Costs, Utilization Linked With Recurrent Clostridioides difficile Infection

Gil Melmed, MD, gastroenterologist, discusses recurrence rates among patients with Clostridioides difficile infection, and breaks down the treatment challenges, high costs, and higher health care utilization this patient population often faces. 

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network, where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today, we are joined by Dr Gil Melmed, gastroenterologist. Dr Melmed discusses recurrence rates among patients with C difficile infection and breaks down the treatment challenges, high costs, and higher health care utilization this patient population often faces. Dr Melmed?

Hi, my name's Gil Melmed. I am a gastroenterologist in Los Angeles working at a major tertiary hospital and see a lot of patients with inflammatory bowel disease, and also involved in our fecal microbiome transplant program.

Recurrent CDI is an important topic, especially in terms of appropriate prevention and management of the initial disease. What can you tell us about the challenges of treating recurring CDI?

For every 4 patients that come with a diagnosis of C difficile infection, we can anticipate that one of those patients is going to develop recurrent C diff infection. That's a pretty high rate of recurrence, if you think about it, with respect to infections in general, that about a quarter of patients will relapse.

That's typically defined as recurrence of symptoms 2 to 8 weeks after a successful treatment. This represents a significant burden because these patients will often not respond to the way that C diff was initially treated.

It's typically considered a failure of treatment, even though there might have been temporary resolution of symptoms. We need to start getting creative and thoughtful about how we're going to manage these patients.

Also, these patients often end up getting really sick and need to be hospitalized. That's another consideration. When it comes to thinking about recurrent C diff infection, recurrent CDI, we do anticipate that these are going to be more refractory, more challenging to treat, and sicker patients that are going to require some creative thinking about how to best manage their disease.

Despite treatment for C difficile, one or more recurrences occurs in 10 to 30% of patients, leading to significant morbidity, high costs, poor quality of life, higher health care utilization, and other negative outcomes. What does this mean for both patients and providers?

Recurrent C diff infection is a very significant burden for the patients, for the providers, and for society, I would say, at large. When it comes to individual patients who have been already suffering from their initial C diff infection, then to have a recurrence, which is more difficult to treat, oftentimes, very significant impact on their quality of life.

Severe diarrhea, severe abdominal symptoms, oftentimes associated with toxicity that lands them up in the hospital, requiring inpatient treatment. These are individuals whose lives, and also, the lives of people who live with them and care for them, are very significantly impacted.

When it comes to health care providers and the health care system, the health care system also suffers significant burden from treatment and management of recurrent C difficile infection. Again, about 25% of patients—as you said, 10 to 30%—about a quarter of patients will end up with recurrence of C diff infection.

Again, these are going to be patients who are sicker and more difficult to manage. They are going to require more hospital visits. They're going to require more outpatient visits. They're going to require more touch points with the health care system, possibly procedures, with colonoscopy, fecal transplant, and more sophisticated therapies.

From a health care utilization standpoint and a societal standpoint, this can represent a very significant burden, both in terms of the indirect costs of the individual who is essentially incapacitated by symptoms, as well as the family that's caring for the individual, the requirements for interactions with the health care system, potential hospitalizations, and the cost of treatment.

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