Fecal transplant most cost-effective first-line treatment for recurrent CDI

Konijeti G. Clin Infect Dis. 2014;doi:10.1093/cid/ciu128.

  • April 9, 2014

Researchers from Massachusetts General Hospital have found that fecal microbiota transplant via colonoscopy was the most cost-effective strategy for first-line treatment of recurrent Clostridium difficile infection.

“In settings where [fecal microbiota transplant] is not available, initial treatment with oral vancomycin was the most cost-effective strategy,” the researchers wrote in Clinical Infectious Diseases. “As more data become available, guidelines should consider incorporating use of [fecal microbiota transplant] earlier in the treatment of CDI, considering its high efficacy and low CDI recurrence rate.”

The researchers constructed a decision-analytic model to compare four treatment strategies: Metronidazole, vancomycin, fidaxomicin (Dificid, Cubist) and fecal microbiota transplant (FMT). The hypothetical cohorts included adult patients with a median age of 65 years. The researchers calculated the cost-effectiveness of the three pharmacologic treatments compared with three possible FMT delivery methods: Colonoscopy, duodenal infusion or enema.

FMT colonoscopy was the most cost-effective method, with an incremental cost-effectiveness ratio of $17,016 compared with vancomycin. FMT by duodenal infusion or enema were not as cost-effective as FMT colonoscopy or oral vancomycin. FMT colonoscopy is cost-effective at cure rates of more than 88.4%, but with lower cure rates, vancomycin is more cost-effective. If the willingness-to-pay threshold increased to $100,000 per quality-adjusted life year, FMT colonoscopy would be most cost-effective at cure rates of more than 84.4%. FMT colonoscopy was cost-effective at recurrence rates of less than 14.9%. If FMT is not available, vancomycin is the most cost-effective treatment.

“Considering the costs and training required to perform FMT, our analysis supports the need for continued standardization of FMT if it is to be used more routinely in the treatment of recurrent CDI,” the researchers wrote. “Future studies examining new treatments for CDI should incorporate FMT to examine comparative effectiveness if FMT becomes more widely adopted.”

Disclosure: One researcher has financial relationships with Cubist Pharmaceuticals, Janssen Pharmaceuticals and Prometheus Inc.