Stewardship / Resistance Scan for Feb 22, 2018

Cost-effective C diff treatment
Latent TB guidelines

Study evaluates cost-effectiveness of Clostridium difficile treatments

A systematic review of treatments for Clostridium difficile infection (CDI) yesterday in Infection Control and Hospital Epidemiology concludes that the most cost-effective treatment remains unclear.

The literature review conducted by researchers from the Cleveland Clinic and the University of Texas School of Public Health included 14 studies on economic valuations of various treatment modalities for initial and recurrent CDI. Thirteen of the studies were conducted in high-income countries in the last 5 years, and more than 90% were deemed moderate-to-high or high-quality. Cost of therapy, time horizon, treatment cure rates, and recurrence rates were common influential factors in the study results.

The researchers found that fidaxomicin, a newer CDI drug, appears to be more cost-effective than other therapies, but not definitively. For initial CDI with no specific disease severity, fidaxomicin was found to be more cost-effective than metronidazole and vancomycin in two studies, but not in the study that accounted for severity. Two studies found fidaxomicin to be the most cost-effective treatment for initial severe CDI, but another concluded differently, possibly because of the higher cure rate of vancomycin and the higher cost of fidaxomicin. Three of five studies found that fidaxomicin was cost-effective for treating recurrent CDI.

The group also found that fecal microbiota transplantation (FMT) by colonoscopy was cost-effective for treating recurrent CDI in all four studies that analyzed it. But FMT via other routes was not found to be cost-effective.

The authors of the meta-analysis say that while fidaxomicin and FMT have opened up a new arena in CDI management, the high cost of these treatments (compared with vancomycin and metronidazole) means that further evaluation of their cost-effectiveness is needed. "Our review informs future research of areas that need improvement and may help policymakers and physicians to critically assess the cost-effectiveness of different CDI treatments," they write.
Feb 21 Infect Control Hosp Epidemiol abstract


WHO releases updated guidelines for management of latent TB

Updated guidelines on management of latent tuberculosis infection (LTBI) from the World Health Organization (WHO) call for expanded access to preventive treatment and testing along with new testing and treatment options.

LTBI is defined as a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens, with no evidence of clinically manifest active TB. People with a latent infection may develop active TB if they don't receive appropriate treatment.

The updated, consolidated guidelines include new recommendations on several different fronts, beginning with who should be prioritized for LTBI testing and preventive treatment. While previous guidelines have prioritized people with HIV and children under the age of 5 who have been in contact with people who have TB, the updated guidelines expand that group to include HIV-negative children, adults, and adolescents who are household contacts of people with bacteriologically confirmed TB. Select household contacts of patients with multidrug-resistant TB are also among those who may be considered for preventive treatment.

The updated guidelines also call for the use of either a tuberculin skin test or an interferon-gamma release assay in LTBI testing but note that such tests are not required for preventive treatment in people with HIV or child household contacts under the age of 5.

For treatment, the guidelines include shorter treatment options. Isoniazid monotherapy for 6 months remains the recommended treatment for children and adults, but rifampicin plus isoniazid daily for 3 months should be offered as an alternative in children and adolescents under the age of 15, and rifapentine plus isoniazid weekly for 3 months may be offered as an alternative for adults and children.
Feb 22 WHO updated guidelines for LTBI management

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