Therapies and Preventive Strategies for Recurrent Clostridium Difficile Infections - Episode 3
A broad view on the impact of recurrent clostridium difficile infection on patients and the healthcare system at large.
Neil Minkoff, MD: One of the things that’s important to bring up is the fact that recurrent Clostridioides difficile infection can be rather debilitating for patients. That might not be completely understood unless you’re actually actively treating these patients. My understanding is that there’s some information on how this affects patients and their quality of life in terms of how debilitating it is. Dr Allegretti, could you speak to some of that, please?
Jessica Allegretti, MD, MPH: Absolutely. This has certainly been looked at. I can speak to anecdotal experience in my own clinic as well, but Paul Feuerstadt [MD]’s group has looked at this in a more systematic way, surveying patients about their quality of life. It’s not surprising that most of these patients note that this dramatically affected the quality of their life, and that persisted after the infection was already cleared. Some of that psychological damage had essentially already been done and continued on with them. This can be stigmatizing for them, especially in our older patients. If they’re living in a facility, rehabilitation center, or nursing home, these patients get isolated pretty dramatically, to the point where a lot of them aren’t allowed to leave their rooms and can’t participate in social activities or use the common TV, for example. For patients who are already at risk for depression and other mental health disorders, this exaggerates that even more.
I’ve also had cases where family members won’t allow these patients to come to their homes for major holidays. It can be awful, knowing that when they’re stable, they’re not contagious and don’t need to be quarantined, especially when they’re no longer having diarrheal symptoms. Then that fear that they’re going to get their family sick or infect somebody else stays with them for quite some time. That leads to excessive or obsessive cleaning habits as well. This can be quite debilitating long term.
Neil Minkoff, MD: When I think about this in terms of this Peer Exchange, there’s the effect on the patient, but then we need to take a step back. We touched a little on population health, but now there are concerns or issues regarding how C diffinfections, or at least recurrent C diff infections, can affect things like health care resource utilization, hospitalization rates, and direct medical costs. Dr Abdallah, is that something you’ve been looking at?
Karina Abdallah, PharmD: Absolutely. From the health plan side, it’s about data and analytics and how close can we get to tying in direct overall total cost of care, not only on the prescription drug side when these patients are outpatient and receive certain therapies, but also tying that back into the medical side, which can be tricky from an analytics perspective. The missing piece here, which Dr Allegretti spoke about, is that any type of tracking outcomes that aren’t on the health system side would be nice to be able to share with the regional payer within that space to ensure that both are on the same page when it comes to first-line agents and how to coordinate them, knowing what patients are prescribed following an inpatient stay, and ensuring that connectivity remains between the health system and the payer.
Kevin U. Stephens, Sr. MD, JD: If I could jump in there for a second, we look at all of the above. You all just hit on pretty much everything I do. We look at outcomes, facilities, and individuals so that if a facility has more infections, we’ll do a quality assessment to see what’s going on. Are there proper precautions like handwashing? We know that it’s contagious sometimes in facilities, so you have to take that into account.
One of the new advances that we’re looking at is the integration of behavioral health with physical health. It’s not just the behavioral health of the patient, but the whole village, if you will, or community. It’s knowing their family members and caregivers. We have to look at the proper dynamics at the home because it could be very toxic and people could get depressed. When patients get depressed, they’re less likely to be compliant, to show up for their appointments, and to take their antibiotics or whatever treatment modality that has been given to them. Those things are very important, so the integration of behavioral health into the medical health is so important, particularly as you look at outcomes.
We look at recurrence as well. If a patient is having recurrence of infection, from a managed care perspective, we look at readmissions and ED [emergency department] visits. Many times, if patients have fever, diarrhea, and so forth, the first thing they do is go to the emergency department. When they have recurrent readmissions, we try to make sure that we do all the things that we have just spoken about to reduce and mitigate readmissions and ED visits.
Neil Minkoff, MD: Let me ask you a question regarding that. When you look at that, do you see a difference between primary infection and recurring infection in terms of how it affects not just the patient but also the entire health care landscape between resource utilization, ED utilization, and so on?
Kevin U. Stephens, Sr. MD, JD: Yes. For lack of a better description, you get the first bite free—in other words, the first infection—for myriad reasons. But when you have a recurrence, then all of a sudden that triggers a whole slew of dynamics, including with the patient themselves and their family members, guardians, caregivers, and so forth. It also includes health care utilization. When you have recurrence, we have to start figuring out, what’s the vector? What’s the pathophysiology? What’s happening? Where is it happening? What can we do to mitigate it, if anything? That just opens a Pandora’s box in a way.
Neil Minkoff, MD: Does anybody else want to weigh in on that in terms of the burden of recurring or continual infections?
Jessica Allegretti, MD, MPH: I’d just note that especially in the earlier days, before we had things like FMT [fecal microbiota transplantation] or some of these microbiome therapeutics, patients would be suffering for years on rounds of antibiotics before they’d end up in a clinic like mine. You can really see the toll that this has taken. They basically have whittled their diets down to almost nothing because they’re scared to eat. They’re not leaving their homes. At least we now have many more tools to be able to treat this infection more effectively, but when I started my program, this was something that shouldn’t be a chronic disease acting more like a chronic disease.
Transcript edited for clarity.