title: Cost-effectiveness of competing strategies for management of recurrent Clostridium difficile infection: a decision analysis.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is an important cause of morbidity and healthcare costs, and is characterized by high rates of disease recurrence. The cost-effectiveness of newer treatments for recurrent CDI has not been examined, yet would be important to inform clinical practice. The aim of this study was to analyze the cost effectiveness of competing strategies for recurrent CDI.
  
  
  METHODS
  We constructed a decision-analytic model comparing 4 treatment strategies for first-line treatment of recurrent CDI in a population with a median age of 65 years: metronidazole, vancomycin, fidaxomicin, and fecal microbiota transplant (FMT). We modeled up to 2 additional recurrences following the initial recurrence. We assumed FMT delivery via colonoscopy as our base case, but conducted sensitivity analyses based on different modes of delivery. Willingness-to-pay threshold was set at $50 000 per quality-adjusted life-year.
  
  
  RESULTS
  At our base case estimates, initial treatment of recurrent CDI using FMT colonoscopy was the most cost-effective strategy, with an incremental cost-effectiveness ratio of $17 016 relative to oral vancomycin. Fidaxomicin and metronidazole were both dominated by FMT colonoscopy. On sensitivity analysis, FMT colonoscopy remained the most cost-effective strategy at cure rates >88.4% and CDI recurrence rates <14.9%. Fidaxomicin required a cost <$1359 to meet our cost-effectiveness threshold. In clinical settings where FMT is not available or applicable, the preferred strategy appears to be initial treatment with oral vancomycin.
  
  
  CONCLUSIONS
  In this decision analysis examining treatment strategies for recurrent CDI, we demonstrate that FMT colonoscopy is the most cost-effective initial strategy for management of recurrent CDI.
authors.affiliation: Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School.
authors.forename: Gauree G
authors.initials: GG
authors.lastname: Konijeti
authors.forename: Jenny
authors.initials: J
authors.lastname: Sauk
authors.forename: Mark G
authors.initials: MG
authors.lastname: Shrime
authors.forename: Meera
authors.initials: M
authors.lastname: Gupta
authors.forename: Ashwin N
authors.initials: AN
authors.lastname: Ananthakrishnan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000191:economics* / Q000627:therapeutic use*; D001691:Biological Therapy / Q000191:economics* / Q000379:methods*; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000382:microbiology / Q000517:prevention & control* / Q000628:therapy*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence
chemical_list: D000900:Anti-Bacterial Agents
keywords: Clostridium difficile infection; fecal microbiota transplant; fidaxomicin; metronidazole; vancomycin