OBJECTIVE: To assess the cost-effectiveness of six treatment strategies for 
patients diagnosed with recurrent Clostridium difficile infection (CDI) in 
Canada: 1. oral metronidazole; 2. oral vancomycin; 3.oral fidaxomicin; 4. fecal 
transplantation by enema; 5. fecal transplantation by nasogastric tube; and 6. 
fecal transplantation by colonoscopy.
PERSPECTIVE: Public insurer for all hospital and physician services.
SETTING: Ontario, Canada.
METHODS: A decision analytic model was used to model costs and lifetime health 
effects of each strategy for a typical patient experiencing up to three 
recurrences, over 18 weeks. Recurrence data and utilities were obtained from 
published sources. Cost data was obtained from published sources and hospitals 
in Toronto, Canada. The willingness-to-pay threshold was $50,000/QALY gained.
RESULTS: Fecal transplantation by colonoscopy dominated all other strategies in 
the base case, as it was less costly and more effective than all alternatives. 
After accounting for uncertainty in all model parameters, there was an 87% 
probability that fecal transplantation by colonoscopy was the most beneficial 
strategy. If colonoscopy was not available, fecal transplantation by enema was 
cost-effective at $1,708 per QALY gained, compared to metronidazole. In 
addition, fecal transplantation by enema was the preferred strategy if the 
probability of recurrence following this strategy was below 8.7%. If fecal 
transplantation by any means was unavailable, fidaxomicin was cost-effective at 
an additional cost of $25,968 per QALY gained, compared to metronidazole.
CONCLUSION: Fecal transplantation by colonoscopy (or enema, if colonoscopy is 
unavailable) is cost-effective for treating recurrent CDI in Canada. Where fecal 
transplantation is not available, fidaxomicin is also cost-effective.