Vol.:(0123456789) 1 3 Digestive Diseases and Sciences https://doi.org/10.1007/s10620-019-05821-1 ORIGINAL ARTICLE Fecal Transplants by Colonoscopy and Capsules Are Cost‑Efective Strategies for Treating Recurrent Clostridioides difficile Infection Yuying Luo 1  · Aimee L. Lucas 2  · Ari M. Grinspan 2 Received: 13 March 2019 / Accepted: 28 August 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 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-efective strategy for managing recurrent CDI. Methods A decision tree analysis was created from a modifed third-party payer’s perspective to compare the cost-efective- ness of fve strategies for patients experiencing their frst CDI recurrence: oral vancomycin, fdaxomicin, fecal microbiota transplant (FMT) via colonoscopy, FMT via oral capsules, and a one-time infusion of bezlotoxumab with vancomycin. Efectiveness 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-efective strategy with an incremental cost–efectiveness ratio (ICER) of $31205/QALY. Sensitivity analyses demonstrated that FMT delivered by oral capsules and colonoscopy was comparable cost-efective modalities. At its current cost and efectiveness, bezlotoxumab was not a cost-efective strategy. Conclusions FMT via oral capsules and colonoscopy is both cost-efective strategies to treat the frst recurrence of CDI. Further real-world economic studies are needed to understand the cost-efectiveness of all available strategies. Keywords Cost-efectiveness · Recurrent Clostridioides difficile infections · Fecal microbiota transplants · Bezlotoxumab Introduction Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated infections in the USA. Recurrent CDI, defned as a relapse after initial treatment, remains a treatment challenge as up to a quarter of patients will expe- rience a recurrence after appropriate antibiotics and nearly half after a second recurrence [1]. This poses an incredible economic burden on the US healthcare system, now esti- mated to be more than $5 billion dollars annually [2]. The landscape for treating CDI has changed dramatically over the past decade. Metronidazole is no longer recom- mended as frst-line treatment for initial or recurrent CDI [3]. Treatment for initial episode of CDI usually comprises a 10-day course of oral vancomycin or fdaxomicin. Guide- lines recommend a tapered or pulsed course of vancomycin or a 10-day course of fdaxomicin for recurrent episodes. Fecal microbiota transplants (FMTs) are recommended after two or more recurrent episodes of CDI. FMT has been shown to be the most efective therapy for recurrent CDI with efcacy above 90% when administered by colonos- copy [4]. Notably, a recent randomized trial demonstrated that FMT delivered by oral capsules is non-inferior to FMT delivered by colonoscopy [5]. In addition, bezlotoxumab, a fully human monoclonal antibody directed against toxin B produced by C. difficile, was recently approved by the FDA for the prevention of CDI recurrence based on two phase 3 clinical trials [6]. However, no clinical recommendations * Yuying Luo yuying.luo@mountsinai.org Ari M. Grinspan ari.grinspan@mountsinai.org 1 Department of Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA 2 The Henry D. Janowitz Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA