179 Cost-Effectiveness Analysis of Starting a Fecal Microbiota Transplantation (FMT) Unit for the Treatment of Recurrent C. difficile Infection Compared With Antibiotic Therapy

INTRODUCTION: Despite the proven efficacy of FMT in recurrent Clostridioides difficile infection (CDI), many hospitals and health regions have yet to establish a program for its use. We assessed the cost effectiveness of FMT (including start-up costs) for recurrent CDI (rCDI) to determine how many patients would need to be treated to make this approach cost effective for a centre. METHODS: We conducted a decision-analytic model comparing six separate strategies for the management of the third recurrence of CDI: each FMT modality (via capsule, enema (Figure 1), or colonoscopy) versus vancomycin, fidaxomicin, and a combined antibiotic model of vancomycin followed by fidaxomicin. At the end of the decision tree, the patient would be in one of 4 health conditions: healthy, mild-to-moderate CDI, post-colectomy, or death. Costs for a FMT start up centre (preparation of donor material, screening costs, etc. Table 1) were calculated over 10 years, and discounted at 5%/year. Our primary outcome was to estimate how many patients would have to be treated with FMT on an annual basis to make a FMT centre cost-effective (WTP of $50,000/QALY) versus antibiotic therapy for the treatment of rCDI. RESULTS: To make any of the FMT modalities cost-effective compared with vancomycin treatment, 26 patients would have to be treated with FMT via enema annually, 32 via capsule, and 31 via colonoscopy (Figure 2). In our base case analysis of all three FMT modalities treating 40 patients/year compared with vancomycin, FMT via enema was the most cost-effective strategy with an incremental cost-effectiveness rate (ICER) of $21,366.03, followed by ICERs of $37,911.01, and $37,743.24 via capsule and colonoscopy, respectively. Treatment with fidaxomicin in these patients was both more expensive and less effective than FMT, as it was dominated by all 3 FMT modalities. When patients were initially treated with vancomycin followed by fidaxomicin if they failed vancomycin, FMT via enema dominated. CONCLUSION: FMT, including start-up and ongoing costs, is cost-effective compared to conventional antibiotics in the treatment of recurrent CDI. Only 26 patients are required to be treated each year with FMT via enema for it to be a cost-effective strategy for rCDI. In healthcare regions where FMT is not currently a therapeutic option, this analysis suggests that despite its higher initial costs, starting up a FMT unit will lead to healthcare savings over time.