Cost-effectiveness of Commercial or Traditional Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection

BACKGROUND: Fecal microbiota transplantation (FMT) is the cost-effective strategy for managing recurrent Clostridioides difficile infection (rCDI). Prior costing models assumed FMT administration via colonoscopy. With the commercialization of microbiota therapeutics for rCDI, this study sought to determine the impact of commercial, Food and Drug Administration (FDA) approved microbiota-based therapeutics relative to traditional FMT on the cost-effectiveness for rCDI. METHODS: We used a Markov model to simulate a cohort of patients with rCDI to evaluate the cost-effectiveness of varied methods of FMT administration for rCDI. The model includes estimates of cure, recurrence, and mortality. Data sources were taken from national guidelines and published literature on treatment outcomes. Outcome measures were quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). RESULTS: FMT by colonoscopy is the cost-effective strategy for preventing second or subsequent rCDI with an incremental cost-effectiveness ratio (ICER) of $44 158. Assuming a willingness-to-pay threshold of $100 000 per quality adjusted life years (QALY) gained, FMT by colonoscopy was optimal in the majority (70%) of simulations. At a willingness-to-pay threshold of $100 000 per quality adjusted life year (QALY), commercial, FDA approved microbiota therapeutics were not cost effective under any circumstance when donor-derived FMT products are available. CONCLUSIONS: Traditional FMT administered by colonoscopy is the optimal cost-effective strategy for preventing second or subsequent episodes of rCDI. If FMT is not available, then microbiota therapeutics are not a cost-effective option for rCDI at current pricing.