Cost-effectiveness of Fecal Microbiota Transplantation for First Recurrent Clostridioides difficile Infection

Abstract

Background: Both the American College of Gastroenterology and the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America 2021 Clostridioides difficile infection (CDI) guidelines recommend fecal microbiota transplantation (FMT) for persons with multiple recurrent CDI. Emerging data suggest that FMT may have high cure rates when used for first recurrent CDI. The aim of this study was to assess the cost-effectiveness of FMT for first recurrent CDI.

Methods: We developed a Markov model to simulate a cohort of patients presenting with initial CDI infection. The model estimated the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the 2021 IDSA guidelines, with the additional option of FMT for first recurrent CDI. The model includes stratification by the severity of initial infection, estimates of cure, recurrence, and mortality. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

Results: When FMT is available for first recurrent CDI, the optimal cost-effective treatment strategy is fidaxomicin for initial nonsevere CDI, vancomycin for initial severe CDI, and FMT for first and subsequent recurrent CDI, with an ICER of $27 135/QALY. In probabilistic sensitivity analysis at a $100 000 cost-effectiveness threshold, FMT for first and subsequent CDI recurrence was cost-effective 90% of the time given parameter uncertainty.

Conclusions: FMT is a cost-effective strategy for first recurrent CDI. Prospective evaluation of FMT for first recurrent CDI is warranted to determine the efficacy and risk of recurrence.

Keywords: Clostridium difficile infection; cost-effectiveness; fecal microbiota transplantation.

Figure 1.

Available treatment options for CDI per IDSA guidelines. In this model FMT was added as an option for first recurrent CDI. Abbreviations: CDI, Clostridium difficile infection; FMT, fecal microbiota transplantation; IDSA, Infectious Diseases Society of America.

Figure 2.

Cost-effectiveness acceptability curve for CDI treatment strategies that shows the probability that a given strategy is cost-effective as a function of WTP per QALY gained. Strategy 3 (red) represents metronidazole for nonsevere initial CDI and vancomycin for severe CDI and recurrent CDI. Strategy 31 (orange) represents vancomycin for initial CDI (nonsevere and severe), fidaxomicin for first recurrent CDI, and rifaximin with vancomycin for subsequent recurrence. Strategy 33 (light green) represents metronidazole for non-severe initial CDI, vancomycin for severe initial CDI, fidaxomicin for recurrent CDI. Strategy 43 (dark green) represents vancomycin for initial CDI (nonsevere and severe), fidaxomicin for first recurrent CDI, and FMT for subsequent recurrence. Strategy 67 (light blue) vancomycin for initial CDI (nonsevere and severe) and FMT for recurrent CDI. Strategy 68 (dark blue) fidaxomicin for nonsevere initial CDI, vancomycin for severe CDI, and FMT for recurrent CDI. Strategy 70 (purple) represents vancomycin for nonsevere CDI, fidaxomicin for severe initial CDI, and FMT for recurrent CDI. Strategy 71 (pink) represents fidaxomicin for initial CDI (nonsevere and severe) and FMT for recurrent CDI. The black boxes highlight the cost-effectiveness frontier, which is the optimal strategy, on average, across all probabilistic sensitivity analysis samples for a given WTP. Abbreviations: CDI, Clostridium difficile infection; FMT, fecal microbiota transplantation; Pr, proportional; QALY, quality-adjusted life-year; WTP, willingness-to-pay.