A prospective, observational study of fidaxomicin use for Clostridioides difficile infection in France

Clinical and economic outcomes associated with fidaxomicin in comparison to vancomycin, metronidazole, and FMT: A systematic literature review

BACKGROUND

There are an estimated half a million cases of Clostridioides difficile infection (CDI), in the United States annually. Fidaxomicin, vancomycin, and metronidazole are commonly used for CDI treatment, with fidaxomicin recommended by clinical guidelines as the preferred treatment for initial and recurrent CDI. This systematic literature review aimed to explore clinical and economic outcomes associated with fidaxomicin use with or without comparison to vancomycin, metronidazole, or fecal microbiota transplantation (FMT).

METHODS

The EMBASE, Medline, EconLit, and Evidence Based Medicine Reviews databases were searched from January 1st, 2012 to December 6th, 2022, as fidaxomicin was first approved for adult use in 2011. Identified publications were assessed and extracted by 2 independent reviewers.

RESULTS

Seventy-nine publications were included. Articles reporting at least 50 patients with follow-up ≤90 days were selected to obtain comparable outcome definitions (N = 14). Sustained clinical cure rate at 30- and 60-days follow-up was higher among fidaxomicin-treated patients (70.0-75.1% and 63.2-78.9%; N = 3) than vancomycin (45.1-58.2% and 38.9-50.0%; N = 3). Lower recurrence rates were reported post-fidaxomicin treatment compared to vancomycin, however the ranges overlapped at 30-, 60-, and 90-days follow-up. Limited outcomes for comparators metronidazole and FMT were identified. Healthcare resource use data were limited, with 2 studies reporting direct costs finding that fidaxomicin use-associated savings were driven by reduced hospital admission-related costs. Fidaxomicin was cost-effective in 14 of 21 economic analyses (11 vs vancomycin). Three studies reported vancomycin or FMT as more cost-effective than fidaxomicin. Fidaxomicin was consistently cost-effective or cost-saving among patients receiving concomitant antibiotics, and patients with cancer or renal impairment. Ten publications reported that the higher acquisition cost of fidaxomicin was offset by reduced recurrence and hospital readmission costs.

CONCLUSIONS

Fidaxomicin was clinically effective compared to vancomycin. Fidaxomicin is often reported as cost-effective, consistently within high-risk subpopulations.

Real-world effectiveness of fidaxomicin in patients at high risk of Clostridioides difficile recurrence

Objective

Compare the real-world impact of fidaxomicin (FDX) and vancomycin (VAN) on Clostridioides difficile infection (CDI) recurrence in a high-risk patient population.

Design

A retrospective, matched-cohort study evaluating hospitalized patients with CDI from January 1, 2016, to November 1, 2022, within a tertiary academic medical center.

Patients

Adult patients with at least 1 prior CDI case who received either FDX or VAN for non-fulminant CDI while admitted, and had at least 1 additional risk factor for recurrence. Risk factors included age >70, solid organ or bone marrow transplant recipients, broad-spectrum antibiotic use within 30 days, or receipt of chemotherapy/immune-modulating agents within 30 days of admission. FDX and VAN patients were matched according to risk factors.

Results

A total of 415 patient admissions were identified. After the exclusion of 92 patients for fulminant CDI, diarrhea from another cause, or use of VAN taper therapy, and 15 unmatched patients, 308 patient admissions were included (68 FDX and 240 VAN patients). There were no significant differences in 4-week recurrence (26% vs 23%; OR 1.1; P = .51), 90-day CDI readmission (29% vs 23%; P = .65), or 90-day all-cause readmission (54% vs 53%; P = .91). There was a significant 17% decrease in 90-day mortality associated with the use of FDX (OR .3; P = .04).

Conclusions

In a real-world high-risk patient population, the use of FDX compared to oral VAN did not result in decreased CDI recurrence within 4 weeks or fewer hospital readmissions within 90 days. Further research is needed to better assess the value of FDX in this patient population.

The Clinical Efficacy, Safety, and Tolerability of Vancomycin for the Treatment of Recurrent Clostridioides difficile Infection - A Systematic Review

Introduction

The aim of this systematic review of randomized clinical trials (RCTs) was to examine the efficacy, safety, and tolerability of vancomycin for treatment of recurrent Clostridioides difficile infection (rCDI).

Methods

The PubMed database was searched from inception to August 23, 2022. An initial screening was performed followed by a full-text evaluation of the papers. Inclusion criteria were RCTs investigating vancomycin for treatment of rCDI.

Results

A total of six studies and 269 patients were included in the review. Three studies used a fixed dose regimen of vancomycin, one study used pulse regimen, one study used a taper-and-pulse regimen, and one study used a taper-and-pulse regimen for the participants with two or more recurrences. The resolution of infection varied from 19% to 58.3% in five of six studies reporting this as an outcome. Four out of six studies reported new episodes of rCDI as an intervention outcome, in those studies 50-63% of participants experienced rCDI. Regarding the safety and tolerability of vancomycin treatment for rCDI, one study described several adverse events regarding gastrointestinal discomfort along with fatigue and skin rash. There were no records of serious adverse events in the included studies.

Conclusion

While oral vancomycin is mostly safe and well tolerated in the RCTs reviewed here, the efficacy for treating rCDI varies greatly from 19-58.3%, and 50-63% of participants experienced new episodes of rCDI.