1Center for Value-Based Care Research,Medicine Institute,Cleveland Clinic,Cleveland,Ohio.
2Department of Management,Policy and Community Health,The University of Texas School of Public Health,Houston,Texas.
Infect Control Hosp Epidemiol. 2018 Apr;39(4):412-424. doi: 10.1017/ice.2017.303. Epub 2018 Feb 21.
BACKGROUND Clostridium difficile infection (CDI) presents a substantial economic burden and is associated with significant morbidity. While multiple treatment strategies have been evaluated, a cost-effective management strategy remains unclear. OBJECTIVE We conducted a systematic review to assess cost-effectiveness analyses of CDI treatment and to summarize key issues for clinicians and policy makers to consider. METHODS We searched PubMed and 5 other databases from inception to August 2016. These searches were not limited by study design or language of publication. Two reviewers independently screened the literature, abstracted data, and assessed methodological quality using the Drummond and Jefferson checklist. We extracted data on study characteristics, type of CDI, treatment characteristics, and model structure and inputs. RESULTS We included 14 studies, and 13 of these were from high-income countries. More than 90% of these studies were deemed moderate-to-high or high quality. Overall, 6 studies used a decision-tree model and 7 studies used a Markov model. Cost of therapy, time horizon, treatment cure rates, and recurrence rates were common influential factors in the study results. For initial CDI, fidaxomicin was a more cost-effective therapy than metronidazole or vancomycin in 2 of 3 studies. For severe initial CDI, 2 of 3 studies found fidaxomicin to be the most cost-effective therapy. For recurrent CDI, fidaxomicin was cost-effective in 3 of 5 studies, while fecal microbiota transplantation (FMT) by colonoscopy was consistently cost-effective in 4 of 4 studies. CONCLUSIONS The cost-effectiveness of fidaxomicin compared with other pharmacologic therapies was not definitive for either initial or recurrent CDI. Despite its high cost, FMT by colonoscopy may be a cost-effective therapy for recurrent CDI. A consensus on model design and assumptions are necessary for future comparison of CDI treatment. Infect Control Hosp Epidemiol 2018;39:412-424.
艰难梭菌感染（CDI）会带来巨大的经济负担，并导致严重的发病率。虽然已经评估了多种治疗策略，但仍不清楚哪种策略具有成本效益。
我们进行了一项系统评价，以评估 CDI 治疗的成本效益分析，并总结临床医生和决策者需要考虑的关键问题。
我们从建库开始至 2016 年 8 月在 PubMed 和其他 5 个数据库中进行了检索。这些检索未对研究设计或出版语言进行限制。两名评审员独立筛选文献、提取数据，并使用 Drummond 和 Jefferson 清单评估方法学质量。我们提取了研究特征、CDI 类型、治疗特征以及模型结构和输入的数据。
我们纳入了 14 项研究，其中 13 项来自高收入国家。这些研究中超过 90%的研究被认为是中高度或高度质量的。总体而言，6 项研究使用决策树模型，7 项研究使用 Markov 模型。治疗费用、时间范围、治疗治愈率和复发率是研究结果的常见影响因素。对于初发性 CDI，3 项研究中的 2 项发现，与甲硝唑或万古霉素相比，非达霉素是更具成本效益的治疗方法。对于严重初发性 CDI，3 项研究中的 2 项发现非达霉素是最具成本效益的治疗方法。对于复发性 CDI，3 项研究中的 3 项发现非达霉素具有成本效益，而结肠镜检查的粪便微生物群移植（FMT）在 4 项研究中的 4 项中一直具有成本效益。
非达霉素与其他药物治疗相比，对于初发性或复发性 CDI 的成本效益并不明确。尽管 FMT 的费用较高，但对于复发性 CDI，FMT 可能是一种具有成本效益的治疗方法。对于未来 CDI 治疗的比较，需要就模型设计和假设达成共识。感染控制与医院流行病学 2018；39：412-424.
