Dubberke Erik R, Puckett Justin T, Obi Engels N, Kamal-Bahl Sachin, Desai Kaushal, Stuart Bruce, Doshi Jalpa A
Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA.
COVIA Health Solutions, Lansdale, Pennsylvania, USA.
Open Forum Infect Dis. 2022 Sep 2;9(10):ofac435. doi: 10.1093/ofid/ofac435. eCollection 2022 Oct.
The 2017 Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) infection (CDI) guideline update recommended treatment with fidaxomicin or vancomycin for CDI. We aimed to examine outpatient CDI treatment utilization before and after the guideline update and compare clinical outcomes associated with fidaxomicin versus vancomycin use.
A pre-post study design was employed using Medicare data. CDI treatment utilization and clinical outcomes (4- and 8-week sustained response, CDI recurrence) were compared between patients indexed from April-September 2017 (preguideline period) and those indexed from April-September 2018 (postguideline period). Clinical outcomes associated with fidaxomicin versus vancomycin were compared using propensity score-matched analyses.
From the pre- to postguideline period, metronidazole use decreased (initial CDI: 81.2% to 53.5%; recurrent CDI: 49.7% to 27.6%) while vancomycin (initial CDI: 17.9% to 44.9%; recurrent CDI: 48.1% to 66.4%) and fidaxomicin (initial CDI: 0.87% to 1.63%; recurrent CDI: 2.2% to 6.0%) use increased significantly ( < .001 for all). However, clinical outcomes did not improve. In propensity score-matched analyses, fidaxomicin versus vancomycin users had 4-week sustained response rates that were higher by 13.5% (95% confidence interval [CI], 4.0%-22.9%; = .0058) and 30.0% (95% CI, 16.8%-44.3%; = .0002) in initial and recurrent CDI cohorts, respectively. Recurrence rates were numerically lower for fidaxomicin in both cohorts.
Vancomycin use increased and metronidazole use decreased after the 2017 guideline update. Fidaxomicin use increased but remained low. Improved outcomes associated with fidaxomicin relative to vancomycin suggest benefits from its greater use in Medicare patients.
2017年美国传染病学会/美国医疗保健流行病学学会（IDSA/SHEA）艰难梭菌感染（CDI）指南更新推荐使用非达霉素或万古霉素治疗CDI。我们旨在研究指南更新前后门诊CDI治疗的使用情况，并比较非达霉素与万古霉素使用相关的临床结局。
采用前后对照研究设计，使用医疗保险数据。比较2017年4月至9月（指南发布前时期）索引的患者与2018年4月至9月（指南发布后时期）索引的患者的CDI治疗使用情况和临床结局（4周和8周持续缓解、CDI复发）。使用倾向评分匹配分析比较非达霉素与万古霉素相关的临床结局。
从指南发布前到发布后时期，甲硝唑的使用减少（初始CDI：81.2%降至53.5%；复发性CDI：49.7%降至27.6%），而万古霉素（初始CDI：17.9%升至44.9%；复发性CDI：48.1%升至66.4%）和非达霉素（初始CDI：0.87%升至1.63%；复发性CDI：2.2%升至6.0%）的使用显著增加（所有P均<0.001）。然而，临床结局并未改善。在倾向评分匹配分析中，非达霉素使用者与万古霉素使用者相比，初始CDI队列和复发性CDI队列的4周持续缓解率分别高出13.5%（95%置信区间[CI]，4.0%-22.9%；P = 0.0058）和30.0%（95%CI，16.8%-44.3%；P = 0.0002）。两个队列中，非达霉素的复发率在数值上均较低。
2017年指南更新后，万古霉素的使用增加，甲硝唑的使用减少。非达霉素的使用增加但仍较低。相对于万古霉素，非达霉素相关结局的改善表明在医疗保险患者中更多使用非达霉素有益。
