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Mohamed MFH, Ward C, Beran A, Abdallah MA, Asemota J, Kelly CR. Efficacy, Safety, and Cost-effectiveness of Bezlotoxumab in Preventing Recurrent Clostridioides difficile Infection : Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:389-401. [PMID: 37395627 DOI: 10.1097/mcg.0000000000001875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/20/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) remains a global health challenge. Bezlotoxumab (BEZ) is a monoclonal antibody against C. difficile toxin B. Two randomized controlled trials (RCTs), MODIFY I and II, confirmed BEZ efficacy in preventing recurrent Clostridioides difficile infection (rCDI). However, there are safety concerns about its use in patients with a history of congestive heart failure. Observational studies have since been conducted, and it is important to explore the consistency of BEZ efficacy, cost-effectiveness, and its safety utilizing these real-world data. METHODS We performed a systematic review and meta-analysis to pool the rate of rCDI in patients receiving BEZ and explore its efficacy and safety in preventing rCDI compared with control. We searched PubMed, EMBASE, Cochrane Library, and Google Scholar from inception through April 2023 for relevant RCTs or observational studies assessing BEZ in preventing rCDI. Single-arm studies describing experience with BEZ in preventing rCDI were also included for proportion meta-analysis. A proportion meta-analysis with a random-effects model was used to pool the rCDI rate with its corresponding 95% CI. In a meta-analysis of efficacy, we generated the relative risk (RR) to compare BEZ versus control in preventing rCDI. RESULTS Thirteen studies including 2 RCTs and 11 observational studies totaling 2337 patients, of which 1472 received BEZ, were included in the analysis. Of the constituent studies, 5 (1734 patients) compared BEZ versus standard-of-care (SOC). Pooled rate of rCDI in patients receiving BEZ was 15.8% (95% CI: 14%-17.8%), and was 28.9% (95% CI: 24%-34.4%) in the SOC. BEZ significantly reduced rCDI risk compared with SOC [RR=0.57 (95% CI: 0.45-0.72, I2 =16%)]. There was no difference in the overall mortality or heart failure risk. Of the 9 included cost-effectiveness analyses, 8 demonstrated BEZ+SOC cost-effectiveness compared with SOC alone. DISCUSSION Our meta-analysis comprising real-world data revealed lower rCDI in patients receiving BEZ and supported its efficacy and safety when added to SOC therapy. The results were consistent across various subgroups. Available cost-effectiveness analyses mostly support BEZ+SOC cost-effectiveness compared with SOC alone.
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Affiliation(s)
| | | | - Azizullah Beran
- Gastroenterology and Hepatology Department, Indiana University, Indianapolis, IN
| | | | - Joseph Asemota
- Division of Gastroenterology, Boston University, Boston, MA
| | - Colleen R Kelly
- The Warren Alpert Medical School of Brown University
- Lifespan Physician Group, The Miriam Hospital, Providence, RI
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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024:e0013523. [PMID: 38421181 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Jacopo Monticelli
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Luigi Principe
- Microbiology and Virology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, Palermo, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
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3
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Yakout A, Bi Y, Harris DM. Clostridioides Difficile: A Concise Review of Best Practices and Updates. J Prim Care Community Health 2024; 15:21501319241249645. [PMID: 38726585 PMCID: PMC11085020 DOI: 10.1177/21501319241249645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Clostridioides difficile infection (CDI) is one of the most common and severe nosocomial infections worldwide. It can also affect healthy individuals in the community. The incidence of CDI has been on the rise globally for the past decade, necessitating a proactive approach to combat its spread; new strategies are being developed to enhance diagnostic accuracy and optimize treatment outcomes. Implementing the 2-step testing has increased diagnostic specificity, reducing the usage of CD-specific antibiotics with no concomitant increase in surgical complication rates. In 2021, the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) shifted its preference for initial treatment to fidaxomicin over vancomycin and metronidazole due to its lower recurrence rate. It also prioritized fidaxomicin for the treatment of recurrent CDI. There are new developments on the frontiers of fecal microbiota therapies, with RBX2660 and SER-109 approved recently by the FDA for prevention, with other microbiome-based therapies in various development and clinical trials. This review offers providers an updated and practical guide for CDI management.
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Affiliation(s)
| | - Yan Bi
- Mayo Clinic, Jacksonville, FL, USA
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Buddle JE, Fagan RP. Pathogenicity and virulence of Clostridioides difficile. Virulence 2023; 14:2150452. [PMID: 36419222 DOI: 10.1080/21505594.2022.2150452] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/02/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Clostridioides difficile is the most common cause of nosocomial antibiotic-associated diarrhea, and is responsible for a spectrum of diseases characterized by high levels of recurrence, morbidity, and mortality. Treatment is complex, since antibiotics constitute both the main treatment and the major risk factor for infection. Worryingly, resistance to multiple antibiotics is becoming increasingly widespread, leading to the classification of this pathogen as an urgent threat to global health. As a consummate opportunist, C. difficile is well equipped for promoting disease, owing to its arsenal of virulence factors: transmission of this anaerobe is highly efficient due to the formation of robust endospores, and an array of adhesins promote gut colonization. C. difficile produces multiple toxins acting upon gut epithelia, resulting in manifestations typical of diarrheal disease, and severe inflammation in a subset of patients. This review focuses on such virulence factors, as well as the importance of antimicrobial resistance and genome plasticity in enabling pathogenesis and persistence of this important pathogen.
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Affiliation(s)
- Jessica E Buddle
- Molecular Microbiology, School of Biosciences, University of Sheffield, Sheffield, UK
| | - Robert P Fagan
- Molecular Microbiology, School of Biosciences, University of Sheffield, Sheffield, UK
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5
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Bai M, Guo H, Zheng XY. Inflammatory bowel disease and Clostridium difficile infection: clinical presentation, diagnosis, and management. Therap Adv Gastroenterol 2023; 16:17562848231207280. [PMID: 38034098 PMCID: PMC10685799 DOI: 10.1177/17562848231207280] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/24/2023] [Indexed: 12/02/2023] Open
Abstract
As a frequent complication of inflammatory bowel disease (IBD), Clostridium difficile infection (CDI) was confirmed to not only aggravate the symptoms of IBD but also result in unexpected outcomes, including death. With the increasing prevalence rate of IBD and the updating of CDI diagnosis, the incidence of CDI in IBD patients is also seen rising. Although a detection method consisting of glutamate dehydrogenase immunoassay or nucleic acid amplification test and then toxin A/B enzyme immunoassay was recommended and widely adopted, the diagnosis of CDI in IBD is still a challenge because of the overlap between the symptoms of CDI in IBD and CDI itself. Vancomycin and fidaxomicin are the first-line therapy for CDI in IBD; however, the treatment has different effects due to the complexity of IBD patients' conditions and the choice of different treatment schemes. Although the use of fecal microbial transplantation is now in the ascendant for IBD management, the prospects are still uncertain and the prevention and treatment of the recurrence of CDI in IBD remain a clinical challenge. In this paper, the epidemiology, pathophysiology, clinical manifestation, prevention, and therapy of CDI in IBD were summarized and presented.
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Affiliation(s)
- Mei Bai
- Department of Gastroenterology, Chongqing General Hospital, Chongqing, China
| | - Hong Guo
- Department of Gastroenterology, Chongqing General Hospital, 28 Jinshan Avenue, Yubei District, Chongqing 401147, China
| | - Xiao-Yao Zheng
- Department of Pharmaceutics, School of Pharmacy, Fudan University, Shanghai, China
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6
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Berry P, Khanna S. Recurrent Clostridioides difficile Infection: Current Clinical Management and Microbiome-Based Therapies. BioDrugs 2023; 37:757-773. [PMID: 37493938 DOI: 10.1007/s40259-023-00617-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 07/27/2023]
Abstract
Clostridioides difficile is one of the most important causes of healthcare-associated diarrhea. The high incidence and recurrence rates of C. difficile infection, as well as its associated morbidity and mortality, are great concerns. The most common complication of C. difficile infection is recurrence, with rates of 20-30% after a primary infection and 60% after three or more episodes. Medical management of recurrent C. difficile infection involves a choice of therapy that is different from the antibiotic used in the primary episode. Patients with recurrent C. difficile infection also benefit from fecal microbiota transplantation or standardized microbiome restoration therapies (approved or experimental) to restore eubiosis. In contrast to antibiotics, microbiome restoration therapies restore a normal gut flora and eliminate C. difficile colonization and infection. Fecal microbiota transplantation in recurrent C. difficile infection has demonstrated higher success rates than vancomycin, fidaxomicin, or placebo. Fecal microbiota transplantation has traditionally been considered safe, with the most common adverse reactions being abdominal discomfort, and diarrhea, and rare serious adverse events. Significant heterogeneity and a lack of standardization regarding the process of preparation, and administration of fecal microbiota transplantation remain a major pitfall. Standardized microbiome-based therapies provide a promising alternative. In the ECOSPOR III trial of SER-109, an oral formulation of bacterial spores, a significant reduction in the recurrence rate (12%) was observed compared with placebo (40%). In the phase III PUNCH CD3 trial, RBX2660 also demonstrated high efficacy rates of 70.6% versus 57.5%. Both these agents are now US Food and Drug Administration approved for recurrent C. difficile infection. Other standardized microbiome-based therapies currently in the pipeline are VE303, RBX7455, and MET-2. Antibiotic neutralization strategies, vaccines, passive monoclonal antibodies, and drug repurposing are other therapeutic strategies being explored to treat C. difficile infection.
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Affiliation(s)
- Parul Berry
- All India Institute of Medical Sciences, New Delhi, India
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, C. difficile Clinic and Microbiome Restoration Program, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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Bromilow T, Holmes H, Coote L, Woods S, Pink J. Cost-Effectiveness Analysis of Antimicrobial Prescribing in the Treatment of Clostridioides Difficile Infection in England. PHARMACOECONOMICS - OPEN 2023; 7:739-750. [PMID: 37306930 PMCID: PMC10471526 DOI: 10.1007/s41669-023-00420-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND An economic model was developed with guidance from the National Institute for Health and Care Excellence (NICE) 'Managing Common Infections' (MCI) Committee to evaluate the cost effectiveness of different antibiotic treatment sequences for treating Clostridioides difficile infection (CDI) in England. METHODS The model consisted of a 90-day decision tree followed by a lifetime cohort Markov model. Efficacy data were taken from a network meta-analysis and published literature, while cost, utility and mortality data were taken from published literature. A treatment sequence was defined as a first-line intervention or a different second-line intervention, and used constant third- and fourth-line interventions. The possible first- and second-line interventions were vancomycin, metronidazole, teicoplanin and fidaxomicin (standard and extended regimens). Total costs and quality-adjusted life-years (QALYs) were calculated and were used to run a fully incremental cost-effectiveness analysis. Threshold analysis was conducted around pricing. RESULTS Sequences including teicoplanin, fidaxomicin (extended regimen) and second-line metronidazole were excluded based on recommendations from the committee. The final pairwise comparison was between first-line vancomycin and second-line fidaxomicin (VAN-FID), and the reverse (FID-VAN). The incremental cost-effectiveness ratio for FID-VAN compared with VAN-FID was £156,000 per QALY gained, and FID-VAN had a 0.2% likelihood of being cost effective at a £20,000 threshold. CONCLUSION First-line vancomycin and second-line fidaxomicin was the most cost-effective treatment sequence at the NICE threshold for treating CDI in England. The main limitation of this study was that the initial cure and recurrence rates of each intervention were applied constantly across each line of treatment and each round of recurrence.
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Affiliation(s)
- Tom Bromilow
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK.
| | - Hayden Holmes
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK
| | - Laura Coote
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK
| | - Sam Woods
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, Heslington, YO10 5NQ, York, UK
| | - Joshua Pink
- National Institute of Health and Care Excellence (NICE), Centre for Guidelines, London, UK
- School of Health and Society, University of Salford, Salford, UK
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8
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Lodise T, Guo A, Yang M, Cook EE, Song W, Yang D, Wang Q, Zhao A, Bochan M. Cost-Effectiveness Analysis of REBYOTA™ (Fecal Microbiota, Live-jslm [FMBL]) Versus Standard of Care for the Prevention of Recurrent Clostridioides difficile Infection in the USA. Adv Ther 2023; 40:2784-2800. [PMID: 37093359 PMCID: PMC10220097 DOI: 10.1007/s12325-023-02505-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/24/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Recurrent Clostridioides difficile infection (rCDI) is common and associated with considerable clinical and economic consequences. REBYOTA™ (fecal microbiota, live-jslm [FMBL]) is a microbiota-based live biotherapeutic approved for the prevention of rCDI following antibiotic treatment for rCDI. We sought to evaluate cost-effectiveness of FMBL compared to standard of care (SOC) from a US third-party payer perspective among patients with one or more (≥ 1) recurrences. METHODS A Markov model with a lifetime time horizon was developed. The model population included adult patients who had ≥ 1 recurrence after a primary CDI episode and had completed ≥ 1 round of antibiotics, or had ≥ 2 severe CDI episodes resulting in hospitalization within the last year. The model consisted of six health states with an 8-week model cycle: rCDI, absence of CDI after recurrence, colectomy, ileostomy, ileostomy reversal, and death. Drug costs and rCDI-related medical costs were estimated in 2022 US dollars and discounted at 3% annually. Deterministic sensitivity analyses were performed. RESULTS Compared to SOC, FMBL at $9000/course resulted in an incremental cost-effectiveness ratio (ICER) of $18,727 per quality-adjusted life year (QALY) gained. The incremental cost was $5336 (FMBL $79,236, SOC $73,900) and the incremental effectiveness was 0.285 QALYs (FMBL 10.346, SOC 10.061). The cumulative drug acquisition and administration costs for the FMBL and SOC arms were $24,245 and $16,876, while rCDI-related medical costs for FMBL and SOC were $54,991 and $57,024, respectively. The ICER in the subgroup of patients at first recurrence was $13,727 per QALY gained. FMBL remained cost-effective across all sensitivity analyses. CONCLUSIONS FMBL was found to be cost-effective compared to SOC for the prevention of rCDI with more benefits among patients at first recurrence, with an ICER far below the payer ICER threshold of $100,000. Patients treated with FMBL experienced higher total QALYs and reduced healthcare resource utilization, including reduced hospitalizations.
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Affiliation(s)
- Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Amy Guo
- HEOR & RWE, Medical Affairs, Ferring Pharmaceuticals, Inc., 100 Interpace Parkway, Parsippany, NJ, 07054, USA.
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Bainum TB, Reveles KR, Hall RG, Cornell K, Alvarez CA. Controversies in the Prevention and Treatment of Clostridioides difficile Infection in Adults: A Narrative Review. Microorganisms 2023; 11:387. [PMID: 36838352 PMCID: PMC9963748 DOI: 10.3390/microorganisms11020387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Clostridioides difficile remains a problematic pathogen resulting in significant morbidity and mortality, especially for high-risk groups that include immunocompromised patients. Both the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA), as well as the American College of Gastroenterology (ACG) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recently provided guideline updates for C. difficile infection (CDI). In this narrative review, the authors reviewed available literature regarding the prevention or treatment of CDI in adults and focused on disagreements between the IDSA/SHEA and ACG guidelines, as well as articles that have been published since the updates. Several options for primary prophylaxis are available, including probiotics and antibiotics (vancomycin, fidaxomicin). The literature supporting fidaxomicin is currently quite limited. While there are more studies evaluating probiotics and vancomycin, the optimal patient populations and regimens for their use have yet to be defined. While the IDSA/SHEA guidelines discourage metronidazole use for mild CDI episodes, evidence exists that it may remain a reasonable option for these patients. Fidaxomicin has an advantage over vancomycin in reducing recurrences, but its use is limited by cost. Despite this, recent studies suggest fidaxomicin's cost-effectiveness as a first-line therapy, though this is highly dependent on institutional contracts and payment structures. Secondary prophylaxis should focus on non-antimicrobial options to lessen the impact on the microbiome. The oral option of fecal microbiota transplantation (FMT), SER109, and the now FDA-approved RBX2660 represent exciting new options to correct dysbiosis. Bezlotoxumab is another attractive option to prevent recurrences. Further head-to-head studies of newer agents will be needed to guide selection of the optimal therapies for CDI primary and secondary prophylaxis.
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Affiliation(s)
- Taryn B. Bainum
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Kelly R. Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Pharmacotherapy Education and Research Center, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Ronald G. Hall
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Kelli Cornell
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Carlos A. Alvarez
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
- Center of Excellence in Real-World Evidence, Texas Tech University Health Sciences Center, Dallas, TX 75235, USA
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10
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Wingen-Heimann SM, Davies K, Viprey VF, Davis G, Wilcox MH, Vehreschild MJGT, Lurienne L, Bandinelli PA, Cornely OA, Vilken T, Hopff SM, Vehreschild JJ, Webber C, Rupnik M, Wilcox M. Clostridioides difficile infection (CDI): A pan-European multi-center cost and resource utilization study, results from the Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI). Clin Microbiol Infect 2022; 29:651.e1-651.e8. [PMID: 36586512 DOI: 10.1016/j.cmi.2022.12.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI) is one of the leading nosocomial infections worldwide, resulting in a significantly increasing burden on the healthcare systems. However, Pan-European data about cost and resource utilization of CDI treatment do not exist. METHODS A retrospective analysis within the Combatting Bacterial Resistance in Europe CDI project was conducted based on resource costs for inpatient treatment and productivity costs. Country-specific cost values were converted to EURO referred to 1 January, 2019 values. Differences in price levels for healthcare services among the participating countries were adjusted by using an international approach of the Organisation for Economic Co-operation and Development. As the study focused on patients with recurrent CDI, the observed study population was categorized into (a) patients with CDI but without CDI recurrence (case group), (b) patients with CDI recurrence (recurrence group), and (c) patients without CDI (control group). RESULTS Overall, 430 hospitalized patients from 12 European countries were included into the analysis between July 2018 and November 2018. Distribution of mean hospital length of stay and mean overall costs per patient between the case group, recurrence group, and control group were as follows: 22 days (95% CI 17-27 days) vs. 55 days (95% CI 17-94 days) vs. 26 days (95% CI 22-31 days; p 0.008) and € 15 242 (95% CI 10 593-19 891) vs. € 52 024 (95% CI 715-103 334) vs. € 21 759 (95% CI 16 484-27 035; p 0.010), respectively. The CDI recurrence rate during the observational period was 18%. Change escalation in CDI medication (OR 3.735) and treatment in an intensive care unit (OR 5.454) were found to be the most important variables associated with increased overall costs of patients with CDI. CONCLUSIONS Treatment of patients with recurrent CDI results in a significant burden. Prevention of CDI recurrences should be in focus of daily patient care to identify the most cost-effective treatment strategy.
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Affiliation(s)
- Sebastian M Wingen-Heimann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; University of Applied Sciences for Economics and Management (FOM), Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn-Cologne Duesseldorf, Cologne, Germany.
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom; The European Study Group for C. difficile, European Society of Clinical Microbiology and Infectious Disease
| | - Virginie F Viprey
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Georgina Davis
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn-Cologne Duesseldorf, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Molecular Medicine Cologne, Cologne, Germany
| | - Tuba Vilken
- University of Antwerp, Vaccine & Infectious Disease Institute, Laboratory of Medical Microbiology, Antwerp, Belgium
| | - Sina M Hopff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn-Cologne Duesseldorf, Cologne, Germany
| | - Jörg Janne Vehreschild
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department II of Internal Medicine, Hematology/Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany
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11
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Granata G, Schiavone F, Pipitone G. Bezlotoxumab in Patients with a Primary Clostridioides difficile Infection: A Literature Review. Antibiotics (Basel) 2022; 11:1495. [PMID: 36358149 PMCID: PMC9687042 DOI: 10.3390/antibiotics11111495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Nowadays, one of the main issues in the management of Clostridioides difficile infection (CDI) is the high rate of recurrences (rCDI), causing increased mortality and higher health care costs. OBJECTIVES To assess the available evidence on the use of bezlotoxumab for the prevention of rCDI during a first CDI episode. METHODS Published articles on bezlotoxumab during a primary CDI episode were identified through computerized literature searches with the search terms [(bezlotoxumab) AND (CDI) OR (Clostridioides difficile infection)] using PubMed and by reviewing the references of retrieved articles. PubMed was searched until 31 August 2022. RESULTS Eighty-eight studies were identified as published from December 2014 to June 2022. Five studies were included in this study, one was a phase III clinical trial and four were sub-analyses or extensions of the previous phase III clinical trial. In the phase III clinical trial, the subgroup analysis on the included primary CDI patients showed that 13.5% of patients receiving bezlotoxumab had an rCDI, whilst 20.9% of patients in the placebo group had an rCDI at the twelve weeks follow-up (absolute difference: -7.4). CONCLUSIONS Bezlotoxumab administration during the standard of care antibiotic therapy is effective and safe in reducing the rate of rCDI. Despite its high cost, evidence suggests considering bezlotoxumab in patients with a primary CDI episode. Further studies are needed to assess the benefit in specific subgroups of primary CDI patients and to define the risk factors to guide bezlotoxumab use.
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Affiliation(s)
- Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, 00149 Rome, Italy
| | - Francesco Schiavone
- Divers and Raiders Group Command “Teseo Tesei” COMSUBIN, Medical Service, Italian Navy, 19025 Portovenere, Italy
| | - Giuseppe Pipitone
- Infectious Disease Unit, ARNAS Civico-Di Cristina, Piazza Leotta, 5, 90100 Palermo, Italy
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12
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Is Three Company or a Crowd? Comparing and Contrasting U.S. and European Clostridioidesdifficile Clinical Practice Guidelines. Antibiotics (Basel) 2022; 11:antibiotics11091247. [PMID: 36140026 PMCID: PMC9495463 DOI: 10.3390/antibiotics11091247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022] Open
Abstract
In 2021, the American College of Gastroenterology (ACG), the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America (IDSA/SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published updated clinical practice guidelines (CPGs) for the management of Clostridioides difficile infections. The differences, sometimes subtle, between these guideline recommendations have caused some debate among clinicians. This paper delves into select key recommendations from each respective CPG and analyzes the differences and evidence associated with each. One primary difference between the CPGs is the preference given to fidaxomicin over vancomycin for initial treatment in non-severe and severe disease endorsed by IDSA/SHEA and ESCMID guidelines, while the ACG-sponsored CPGs do not offer a preference. The emphasis on cost effective data was also a noticeable difference between the CPGs and thus interpretation of the available evidence. When using guidelines to help support local practice or institutional treatment pathways, clinicians should carefully balance CPG recommendations with local patient populations and feasibility of implementation, especially when multiple guidelines for the same disease state exist.
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13
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Hyte ML, Arphai LJ, Vaughn CJ, Durham SH. The Role of Bezlotoxumab for the Prevention of Recurrent Clostridioides difficile Infections: A Review of the Current Literature and Paradigm Shift after 2021. Antibiotics (Basel) 2022; 11:antibiotics11091211. [PMID: 36139989 PMCID: PMC9495019 DOI: 10.3390/antibiotics11091211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
Clostridioides difficile infections (CDIs), and particularly recurrent infections, cause a significant burden on the health-care system. Bezlotoxumab is a new agent for the prevention of recurrent CDIs that has shown strong efficacy and high tolerability in clinical trials. The purpose of this review is to evaluate the published literature for bezlotoxumab, with a focus on literature published since the release of the 2021 focused update to the CDI treatment guidelines. A Medline/PubMed search for “bezlotoxumab” was conducted, resulting in 152 articles. Seventeen studies are included in this review, after excluding non-English-language papers, phase I and II trials, and review articles. Studies published since the 2021 focused update support the recommendations in those guidelines. Furthermore, real-world studies have shown similar results to larger clinical trials. Those with more risk factors for recurrent CDI appear to benefit most from bezlotoxumab. Currently, there are no data to support the use of bezlotoxumab outside current guideline recommendations, but future trials may build on the data seen in real-world studies to further elucidate the place in therapy for bezlotoxumab.
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Affiliation(s)
- Melanie L. Hyte
- Edward Via College of Osteopathic Medicine, Auburn Campus, Auburn, AL 36832, USA
| | - Lee J. Arphai
- VA Northeast Ohio Healthcare System, Cleveland, OH 44106, USA
| | - Charles J. Vaughn
- Harrison College of Pharmacy, Auburn University, Auburn, AL 36849, USA
| | - Spencer H. Durham
- Harrison College of Pharmacy, Auburn University, Auburn, AL 36849, USA
- Correspondence:
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14
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Raeisi H, Azimirad M, Nabavi-Rad A, Asadzadeh Aghdaei H, Yadegar A, Zali MR. Application of recombinant antibodies for treatment of Clostridioides difficile infection: Current status and future perspective. Front Immunol 2022; 13:972930. [PMID: 36081500 PMCID: PMC9445313 DOI: 10.3389/fimmu.2022.972930] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
Clostridioides difficile (C. difficile), known as the major cause of antibiotic-associated diarrhea, is regarded as one of the most common healthcare-associated bacterial infections worldwide. Due to the emergence of hypervirulent strains, development of new therapeutic methods for C. difficile infection (CDI) has become crucially important. In this context, antibodies have been introduced as valuable tools in the research and clinical environments, as far as the effectiveness of antibody therapy for CDI was reported in several clinical investigations. Hence, production of high-performance antibodies for treatment of CDI would be precious. Traditional approaches of antibody generation are based on hybridoma technology. Today, application of in vitro technologies for generating recombinant antibodies, like phage display, is considered as an appropriate alternative to hybridoma technology. These techniques can circumvent the limitations of the immune system and they can be exploited for production of antibodies against different types of biomolecules in particular active toxins. Additionally, DNA encoding antibodies is directly accessible in in vitro technologies, which enables the application of antibody engineering in order to increase their sensitivity and specificity. Here, we review the application of antibodies for CDI treatment with an emphasis on recombinant fragment antibodies. Also, this review highlights the current and future prospects of the aforementioned approaches for antibody-mediated therapy of CDI.
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Affiliation(s)
- Hamideh Raeisi
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Azimirad
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Nabavi-Rad
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- *Correspondence: Abbas Yadegar, ;
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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15
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Thandavaram A, Channar A, Purohit A, Shrestha B, Patel D, Shah H, Hanna K, Kaur H, Alazzeh MS, Mohammed L. The Efficacy of Bezlotoxumab in the Prevention of Recurrent Clostridium difficile: A Systematic Review. Cureus 2022; 14:e27979. [PMID: 36120235 PMCID: PMC9468512 DOI: 10.7759/cureus.27979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/13/2022] [Indexed: 11/26/2022] Open
Abstract
Clostridium difficile infection (CDI) is the most common nosocomial infection in hospitals. Despite the fact that CDI has treatment options, recurrence is common after the treatment, recurrence will occur in approximately 20%-35% of people initially affected, with 40%-60% of these having a second recurrence. Patients are more likely to have several recurrences after the second, which can lead to antibiotic overuse, and as a result, CDI-related health care expenses, hospitalizations, and mortality are on the rise. The first treatment to receive Food and Drug Administration (FDA) approval for the prevention of C. difficile recurrence is bezlotoxumab, a novel human monoclonal antibody against C. difficile toxin B. In the present systematic review, we assessed various studies from PubMed, PubMed Central (PMC), Google Scholar, and Science direct that evaluated the efficacy of bezlotoxumab in the prevention of recurrent C. difficile (rCDI), and we also briefly discussed the pathophysiology of C. difficile and the risk factors for recurrence of C. difficile. The major MODIFY trial has proven the efficacy, pooled analysis of MODIFY 1 AND 2 trials demonstrated the following results as compared to placebo (bezlotoxumab: 129/781 [16.5] placebo:206/773 [26.6] -10.0% [95% CI -14.0 to -6.0], p<0.0001) with number needed to treat (NNT) of 10. All other observational studies also showed a positive response with bezlotoxumab in the prevention of C. difficile. In conclusion, bezlotoxumab is a great option adjunctive with standard of care CDI antibiotics for the prevention of rCDI in high-risk adults.
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16
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Alonso CD, Maron G, Kamboj M, Carpenter PA, Gurunathan A, Mullane KM, Dubberke ER. American Society for Transplantation and Cellular Therapy Series: #5-Management of Clostridioides difficile Infection in Hematopoietic Cell Transplant Recipients. Transplant Cell Ther 2022; 28:225-232. [PMID: 35202891 DOI: 10.1016/j.jtct.2022.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 12/17/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A completely new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and then answered FAQs and finalized topics with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. This fifth guideline in the series focuses on Clostridioides difficile infection with FAQs that address the prevalence, incidence, clinical features, colonization versus infection, clinical complications, diagnostic considerations, pharmacological therapies for episodic or recurrent infection, and the roles of prophylactic antibiotics, probiotics, and fecal microbiota transplantation.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Mini Kamboj
- Division of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Kathleen M Mullane
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, Illinois
| | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri
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17
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Abstract
![]()
The paradigm of antivirulence
therapy dictates that bacterial pathogens
are specifically disarmed but not killed by neutralizing their virulence
factors. Clearance of the invading pathogen by the immune system is
promoted. As compared to antibiotics, the pathogen-selective antivirulence
drugs hold promise to minimize collateral damage to the beneficial
microbiome. Also, selective pressure for resistance is expected to
be lower because bacterial viability is not directly affected. Antivirulence
drugs are being developed for stand-alone prophylactic and therapeutic
treatments but also for combinatorial use with antibiotics. This Review
focuses on drug modalities that target bacterial exotoxins after the
secretion or release-upon-lysis. Exotoxins have a significant and
sometimes the primary role as the disease-causing virulence factor,
and thereby they are attractive targets for drug development. We describe
the key pre-clinical and clinical trial data that have led to the
approval of currently used exotoxin-targeted drugs, namely the monoclonal
antibodies bezlotoxumab (toxin B/TcdB, Clostridioides difficile), raxibacumab (anthrax toxin, Bacillus anthracis), and obiltoxaximab (anthrax toxin, Bacillus anthracis), but also to challenges with some of the promising leads. We also
highlight the recent developments in pre-clinical research sector
to develop exotoxin-targeted drug modalities, i.e., monoclonal antibodies,
antibody fragments, antibody mimetics, receptor analogs, neutralizing
scaffolds, dominant-negative mutants, and small molecules. We describe
how these exotoxin-targeted drug modalities work with high-resolution
structural knowledge and highlight their advantages and disadvantages
as antibiotic alternatives.
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Affiliation(s)
- Moona Sakari
- Institute of Biomedicine, Research Unit for Infection and Immunity, University of Turku, Kiinamyllynkatu 10, FI-20520 Turku, Finland
| | - Arttu Laisi
- Institute of Biomedicine, Research Unit for Infection and Immunity, University of Turku, Kiinamyllynkatu 10, FI-20520 Turku, Finland
| | - Arto T. Pulliainen
- Institute of Biomedicine, Research Unit for Infection and Immunity, University of Turku, Kiinamyllynkatu 10, FI-20520 Turku, Finland
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18
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van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 210] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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19
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Raj GM, Priyadarshini R, Murugesan S, Adhimoolam M. Monoclonal Antibodies Against Infectious Microbes: So Long and Too Little! Infect Disord Drug Targets 2021; 21:4-27. [PMID: 32164518 DOI: 10.2174/1871526520666200312154649] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 11/22/2022]
Abstract
Monoclonal antibodies (mAbs) as alternatives or more often as complementary to the conventional antimicrobials have been developed for the management of infectious conditions for the past two decades. These pharmacotherapeutic strategies are inevitable as the burden of antimicrobial resistance is far-reaching in recent times. MAbs are part of the targeted pharmacotherapy armamentarium with a high degree of specificity - hence, exert comparatively superior efficacy and tolerability than the conventional polyclonal antisera. So far, only five mAbs have been approved for the management of infectious states, since the marketing authorization (1998) given to palivizumab (Synagis®) for the prophylaxis of lower respiratory tract disease caused by a respiratory syncytial virus in pediatric patients. Ibalizumab-uiyk (Trogarzo™) used for the management of multidrug-resistant HIV-1 infection not yielding to at least 10 antiretroviral drugs, was approved recently. Among the three antibacterial mAbs, raxibacumab (ABthrax®/ Anthrin®) and obiltoxaximab (Anthim®) are indicated for the treatment and prophylaxis of inhalation anthrax due to Bacillus anthracis; bezlotoxumab (Zinplava®) is used to reduce the recurrence of Clostridium difficile infection. There are also around 30 and 15 mAbs in different phases of development for viral and bacterial conditions. As alternatives to the traditional antivirals and antibacterials, the antimicrobial mAbs are the need of the hour. These mAbs are more relevant to the management of conditions like emerging viral outbreaks wherein there is a lack of prophylactic vaccines. The current cutting-edge engineering technologies revolutionizing the production of mAbs include phagedisplayed antibody libraries, cloning from single-memory B cells or single-antibody-secreting plasma B cells, proteomics-directed cloning of mAbs from serum clubbed with high-throughput sequencing techniques. Yet, the cost of manufacture continues to be the main limiting factor. In this review, the different therapeutic monoclonal antibodies directed against the microbial pathogens are discussed.
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Affiliation(s)
- Gerard M Raj
- Department of Pharmacology, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Puducherry 605102, India
| | - Rekha Priyadarshini
- Department of Pharmacology, Indira Gandhi Medical College & Research Institute (IGMC & RI), Puducherry 605009, India
| | - Sakthibalan Murugesan
- Department of Pharmacology, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Puducherry 605102, India
| | - Mangaiarkkarasi Adhimoolam
- Department of Pharmacology, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Puducherry 605102, India
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20
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Jakobs F, Wingen-Heimann SM, Jeck J, Kron A, Cornely OA, Kron F. A budget impact analysis of bezlotoxumab versus standard of care antibiotics only in patients at high risk of CDI recurrence from a hospital management perspective in Germany. BMC Health Serv Res 2021; 21:939. [PMID: 34496836 PMCID: PMC8428130 DOI: 10.1186/s12913-021-06970-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 08/26/2021] [Indexed: 11/12/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is one of the leading nosocomial infections, resulting in increased hospital length of stay and additional treatment costs. Bezlotoxumab, the first monoclonal antibody against CDI, has an 1 A guideline recommendation for prevention of CDI, after randomized clinical trials demonstrated its superior efficacy vs. placebo. Methods The budget impact analysis at hand is focused on patients at high risk of CDI recurrence. Treatment with standard of care (SoC) + bezlotoxumab was compared with current SoC alone in the 10 most associated Diagnosis Related Groups to identify, analyze, and evaluate potential cost savings per case from the German hospital management perspective. Based on variation in days to rehospitalization, three different case consolidation scenarios were assessed: no case consolidation, case consolidation for the SoC + bezlotoxumab treatment arm only, and case consolidation for both treatment arms. Results On average, the budget impact amounted to € 508.56 [range: € 424.85 - € 642.19] for no case consolidation, € 470.50 [range: € 378.75 - € 601.77] for case consolidation in the SoC + bezlotoxumab treatment arm, and € 618.00 [range: € 557.40 - € 758.41] for case consolidation in both treatment arms. Conclusions The study demonstrated administration of SoC + bezlotoxumab in patients at high risk of CDI recurrence is cost-saving from a hospital management perspective. Reduced length of stay in bezlotoxumab treated patients creates free spatial and personnel capacities for the treating hospital. Yet, a requirement for hospitals to administer bezlotoxumab is the previously made request for additional fees and a successful price negotiation.
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Affiliation(s)
- Florian Jakobs
- Faculty of Medicine, Department I of Internal Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.,Network Genomic Medicine, University Hospital of Cologne, Cologne, Germany.,VITIS Healthcare Group, Cologne, Germany
| | - Sebastian Marcel Wingen-Heimann
- Faculty of Medicine, Department I of Internal Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.,VITIS Healthcare Group, Cologne, Germany.,Faculty of Medicine, University of Cologne, University Hospital Cologne, Excellence Center for Medical Mycology (ECMM), Cologne, Germany.,FOM University of Applied Sciences, Essen, Germany
| | - Julia Jeck
- VITIS Healthcare Group, Cologne, Germany
| | - Anna Kron
- Faculty of Medicine, Department I of Internal Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.,Network Genomic Medicine, University Hospital of Cologne, Cologne, Germany.,VITIS Healthcare Group, Cologne, Germany.,Faculty of Medicine, Center for Integrated Oncology (CIO ABCD), University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Oliver Andreas Cornely
- Faculty of Medicine, Department I of Internal Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.,Faculty of Medicine, University of Cologne, University Hospital Cologne, Excellence Center for Medical Mycology (ECMM), Cologne, Germany.,Faculty of Medicine, Center for Integrated Oncology (CIO ABCD), University of Cologne, University Hospital Cologne, Cologne, Germany.,Faculty of Medicine, University of Cologne, University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany.,Faculty of Medicine, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Florian Kron
- Faculty of Medicine, Department I of Internal Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany. .,VITIS Healthcare Group, Cologne, Germany. .,FOM University of Applied Sciences, Essen, Germany. .,Faculty of Medicine, Center for Integrated Oncology (CIO ABCD), University of Cologne, University Hospital Cologne, Cologne, Germany.
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21
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Johnson S, Lavergne V, Skinner AM, Gonzales-Luna AJ, Garey KW, Kelly CP, Wilcox MH. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Clin Infect Dis 2021; 73:755-757. [PMID: 34492699 DOI: 10.1093/cid/ciab718] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Indexed: 02/07/2023] Open
Abstract
This clinical practice guideline is a focused update on management of Clostridioides difficile infection (CDI) in adults specifically addressing the use of fidaxomicin and bezlotoxumab for the treatment of CDI. This guideline was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). This guideline is intended for use by healthcare professionals who care for adults with CDI, including specialists in infectious diseases, gastroenterologists, hospitalists, pharmacists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the management CDI are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the management of CDI in adults. The panel followed a systematic process which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development, and Evaluation). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Stuart Johnson
- Department of Research and Medicine, Edward Hines Jr Veterans Administration Hospital, Hines, Illinois, USA.,Loyola University Medical Center, Maywood, Illinois, USA
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Research Center, University of Montreal, Montreal, Quebec, Canada
| | - Andrew M Skinner
- Department of Research and Medicine, Edward Hines Jr Veterans Administration Hospital, Hines, Illinois, USA.,Loyola University Medical Center, Maywood, Illinois, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Ciaran P Kelly
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, and Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
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22
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Johnson TM, Molina KC, Howard AH, Schwarz K, Allen L, Huang M, Bajrovic V, Miller MA. Real-World Comparison of Bezlotoxumab to Standard of Care Therapy for Prevention of Recurrent Clostridioides difficile Infection in Patients at High Risk for Recurrence. Clin Infect Dis 2021; 74:1572-1578. [PMID: 34665248 DOI: 10.1093/cid/ciab674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bezlotoxumab (BEZ) is a monoclonal antibody used to prevent recurrent Clostridioides difficile infection (rCDI). This study investigates BEZ effectiveness in relation to rCDI and patient-specific risk factors in a real-world setting. METHODS A matched, retrospective cohort study was conducted from 2015 to 2019 to compare BEZ to historical standard of care (SoC) therapy with vancomycin or fidaxomicin. The primary outcome was incidence of 90-day rCDI. Secondary outcomes were incidence of all-cause hospital readmission and all-cause mortality at 90 days, infusion-related reactions, and incidence of heart failure exacerbation. Baseline confounding was addressed using inverse probability of treatment weighting (IPTW). RESULTS Overall, 107 participants were included (54 BEZ and 53 SoC). Mean number of prior CDI episodes was 2, median number of risk factors for rCDI was 4, and 28% of participants had severe CDI. Incidence of 90-day rCDI was 11% BEZ vs 43% SoC (P = < .001) and 90-day all-cause readmission was 40% BEZ vs 64% SoC (P = .011). In IPTW-adjusted analyses, BEZ was associated with significantly reduced odds of rCDI (odds ratio [OR], 0.14 [95% confidence interval {CI}: .05-.41]) and all-cause readmission (OR, 0.36 [95% CI: .16-.81]). No safety signals were detected with BEZ use. CONCLUSIONS BEZ is effective for the prevention of rCDI and reduction in all-cause hospital readmission for patients at high risk for recurrence, supporting current guideline recommendations.
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Affiliation(s)
- Tanner M Johnson
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Kyle C Molina
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Amanda H Howard
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Kerry Schwarz
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Lorna Allen
- Department of Medicine-Infectious Diseases, University of Colorado Hospital, Aurora, Colorado, USA
| | - Misha Huang
- Department of Medicine-Infectious Diseases, University of Colorado Hospital, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Valida Bajrovic
- Department of Medicine-Infectious Diseases, University of Colorado Hospital, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew A Miller
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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23
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Khanna S. My Treatment Approach to Clostridioides difficile Infection. Mayo Clin Proc 2021; 96:2192-2204. [PMID: 34175104 DOI: 10.1016/j.mayocp.2021.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
Clostridioides difficile infection is the most common cause of infectious diarrhea in hospitals with an increasing incidence in the community. Clinical presentation of C difficile infection ranges from diarrhea manageable in the outpatient setting to fulminant infection requiring intensive care admission. There have been significant advances in the management of primary and recurrent C difficile infection including diagnostics, newer antibiotics, antibody treatments, and microbiome restoration therapies. Because of the risk of clinical false-positive results with the polymerase chain reaction test, a two-step assay combining an enzyme immune assay for glutamate dehydrogenase and the C difficile toxin is being used. Cost permitting, I treat a first episode of C difficile infection preferably with fidaxomicin over vancomycin but not metronidazole. The most common complication after C difficile infection is recurrence. I manage a first recurrence with a vancomycin taper and pulse or fidaxomicin and recommend a single dose of intravenous bezlotoxumab (a monoclonal antibody against the toxin B) to reduce recurrence rates for those patients at high risk. Patients with multiply recurrent C difficile infection are managed with a course of antibiotics such as vancomycin or fidaxomicin followed by microbiota restoration. The success of fecal microbiota transplantation is greater than 85%, compared with the 40% to 50% success rate of antibiotics in this situation. Fecal microbiota transplantation is heterogeneous and has rare but serious risks such as transmission of infections. Standardized microbiota restoration therapies are in clinical development and have completed phase III clinical trials. This review answers common clinical questions in the management of C difficile infection.
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Affiliation(s)
- Sahil Khanna
- C difficile Clinic and Microbiome Restoration Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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24
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Johnson S, Lavergne V, Skinner AM, Gonzales-Luna AJ, Garey KW, Kelly CP, Wilcox MH. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Clin Infect Dis 2021; 73:e1029-e1044. [PMID: 34164674 DOI: 10.1093/cid/ciab549] [Citation(s) in RCA: 217] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Indexed: 12/19/2022] Open
Abstract
This clinical practice guideline is a focused update on management of Clostridioides difficile infection (CDI) in adults specifically addressing the use of fidaxomicin and bezlotoxumab for the treatment of CDI. This guideline was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). This guideline is intended for use by healthcare professionals who care for adults with CDI, including specialists in infectious diseases, gastroenterologists, hospitalists, pharmacists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the management CDI are based upon evidence derived from topic-specific systematic literature reviews.Summarized below are the recommendations for the management of CDI in adults. The panel followed a systematic process which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Stuart Johnson
- Department of Research and Medicine, Edward Hines Jr Veterans Administration Hospital, Hines, and Loyola University Medical Center, Maywood, Illinois, Loyola University Medical Center, Maywood, Illinois
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada; Research Center, University of Montreal, Montreal, Quebec, Canada
| | - Andrew M Skinner
- Department of Research and Medicine, Edward Hines Jr Veterans Administration Hospital, Hines, and Loyola University Medical Center, Maywood, Illinois, Loyola University Medical Center, Maywood, Illinois
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Ciaran P Kelly
- Dept of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, and Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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25
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Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol 2021; 116:1124-1147. [PMID: 34003176 DOI: 10.14309/ajg.0000000000001278] [Citation(s) in RCA: 197] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 03/25/2021] [Indexed: 02/06/2023]
Abstract
Clostridioides difficile infection occurs when the bacterium produces toxin that causes diarrhea and inflammation of the colon. These guidelines indicate the preferred approach to the management of adults with C. difficile infection and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations Assessment, Development, and Evaluation but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not the only, approach to clinical scenarios.
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Affiliation(s)
- Colleen R Kelly
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Monika Fischer
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry LaPlante
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
| | - David B Stewart
- Department of Surgery, University of Arizona Health Sciences, Tucson, Arizona, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Neil H Stollman
- Division of Gastroenterology, Alta Bates Summit Medical Center, East Bay Center for Digestive Health, Oakland, California, USA
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26
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Cost-effectiveness of bezlotoxumab and fidaxomicin for initial Clostridioides difficile infection. Clin Microbiol Infect 2021; 27:1448-1454. [PMID: 33878506 DOI: 10.1016/j.cmi.2021.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Treatment of Clostridioides difficile infection (CDI) has undergone significant change in recent years with the introduction of fidaxomicin and bezlotoxumab. This study evaluated the cost-effectiveness of fidaxomicin and bezlotoxumab for initial CDI compared with standard therapy with oral vancomycin. METHODS A Markov model with eight health states was built based on transition probabilities, costs and health utilities derived from literature to evaluate the cost-effectiveness of standard fidaxomicin, bezlotoxumab plus vancomycin, and extended-pulsed fidaxomicin versus standard oral vancomycin over a lifetime horizon from the US societal perspective. RESULTS For overall CDI treatment, oral vancomycin had a cost of $39 178 and was associated with a gain of 11.64 quality-adjusted life-years (QALYs). Extended-pulsed fidaxomicin had a higher QALY gain of 11.65 at a lower cost of $37 613, and therefore was dominant over vancomycin. Standard fidaxomicin had a QALY gain of 11.94 versus vancomycin at an incremental cost of $495 per QALY. Bezlotoxumab plus vancomycin led to a QALY gain of 11.77 at an incremental cost of $17 746 per QALY. At the willingness-to-pay (WTP) threshold of $150 000 per QALY, extended-pulsed fidaxomicin, bezlotoxumab plus vancomycin and standard fidaxomicin were more cost-effective compared with vancomycin alone, yielding incremental net monetary benefits of $3248, $17 011 and $44 308, respectively. One-way sensitivity analysis suggested that the probabilities of sustained cure from the initial episode were the most sensitive inputs, and results were overall not particularly sensitive to any drug costs. CONCLUSIONS Based on a WTP threshold of $150 000, standard fidaxomicin was estimated to be the most cost-effective treatment. Standard-of-care vancomycin was dominated by extended-pulsed fidaxomicin for treating an episode of CDI and preventing further recurrence, and the addition of bezlotoxumab to vancomycin was dominated by standard fidaxomicin.
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27
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Kampouri E, Croxatto A, Prod’hom G, Guery B. Clostridioides difficile Infection, Still a Long Way to Go. J Clin Med 2021; 10:jcm10030389. [PMID: 33498428 PMCID: PMC7864166 DOI: 10.3390/jcm10030389] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/11/2022] Open
Abstract
Clostridioides difficile is an increasingly common pathogen both within and outside the hospital and is responsible for a large clinical spectrum from asymptomatic carriage to complicated infection associated with a high mortality. While diagnostic methods have considerably progressed over the years, the optimal diagnostic algorithm is still debated and there is no single diagnostic test that can be used as a standalone test. More importantly, the heterogeneity in diagnostic practices between centers along with the lack of robust surveillance systems in all countries and an important degree of underdiagnosis due to lack of clinical suspicion in the community, hinder a more accurate evaluation of the burden of disease. Our improved understanding of the physiopathology of CDI has allowed some significant progress in the treatment of CDI, including a broader use of fidaxomicine, the use of fecal microbiota transplantation for multiples recurrences and newer approaches including antibodies, vaccines and new molecules, already developed or in the pipeline. However, the management of CDI recurrences and severe infections remain challenging and the main question remains: how to best target these often expensive treatments to the right population. In this review we discuss current diagnostic approaches, treatment and potential prevention strategies, with a special focus on recent advances in the field as well as areas of uncertainty and unmet needs and how to address them.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
| | - Antony Croxatto
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Guy Prod’hom
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
- Correspondence: ; Tel.: +41-21-314-1643
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28
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Gupta A, Ananthakrishnan AN. Economic burden and cost-effectiveness of therapies for Clostridiodes difficile infection: a narrative review. Therap Adv Gastroenterol 2021; 14:17562848211018654. [PMID: 34104214 PMCID: PMC8170348 DOI: 10.1177/17562848211018654] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile is the most common cause of healthcare-associated diarrhea. Disease complications as well as recurrent infections contribute significantly to morbidity and mortality. Over the past decades, there has been a rapid increase in the incidence of C. difficile infection (CDI), with a rise in the number of community-acquired cases. CDI has a profound economic impact on both the healthcare system and patients, secondary to recurrences, hospitalization, prolonged length of stay, cost of treatment, and indirect societal costs. With emergence of newer treatment options, the standard of care is shifting from metronidazole and vancomycin towards fidaxomicin and fecal microbiota transplantation (FMT), which despite being more expensive, are more efficacious in preventing recurrences and hence overall are more beneficial forms of therapy per cost-effectiveness analyses. Data regarding preferred route of FMT, timing of FMT, and non-conventional therapies such as bezlotoxumab is scant. There is a need for further studies to elucidate the true attributable costs of CDI as well as continued cost-effectiveness research to reduce the economic burden associated with the disease and improve clinical practice.
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Affiliation(s)
- Akshita Gupta
- Department of Medicine, Massachusetts General
Hospital, Boston, MA, USA
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29
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Sehgal K, Khanna S. Immune response against Clostridioides difficile and translation to therapy. Therap Adv Gastroenterol 2021; 14:17562848211014817. [PMID: 33995585 PMCID: PMC8111532 DOI: 10.1177/17562848211014817] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/12/2021] [Indexed: 02/04/2023] Open
Abstract
The pathogenesis of Clostridioides difficile infection (CDI) has largely been attributed to the action of two major toxins - A and B. An enhanced systemic humoral immune response against these toxins has been shown to be protective against recurrent CDI. Over the years, fully human monoclonal antibodies against both of these toxins have been developed in an attempt to counter the increasing incidence of recurrent CDI. Clinical trials conducted to evaluate the efficacy of anti-toxin A monoclonal antibody, actoxumab, and anti-toxin B monoclonal antibody, bezlotoxumab, demonstrated that bezlotoxumab substantially lowered the rate of recurrent infection, while actoxumab did not. A significant therapeutic benefit was appreciated in patients with at least one high-risk factor for recurrence, including, age ⩾65 years, immunocompromised state, prior CDI and severe CDI. In light of toxins A and B being immunogenic, vaccine trials are underway with the aim to prevent primary infection.
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Affiliation(s)
- Kanika Sehgal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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30
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Durham SH, Le P, Cassano AT. Navigating changes in Clostridioides difficile prevention and treatment. J Manag Care Spec Pharm 2020; 26:S3-S23. [PMID: 33533699 PMCID: PMC10408425 DOI: 10.18553/jmcp.2020.26.12-a.s3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Clostridioides difficile (C. difficile, previously known as Clostridium difficile) infections are a major health care concern. The Centers for Disease Control and Prevention (CDC) estimates that C. difficile causes almost half a million illnesses in the United States yearly, and approximately 1 in 5 patients with a C. difficile infection (CDI) will experience 1 or more recurrent infections. The incidence of infection has risen dramatically in recent years, and infection severity has increased due to the emergence of hypervirulent strains. There have been noteworthy advances in the development of CDI prevention and treatment, including a growth in the understanding of the role a patient's gut microbiome plays. The 2017 Infectious Diseases Society of America (IDSA) guidelines made a significant change in treatment recommendations for first time CDI episodes by recommending the use of oral vancomycin or fidaxomicin in place of metronidazole as a first-line treatment. The guidelines also included detailed recommendations on the use of fecal microbiota transplant (FMT) in those patients who experience 3 or more recurrent CDI episodes. A number of novel therapies for the treatment of CDI are in various stages of development. Treatments currently in phase 3 trials include the antibiotic ridinilazole, the microbiome products SER-109 and RBX2660, and a vaccine. All of these agents have shown promise in phase 1 and 2 trials. Additionally, several other antibiotic and microbiome candidates are currently in phase 1 or phase 2 trials. A qualitative review and evaluation of the literature on the cost-effectiveness of treatments for CDI in the U.S. setting was conducted, and the summary provided herein. Due to the higher cost of newer agents, cost-effectiveness evaluations will continue to be critical in clinical decision making for CDI. This paper reviews the updated CDI guidelines for prevention and treatment, the role of the microbiome in new and recurrent infections, pipeline medications, and comparative effectiveness research (CER) data on these treatments. DISCLOSURES: Durham and Le have nothing to disclose. Cassano reports consulting fees from Baxter Healthcare. Peer reviewers Drs. Ami Gopalan and Mark Rubin and Ms. Kathleen Jarvis have nothing to disclose. Planners Dr. Christine L. Cooper and Ms. Susan Yarbrough have nothing to disclose.
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Affiliation(s)
- Spencer H Durham
- BCPS, BCIDP, Auburn University Harrison School of Pharmacy, Auburn, AL
| | - Phuc Le
- Lerner College of Medicine, Case Western Reserve University and Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH
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31
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Giacobbe DR, Dettori S, Di Bella S, Vena A, Granata G, Luzzati R, Petrosillo N, Bassetti M. Bezlotoxumab for Preventing Recurrent Clostridioides difficile Infection: A Narrative Review from Pathophysiology to Clinical Studies. Infect Dis Ther 2020; 9:481-494. [PMID: 32632582 PMCID: PMC7452994 DOI: 10.1007/s40121-020-00314-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) and recurrent CDI (rCDI) remain associated with a reduction in the patients’ quality of life and with increased healthcare costs. Bezlotoxumab is a monoclonal antibody against toxin B of C. difficile, approved for prevention of rCDI. In this narrative review, we briefly discuss the pathophysiology of CDI and the mechanism of action of bezlotoxumab, as well as the available evidence from investigational and observational studies in terms of efficacy, effectiveness, and safety of bezlotoxumab for the prevention of rCDI. Overall, bezlotoxumab has proved efficacious in reducing the burden of rCDI, thereby providing clinicians with an important novel strategy to achieve sustained cure. Nonetheless, experiences outside randomized controlled trials (RCTs) remain scant, and mostly represented by case series without a control group. Along with the conduction of RCTs to directly compare bezlotoxumab with faecal microbiota transplantation (or to precisely evaluate the role of their combined use), further widening our post-marketing experience remains paramount to firmly guide the use of bezlotoxumab outside RCTs, and to clearly identify those real-life settings where its preventive benefits can be exploited most.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy.
- Department of Health Sciences, University of Genoa, Genoa, Italy.
| | - Silvia Dettori
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
| | - Guido Granata
- Clinical and Research Department for Infectious Diseases, Severe and Immunedepression-Associated Infections Unit, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, Severe and Immunedepression-Associated Infections Unit, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
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32
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Rao K, Malani PN. Diagnosis and Treatment of Clostridioides (Clostridium) difficile Infection in Adults in 2020. JAMA 2020; 323:1403-1404. [PMID: 32150234 DOI: 10.1001/jama.2019.3849] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Preeti N Malani
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Associate Editor
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33
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Cho JM, Pardi DS, Khanna S. Update on Treatment of Clostridioides difficile Infection. Mayo Clin Proc 2020; 95:758-769. [PMID: 32247350 DOI: 10.1016/j.mayocp.2019.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/30/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023]
Abstract
Clostridioides difficile infection (CDI) is the leading cause of health care-associated infections in the United States. The increasing incidence and recurrence rates of CDI together with its associated morbidity and mortality are great concerns. Newer treatment methods, such as narrow-spectrum antibiotics, monoclonal antibodies, and microbial replacement therapies, are being developed and implemented. We searched PubMed to identify published literature from 2010 to 2018 using the following keywords: Clostridium difficile, treatment, and therapy. Cited references were also used to identify relevant literature. This review focuses on the current standard of therapy and emerging therapies for CDI and summarizes the updated guidelines on treatment of CDI.
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Affiliation(s)
- Janice M Cho
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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34
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Luo Y, Lucas AL, Grinspan AM. Fecal Transplants by Colonoscopy and Capsules Are Cost-Effective Strategies for Treating Recurrent Clostridioides difficile Infection. Dig Dis Sci 2020; 65:1125-1133. [PMID: 31493042 DOI: 10.1007/s10620-019-05821-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/28/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recurrent Clostridioides difficile infections (CDIs) occur frequently and pose a substantial economic burden on the US healthcare system. The landscape for the treatment of CDI is evolving. AIM To elucidate the most cost-effective strategy for managing recurrent CDI. METHODS A decision tree analysis was created from a modified third-party payer's perspective to compare the cost-effectiveness of five strategies for patients experiencing their first CDI recurrence: oral vancomycin, fidaxomicin, fecal microbiota transplant (FMT) via colonoscopy, FMT via oral capsules, and a one-time infusion of bezlotoxumab with vancomycin. Effectiveness measures were quality-adjusted life years (QALY). A willingness-to-pay (WTP) threshold of $100,000 per QALY was set. One-way and probabilistic sensitivity analyses were performed. RESULTS Base-case analysis showed that FMT via colonoscopy was associated with the lowest cost at $5250 and that FMT via capsules was also a cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of $31205/QALY. Sensitivity analyses demonstrated that FMT delivered by oral capsules and colonoscopy was comparable cost-effective modalities. At its current cost and effectiveness, bezlotoxumab was not a cost-effective strategy. CONCLUSIONS FMT via oral capsules and colonoscopy is both cost-effective strategies to treat the first recurrence of CDI. Further real-world economic studies are needed to understand the cost-effectiveness of all available strategies.
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Affiliation(s)
- Yuying Luo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY, 10029, USA.
| | - Aimee L Lucas
- The Henry D. Janowitz Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Ari M Grinspan
- The Henry D. Janowitz Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA
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Challa AP, Lavieri RR, Lewis JT, Zaleski NM, Shirey-Rice JK, Harris PA, Aronoff DM, Pulley JM. Systematically Prioritizing Candidates in Genome-Based Drug Repurposing. Assay Drug Dev Technol 2019; 17:352-363. [PMID: 31769998 PMCID: PMC6921094 DOI: 10.1089/adt.2019.950] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Drug repurposing is the application of approved drugs to treat diseases separate and distinct from their original indications. Herein, we define the scope of all practical precision drug repurposing using DrugBank, a publicly available database of pharmacological agents, and BioVU, a large, de-identified DNA repository linked to longitudinal electronic health records at Vanderbilt University Medical Center. We present a method of repurposing candidate prioritization through integration of pharmacodynamic and marketing variables from DrugBank with quality control thresholds for genomic data derived from the DNA samples within BioVU. Through the synergy of delineated "target-action pairs," along with target genomics, we identify ∼230 "pairs" that represent all practical opportunities for genomic drug repurposing. From this analysis, we present a pipeline of 14 repurposing candidates across 7 disease areas that link to our repurposability platform and present high potential for randomized controlled trial startup in upcoming months.
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Affiliation(s)
- Anup P. Challa
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert R. Lavieri
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Judith T. Lewis
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicole M. Zaleski
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jana K. Shirey-Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul A. Harris
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David M. Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jill M. Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
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Mendo-Lopez R, Villafuerte-Gálvez J, White N, Mahoney MV, Kelly CP, Alonso CD. Recent developments in the management of recurrent Clostridioides difficile infection. Anaerobe 2019; 62:102108. [PMID: 31606481 DOI: 10.1016/j.anaerobe.2019.102108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/23/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022]
Abstract
Clostridioides (formerly Clostridium) difficile is responsible for a substantial burden of nosocomial infection. Recurrent C. difficile infection (rCDI) remains a concern due to its high morbidity, mortality, and cost. Despite the updated 2017 IDSA C. difficile treatment guidelines, there remains a lack of well-studied preventive control measures and treatment modalities for rCDI. There are ongoing efforts to develop novel therapies, such as new antibiotics with a lesser impact on gut microbiota and more targeted therapies, such as bacteriotherapy. This mini review highlights key rCDI management updates, preventive measures and ongoing research on novel treatment strategies including bacteriotherapy.
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Affiliation(s)
- Rafael Mendo-Lopez
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Javier Villafuerte-Gálvez
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nicole White
- Department of Medicine, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciaran P Kelly
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Carolyn D Alonso
- Department of Medicine, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Early Readmission Predicts Increased Mortality in Cirrhosis Patients After Clostridium difficile Infection. J Clin Gastroenterol 2019; 53:e322-e327. [PMID: 30045168 DOI: 10.1097/mcg.0000000000001090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
GOALS We sought to determine the impact of Clostridium difficile infections (CDI) in cirrhosis by evaluating trends and outcomes of early readmission and mortality. BACKGROUND The incidence of CDI in cirrhotics is increasing. STUDY We analyzed the Nationwide Readmissions Database (2011 to 2014) for hospitalized patients with CDI and differentiated them by presence of cirrhosis. Baseline characteristics, surgical rates, and outcomes were collected. The primary outcomes of interest included readmission and mortality rates. RESULTS Of 366,283 patients hospitalized with CDI, 12,274 (3.4%) had cirrhosis, of which 7741 (63.1%) were decompensated. Among patients with CDI, 30-day readmission rates (33% vs. 24%), index admission mortality (5% vs. 2.5%), and calendar-year mortality (9% vs. 4%) were higher in patients with cirrhosis compared with those without cirrhosis. Recurrent CDI (rCDI) (46%) and cirrhosis-related complications (34.6%) were the most common reasons for readmission. Patients with decompensated cirrhosis were more likely to be readmitted within 30-days than those with compensated cirrhosis [odds ratio (OR), 1.19; 95% confidence interval (CI), 1.03-1.36]. Multivariable analyses revealed that among patients with cirrhosis, index colectomy (OR, 6.50; 95% CI, 1.61-26.24) and decompensation (OR, 3.61; 95% CI, 2.49-5.23) predicted index admission mortality. In addition, 30-day readmission (OR, 3.71; 95% CI, 2.95-4.67) and decompensated cirrhosis (OR, 1.49; 95% CI, 1.17-1.89) independently predicted calendar-year mortality. CONCLUSIONS One-third of CDI patients with cirrhosis were readmitted within 30-days, most commonly because of rCDI. The mortality associated with CDI in patients with cirrhosis is high, with decompensation and 30-day readmission heralding a poor prognosis. Reducing rCDI-related readmissions may potentially improve these outcomes.
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Reducing Cost and Complexity of Fecal Microbiota Transplantation Using Universal Donors for Recurrent Clostridium difficile Infection. Adv Ther 2019; 36:2052-2061. [PMID: 31154629 PMCID: PMC6822862 DOI: 10.1007/s12325-019-00974-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Indexed: 12/15/2022]
Abstract
Introduction Fecal microbiota transplantation resolves recurrent Clostridium difficile infections in greater than 82% of patients. Highly screened, processed universal donor fecal material is available. We compared cost and scheduling efficiency of fecal microbiota transplantation by universal donors to patient-directed donors. Methods Medical records from a prospectively maintained database of recurrent C. difficile patients who underwent fecal microbiota transplantation between 2012 and 2017 were reviewed retrospectively. Patient-directed donor stool was prepared in our microbiology laboratory using protocol-based screening. We transitioned to purchasing and using universal donor fecal material in 2015. Clinical outcomes, adverse events, time between consult to infusion, consultation fees, and material costs were compared. This was a retrospective comparison of two historical cohorts. Results A total of 111 fecal microbiota transplantations were performed on 105 patients (56 from patient-directed donors and 55 from universal donors). Median recipient age was 66 years (18–96) with male to female ratio of 1:2.7, equivalent in both cohorts. Total consultation fees were significantly lower in the universal donor group owing to fewer infectious disease consultations. Costs for donor screening and stool preparation were lower in the universal donor cohort ($485.0 vs. $1189.90 ± 541.4, p < 0.001, 95% CI 559.9–849.9). Time from consultations to infusion was shorter in the universal donor cohort (18.9 ± 19.1 vs. 36.4 ± 23.3 days, p < 0.001, 95% CI 9.521–25.591). Recurrences within 8 weeks after fecal microbiota transplantation were equivalent (p = 0.354). Adverse events were equivalent. Conclusions Fecal microbiota transplantation using universal donors versus patient-directed donors for recurrent C. difficile showed comparable efficacy and short-term complications. The use of universal donors resulted in significant cost savings and scheduling efficiency.
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Dinh A, Le Monnier A, Emery C, Alami S, Torreton É, Duburcq A, Barbier F. Predictors and burden of hospital readmission with recurrent Clostridioides difficile infection: a French nation-wide inception cohort study. Eur J Clin Microbiol Infect Dis 2019; 38:1297-1305. [PMID: 30941532 DOI: 10.1007/s10096-019-03552-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/26/2019] [Indexed: 12/17/2022]
Abstract
To investigate the predictors and burden of hospital readmission with recurrent Clostridioides difficile infection (rCDI) in a large European healthcare system with a low prevalence of hyper-virulent C. difficile clones. We conducted an inception cohort study based on an exhaustive health insurance database and including all survivors of a first hospital stay with CDI over a one-year period (2015) in France. Readmissions with rCDI were defined as a novel hospital stay with CDI within 12 weeks following discharge of the index hospitalization. Risk factors for readmission with rCDI were investigated through multivariate logistic regression analyses. Among the 14,739 survivors of the index hospital stay (females, 57.3%; median age, 74 [58-84] years), 2135 (14.5%) required at least one readmission with rCDI. Independent predictors of readmission were age ≥ 65 years (adjusted odds ratio (aOR), 1.34, 95% confidence interval (CI), 1.21-1.49, P < 0.0001), immunosuppression (aOR, 1.27, 95% CI, 1.15-1.41, P < 0.0001), chronic renal failure (aOR, 1.29, 95% CI, 1.14-1.46, P < 0.0001), and a previous history of CDI (aOR, 2.05, 95% CI, 1.55-2.71, P < 0.0001). The cumulative number of risk factors was independently associated with the hazard of readmission. Mean acute care costs attributable to rCDI were 5619 ± 3594 Euros for readmissions with rCDI as primary diagnosis (mean length of stay, 11.3 ± 10.2 days) and 4851 ± 445 Euros for those with rCDI as secondary diagnosis (mean length of stay, 16.8 ± 18.2 days), for an estimated annual nation-wide cost of 14,946,632 Euros. Hospital readmissions with rCDI are common after an index episode and drive major healthcare expenditures with substantial bed occupancy, strengthening the need for efficient secondary prevention strategies in high-risk patients.
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Affiliation(s)
- Aurélien Dinh
- Infectious Diseases Unit, APHP, Raymond-Poincaré University Hospital, Garches, France.,Versailles-Saint Quentin University, Versailles, France
| | - Alban Le Monnier
- Department of Clinical Microbiology, GH Paris Saint-Joseph Hospital, Paris, France.,EA4043-UBaPS, Saclay - Paris Sud University, Châtenay-Malabry, France
| | | | | | | | | | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, 14, Hospital Bd, 45100, Orléans, France.
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Hypoalbuminemia as predictor of recurrence of Clostridium difficile infection. Wien Klin Wochenschr 2019; 131:68-74. [PMID: 30617709 PMCID: PMC6394683 DOI: 10.1007/s00508-018-1432-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Abstract
Background Novel drugs for Clostridium difficile (C. difficile) infections have been proven to reduce recurrent infections. Because of their high financial costs, identification of patients at high risk for recurrence is essential to provide optimal treatment. The ATLAS score’s ability to predict 90-day recurrence, disease complications and 1‑year all-cause mortality was evaluated. Methods 144 consecutive symptomatic patients with positive stool test for C. difficile were enrolled. The ATLAS score (consisting of the variables age, temperature, leukocyte count, albumin, systemic antibiotics, serum creatinine) was calculated and patients were stratified into 4 subgroups according to their scores. A Cox regression model was used to estimate the extent to which ATLAS was associated with 90-day recurrence. Furthermore, the score was correlated with disease complications and one-year all-cause mortality. Results ATLAS was unable to predict 90-day recurrence (p = 0.064, HR 1.134 [0.993;1.295]), but performed well for disease complications (D = 0.382, p < 0.001, HR 1.547 [1.266;1.889]) and mortality (p < 0.001, HR 1.374 [1.194;1.583]). Serum albumin was the only parameter able to predict 90-day recurrence (p = 0.016, HR 0.958 [0.926;0.992]) and was also a predictor of disease complications (p < 0.001, HR 0.865[0.809;0.924]) and one-year all-cause mortality (p < 0.001, HR 0.923 [0.896;0.950]). A threshold of 33.1g/L (sensitivity = 56%, specificity = 80%, AUC 0.683) and 29.2g/L (sensitivity = 75%, specificity = 70%, AUC 0.763) of serum albumin could be identified to be predictive for 90-day recurrence and one-year all-cause mortality, respectively. Conclusions Serum albumin and ATLAS are predictors of disease complications and mortality, while only serum albumin is significantly associated with 90-day disease recurrence.
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Dieterle MG, Rao K, Young VB. Novel therapies and preventative strategies for primary and recurrent Clostridium difficile infections. Ann N Y Acad Sci 2019; 1435:110-138. [PMID: 30238983 PMCID: PMC6312459 DOI: 10.1111/nyas.13958] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/16/2018] [Accepted: 08/03/2018] [Indexed: 12/15/2022]
Abstract
Clostridium difficile is the leading infectious cause of antibiotic-associated diarrhea and colitis. C. difficile infection (CDI) places a heavy burden on the healthcare system, with nearly half a million infections yearly and an approximate 20% recurrence risk after successful initial therapy. The high incidence has driven new research on improved prevention such as the emerging use of probiotics, intestinal microbiome manipulation during antibiotic therapies, vaccinations, and newer antibiotics that reduce the disruption of the intestinal microbiome. While the treatment of acute C. difficile is effective in most patients, it can be further optimized by adjuvant therapies that improve the initial treatment success and decrease the risk of subsequent recurrence. Finally, the high risk of recurrence has led to multiple emerging therapies that target toxin activity, recovery of the intestinal microbial community, and elimination of latent C. difficile in the intestine. In summary, CDIs illustrate the complex interaction among host physiology, microbial community, and pathogen that requires specific therapies to address each of the factors leading to primary infection and recurrence.
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Affiliation(s)
- Michael G. Dieterle
- University of Michigan Medical School, Medical Scientist Training Program (MSTP), Ann Arbor, Michigan
- University of Michigan Department of Microbiology and Immunology, Ann Arbor, Michigan
| | - Krishna Rao
- University of Michigan Department of Internal Medicine, Infectious Diseases Division, Ann Arbor, Michigan
| | - Vincent B. Young
- University of Michigan Department of Microbiology and Immunology, Ann Arbor, Michigan
- University of Michigan Department of Internal Medicine, Infectious Diseases Division, Ann Arbor, Michigan
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Leedahl DD, Personett HA, Nagpal A, Barreto EF. Prevention of Clostridium difficile Infection in Critically Ill Adults. Pharmacotherapy 2019; 39:399-407. [PMID: 30506900 DOI: 10.1002/phar.2200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The incidence and severity of Clostridium difficile infection (CDI) remain high across intensive care units in the United States despite national efforts to decrease this escalating health care burden. Most published literature and guidelines address treatment rather than prevention, yet this approach may be too downstream to limit morbidity and mortality from the disease and its complications. Mechanisms to prevent CDI successfully include reducing modifiable risk factors and minimizing horizontal transmission of C. difficile spores between patients and the health care environment. Because CDI prevention is characterized by a bundled approach, it is difficult to quantify the individual impact of any one element; however, a number of patient- and facility-level strategies can be considered for CDI prevention. Robust hygiene strategies, diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin in the setting of systemic antibiotics have all demonstrated benefit. The preventive roles of deprescribing acid suppressants, routine use of probiotics, or early fecal microbiota transplantation remain unclear. The focus of this review is to summarize the evidence related to primary and secondary CDI prevention in critically ill adults and provide a concise implementation pathway for clinicians and policymakers.
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Affiliation(s)
- David D Leedahl
- Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
| | | | - Avish Nagpal
- Infectious Diseases, Sanford Medical Center, Fargo, North Dakota
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Doctor, my patient has CDI and should continue to receive antibiotics. The (unresolved) risk of recurrent CDI. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32 Suppl 2:47-54. [PMID: 31475811 PMCID: PMC6755365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recurrence rate ranges from 12% to 40% of all cases of Clostridium difficile infection (CDI) and proposes an exceptional clinical challenge. Conventionally, treatment options of CDI have been limited to regimes of established antibiotics (eg, pulsed/tapered vancomycin) or "improvised" alternative antibiotics (eg. teicoplanin, tigecycline, nitazoxanide or rifaximin) occasionally even in combination, but faecal microbiota transplantation is emerging as a useful and quite safe alternative. In recent years, promising new strategies have emerged for effective prevention of recurrent CDI (rCDI) including new an-timicrobials (eg, fidaxomicin) and monoclonal antibodies (eg, bezlotoxumab). Despite promising progress in this area, difficulties remain for making the best use of these resources due to uncertainty over patient selection. This positioning review describes the current epidemiology of rCDI, its clinical impact and risk factors, some of the measures used for treating and preventing rCDI, and some of the emerging treatment options. It then describes some of the barriers that need to be overcome.
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Pouch SM, Friedman-Moraco RJ. Prevention and Treatment of Clostridium difficile-Associated Diarrhea in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:733-748. [PMID: 30146033 DOI: 10.1016/j.idc.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection is a significant cause of morbidity and mortality in solid organ transplant recipients. Risk factors in this population include frequent hospitalizations, receipt of immunosuppressive agents, and intestinal dysbiosis triggered by several factors, including exposure to broad-spectrum antimicrobials. The incidence and potential for significant adverse outcomes among solid organ transplant recipients with C difficile infection highlight the evolving need for strategic C difficile infection risk factor modification and novel approaches to disease management in this patient population. This review focuses on current concepts related to the prevention and treatment of C difficile infection in solid organ transplant recipients.
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Affiliation(s)
- Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA.
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA
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Alonso CD, Mahoney MV. Bezlotoxumab for the prevention of Clostridium difficile infection: a review of current evidence and safety profile. Infect Drug Resist 2018; 12:1-9. [PMID: 30588042 PMCID: PMC6301304 DOI: 10.2147/idr.s159957] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a leading nosocomial disease estimated to cause nearly half a million cases in the United States annually. Recurrent CDI (rCDI) affects ~25% of patients after completion of standard of care therapy and is associated with substantial health care costs and a negative impact on patient's overall markers of quality of life. Bezlotoxumab is the first of its kind monoclonal antibody directed against C. difficile toxin B and indicated for prevention of rCDI in at-risk patients. For the present review, we assessed English-language studies evaluating the clinical efficacy, safety, and pharmacokinetics of bezlotoxumab in humans. Relevant studies were obtained through PubMed, Embase, Cochrane database library, Web of Science, and clinicaltrials.gov. Overall, bezlotoxumab demonstrated a 40% relative reduction rate (absolute rate reduction of ~10%) and a number needed to treat of 10 patients with a favorable safety profile. Special populations, including the elderly, immunocompromised, and patients with end-stage renal disease were evaluated in post hoc analyses with a similarly favorable reduction in rCDI. This review presents and interprets the most recent safety data and the clinical application of bezlotoxumab, highlighting specific high-risk patient populations.
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Affiliation(s)
- Carolyn D Alonso
- Department of Medicine, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA,
- Harvard Medical School, Boston, MA, USA,
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Brown CC, Manis MM, Bohm NM, Curry SR. Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection. Ann Pharmacother 2018; 53:396-401. [PMID: 30450942 DOI: 10.1177/1060028018815170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To summarize and critically appraise the evidence regarding oral vancomycin prophylaxis (OVP) to prevent recurrent Clostridium difficile infections (RCDIs), identify potential consequences of this emerging practice, and highlight future directions of study. DATA SOURCES A MEDLINE literature search of English-language publications from 1947 through September 2018 was performed using the search terms vancomycin and C difficile and prophylaxis. Clinical trials were identified on the National Library of Medicine clinical trials registry. STUDY SELECTION AND DATA EXTRACTION All clinical studies (n = 3) assessing oral vancomycin for secondary prophylaxis of C difficile infection (CDI) were evaluated by all authors. Other search results and references in selected publications were used for background and discussion. DATA SYNTHESIS OVP reduced the risk of RCDI in high-risk patients taking systemic antibiotics. Variable dosing regimens and lack of safety data are limitations. OVP may have an adverse impact on the gastrointestinal microbiome, but this was not examined in the clinical studies. Relevance to Patient Care and Clinical Practice: Although current studies are limited by methodological concerns, clinicians can consider vancomycin 125 mg orally once or twice daily in high-risk patients receiving broad-spectrum antibacterial agents. Results of ongoing trials will define the most appropriate regimen and its impact on outcomes, including collateral damage. CONCLUSIONS OVP reduces the risk of RCDIs and should be considered on a case-by-case basis. Caution is warranted before routine use is implemented because the impact on long-term outcomes has not been assessed and the optimal regimen has not been defined.
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Affiliation(s)
- Chase C Brown
- 1 Medical University of South Carolina, Charleston, SC, USA
| | - Melanie M Manis
- 2 Samford University McWhorter School of Pharmacy, Birmingham, AL, USA
| | - Nicole M Bohm
- 1 Medical University of South Carolina, Charleston, SC, USA.,3 Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Scott R Curry
- 1 Medical University of South Carolina, Charleston, SC, USA
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Basu A, Prabhu VS, Dorr MB, Golan Y, Dubberke ER, Cornely OA, Heimann SM, Pedley A, Xu R, Hanson ME, Marcella S. Bezlotoxumab Is Associated With a Reduction in Cumulative Inpatient-Days: Analysis of the Hospitalization Data From the MODIFY I and II Clinical Trials. Open Forum Infect Dis 2018; 5:ofy218. [PMID: 30460321 PMCID: PMC6237242 DOI: 10.1093/ofid/ofy218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/31/2018] [Indexed: 12/17/2022] Open
Abstract
Background Patients with recurrent Clostridium difficile infection (rCDI) are more likely to have a hospital readmission and spend increased time in inpatient settings compared with patients with primary CDI. MODIFY I and II demonstrated that bezlotoxumab significantly reduced rCDI vs placebo. A post hoc within-trial analysis assessed whether bezlotoxumab was associated with a reduction in cumulative inpatient-days. Methods Data were pooled from the MODIFY trials to estimate the cumulative hospitalized days summed over the 84-day follow-up period. We adjusted inpatient use data from pooled MODIFY I and II for survival and censoring to estimate 84-day cumulative inpatient-days, overall and for subgroups. Treatment effects were obtained using recycled predictions based on trial protocol and rCDI risk, and 95% confidence intervals were obtained using 1000 bootstrap replicates. Results Mean cumulative inpatient-days were greater in the placebo arm (14.1 days) vs the bezlotoxumab arm (12.1 days) in the overall population. The mean difference between treatment groups was 2.1 days (95% confidence interval, –0.4 to –3.7). This was consistent in participants with risk factors for rCDI: age ≥65 years, compromised immunity, severe CDI, prior CDI, and ribotype 027/078/244 infection. As the number of risk factors increased, bezlotoxumab resulted in greater reductions in the number of inpatient-days compared with placebo (difference: –1.2 days, –2.3 days, –2.5 days, and –3.0 days for 0, 1, 2, and ≥3 risk factors, respectively). Conclusions Bezlotoxumab was associated with a reduction in cumulative inpatient-days, suggesting that treatment with bezlotoxumab may substantially reduce rCDI-associated health care resource use. Trial registrations. MODIFY I (MK-3415A-001, NCT01241552) and II (MK-3415A-002, NCT01513239)
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Affiliation(s)
- Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington
| | | | | | - Yoav Golan
- New England Medical Center, Tufts University, Boston, Massachusetts
| | - Erik R Dubberke
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Department I of Internal Medicine, ECMM Excellence Center of Medical Mycology, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Sebastian M Heimann
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | | | - Ruifeng Xu
- Merck & Co., Inc., Kenilworth, New Jersey
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Salavert M, Cobo J, Pascual Á, Aragón B, Maratia S, Jiang Y, Aceituno S, Grau S. Cost-Effectiveness Analysis of Bezlotoxumab Added to Standard of Care Versus Standard of Care Alone for the Prevention of Recurrent Clostridium difficile Infection in High-Risk Patients in Spain. Adv Ther 2018; 35:1920-1934. [PMID: 30328061 PMCID: PMC6223985 DOI: 10.1007/s12325-018-0813-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Indexed: 12/12/2022]
Abstract
Introduction Clostridium difficile infection (CDI) is the major cause of infectious nosocomial diarrhoea and is associated with considerable morbidity, mortality and economic impact. Bezlotoxumab administered in combination with standard of care (SoC) antibiotic therapy prevents recurrent CDI. This study assessed the cost-effectiveness of bezlotoxumab added to SoC, compared to SoC alone, to prevent the recurrence of CDI in high-risk patients from the Spanish National Health System perspective. Methods A Markov model was used to simulate the natural history of CDI over a lifetime horizon in five populations of patients at high risk of CDI recurrence according to MODIFY trials: (1) ≥ 65 years old; (2) severe CDI; (3) immunocompromised; (4) ≥ 1 CDI episode in the previous 6 months; and (5) ≥ 65 years old and with ≥ 1 CDI episode in the previous 6 months. The incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life-year (QALY) gained was calculated. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were performed. Results In all patient populations (from 1 to 5), bezlotoxumab added to SoC reduced CDI recurrence compared to SoC alone by 26.4, 19.5, 21.2, 26.6 and 39.7%, respectively. The resulting ICERs for the respective subgroups were €12,724, €17,495, €9545, €7386, and €4378. The model parameters with highest impact on the ICER were recurrence rate (first), mortality, and utility values. The probability that bezlotoxumab was cost-effective at a willingness-to-pay threshold of €21,000/QALY was 85.5%, 54.1%, 86.0%, 94.5%, 99.6%, respectively. Conclusion The results suggest that bezlotoxumab added to SoC compared to SoC alone is a cost-effective treatment to prevent the recurrence of CDI in high-risk patients. The influence of changes in model parameters on DSA results was higher in patients ≥ 65 years old, with severe CDI and immunocompromised. Additionally, PSA estimated that the probability of cost-effectiveness exceeded 85% in most subgroups. Funding Merck Sharp & Dohme Corp. Electronic supplementary material The online version of this article (10.1007/s12325-018-0813-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario La Fe, Valencia, Spain.
| | - Javier Cobo
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Álvaro Pascual
- Clinical Microbiology and Infectious Diseases Unit, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBIS), Universidad de Sevilla, Seville, Spain
| | | | | | - Yiling Jiang
- Merck Sharp & Dohme Ltd, Hoddesdon, Hertfordshire, UK
| | | | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, Spain
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49
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Johnson S, Gerding DN. Bezlotoxumab. Clin Infect Dis 2018; 68:699-704. [DOI: 10.1093/cid/ciy577] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/10/2018] [Indexed: 01/05/2023] Open
Affiliation(s)
- Stuart Johnson
- Hines Veterans Affairs Hospital, Hines, Illinois
- Loyola University Medical Center, Maywood, Illinois
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50
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Cost-effectiveness of three different strategies for the treatment of first recurrent Clostridium difficile infection diagnosed in a community setting. Infect Control Hosp Epidemiol 2018; 39:924-930. [PMID: 29961435 DOI: 10.1017/ice.2018.139] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE A significant portion of patients with Clostridium difficile infections (CDI) experience recurrence, and there is little consensus on its treatment. With the availability of newer agents for CDI and the added burdens of recurrent disease, a cost-effectiveness analysis may provide insight on the most efficient use of resources. DESIGN A decision-tree analysis was created to compare the cost-effectiveness of 3 possible treatments for patients with first CDI recurrence: oral vancomycin, fidaxomicin, or bezlotoxumab plus vancomycin. The model was performed from a payer's perspective with direct cost inputs and a timeline of 1 year. A systematic review of literature was performed to identify clinical, utility, and cost data. Quality-adjusted life years (QALY) and incremental cost-effectiveness ratios were calculated. The willingness-to-pay (WTP) threshold was set at $100,000 per QALY gained. The robustness of the model was tested using one-way sensitivity analyses and probabilistic sensitivity analysis. RESULTS Vancomycin had the lowest cost ($15,692) and was associated with a QALY gain of 0.8019 years. Bezlotoxumab plus vancomycin was a dominated strategy. Fidaxomicin led to a higher QALY compared to vancomycin, at an incremental cost of $500,975 per QALY gained. Based on our WTP threshold, vancomycin alone was the most cost-effective regimen for treating the first recurrence of CDI. Sensitivity analyses demonstrated the model's robustness. CONCLUSIONS Vancomycin alone appears to be the most cost-effective regimen for the treatment of first recurrence of CDI. Fidaxomicin alone led to the highest QALY gained, but at a cost beyond what is considered cost-effective.
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