At recent Sutter meetings with SNF partners, potential transfers of patients with a first episode of Clostridioides difficile (C. diff.) with orders for the expensive antimicrobial fidaxomicin (Dificid), were sometimes slow to place for fear that insurers might only approve Vancomycin. 

Vancomycin has traditionally served as the primary therapeutic agent for first episodes of C. diff. since it is inexpensive (<$100) and well tolerated. Dificid and the recently available generic version are expensive, with a retail price between $2500 and $5400 for a 10-day course of one tablet twice daily. Both are equally effective at curing the initial infection, but fidaxomicin is significantly better at preventing its recurrence.

In June 2021, IDSA (Infectious Disease Society of America), SHEA (Society for Healthcare Epidemiology of America), and ESCMID (European Society of Clinical Microbiology and Infectious Diseases) updated their guidelines to recommend fidaxomicin as the “preferred choice” for a first episode of C. diff. but acknowledged vancomycin was still an acceptable alternative. The ACG (American College of Gastroenterology) in 2021 stated either drug was acceptable, but fidaxomicin may be particularly beneficial for patients at high risk for recurrence. Many of our rehab patients are at high risk for recurrence due to advanced age, immunocompromised status, or  are those with severe cases of C.diff.

The usual recurrence rate for 30 days is about 13% with fidaxomicin vs 26.6% with Vancomycin. In addition, fidaxomicin has a narrow spectrum of activity with reduced adverse impact on the gut microbiota compared to vancomycin, which is much more disruptive to healthy gut flora. Fidaxomicin also has a higher and more persistent concentration, allowing killing of newly formed CDI from the spore phase of CDI. CDI is also becoming resistant to vancomycin with recent studies showing reduced susceptibility of 26-34% of CDI isolates. 

ACG has done a cost-effective analysis on the overall initial higher cost of fidaxomicin that is offset by the lower cost d/t less recurrences leading to near equivalent cost. 

My source for this information is Open Evidence AI which is available to clinicians on their computers as well as devices. To learn more about this tool, go to: https://www.openevidence.com/

This AI tool data source includes:  NEJM (New England Journal of Medicine), The JAMA Network (Journal of American Medical Association), The Lancet, and Elsevier’s Vast Clinical Library. This means that your clinical question is footnoted with live links to the article that provide reliable evidence for their findings. This feature may strengthen peer to peer appeals of denials.

Returning to our Sutter meetings, their Physician Liaison and discharge planners encourage facilities to contact them to ensure either timely prior authorization or sometimes, discounted private purchase of fidaxomicin from an outpatient pharmacy.  The other issue that may come up is that for patients on traditional fee-for-service Medicare Part A coverage, the skilled nursing facility must cover the costs of medications under their PDPM-determined per diem payments—and $250 to $500+ daily for an oral medication would significantly erode the facility’s ability to recoup the costs of care.  Medical directors and attending physicians may be asked by the facility to change fidaxomicin orders to vancomycin.  If I were in that position, since most of our patients are at high risk for relapse, I would encourage the facility to stick with Fidaxomicin and set up physician to physician appeals call.

I so appreciate collaborative partnerships that navigate complex problems for the benefit of their mutual patients.