In talking to healthcare leaders about drug utilization, the Lumere Pharmacy team has fielded many questions concerning the application of clinical evidence to specific drugs and drug categories. I address one popular topic below.
DEAR LUMERE: With so many options available for the treatment of C. diff-associated diarrhea (CDAD), can we simply choose metronidazole since it’s the least expensive therapy? – CONCERNED ABOUT C. DIFF
DEAR CONCERNED ABOUT C. DIFF: Unfortunately, it’s not that simple—price is just one of several factors you need to consider when choosing the right CDAD therapy. It’s true that providers have often turned to metronidazole as a first-line treatment for CDAD, given its attractive price point and modest efficacy. However, the body of evidence indicates that both vancomycin and fidaxomicin provide a more effective symptomatic cure.1 In fact, recently updated clinical practice guidelines now recommend vancomycin or fidaxomicin over metronidazole.2
Vancomycin or fidaxomicin?
The high cost of fidaxomicin can be a tough pill to swallow, especially since many hospitals have been able to control vancomycin costs by compounding its intravenous formulation into an oral solution. Additionally, the FDA has recently approved an oral liquid formulation.
However, while vancomycin can provide sufficient cure at a lower cost, the clinical benefits of the higher-priced fidaxomicin may make it a worthy investment. When deciding between the two, keep in mind that fidaxomicin has been associated with fewer re-hospitalizations due to infection recurrence, suggesting greater long-term cost savings.3
FMT for recurrent cases
For the treatment of a recurrent episode, a fecal microbiota transplant (FMT) is a highly effective option, with some studies reporting cure rates as high as 90%.4 Although FMT can be associated with considerable ancillary costs, including vendor-charged shipping and processing fees or donor laboratory testing, these costs may be offset by a reduction in re-infection hospitalizations.5
Rather than cost, your hospital’s therapy selection should be based on the type and severity of the CDAD episode. Additionally, I recommend conducting a thorough analysis of your patient outcomes, including infection recurrences, to guide formulary standardization considerations.
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1 “A Meta-Analysis of Metronidazole and Vancomycin for the Treatment of Clostridium Difficile Infection, Stratified by Disease Severity.” Di X, Bai N, Zhang X, Liu B, et al. The Brazilian Journal of Infectious Diseases, (05/2015)
2 “Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).” McDonald L, Gerding D, Johnson S, et al. Clinical Infectious Diseases, (02/2018)
3“Cost-effectiveness analysis evaluating fidaxomicin versus oral vancomycin for the treatment of Clostridium difficile infection in the United States.” Stranges PM, Hutton DW, Collins CD. Value in Health, (03/2013)
4“Randomised clinical trial: faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection.” Cammarota G1, Masucci L, Ianiro G, et al. Alimentary Pharmacology & Therapeutics, (05/2015)
5“Systematic review of intestinal microbiota transplantation (fecal bacteriotherapy) for recurrent Clostridium difficile infection.” Gough E1, Shaikh H, Manges AR. Clinical Infectious Diseases, (11/2011)