title: Cost-Effectiveness Analysis of Five Competing Strategies for the Management of Multiple Recurrent Community-Onset Clostridium difficile Infection in France.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is characterized by high rates of recurrence, resulting in substantial health care costs. The aim of this study was to analyze the cost-effectiveness of treatments for the management of second recurrence of community-onset CDI in France.
  
  
  METHODS
  We developed a decision-analytic simulation model to compare 5 treatments for the management of second recurrence of community-onset CDI: pulsed-tapered vancomycin, fidaxomicin, fecal microbiota transplantation (FMT) via colonoscopy, FMT via duodenal infusion, and FMT via enema. The model outcome was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) among the 5 treatments. ICERs were interpreted using a willingness-to-pay threshold of €32,000/QALY. Uncertainty was evaluated through deterministic and probabilistic sensitivity analyses.
  
  
  RESULTS
  Three strategies were on the efficiency frontier: pulsed-tapered vancomycin, FMT via enema, and FMT via colonoscopy, in order of increasing effectiveness. FMT via duodenal infusion and fidaxomicin were dominated (i.e. less effective and costlier) by FMT via colonoscopy and FMT via enema. FMT via enema compared with pulsed-tapered vancomycin had an ICER of €18,092/QALY. The ICER for FMT via colonoscopy versus FMT via enema was €73,653/QALY. Probabilistic sensitivity analysis with 10,000 Monte Carlo simulations showed that FMT via enema was the most cost-effective strategy in 58% of simulations and FMT via colonoscopy was favored in 19% at a willingness-to-pay threshold of €32,000/QALY.
  
  
  CONCLUSIONS
  FMT via enema is the most cost-effective initial strategy for the management of second recurrence of community-onset CDI at a willingness-to-pay threshold of €32,000/QALY.
authors.affiliation: Univ. Lille, CHU Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins, Lille, France.
authors.forename: Emilie
authors.identifier: http://orcid.org/0000-0002-4025-190X
authors.initials: E
authors.lastname: Baro
authors.affiliation: CHU Lille, Maladies Infectieuses, French Group of Faecal Microbiota Transplantation (GFTF), Lille, France.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Galperine
authors.affiliation: CHU Lille, Direction de la Recherche en Santé, Lille, France.
authors.forename: Fanette
authors.initials: F
authors.lastname: Denies
authors.affiliation: Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France.
authors.forename: Damien
authors.initials: D
authors.lastname: Lannoy
authors.affiliation: CHU Lille, Département d'Information Médicale, Lille, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Lenne
authors.affiliation: Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France.
authors.forename: Pascal
authors.initials: P
authors.lastname: Odou
authors.affiliation: CHU Lille, Maladies Infectieuses, French Group of Faecal Microbiota Transplantation (GFTF), Lille, France.|Univ. Lille, CHU Lille, EA 7366 - Recherche Translationnelle: Relations Hôte-Pathogènes, Lille, France.
authors.forename: Benoit
authors.initials: B
authors.lastname: Guery
authors.affiliation: Univ. Lille, CHU Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins, Lille, France.
authors.forename: Benoit
authors.initials: B
authors.lastname: Dervaux
mesh_terms: D000617:Aminoglycosides / Q000191:economics / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use; D016360:Clostridioides difficile; D017714:Community-Acquired Infections / Q000191:economics* / Q000628:therapy*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004761:Enterocolitis, Pseudomembranous / Q000191:economics* / Q000628:therapy*; D000069467:Fecal Microbiota Transplantation / Q000191:economics / Q000379:methods; D000077732:Fidaxomicin; D005602:France; D017048:Health Care Costs; D006801:Humans; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D014640:Vancomycin / Q000191:economics / Q000627:therapeutic use
chemical_list: D000617:Aminoglycosides; D000900:Anti-Bacterial Agents; D014640:Vancomycin; D000077732:Fidaxomicin