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Professor and Chair
Department of Pharmacy Practice and Translational Research
University of Houston College of Pharmacy
Kevin Garey, PharmD, MS, has disclosed that he has received contracted research support from Acurx Pharmaceuticals, Paratek Pharmaceuticals, and Summit Pharmaceuticals.
Clostridioides difficile infection (CDI) is a major public health concern that requires urgent and immediate action, according to the Centers for Disease Control and Prevention. The patient and economic burden of CDI was evident in many of the presentations at IDWeek 2021. Here’s my take on how we may be able to use these data in our own practices to effect change in the near future.
The 2017 Infectious Diseases Society of America (IDSA) CDI guidelines update included recommendations to phase out metronidazole as a preferred antibiotic in favor of either vancomycin or fidaxomicin for first-line treatment of CDI. Dubberke and colleagues presented changes in CDI antibiotic use and clinical outcomes after the publication of this guideline. Using data from the Medicare claims database (2017-2018), investigators showed a decreased use of metronidazole (28% absolute decrease) with a similar increase in use of vancomycin (27% absolute increase) and little change in use of fidaxomicin. Unfortunately, improvements in overall CDI outcomes did not occur with this change in prescribing, possibly because vancomycin did not elicit meaningfully improved outcomes when compared with metronidazole.
Although still uncommonly used, fidaxomicin demonstrated superior recurrence and sustained recurrence rates compared with either vancomycin or metronidazole. These results, therefore, support the 2021 change in IDSA guidance recommending fidaxomicin over vancomycin and may improve patient outcomes.
Combining medical and pharmacy databases, Black and colleagues used the HealthVerity database to better understand healthcare resource utilization in approximately 6000 patients with CDI, with a particular focus on recurrent CDI. The majority of patients received vancomycin regardless of CDI episode (54%-67%), with fidaxomicin used in 7.5% of patients with first occurrence. The use of fecal microbiota transplant increased considerably after the third CDI episode (13%-21%).
Investigators found that healthcare resource utilization was common in this patient population. Indeed, before the first CDI episode, 25% of patients had visited the emergency department (ED), 50% had an inpatient admission, 34% had an outpatient hospital visit, and 65% had an office visit. At follow-up for the first episode, 70% of patients had visited the ED, 72% had an inpatient admission, 90% had an outpatient hospital visit, and 94% had an office visit. Furthermore, all healthcare contact points increased as the number of CDI episodes increased.
Transitions of Care
Another presentation at IDWeek 2021 investigated transitions of care after a CDI episode, with a particular focus on hospital readmissions. Drwiega and colleagues studied 185 CDI episodes at the University of Illinois at Chicago and noted that very few (12%) had a CDI-specific follow-up medical appointment within their healthcare network in the following 30 days. Ninety-day CDI recurrence occurred in more than 12% of the population, of which many (44%) were rehospitalized due to the CDI recurrence. Investigators note that further study should be conducted to ascertain if a follow-up appointment for CDI could decrease the hospitalization rate associated with recurrent CDI.
Two studies examined the economic and mortality burden of CDI at IDWeek 2021.
In the first, Yu and colleagues assessed the burden of CDI in Medicare Advantage enrollees, a population that includes almost 40% of the Medicare population. Matching approximately 15,000 CDI cases to an equal number of non-CDI controls, investigators identified approximately $14,000 higher healthcare costs for patients with CDI per episode in the 2 months after diagnosis.
One-year mortality was 8% higher in the CDI case group compared with the propensity-matched, non-CDI group.
In a separate study, using data from the Medicare 5% fee-for-service database, Olsen and colleagues examined the healthcare costs of CDI based on whether the patient died. In the analysis, 60,492 CDI cases were matched 1:4 with approximately 250,000 non-CDI controls. Patients with hospital-onset CDI or other healthcare facility–onset CDI accounted for the majority of cases (78%) and also the largest cost differential between cases and controls ($15,000-$30,000), adjusting for patient underlying medical conditions and 1-year mortality status.
These studies emphasize that preventing CDI in this older population of patients may improve outcomes and reduce healthcare utilization and associated costs.
Taken together, these presentations demonstrate a significant influence of international treatment guidelines to change prescribing patterns in a way that will hopefully improve patient outcomes and decrease patient burden. The economic burden of CDI is still considerable and warrants interventions for primary and recurrent CDI. Possible interventions to improve patient outcomes and lessen healthcare costs include increased use of therapies that lessen the likelihood of CDI recurrence and improvements in transitions of care. [Link to this track’s program page]
Do your patients attend follow-up appointments for Clostridioides difficile infection? Join the conversation by posting in the discussion section.