Dificlir significantly reduces recurrence and mortality when used first-line in patients with CDI

Data presented from the CDI Service Evaluation study shows that the adoption pattern of treatment impacts CDI outcomes.

Compared with traditional broad-spectrum antibiotics, first-line use of fidaxomicin, a targeted treatment, in all CDI patients provides improved outcomes in terms of recurrence rate, all-cause mortality and cost effectiveness, compared to use in selected patients only. (8) CDI is associated with high-mortality (5,6,7) and cost burden, (9) therefore reducing the incidence and recurrence of CDI is a priority for clinicians, payers and health authorities alike.

Presented at the 5th International Clostridium Difficile Symposium (ICDS) in Bled, Slovenia, the CDI Service Evaluation Study analysed a large dataset of over 1450 CDI patient episodes. As a real-world multi-centre study, it assessed the effectiveness of current CDI treatment for UK patients in NHS Secondary Care Trusts in England. (8)

“CDI is a significant burden for patients and the NHS, and reducing its incidence and recurrence is a priority”, comments Dr Simon Goldenberg, Consultant Microbiologist and Infection Control Doctor, Guy’s and St Thomas’ NHS Foundation Trust. “This study builds on the growing evidence that adopting fidaxomicin as first-line treatment for all patients with CDI, rather than reserving it for more severe cases, provides more optimal outcomes in terms of recurrence, all-cause mortality and cost effectiveness compared to older treatments – vancomycin and metronidazole. A previous study also showed that first-line use of fidaxomicin could reduce environmental contamination compared to those treated with vancomycin or metronidazole, further demonstrating the role fidaxomicin may play in reducing the spread and incidence of CDI alongside stringent hospital hygiene protocols.”

Over 1450 patient episodes were included in the analysis conducted in seven UK hospitals that introduced fidaxomicin, a narrow-spectrum antibiotic for the treatment of confirmed CDI in adults, between July 2012 and July 2013. (8) Data collected were compared with a retrospective cohort treated with broad-spectrum antibiotics, vancomycin or metronidazole, during the previous 12-month period. (8)

Patterns of fidaxomicin use differed between the seven centres, with centres A and B treating with fidaxomicin as first-line treatment for all patients and the other five centres using fidaxomicin as first-line treatment only in selected patients for both primary and recurrent CDI. (8)

Data collected on 177 patient episodes treated first-line with fidaxomicin in centres A and B, showed a significant reduction in 28-day all-cause mortality, from 18.2% to 3.1% (P<0.001) and 17.3% to 6.3% (P<0.05) respectively. (8,10) The real-world analysis also supports clinical trial data in highlighting dramatically reduced recurrence rates: from 12.1% and 23.5% in centres A and B with standard of care treatments (vancomycin and metronidazole), to 3.1% in both these centres where fidaxomicin was used first-line. (8) For every 50 patients treated, this would result in five and ten recurrences avoided in the two centres respectively. (8) “Good antimicrobial stewardship includes using, where possible, narrow-spectrum rather than a broad-spectrum treatment,” comments Professor Mark Wilcox, Professor of Medical Microbiology, Leeds Teaching Hospitals & University of Leeds. “Fidaxomicin has limited activity against the ‘good bacteria’ in the gut and so can be considered to be a targeted treatment option. Preservation of the gut microflora likely contributes to the lower rates of recurrence seen after fidaxomicin treatment of CDI compared with those associated with broader-spectrum antibiotics like vancomycin.”

A CDI recurrence adds an additional £20,249 on top of the £13,146 spent to treat the initial infection due to prolonged hospital stay, ICU stay, high cost drugs and the surgery necessary to tackle it, as seen in the real-world evidence. (11) An in-depth costing analysis at the two centres that adopted fidaxomicin as a first-line treatment revealed that in centre A the five recurrences that could be avoided for every 50 patients treated with the narrow-spectrum antibiotic would result in a cost saving of £19,490, and in centre B, for the ten recurrences avoided, a cost saving of £121,144.8 With 16,947 cases of CDI reported in the UK between April 2013 and March 2014, (1,2,3,4) the potential NHS cost saving for the treatment of this potentially fatal condition is likely to be far greater.

Guidance from Public Health England recommends fidaxomicin as an initial treatment option for severe cases of CDI in patients at high risk for recurrence; in addition, fidaxomicin is the preferred treatment for recurrent CDI. (12)

References:

1. Public Health England, Clostridium difficile infection: annual data. C. difficile infections: quarterly counts by acute trust and CCG and financial year counts and rates by acute trust and CCG, May 2014. Available online via: https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data [Last accessed, May 2015].
2. Health Protection Scotland, Quarterly report on the surveillance of Clostridium difficile infection in Scotland, January – March 2014. July 2014. Available online via: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=50174 [Last accessed, May 2015].
3. HSCNI Public Health Agency, Summary Tables for Clostridium difficile and MRSA (Meticillin Resistant Staphylococcus aureus) cases 2006/07 to 2014/15. Available online via: http://www.publichealth.hscni.net/sites/default/files/End%20August%202014.pdf [Last accessed, May 2015].
4. Public Health Wales. Clostridium difficile and Staphylococcus aureus Bacteraemia Monthly Update. Available online via: http://www.wales.nhs.uk/sites3/page.cfm?orgid=379&pid=67899 [Last accessed, May 2015].
5. Office for National Statistics, Statistical bulletin: Deaths Involving Clostridium difficile, England and Wales, 2012, August 2013. Available online via: http://www.ons.gov.uk/ons/rel/subnational-health2/deaths-involving-clostridium-difficile/2012/stb-deaths-involving-clostridium-difficile-2012.html [Last accessed, May 2015].
6. General Register Office for Scotland. Clostridium Difficile (C.diff) Deaths. Deaths for which Clostridium difficile was mentioned on the death certificate (either as the underlying cause of death or as a contributory factor), Scotland, 2000-2013. Available online via: http://www.nrscotland.gov.uk/files//statistics/c-diff-deaths/2013/c-diff-2013-tab6.pdf [Last accessed, May 2015].
7. Northern Ireland Statistics & Research Agency. Healthcare-Associated Infection. Deaths Registered with Clostridium difficile Mentioned on the Death Certificate, 2003-2013. Available at: http://www.nisra.gov.uk/demography/default.asp29.htm [Last accessed, May 2015].
8. Howard P et al. The impact of the introduction of fidaxomicin on the management of Clostridium difficile infection in 7 NHS secondary care Trusts in England. Poster presented at ICDS 2015.
9. Department of Health, NHS Outcomes Framework: Impact Assessment (5014), December 2010. Available online via: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213792/dh_122953.pdf [Last accessed, May 2015].
10. Howard P et al. The impact of the introduction of fidaxomicin on the management of Clostridium difficile infection in 7 NHS secondary care Trusts in England. Abstract presented at ICDS 2015.
11. St George’s: Cost-effectiveness of fidaxomicin as first-line treatment for Clostridium difficile infection presentation, 2014. Astellas Pharma Ltd Data on File DIF14036UK(2).
12. Public Health England, Updated guidance on the management and treatment of Clostridium difficile infection, May 2013. Available online via: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/321891/Clostridium_difficile_management_and_treatment.pdf [Last accessed, May 2015].