Cost-effectiveness of three different strategies for the treatment of first recurrent Clostridium difficile infection diagnosed in a community setting.

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.

Clinical utility of cerebral angiography in the preoperative assessment of endocarditis.

Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3-9.3%). Five had viridans group streptococci as the causative IE microorganism (p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879-0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945-0.998) and 0.944 (95% CI 0.883-0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.

Impact of isolation on hospital consumer assessment of healthcare providers and systems scores: is isolation isolating?

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used to measure the effect of isolation on patient satisfaction. Isolated patients reported lower scores for questions regarding physician communication and staff responsiveness. Overall scores for these domains were lower in isolated than in nonisolated patients.

Anti-infective therapy at the end of life: ethical decision-making in hospice-eligible patients.

Clear guidelines addressing the ethically appropriate use of anti-infectives in the setting of hospice care do not exist. There is lack of understanding about key treatment decisions related to infection treatment for patients who are eligible for hospice care. Ethical concerns about anti-infective use at the end of life include: (1) delaying transition to hospice, (2) prolonging a dying process, (3) prescribing regimens incongruent with a short life expectancy and goals of care, (4) increasing the reservoir of potential resistant pathogens, (5) placing unreasonable costs on a capitated hospice system. Although anti-infectives are thought to be relatively safe, they can place a burden on patients and be inconsistent to particular care plans. The current complex, and at times fragmented, medical care often fails to address these issues in decision-making. In many ways, the ethics governing the end of life decisions related to dialysis, hydration/nutrition, and hypercalcemia parallel those of anti-infectives. In this article we articulate important elements in ethical decision-making in the application of anti-infectives for patients who are eligible for hospice care, and we point to the need for prospective studies to help refine particular guidelines in these cases.