Cost-effectiveness in Clostridium difficile treatment decision-making

Table 1 Summary of the most relevant therapeutic issues in Clostridium difficile infection

Level	Issues
Patient level	Recurrence of CDI is a serious and difficult-to-treat problem[26]
	Patient groups at high risk of recurrence or those for whom the impact of recurrence would be most dramatic include those with multiple comorbidities, who are immunocompromised, who are receiving certain concomitant antibiotics[26, who have had CDI previously, who are renally impaired, who are aged 65 yr or over, patients awaiting further treatment (for example chemotherapy) or rehabilitation (for example after cerebrovascular event)
Population level	The rate of person-to-person transmission of C. difficile is a complicating problem
	The risk for development of vancomycin-resistant enterococci or other antibiotic induced resistant bacteria, although it is not a major issue in daily practice

CDI: Clostridium difficile infection.

Table 2 Summary of the most relevant economic issues in Clostridium difficile infection

Level	Issues
Patient level	The cost of recurrence of CDI is high
	CDI leads to additional costs: extra diagnostic tests, extra antibiotics and other medication, time spent by nurse and physician on the ward
	The additional circumstances of these seriously ill patients (e.g., not completing primary therapy, thereby complicating cure or improvement of their disease state) due to CDI should be reflected in the CEA
Population level	The rate of person-to-person transmission of C. difficile is a complicating problem with high costs
	The increased length and overall cost of hospitalization with CDI, including the costs of measures to isolate the patient and other clinical measures to prevent person-to-person transmission, as well as the costs of closing and cleaning wards
	The consequences of developing vancomycin-resistant enterococci or other antibiotic induced resistant enterococci are not integrated in standard cost-effectiveness evaluations

CDI: Clostridium difficile infection; CEA: Carcinoembryonic antigen.

Table 3 Similarities and differences between a patient-based and population based cost-effectiveness model

Patient-based cost-effectiveness model	Population-based cost-effectiveness model
Similarities
Patient-related therapeutic and economic measures for clinical and economic evaluations
Differences
	The relevant economic issues, as indicated for CDI like:
	increasing incidence of CDI,
	person-to person transmission of CDI,
	development of vancomycin-resistant enterococci (VRE),
	or other antibiotic induced resistant bacteria,
	impact for department of microbiology diagnostic testing
	isolation measures and
	closing of wards of hospitals
	other supra-patient effects
Limited health economic outcome in terms of time horizon and perspective
The patient-based cost-effectiveness model only captures the short-term time horizon of the CDI episode within the hospital setting at a patient level