title: An Economic Analysis of Strategies to Control Clostridium Difficile Transmission and Infection Using an Agent-Based Simulation Model.
abstract: BACKGROUND
  A number of strategies exist to reduce Clostridium difficile (C. difficile) transmission. We conducted an economic evaluation of "bundling" these strategies together.
  
  
  METHODS
  We constructed an agent-based computer simulation of nosocomial C. difficile transmission and infection in a hospital setting. This model included the following components: interactions between patients and health care workers; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. Six interventions were introduced alone and "bundled" together: (a) aggressive C. difficile testing; (b) empiric isolation and treatment of symptomatic patients; (c) improved adherence to hand hygiene and (d) contact precautions; (e) improved use of soap and water for hand hygiene; and (f) improved environmental cleaning. Our analysis compared these interventions using values representing 3 different scenarios: (1) base-case (BASE) values that reflect typical hospital practice, (2) intervention (INT) values that represent implementation of hospital-wide efforts to reduce C. diff transmission, and (3) optimal (OPT) values representing the highest expected results from strong adherence to the interventions. Cost parameters for each intervention were obtained from published literature. We performed our analyses assuming low, normal, and high C. difficile importation prevalence and transmissibility of C. difficile.
  
  
  RESULTS
  INT levels of the "bundled" intervention were cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in all importation prevalence and transmissibility scenarios. OPT levels of intervention were cost-effective for normal and high importation prevalence and transmissibility scenarios. When analyzed separately, hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were the interventions that had the greatest impact on both cost and effectiveness.
  
  
  CONCLUSIONS
  A combination of available interventions to prevent CDI is likely to be cost-effective but the cost-effectiveness varies for different levels of intensity of the interventions depending on epidemiological conditions such as C. difficile importation prevalence and transmissibility.
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Nelson
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: Makoto
authors.initials: M
authors.lastname: Jones
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: Molly
authors.initials: M
authors.lastname: Leecaster
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: Matthew H
authors.initials: MH
authors.lastname: Samore
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: William
authors.initials: W
authors.lastname: Ray
authors.affiliation: Infection Control Program, Geneva Hospitals, Geneva, Switzerland.
authors.forename: Angela
authors.initials: A
authors.lastname: Huttner
authors.affiliation: Infection Control Program, Geneva Hospitals, Geneva, Switzerland.
authors.forename: Benedikt
authors.initials: B
authors.lastname: Huttner
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: Karim
authors.initials: K
authors.lastname: Khader
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, United States of America.
authors.forename: Vanessa W
authors.initials: VW
authors.lastname: Stevens
authors.affiliation: Edward Hines Jr. VA Hospital, Hines, IL, United States of America.
authors.forename: Dale
authors.initials: D
authors.lastname: Gerding
authors.affiliation: Iowa City Veterans Affairs Health Care System, Iowa City, IA, United States of America.|Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America.
authors.forename: Marin L
authors.initials: ML
authors.lastname: Schweizer
authors.affiliation: Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States of America.|Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Rubin
mesh_terms: D016360:Clostridioides difficile / Q000302:isolation & purification*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003428:Cross Infection / Q000175:diagnosis / Q000517:prevention & control* / Q000635:transmission*; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis / Q000517:prevention & control* / Q000635:transmission*; D063373:Hand Hygiene / Q000191:economics / Q000379:methods; D006761:Hospitals; D006801:Humans; D017053:Infection Control / Q000191:economics* / Q000379:methods*; D018803:Models, Economic; D012915:Soaps / Q000191:economics / Q000627:therapeutic use
chemical_list: D012915:Soaps