Infectious Disease

Should fidaxomicin be the preferred treatment for C. difficile?

January 21, 2022

2 minutes read

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Brock does not report any relevant financial information.

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New guidelines issued in 2021 favored fidaxomicin as the first-line treatment for Clostridioides difficile infections, despite concerns about cost.

We asked a member of the editorial board of Infectious Disease News Jeff Brock, PharmD, MBA, BCPS-AQ ID, an infectious disease pharmacist at Mercy Medical Center in Des Moines, Iowa, if the new guidelines are correct.

As most clinicians know, the Infectious Diseases Society of America and Society for Health Care Epidemiology of America clinical practice guidelines for the management of Clostridioides difficile (CDI) infections have recently been updated.

Jeff Brock, PharmD, MBA, BCPS-AQ ID
Jeff Rock

This latest iteration now recommends fidaxomicin as the treatment of choice for initial and first relapse episodes of CDI. Ever since fidaxomicin was approved for CDI treatment, I have been an enthusiastic supporter of its use as clinical trials have shown a significant reduction in the risk of recurrent CDI when used for initial or first recurrent cases. I also appreciate the fact that fidaxomicin has a narrow spectrum of activity compared to vancomycin and metronidazole and less overall impact on the human microbiome.

Unfortunately, the cost of treatment has been a significant impediment to its implementation over the years. The average wholesale price for a fidaxomicin treatment is about four times higher than that for vancomycin oral capsules. When fidaxomicin is started in inpatients, hospitals are not reimbursed for this cost, which can severely impact a pharmacy’s budget.

Discharging hospitalized patients on fidaxomicin can also be difficult, even if the patient has insurance. Although insurance companies offer some coverage for fidaxomicin, many patients still have to pay hundreds of dollars in co-payments at the pharmacy when they pick up their prescription. This often leads to calls to the prescribing doctor for a prescription for vancomycin.

It is currently unknown whether giving fidaxomicin to inpatients and switching to oral vancomycin at discharge is associated with the same benefits of reducing recurrence rates. The manufacturer of fidaxomicin offers a patient assistance program that can reduce fidaxomicin co-payments for qualifying patients. However, patients who have Medicare or Medicaid are not eligible for patient assistant programs. Unfortunately, I have found that many of our patients who present with CDI are covered by one of these programs.

While I consider fidaxomicin to be the best treatment option for CDI due to its pharmacokinetics and pharmacodynamics and its ability to reduce recurrent disease, I disagree that it should be given preferential treatment due to the high cost of treatment and the barriers to patient access. If the cost of fidaxomicin was more reasonable, my opinion would change.

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