Jim Kling

October 25, 2013

SAN DIEGO — A new analysis of the cost effectiveness of various strategies to combat recurring Clostridium difficile infections (CDIs) shows that fecal microbial transplantation delivered by colonoscopy is the best approach.

"Fecal transplant has emerged as a new and effective therapy for CDI, but we know there are costs associated with it," Gauree Gupta Konijeti, MD, a fellow at Massachusetts General Hospital in Boston, told Medscape Medical News. "We wanted to see whether it makes sense on a cost-effectiveness scale."

Dr. Konijeti presented the results here at the American College of Gastroenterology 2013 Annual Scientific Meeting.

There are now several options available to treat the condition, but they have not been evaluated for cost effectiveness when both the initial treatment cost and the health benefits of preventing recurrence have been taken into account.

Dr. Konijeti and her team used a decision-analytic model to compare the cost effectiveness of 4 treatment strategies for a first episode of CDI: fecal transplantation, metronidazole, vancomycin, and fidaxomicin. The team tested up to 2 recurrences after the initial episode.

Fecal transplantation delivered by colonoscopy had an incremental cost-effectiveness ratio of $46,419, compared with vancomycin. It also easily outperformed fidaxomicin and metronidazole because of the higher costs and lower efficacy of these drugs.

Fecal transplantation remained the most cost-effective approach, with cure rates higher than 96.4%, a CDI recurrence rate below 6.9%, and a cost of less than $1223.

The researchers also constructed a model of fecal transplantation that was delivered by enema or nasoduodenal infusion, but found that colonoscopy was more cost effective because it's efficacy is better than the other 2 delivery systems.

Transplantation by Enema or Nasoduodenal Infusion

Dr. Konijeti expressed optimism that fecal transplantation delivered by enema or nasoduodenal infusion could, with improvements, match the efficacy of colonoscopy-delivered transplants. "We typically use lower fecal microbiota doses for nasoduodenal and enema delivery, which might be one of the reasons they don't have similar efficacy," she said.

If comparable efficacy could be achieved, these delivery systems would be preferable because they cost less than colonoscopy.

In clinical settings where colonoscopy was not available, the researchers found that vancomycin was the most cost-effective option. The cost of fidaxomicin, at $462,706 per quality-adjusted life year, is prohibitive compared with the older drug.

"It's a timely study because recurrent C difficile is truly recurrent; a lot of patients have multiple episodes over a period of time," session moderator Jonathan Leighton, MD, from Mayo Clinic Arizona in Scottsdale, told Medscape Medical News. "I think the primary reason that fecal transplant was shown to be the most cost-effective strategy is that, at least in studies to date, fecal transplant has the highest cure rates. You don't have multiple recurrences if you treat them that way."

Dr. Konijeti and Dr. Leighton have disclosed no relevant financial relationships.

American College of Gastroenterology 2013 Annual Scientific Meeting and Postgraduate Course: Abstract 9. Presented October 14, 2013.

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