donors is vital in the process of implementing a FMTC. The rigorous clinical evaluation of donors allowed the rational use of resources. A transplant center enables treatment on demand, on a larger scale, less personalized, with more security and traceability. This protocol provides subsidies for conducting FMT in emerging countries.
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Affiliation(s)
| | - Eduardo Garcia Vilela
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
| | | | - Laiane Alves LeÃo
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
| | - Karine Sampaio Lima
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
| | | | - Amanda Nádia Diniz
- Universidade Federal de Minas Gerais, Escola de Veterinária, Belo Horizonte, MG, Brasil
| | - Luiz Gonzaga Vaz Coelho
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
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21
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Shaffer SR, Witt J, Targownik LE, Kao D, Lee C, Smieliauskas F, Rubin DT, Singh H, Bernstein CN. Cost-effectiveness analysis of a fecal microbiota transplant center for treating recurrent C.difficile infection. J Infect 2020; 81:758-765. [PMID: 32980389 DOI: 10.1016/j.jinf.2020.09.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 09/06/2020] [Accepted: 09/13/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We assessed the cost-effectiveness of establishing a fecal microbial transplant (FMT) unit in Canada for the treatment of recurrent CDI. DESIGN We performed a cost-effectiveness analysis to determine the number of patients with recurrent CDI needed to treat (NNT) annually to make establishing a FMT unit cost-effective. We compared treating patients for their second recurrence of CDI with FMT in a jurisdiction with a FMT unit, compared to being treated with antibiotics; then sent to a medical center with FMT available for the third recurrence. We used a willingness to pay threshold of $50,000 per quality-adjusted-life-year gained. RESULTS The minimum annual NNT was 15 for FMT via colonoscopy, 17 for FMT via capsule, and 44 for FMT via enema compared with vancomycin, and 16, 18, and 47 compared with fidaxomicin, respectively. A medical center's minimum catchment area when establishing a FMT unit would have to be 56,849 if using FMT via colonoscopy, or 64,429 if using capsules. CONCLUSION We report the minimum number of patients requiring treatment annually with FMT to achieve cost-effectiveness, when including start-up and ongoing costs. FMT is cost-effective in Canada in populations with a sufficient number of eligible patients, ranging from 15 to 47 depending on the FMT modality used. This is crucial for medical jurisdictions making decisions about establishing a FMT unit for the treatment of recurrent CDI. The cost-effectiveness can be generalized in other countries.
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Affiliation(s)
- Seth R Shaffer
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada; Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Julia Witt
- Department of Economics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dina Kao
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Christine Lee
- Hamilton Regional Laboratory Medicine Program, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, British Columbia, Canada
| | - Fabrice Smieliauskas
- Economics, Wayne State University, Detroit, MI, USA; Pharmacy Practice, Wayne State University, Detroit, MI, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
| | - Harminder Singh
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; University of Manitoba IBD Clinical and Research Center, Winnipeg, Manitoba, Canada.
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Barker AK, Scaria E, Safdar N, Alagoz O. Evaluation of the Cost-effectiveness of Infection Control Strategies to Reduce Hospital-Onset Clostridioides difficile Infection. JAMA Netw Open 2020; 3:e2012522. [PMID: 32789514 PMCID: PMC7426752 DOI: 10.1001/jamanetworkopen.2020.12522] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 05/25/2020] [Indexed: 12/14/2022] Open
Abstract
Importance Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile. Objective To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles. Design, Setting, and Participants This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature. Interventions Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers. Main Outcomes and Measures Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY). Results In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively. Conclusions and Relevance The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.
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Affiliation(s)
- Anna K. Barker
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison
| | - Elizabeth Scaria
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin–Madison
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Oguzhan Alagoz
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin–Madison
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Abstract
PURPOSE OF REVIEW Clostridioides difficile infection (CDI) is a significant burden on the health system, especially due to high recurrence rates. Since the beginning of the CDI epidemic in early 2000s, many strategies for combatting recurrence have been explored, with moderate success so far. This review will focus on the most recent developments in recurrent CDI prevention and treatment. RECENT FINDINGS There are two main mechanisms of CDI recurrence: alteration in microbiome and poor antibody response. Development of new antibiotics aims to minimize damage to the microbiome. Fecal transplant or other microbiome replacement therapies seek to replenish the missing elements in the microbiome. Fecal microbiota transplant is the most effective treatment for prevention of CDI recurrenceso far, but is difficult to standardize and regulate, leading to efforts to develop microbiome-derived therapeutics. A deficiency in developing antibodies to C. difficile toxins is another mechanism of recurrence. Active immunization using toxoid vaccines or passive immunization using mAbs address this aspect. SUMMARY There are promising new treatments for recurrent CDI in development. Fecal microbiota transplant remains the most effective therapy for multiply recurrent CDI. New antibiotics, microbiome-derived therapeutics, and immunologic therapies are in development.
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Abdali ZI, Roberts TE, Barton P, Hawkey PM. Economic evaluation of Faecal microbiota transplantation compared to antibiotics for the treatment of recurrent Clostridioides difficile infection. EClinicalMedicine 2020; 24:100420. [PMID: 32637898 PMCID: PMC7327885 DOI: 10.1016/j.eclinm.2020.100420] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/23/2020] [Accepted: 05/29/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a hospital acquired disease associated with significant morbidity, hospitalisation and mortality. Almost 30% of treated patients experience at least one recurrence after treatment of their first episode. Treatment of recurrent CDI (rCDI) utilises vancomycin or fidaxomicin, however, a newer treatment option is faecal microbial transplantation (FMT) administered by nasogastric tube (NGT) or colonoscopy. It is associated with higher cure and lower recurrence rates than fidaxomicin or vancomycin. The aim of this analysis is to evaluate the cost effectiveness of FMT for rCDI using the latest and best evidence. METHOD A cost utility analysis was conducted using a decision model representing the cost per additional Quality Adjusted Life Year (QALY) from a National Health Service (NHS) perspective. A Markov model was constructed to compare FMT NGT and colonoscopy to antibiotic treatment (fidaxomicin or vancomycin). The model was informed by a literature review of clinical evidence, specifically focussing on hospitalised patients with rCDI over 65 years. Both deterministic and probabilistic sensitivity analyses were performed to assess uncertainties around the model inputs and assumptions. FINDINGS The base case analysis showed that FMT is a less costly and more effective treatment than either fidaxomicin or vancomycin. FMT colonoscopy was slightly more effective than FMT NGT leading to an additional 0.012 QALYs but more expensive and the incremental cost effectiveness ratio (ICER) was £242,514/QALY. The Probabilistic sensitivity analysis based on 10,000 simulations suggested the probability of FMT NGT being cost effective was almost 78% at £20,000/QALY Willingness-To-Pay (WTP) threshold. INTERPRETATION FMT is both more effective and less costly option than antimicrobial therapy. FMT NGT was the preferred route of administration and is likely to be considered the most cost-effective strategy by decision makers given current acceptable thresholds.
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Affiliation(s)
- Zainab I Abdali
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Tracy E Roberts
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Pelham Barton
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Peter M Hawkey
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
- Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, United Kingdom
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Luo Y, Lucas AL, Grinspan AM. Fecal Transplants by Colonoscopy and Capsules Are Cost-Effective Strategies for Treating Recurrent Clostridioides difficile Infection. Dig Dis Sci 2020; 65:1125-1133. [PMID: 31493042 DOI: 10.1007/s10620-019-05821-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/28/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recurrent Clostridioides difficile infections (CDIs) occur frequently and pose a substantial economic burden on the US healthcare system. The landscape for the treatment of CDI is evolving. AIM To elucidate the most cost-effective strategy for managing recurrent CDI. METHODS A decision tree analysis was created from a modified third-party payer's perspective to compare the cost-effectiveness of five strategies for patients experiencing their first CDI recurrence: oral vancomycin, fidaxomicin, fecal microbiota transplant (FMT) via colonoscopy, FMT via oral capsules, and a one-time infusion of bezlotoxumab with vancomycin. Effectiveness measures were quality-adjusted life years (QALY). A willingness-to-pay (WTP) threshold of $100,000 per QALY was set. One-way and probabilistic sensitivity analyses were performed. RESULTS Base-case analysis showed that FMT via colonoscopy was associated with the lowest cost at $5250 and that FMT via capsules was also a cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of $31205/QALY. Sensitivity analyses demonstrated that FMT delivered by oral capsules and colonoscopy was comparable cost-effective modalities. At its current cost and effectiveness, bezlotoxumab was not a cost-effective strategy. CONCLUSIONS FMT via oral capsules and colonoscopy is both cost-effective strategies to treat the first recurrence of CDI. Further real-world economic studies are needed to understand the cost-effectiveness of all available strategies.
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Affiliation(s)
- Yuying Luo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY, 10029, USA.
| | - Aimee L Lucas
- The Henry D. Janowitz Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Ari M Grinspan
- The Henry D. Janowitz Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
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26
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Xuan S, Zangwill KM, Ni W, Ma J, Hay JW. Cost-Effectiveness Analysis of Four Common Diagnostic Methods for Clostridioides difficile Infection. J Gen Intern Med 2020; 35:1102-1110. [PMID: 32016703 PMCID: PMC7174536 DOI: 10.1007/s11606-019-05487-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/08/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND No studies have evaluated the cost-effectiveness of single and two-step different diagnostic test strategies for Clostridioides difficile infection (CDI), including direct and indirect costs. OBJECTIVE To evaluate the cost-effectiveness of commonly available diagnostic tests for CDI including nucleic acid amplification testing (NAAT) alone, glutamate dehydrogenase followed by enzyme immunoassay for toxin (GDH/EIA), GDH then NAAT (GDH/NAAT), and NAAT then EIA (NAAT/EIA). DESIGN Decision tree model from the US societal perspective with inputs derived from the literature. Willingness-to-pay threshold was set at $150,000 per quality-adjusted life year (QALY) gained. To assess the impact of uncertainty in model inputs on the findings, we performed one-way and probabilistic sensitivity analyses. PARTICIPANTS We conducted the analysis to represent a population aged 65 years old with diarrhea who received a CDI diagnostic test. MAIN MEASURES Incremental cost-effectiveness ratios (ICER) and incremental net monetary benefits (INMB). KEY RESULTS NAAT alone was the most cost-effective approach overall; GDH/NAAT was the most cost-effective two-step option. NAAT alone led to the highest QALYs gained, at an incremental cost of $54,547 (vs. GDH/NAAT), $55,410 (vs. GDH/EIA), and $50,231 (vs. NAAT/EIA) per QALY gained. NAAT/EIA was not cost-effective compared to any other strategy. GDH/NAAT resulted in a higher QALY compared to GDH/EIA, at an incremental cost of $96,841 per QALY gained. Variability in the likelihood of comorbidities, CDI probability, and age at disease onset did not substantially change the results. One-way sensitivity analyses showed that results were most sensitive to likelihood of recurrence, followed by CDI mortality rate and probability of severe CDI. Probabilistic sensitivity analyses explored known uncertainties in the base case and confirmed the robustness of the results. CONCLUSIONS NAAT alone and GDH/NAAT (among the two-step options) were the most cost-effective diagnostic test approaches for CDI.
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Affiliation(s)
- Si Xuan
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Kenneth M Zangwill
- Division of Pediatric Infectious Diseases and Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Weiyi Ni
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Junjie Ma
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Joel W Hay
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA. .,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA.
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27
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A systematic review of economic evaluation in fecal microbiota transplantation. Infect Control Hosp Epidemiol 2020; 41:458-466. [DOI: 10.1017/ice.2019.371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractBackground:Fecal microbiota transplantation (FMT) is an effective therapy in recurrent Clostridium difficile infection (rCDI). It is only recommended for this indication by European and American guidelines. Other indications of FMT are being studied, such as inflammatory bowel disease (IBD), and they have shown promising results.Objectives:To identify and review published FMT-related economic evaluations (EEs) to assess their quality and the economic impact of FMT in the treatment of these diseases.Data sources:The systematic literature research was conducted in both PubMed and Cochrane to identify EEs published before July 1, 2019.Study eligibility criteria:Articles were included if they concerned FMT (whatever the disease and its line of treatment), if they reported full or partial EEs, and if they were written in English. Articles were excluded if they did not concern FMT; if they did not report an EE; or if they were a systematic review, editorial, comment, letter to the editor, practice point, or poster.Methods:A measurement tool, AMSTAR, was used to optimize the quality of this systematic review. Based on the CHEERS checklist, data were identified and extracted from articles. The quality of each EE was assessed using the Drummond checklist.Results:Overall, 9 EEs were included: all EEs were full evaluations and 8 were cost-utility analyses (CUAs). All EEs had a Drummond score ≥ 7, which indicated high quality. All CUAs related to rCDI and IBD concluded that FMT was cost-effective compared with other reference treatments, at a threshold ≤$50,000/QALY. One EE about initial CDI showed that FMT was dominated by metronidazole.Conclusions:Despite a limited number of EEs, FMT seems to be a promising and cost-effective treatment for rCDI. More EE studies on other diseases like IBD are necessary to address FMT efficiency for new indications. Therefore, our systematic review provides a framework for healthcare decision making.
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Scheeler A. Where Stool is a Drug: International Approaches to Regulating the use of Fecal Microbiota for Transplantation. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:524-540. [PMID: 31957572 DOI: 10.1177/1073110519897729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Regulatory agencies vary widely in their classification of FMT, with significant impact on patient access. This article conducts a global survey of national regulations and collates existing FMT classification statuses, ultimately suggesting that the human cell and tissue product designation best fits FMT's characteristics and that definitional objectives to that classification may be overcome.
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Affiliation(s)
- Alexandra Scheeler
- Alexandra Scheeler, M.T.S., is a M.B.A. student at the Georgetown McDonough School of Business, and also holds degrees from Princeton University and Harvard Divinity School. She was previously the Regulatory Affairs Manager at OpenBiome, a non-profit stool bank in Cambridge, MA
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29
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Prabhu VS, Dubberke ER, Dorr MB, Elbasha E, Cossrow N, Jiang Y, Marcella S. Cost-effectiveness of Bezlotoxumab Compared With Placebo for the Prevention of Recurrent Clostridium difficile Infection. Clin Infect Dis 2019; 66:355-362. [PMID: 29106516 DOI: 10.1093/cid/cix809] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium difficile infection (CDI) is the most commonly recognized cause of recurrent diarrhea. Bezlotoxumab, administered concurrently with antibiotics directed against C. difficile (standard of care [SoC]), has been shown to reduce the recurrence of CDI, compared with SoC alone. This study aimed to assess the cost-effectiveness of bezlotoxumab administered concurrently with SoC, compared with SoC alone, in subgroups of patients at risk of recurrence of CDI. Methods A computer-based Markov health state transition model was designed to track the natural history of patients infected with CDI. A cohort of patients entered the model with either a mild/moderate or severe CDI episode, and were treated with SoC antibiotics together with either bezlotoxumab or placebo. The cohort was followed over a lifetime horizon, and costs and utilities for the various health states were used to estimate incremental cost-effectiveness ratios (ICERs). Both deterministic and probabilistic sensitivity analyses were used to test the robustness of the results. Results The cost-effectiveness model showed that, compared with placebo, bezlotoxumab was associated with 0.12 quality-adjusted life-years (QALYs) gained and was cost-effective in preventing CDI recurrences in the entire trial population, with an ICER of $19824/QALY gained. Compared with placebo, bezlotoxumab was also cost-effective in the subgroups of patients aged ≥65 years (ICER of $15298/QALY), immunocompromised patients (ICER of $12597/QALY), and patients with severe CDI (ICER of $21430/QALY). Conclusions Model-based results demonstrated that bezlotoxumab was cost-effective in the prevention of recurrent CDI compared with placebo, among patients receiving SoC antibiotics for treatment of CDI.
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Affiliation(s)
| | | | | | | | | | - Yiling Jiang
- Merck Sharp & Dohme Ltd, Hoddesdon, Hertfordshire, United Kingdom
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30
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Mullish BH, Quraishi MN, Segal JP, McCune VL, Baxter M, Marsden GL, Moore D, Colville A, Bhala N, Iqbal TH, Settle C, Kontkowski G, Hart AL, Hawkey PM, Williams HR, Goldenberg SD. The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications: joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines. J Hosp Infect 2019; 100 Suppl 1:S1-S31. [PMID: 30173851 DOI: 10.1016/j.jhin.2018.07.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Benjamin H Mullish
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - Mohammed Nabil Quraishi
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan P Segal
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Inflammatory Bowel Disease Unit, St Mark's Hospital, Harrow, London, UK
| | - Victoria L McCune
- Public Health England, Public Health Laboratory Birmingham, Birmingham, UK; Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Melissa Baxter
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - David Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alaric Colville
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Neeraj Bhala
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Applied Health Research, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
| | - Tariq H Iqbal
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham, UK
| | - Christopher Settle
- Department of Microbiology, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Ailsa L Hart
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Inflammatory Bowel Disease Unit, St Mark's Hospital, Harrow, London, UK
| | - Peter M Hawkey
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Horace Rt Williams
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - Simon D Goldenberg
- Centre for Clinical Infection and Diagnostics Research, King's College London, London, UK; Department of Microbiology, Guy's and St Thomas' NHS Foundation Trust, London UK.
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31
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Leshem A, Horesh N, Elinav E. Fecal Microbial Transplantation and Its Potential Application in Cardiometabolic Syndrome. Front Immunol 2019; 10:1341. [PMID: 31258528 PMCID: PMC6587678 DOI: 10.3389/fimmu.2019.01341] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/28/2019] [Indexed: 12/12/2022] Open
Abstract
Newly revealed links between inflammation, obesity, and cardiometabolic syndrome have created opportunities to try previously unexplored therapeutic modalities in these common and life-risking disorders. One potential modulator of these complex disorders is the gut microbiome, which was described in recent years to be altered in patients suffering from features of cardiometabolic syndrome and to transmit cardiometabolic phenotypes upon transfer into germ-free mice. As a result, there is great interest in developing new modalities targeting the altered commensal bacteria as a means of treatment for cardiometabolic syndrome. Fecal microbiota transplantation (FMT) is one such modality in which a disease-associated microbiome is replaced by a healthy microbiome configuration. So far clinical use of FMT has been overwhelmingly successful in recurrent Clostridium difficile infection and is being extensively studied in other microbiome-associated pathologies such as cardiometabolic syndrome. This review will focus on the rationale, promises and challenges in FMT utilization in human disease. In particular, it will overview the role of the gut microbiota in cardiometabolic syndrome and the rationale, experience, and prospects of utilizing FMT treatment as a potential preventive and curative treatment of metabolic human disease.
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Affiliation(s)
- Avner Leshem
- Immunology Department, Weizmann Institute of Science, Rehovot, Israel.,Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nir Horesh
- Immunology Department, Weizmann Institute of Science, Rehovot, Israel.,Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Ramat Gan, Israel
| | - Eran Elinav
- Immunology Department, Weizmann Institute of Science, Rehovot, Israel.,Cancer-Microbiome Division, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
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32
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Dehlholm-Lambertsen E, Hall BK, Jørgensen SMD, Jørgensen CW, Jensen ME, Larsen S, Jensen JS, Ehlers L, Dahlerup JF, Hvas CL. Cost savings following faecal microbiota transplantation for recurrent Clostridium difficile infection. Therap Adv Gastroenterol 2019; 12:1756284819843002. [PMID: 31007720 PMCID: PMC6460887 DOI: 10.1177/1756284819843002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/26/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Recurrent Clostridium difficile infection (rCDI) is becoming increasingly common. Faecal microbiota transplantation (FMT) is effective for rCDI, but the costs of an FMT and hospital cost savings related to FMT are unknown. The aim of this study was to calculate the cost of an FMT and the total hospital costs before and after FMT. METHODS This was an observational single-centre study, carried out in a public teaching hospital. We included all patients referred for rCDI from January 2014 through December 2015 and documented costs related to donor screening, laboratory processing, and clinical FMT application. We calculated patient-related hospital costs 1 year before FMT (pre-FMT) and 1 year after FMT (post-FMT). Sensitivity analyses were applied to assess the robustness of the results. RESULTS We included 50 consecutive adult patients who had a verified diagnosis of rCDI and were referred for FMT. The average cost of an outpatient FMT procedure if donor faeces were applied by colonoscopy was €3,326 per patient and €2,864 if donor faeces were applied using a nasojejunal tube. The total annual pre-FMT hospital costs per patient were €56,415 (95% confidence interval (CI) 41,133-71,697), and these costs dropped by 42% to €32,816 (22,618-42,014) post-FMT (p = 0.004). The main cost driver was hospital admissions. Sensitivity analyses demonstrated cost reductions in all scenarios. CONCLUSIONS In a public hospital with an implemented FMT service, the average cost of FMT applied by either colonoscopy or nasojejunal tube was €3,095. Total hospital costs dropped by 42% the first year after FMT. The reduction was mainly caused by reductions in the number of hospital admissions and in length of stay.
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Affiliation(s)
| | | | - Simon M. D. Jørgensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mia E. Jensen
- School of Medicine and Health (SMH), Aalborg University, Denmark
| | - Sara Larsen
- School of Medicine and Health (SMH), Aalborg University, Denmark
| | | | - Lars Ehlers
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
| | - Jens F. Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Factors Associated With Health Care Utilization of Recurrent Clostridium difficile Infection in New York State. J Clin Gastroenterol 2019; 53:298-303. [PMID: 29570171 DOI: 10.1097/mcg.0000000000001022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The incidence of infection due to Clostridium difficile infection (CDI) and subsequent economic burden are substantial. GOALS The impact of changing practice patterns on demographics at risk and utilization of health care resources for recurrence of CDI remains unclear. STUDY A total of 291,163 patients hospitalized for CDI were identified from 1995 to 2014 from the New York SPARCS database. The χ test, the Welch t test, and multivariable logistic regression analysis were performed to evaluate factors related to readmission. RESULTS Hospital admissions and readmissions for CDI peaked in 2008 at 20,487 and 13,795, respectively, and have since decreased (linear trend, 0.9706 and 0.9464, respectively; P<0.0001). In total, 60,077 (21%) patients required ≥2 admissions. Risk factors for readmission included: age 55 to 74, government insurance, hypertension, diabetes, anemia, hypothyroidism, chronic pulmonary disease, rheumatoid arthritis, renal failure, peripheral vascular disease, and depression (all P<0.05). Trends in surgery showed a similar peak in 2008 at 165 and have since decreased (linear trend, 0.8660; P<0.0001). A total of 1830 (0.63%) patients with CDI underwent surgery, with emergent being more common than elective (71% vs. 29%). CONCLUSIONS Hospital admissions and readmissions for CDI peaked in 2008 and have since been steadily declining. These trends may be secondary to improved diagnostic capabilities and evolving antibiotic regimens. More than 1 in 5 hospitalized patients had at least 1 readmission. Numerous risk factors for these patients have been identified. Although <1% of all patients with CDI undergo surgery, these rates have also been declining.
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Li Y, Zou Z, Bian X, Huang Y, Wang Y, Yang C, Zhao J, Xie L. Fecal microbiota transplantation research output from 2004 to 2017: a bibliometric analysis. PeerJ 2019; 7:e6411. [PMID: 30809438 PMCID: PMC6387576 DOI: 10.7717/peerj.6411] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/01/2019] [Indexed: 12/15/2022] Open
Abstract
Background Fecal microbiota transplantation (FMT) is an emerging therapy against Clostridium difficile infection (CDI) and inflammatory bowel disease (IBD). Although the therapy has gained prominence, there has been no bibliometric analysis of FMT. Methods Studies published from 2004 to 2017 were extracted from the Science Citation Index Expanded. Bibliometric analysis was used to evaluate the number or cooperation network of publications, countries, citations, references, journals, authors, institutions and keywords. Results A total of 796 items were included, showing an increasing trend annually. Publications mainly came from 10 countries, led by the US (n = 363). In the top 100 articles ranked by the number of citations (range 47–1,158), American Journal of Gastroenterology (2017 IF = 10.231) took the top spot. The co-citation network had 7 co-citation clusters headed by ‘recurrent Clostridium difficile infection’. The top 7 keywords with the strongest citation bursts had three parts, ‘microbiota’, ‘ diarrhea ’, and ‘case series’. All keywords were divided into four domains, ‘disease’, ‘nosogenesis’, ‘trial’, and ‘therapy’. Conclusions This study shows the research performance of FMT from 2004 to 2017 and helps investigators master the trend of FMT, which is also an ongoing hotspot of research.
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Affiliation(s)
- Yan Li
- Department of General Surgery, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Ziyuan Zou
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaohui Bian
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Yushan Huang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Yanru Wang
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangzhou, China
| | - Chen Yang
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian Zhao
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Lang Xie
- Department of General Surgery, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
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Barbut F, Galperine T, Vanhems P, Le Monnier A, Durand-Gasselin B, Canis F, Jeanbat V, Duburcq A, Alami S, Bensoussan C, Fagnani F. Quality of life and utility decrement associated with Clostridium difficile infection in a French hospital setting. Health Qual Life Outcomes 2019; 17:6. [PMID: 30634997 PMCID: PMC6329091 DOI: 10.1186/s12955-019-1081-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 01/03/2019] [Indexed: 12/23/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is associated with a substantial Quality of life impact on patients that has not been so far measured with a generic validated instrument. Methods A prospective study was performed in 7 French acute-care settings in patients presenting with a bacteriologically-confirmed CDI. The EQ-5D-3 L was filled in by patients at 7 ± 2 days after CDI diagnosis to describe their state of health at that date as well as their state of health immediately before the CDI episode (baseline). Individual utility decrement was obtained by subtracting the corresponding utilities. The Quality Adjusted Life Year (QALY) loss was calculated by multiplying the days spent from baseline to the date of the interview, by the decrement of utility. A multivariate analysis of variance of the utility decrement according to CDI and patients characteristics was performed. Results Eighty patients were enrolled (mean age: 69.4 years, 55% females). The utility scores dropped from a mean 0.542 (SD: 0.391) at baseline to 0.050 (SD: 0.404) during the CDI episode with a mean adjusted utility decrement of 0.492 (SD: 0.398) point. This decrement increased significantly with CDI severity (Zar score ≥ 3) (p = 0.001), in patients with a positive baseline utility (p = 0.032), in women as compared to men (p = 0.041) and in patients aged more than 65 years (p = 0.041). No association with the Charlson index was found. The associated QALY loss not integrating the excess mortality was 0.028 (SD: 0.053). Conclusions The impact on quality of life of CDI episodes is major and translates in a substantial QALY loss despite their short duration. Electronic supplementary material The online version of this article (10.1186/s12955-019-1081-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Frédéric Barbut
- National Reference Laboratory for Clostridium difficile, Hôpital Saint-Antoine, 34 rue Crozatier, 75012, Paris, France. .,Université Paris Descartes, UMR-S1139, Sorbonne Paris Cité, Paris, France.
| | - Tatiana Galperine
- CHRU Lille, Maladies Infectieuses, French Group of Faecal Microbiota Transplantation (GFTF), Lille, France
| | - Philippe Vanhems
- Groupement Hospitalier Edouard Herriot, Unité d'Hygiène, Epidémiologie et Prévention, Hospices Civils de Lyon, and Université Lyon 1, Lyon, France
| | - Alban Le Monnier
- Laboratoire de Microbiologie Clinique, GH Paris Saint-Joseph, Paris, France
| | - Bernard Durand-Gasselin
- Hôpital Léopold Bellan, Service de gériatrie and Fondation Hospitalière Ste Marie Service de Soins de Suite et de Réadaptation gérontologique, Paris, France
| | - Frédérique Canis
- Centre hospitalier de Valenciennes, UF de Microbiologie, Pôle de Biologie Médicale, Valenciennes, France
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Ramai D, Zakhia K, Ofosu A, Ofori E, Reddy M. Fecal microbiota transplantation: donor relation, fresh or frozen, delivery methods, cost-effectiveness. Ann Gastroenterol 2019; 32:30-38. [PMID: 30598589 PMCID: PMC6302197 DOI: 10.20524/aog.2018.0328] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/08/2018] [Indexed: 12/15/2022] Open
Abstract
Fecal microbiota transplantation (FMT) has evolved into a robust and efficient means for treating recurrent Clostridium difficile infection (CDI). Our narrative review looks at the donor selection, preparation, delivery techniques and cost-effectiveness of FMT. We searched electronic databases, including PubMed, MEDLINE, Google Scholar, and Cochrane Databases, for studies that compared the biological effects of donor selection, fresh or frozen fecal preparation, and various delivery techniques. We also evaluated the cost-effectiveness and manually searched references to identify additional relevant studies. Overall, there is a paucity of studies that directly compare outcomes associated with related and non-related stool donors. However, inferences from prior studies indicate that the success of FMT does not depend on the donor-patient relationship. Over time, the use of unrelated donors has increased because of the formation of stool banks and the need to save processing time and capital. However, longitudinal studies are needed to clarify the optimal freezing time before microbial function declines. Several FMT techniques have been developed, such as colonoscopy, enema, nasogastric or nasojejunal tubes, and capsules. The comparable and high efficacy of FMT capsules, combined with their convenience, safety and aesthetically tolerable mode of delivery, makes it an attractive option for many patients. Cost-effective models comparing these various approaches support the use of FMT via colonoscopy as being the best strategy for the treatment of recurrent CDI.
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Affiliation(s)
- Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Daryl Ramai)
| | - Karl Zakhia
- Department of Medicine, Elmhurst Medical Center, Queens (Karl Zakhia)
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Andrew Ofosu, Emmanuel Ofori, Madhavi Reddy), New York, USA
| | - Emmanuel Ofori
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Andrew Ofosu, Emmanuel Ofori, Madhavi Reddy), New York, USA
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Andrew Ofosu, Emmanuel Ofori, Madhavi Reddy), New York, USA
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Pouch SM, Friedman-Moraco RJ. Prevention and Treatment of Clostridium difficile-Associated Diarrhea in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:733-748. [PMID: 30146033 DOI: 10.1016/j.idc.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection is a significant cause of morbidity and mortality in solid organ transplant recipients. Risk factors in this population include frequent hospitalizations, receipt of immunosuppressive agents, and intestinal dysbiosis triggered by several factors, including exposure to broad-spectrum antimicrobials. The incidence and potential for significant adverse outcomes among solid organ transplant recipients with C difficile infection highlight the evolving need for strategic C difficile infection risk factor modification and novel approaches to disease management in this patient population. This review focuses on current concepts related to the prevention and treatment of C difficile infection in solid organ transplant recipients.
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Affiliation(s)
- Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA.
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA
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Barlam TF, Soria-Saucedo R, Ameli O, Cabral HJ, Kaplan WA, Kazis LE. Retrospective analysis of long-term gastrointestinal symptoms after Clostridium difficile infection in a nonelderly cohort. PLoS One 2018; 13:e0209152. [PMID: 30557401 PMCID: PMC6296708 DOI: 10.1371/journal.pone.0209152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 12/02/2018] [Indexed: 12/27/2022] Open
Abstract
Elderly patients and those with comorbid conditions are at high risk for poor outcomes after Clostridium difficile infection (CDI) but outcomes in a healthier, nonelderly population are not well described. We sought to investigate gastrointestinal diagnoses and CDI during hospitalizations in the 24 to 36 months after an initial episode of CDI in nonelderly patients in a cohort with an overall low prevalence of comorbid conditions. We performed a retrospective analysis of hospital admissions from 2010–2013 using the Truven MarketScan database of employment-based private insurance claims. Subjects <65 years of age and their adult dependents (> = 18 years old); a CDI diagnosis in 2011 (index date); at least 12 months of pre-index continuous enrollment; and 24–36 months of continuous post-index enrollment were included. The 12 months of each subject’s enrollment prior to the index date for a CDI served as the reference period for the analyses of that subject’s post-CDI time periods. Hospital claims during the follow-up period were evaluated for gastrointestinal diagnoses and/or CDI ICD-9 codes. The risk of gastrointestinal diagnoses was assessed using Cox proportional hazards models adjusted for a pre-specified set of baseline demographic and clinical factors. During 2011, 5,632 subjects with CDI met the inclusion criteria for our study. The risk of gastrointestinal diagnoses in patients with a CDI diagnostic code for the same admission was almost 8-fold higher 3 months post-CDI (hazard ratio (HR) = 7.56; 95% confidence interval (CI): 2.97–19.19) than for subjects without CDI and remained statistically significant until month 24 (HR = 1.47; 95% CI = 1.04–2.08). After CDI, patients remained at risk for gastrointestinal symptoms with CDI for up to two years. There is an important, long-term healthcare burden after CDI in this population.
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Affiliation(s)
- Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
| | - Rene Soria-Saucedo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy at the University of Florida, Gainesville, Florida, United States of America
| | - Omid Ameli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Howard J. Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Warren A. Kaplan
- Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Lewis E. Kazis
- Health Outcomes Unit, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Mullish BH, Quraishi MN, Segal JP, Williams HRT, Goldenberg SD. Introduction to the joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) faecal microbiota transplant guidelines. J Hosp Infect 2018; 100:130-132. [PMID: 30241676 DOI: 10.1016/j.jhin.2018.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 01/28/2023]
Affiliation(s)
- B H Mullish
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - M N Quraishi
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J P Segal
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Inflammatory Bowel Disease Unit, St Mark's Hospital, Harrow, London, UK
| | - H R T Williams
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington, London, UK
| | - S D Goldenberg
- Centre for Clinical Infection and Diagnostics Research, King's College London, London, UK; Department of Microbiology, Guy's and St Thomas' NHS Foundation Trust, London UK.
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Stripling J, Rodriguez M. Current Evidence in Delivery and Therapeutic Uses of Fecal Microbiota Transplantation in Human Diseases-Clostridium difficile Disease and Beyond. Am J Med Sci 2018; 356:424-432. [PMID: 30384951 DOI: 10.1016/j.amjms.2018.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 12/18/2022]
Abstract
The use of fecal microbiota transplantation (FMT) was first described in China in the 4th century by Ge Hong when "yellow soup," a fecal slurry, was administered for the treatment of severe food poisoning and diarrhea, a practice that continued for centuries. Bedouin groups also consumed stools of their camels as a remedy for dysentery. FMT was also applied in veterinary medicine in Europe in the 16th century. Additional therapeutic use of human excretions was described in Europe in the 18th and 19th century and in World War II, when gut bacteria were administered to German soldiers suffering from dysentery in the North African campaign. More scientifically, Eismann, in 1958, utilized fecal transplantation via enema in 4 patients for the treatment of severe pseudomembranous colitis with success. Following this report a number of isolated cases were published describing the use of FMT by different delivery routes for the treatment of a variety of illnesses.
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Affiliation(s)
- Joshua Stripling
- University of Alabama at Birmingham, Division of Infectious Diseases, Birmingham, Alabama
| | - Martin Rodriguez
- University of Alabama at Birmingham, Division of Infectious Diseases, Birmingham, Alabama.
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Ford DC, Schroeder MC, Ince D, Ernst EJ. Cost-effectiveness analysis of initial treatment strategies for mild-to-moderate Clostridium difficile infection in hospitalized patients. Am J Health Syst Pharm 2018; 75:1110-1121. [DOI: 10.2146/ajhp170554] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Diana C. Ford
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mary C. Schroeder
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
| | - Dilek Ince
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Erika J. Ernst
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
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Cost-effectiveness analysis of ribotype-guided fecal microbiota transplantation in Chinese patients with severe Clostridium difficile infection. PLoS One 2018; 13:e0201539. [PMID: 30048534 PMCID: PMC6062131 DOI: 10.1371/journal.pone.0201539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background Clostridium difficile infection (CDI) caused by ribotype 002 strain is associated with poor outcomes in Chinese patients. Fecal microbiota transplantation (FMT) is an effective but costly treatment for CDI. We aimed to examine potential cost-effectiveness of ribotype-guided FMT in Chinese patients with severe CDI. Methods A decision-analytic model was designed to simulate outcomes of ribotype 002-guided FMT versus vancomycin treatment in Chinese patients with severe CDI in the hospital setting. Outcome measures included mortality rate; direct medical cost; and quality-adjusted life year (QALY) loss for CDI. Sensitivity analysis was performed to examine robustness of base-case results. Results Comparing to vancomycin treatment, ribotype-guided FMT group reduced mortality (11.6% versus 17.1%), cost (USD8,807 versus USD9,790), and saved 0.472 QALYs in base-case analysis. One-way sensitivity analysis found the ribotype-guided FMT group to remain cost-effective when patient acceptance rate of FMT was >0.6% and ribotype 002 prevalence was >0.07%. In probabilistic sensitivity analysis, ribotype-guided FMT gained higher QALYs at 100% of simulations with mean QALY gain of 0.405 QALYs (95%CI: 0.400–0.410; p<0.001). The ribotype-guided group was less costly in 97.9% of time, and mean cost-saving was USA679 (95%CI: 670–688; p<0.001). Conclusions In the present model, ribotype-guided FMT appears to be a potential option to save QALYs and cost when comparing with vancomycin. The cost-effectiveness of ribotype-guided FMT is subject to the patient acceptance to FMT and prevalence of ribotype 002.
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Cost-effectiveness of three different strategies for the treatment of first recurrent Clostridium difficile infection diagnosed in a community setting. Infect Control Hosp Epidemiol 2018; 39:924-930. [PMID: 29961435 DOI: 10.1017/ice.2018.139] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE A significant portion of patients with Clostridium difficile infections (CDI) experience recurrence, and there is little consensus on its treatment. With the availability of newer agents for CDI and the added burdens of recurrent disease, a cost-effectiveness analysis may provide insight on the most efficient use of resources. DESIGN A decision-tree analysis was created to compare the cost-effectiveness of 3 possible treatments for patients with first CDI recurrence: oral vancomycin, fidaxomicin, or bezlotoxumab plus vancomycin. The model was performed from a payer's perspective with direct cost inputs and a timeline of 1 year. A systematic review of literature was performed to identify clinical, utility, and cost data. Quality-adjusted life years (QALY) and incremental cost-effectiveness ratios were calculated. The willingness-to-pay (WTP) threshold was set at $100,000 per QALY gained. The robustness of the model was tested using one-way sensitivity analyses and probabilistic sensitivity analysis. RESULTS Vancomycin had the lowest cost ($15,692) and was associated with a QALY gain of 0.8019 years. Bezlotoxumab plus vancomycin was a dominated strategy. Fidaxomicin led to a higher QALY compared to vancomycin, at an incremental cost of $500,975 per QALY gained. Based on our WTP threshold, vancomycin alone was the most cost-effective regimen for treating the first recurrence of CDI. Sensitivity analyses demonstrated the model's robustness. CONCLUSIONS Vancomycin alone appears to be the most cost-effective regimen for the treatment of first recurrence of CDI. Fidaxomicin alone led to the highest QALY gained, but at a cost beyond what is considered cost-effective.
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Safety and efficacy of encapsulated fecal microbiota transplantation for recurrent Clostridium difficile infection: a systematic review. Eur J Gastroenterol Hepatol 2018; 30:730-734. [PMID: 29688901 DOI: 10.1097/meg.0000000000001147] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Fecal microbial transplantation (FMT) has been shown to be effective for the treatment of recurrent clostridium difficile infection (CDI). The efficacy and safety of freeze-dried encapsulated FMT for the treatment of recurrent CDI is unclear. We performed a systematic review to evaluate and analyze the current evidence in this respect. MATERIALS AND METHODS A systematic literature search was performed using the PubMed, Embase, and Medline databases until December 2017 to identify all original studies that investigated the role of administration of encapsulated FMT in recurrent CDI. The study included patients of all ages. Two independent reviewers extracted data and assessed the quality of publications; a third investigator resolved any discrepancies. RESULTS A total of six studies, five case series and one randomized-controlled trial, were included in this review. Overall, 341 patients completed treatment with encapsulated FMT. Only three major adverse events were reported and no deaths occurred directly related to FMT. In all, 285 patients responded to the first treatment, with no recurrence during the specified follow-up period set to meet the primary endpoint. Forty-two patients underwent a second treatment, with resolution of symptoms in 28 patients. At least five patients were reported to undergo a third treatment, with resolution in three of them. Only one patient was reported to have received four treatments without long-term resolution of symptoms. CONCLUSION Low-quality to moderate-quality evidence showed that encapsulated FMT is safe and cost-effective for the treatment and prevention of recurrent CDI. Its efficacy is not inferior to FMT performed through the nonoral route. Randomized-controlled trials are necessary to compare its efficacy with oral antimicrobial drugs and also to evaluate the potential adverse effects associated with the treatment.
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Loo VG, Davis I, Embil J, Evans GA, Hota S, Lee C, Lee TC, Longtin Y, Louie T, Moayyedi P, Poutanen S, Simor AE, Steiner T, Thampi N, Valiquette L. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. ACTA ACUST UNITED AC 2018. [DOI: 10.3138/jammi.2018.02.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vivian G Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Ian Davis
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Embil
- Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gerald A Evans
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Susy Hota
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christine Lee
- St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Yves Longtin
- Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Thomas Louie
- Peter Lougheed Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Susan Poutanen
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew E Simor
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Theodore Steiner
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Thampi
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Louis Valiquette
- Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
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MESSIAS BRUNOAMANTINI, FRANCHI BÁRBARAFREITAS, PONTES PEDROHENRIQUE, BARBOSA DANIELÁTILADEANDRADEMEDEIROS, VIANA CÉSARAUGUSTOSANITA. Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review. Rev Col Bras Cir 2018; 45:e1609. [PMID: 29846464 DOI: 10.1590/0100-6991e-20181609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/25/2018] [Indexed: 12/31/2022] Open
Abstract
ABSTRACT Clostridium difficile infection is a common complication following intestinal dysbiosis caused by abusive antibiotic use. It presents medical importance due to the high rates of recurrence and morbidity. Fecal microbiota transplantation is an effective alternative for the treatment of recurrent and refractory C. difficile infection and consists of introducing the intestinal microbiota from a healthy donor into a patient with this infection. The exact physiological mechanism by which fecal microbiota transplantation alters the intestinal microbiota is not well established, but it is clear that it restores the diversity and structure of the microbiota by promoting increased resistance to colonization by C. difficile. Several routes of transplant administration are being studied and used according to the advantages presented. All forms of application had a high cure rate, and the colonoscopic route was the most used. No relevant complications and adverse events have been documented, and the cost-effectiveness over conventional treatment has proven advantageous. Despite its efficacy, it is not commonly used as initial therapy, and more studies are needed to establish this therapy as the first option in case of refractory and recurrent Clostridium difficileinfection.
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Zhang F, Cui B, He X, Nie Y, Wu K, Fan D. Microbiota transplantation: concept, methodology and strategy for its modernization. Protein Cell 2018; 9:462-473. [PMID: 29691757 DOI: 10.1007/s13238-018-0541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/08/2018] [Indexed: 05/25/2023] Open
Abstract
Fecal microbiota transplantation (FMT) has become a research focus of biomedicine and clinical medicine in recent years. The clinical response from FMT for different diseases provided evidence for microbiota-host interactions associated with various disorders, including Clostridium difficile infection, inflammatory bowel disease, diabetes mellitus, cancer, liver cirrhosis, gut-brain disease and others. To discuss the experiences of using microbes to treat human diseases from ancient China to current era should be important in moving standardized FMT forward and achieving a better future. Here, we review the changing concept of microbiota transplantation from FMT to selective microbiota transplantation, methodology development of FMT and step-up FMT strategy based on literature and state experts' perspectives.
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Affiliation(s)
- Faming Zhang
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China.
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, 211166, China.
- Division of Microbiotherapy, Sir Run Run Shaw Hospital, Nanjing Medical University, Nanjing, 211166, China.
| | - Bota Cui
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, 211166, China
| | - Xingxiang He
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China
| | - Yuqiang Nie
- Department of Gastroenterology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, 510180, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology & Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
- National Clinical Research Center for Digestive Diseases, Xi'an, 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology & Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
- National Clinical Research Center for Digestive Diseases, Xi'an, 710032, China
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Zhang F, Cui B, He X, Nie Y, Wu K, Fan D. Microbiota transplantation: concept, methodology and strategy for its modernization. Protein Cell 2018; 9:462-473. [PMID: 29691757 PMCID: PMC5960466 DOI: 10.1007/s13238-018-0541-8] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/08/2018] [Indexed: 02/06/2023] Open
Abstract
Fecal microbiota transplantation (FMT) has become a research focus of biomedicine and clinical medicine in recent years. The clinical response from FMT for different diseases provided evidence for microbiota-host interactions associated with various disorders, including Clostridium difficile infection, inflammatory bowel disease, diabetes mellitus, cancer, liver cirrhosis, gut-brain disease and others. To discuss the experiences of using microbes to treat human diseases from ancient China to current era should be important in moving standardized FMT forward and achieving a better future. Here, we review the changing concept of microbiota transplantation from FMT to selective microbiota transplantation, methodology development of FMT and step-up FMT strategy based on literature and state experts' perspectives.
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Affiliation(s)
- Faming Zhang
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China.
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, 211166, China.
- Division of Microbiotherapy, Sir Run Run Shaw Hospital, Nanjing Medical University, Nanjing, 211166, China.
| | - Bota Cui
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, 211166, China
| | - Xingxiang He
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China
| | - Yuqiang Nie
- Department of Gastroenterology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, 510180, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology & Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
- National Clinical Research Center for Digestive Diseases, Xi'an, 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology & Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
- National Clinical Research Center for Digestive Diseases, Xi'an, 710032, China
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Le P, Nghiem VT, Mullen PD, Deshpande A. Cost-Effectiveness of Competing Treatment Strategies for Clostridium difficile Infection: A Systematic Review. Infect Control Hosp Epidemiol 2018; 39:412-424. [PMID: 29463339 PMCID: PMC5869164 DOI: 10.1017/ice.2017.303] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) presents a substantial economic burden and is associated with significant morbidity. While multiple treatment strategies have been evaluated, a cost-effective management strategy remains unclear. OBJECTIVE We conducted a systematic review to assess cost-effectiveness analyses of CDI treatment and to summarize key issues for clinicians and policy makers to consider. METHODS We searched PubMed and 5 other databases from inception to August 2016. These searches were not limited by study design or language of publication. Two reviewers independently screened the literature, abstracted data, and assessed methodological quality using the Drummond and Jefferson checklist. We extracted data on study characteristics, type of CDI, treatment characteristics, and model structure and inputs. RESULTS We included 14 studies, and 13 of these were from high-income countries. More than 90% of these studies were deemed moderate-to-high or high quality. Overall, 6 studies used a decision-tree model and 7 studies used a Markov model. Cost of therapy, time horizon, treatment cure rates, and recurrence rates were common influential factors in the study results. For initial CDI, fidaxomicin was a more cost-effective therapy than metronidazole or vancomycin in 2 of 3 studies. For severe initial CDI, 2 of 3 studies found fidaxomicin to be the most cost-effective therapy. For recurrent CDI, fidaxomicin was cost-effective in 3 of 5 studies, while fecal microbiota transplantation (FMT) by colonoscopy was consistently cost-effective in 4 of 4 studies. CONCLUSIONS The cost-effectiveness of fidaxomicin compared with other pharmacologic therapies was not definitive for either initial or recurrent CDI. Despite its high cost, FMT by colonoscopy may be a cost-effective therapy for recurrent CDI. A consensus on model design and assumptions are necessary for future comparison of CDI treatment. Infect Control Hosp Epidemiol 2018;39:412-424.
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Affiliation(s)
- Phuc Le
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Van T. Nghiem
- Department of Management, Policy and Community Health, The University of Texas School of Public Health, Houston, Texas
| | - Patricia Dolan Mullen
- Department of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, The University of Texas School of Public Health, Houston, Texas
| | - Abhishek Deshpande
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
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