Round 2 of the Great ID Debates of #ASHP18 @ASHPOfficial comes to us from the brilliant minds of @SIDPharm members @TimbrookTT and @julie_justo. To start us off, Tristan makes the case for #fidaxomicin (FID) for treatment of Clostridioides difficile (#cdiff) infection 
.@TimbrookTT sets up the major points for FID in the treatment of #Cdiff: 1- ⬇️recurrence compared to #vancomycin (VAN) in RCTs + ⬆️in cure without recurrence (aka global clinical cure) 2- this held up in real-world data 3- cost-effectiveness analyses support 1st line use #ASHP18
.@TimbrookTT notes the 2018 @IDSAInfo guidelines for #cdiff (idsociety.org/practice-guide…) recommend FID equally to VAN and for first recurrence, quality of evidence is higher 👀🤔#ASHP18
.@TimbrookTT reviews 2011 RCT of FID v VAN for initial #cdiff episode (ncbi.nlm.nih.gov/pubmed/21288078) ➡️FID noninferior to VAN for clinical cure & associated w/ significantly lower rates of recurrence. No difference for NAP1/BI/027 strains but be careful with subgroup analysis #ASHP18
More phase 3⃣data shared by @TimbrookTT (meanwhile, on stage, @julie_justo is calm, cool, and collected). Here, FID shows ⬆️clinical cure among patients on concomitant antibiotics and ⬇️recurrence among patients with cancer #ASHP18
.@TimbrookTT reminds audience of great point: "Whenever you’re evaluating literature, think about plausibility of authors conclusions. Is it plausibile that FID would have ⬇️ recurrence compared to VAN?" Dr. Timbrook thinks, yes. #ASHP18
.@TimbrookTT continues to make the case for FID in the treatment of #cdiff by citing real-world clinical data as well as recent data from @ESCMID Congress 2018 showing VAN-treated patients were more likely to develop #VRE than patients treated with other therapies #ASHP18
The #fidaxomicin side closes out w/cost-effectiveness data, including this study from @SIDPharm member @JGPharmD showing cost savings of $3,047 per patient treated w/FID (ncbi.nlm.nih.gov/pubmed/26324268). @TimbrookTT closing argument: "so FID is kind of awesome, I guess" #ASHP18
NEXT UP! @julie_justo takes the stage to make the case for #vancomycin (VAN) in the treatment of #cdiff. Her main points: 1- VAN is the gold standard ⭐️2- patient accessibility to VAN >>> FID 3- differences in recurrence rates can be mitigated by other factors #ASHP18
.@julie_justo also highlights the new #cdiff guidelines, noting VAN is the recommended treatment for all definitions of #cdiff. FID seems to be missing from some of these categories. whatcha think, @TimbrookTT 🤔 #ASHP18
and @julie_justo reminds us not to mess with success. VAN has shown superiority over other therapies, but no studies show FID superiority over VAN.
Justo: "RIP tolevamer, we really appreciate the comparator data you gave us” #ASHP18
Justo: "RIP tolevamer, we really appreciate the comparator data you gave us” #ASHP18
.@julie_justo to the audience: "I'm not hiding data from you!" There are no differences in clinical cure, yet VAN is associated w/ ⬇️sustained response compared to FID. However, there's a lot more to consider why this is the case. #ASHP18
And let's be real... VAN plays well with others. It is accessible, available, comes in capsules and liquid, and affordable for most patients. Check out that price comparison... woof. #ASHP18 @julie_justo
.@julie_justo asks, can we really use FID first-line in everyone? Realistically, no. The. Struggle. Is. Real. Have you ever tried to get this drug approved for your patient? Absolute nightmare. #ASHP18
As for the recurrence data favoring FID... it is compared to VAN x 10 days. What about extended courses, taper, and/or pulse regimens of VAN to ⬇️recurrence? @julie_justo "I can’t remember the last time I gave a patient only 10 days of vancomycin” #ASHP18
This study found for early fecal microbiota transplant (FMT) a NNT to save 1 life @ 3 months in severe CDI cases of TWO! ncbi.nlm.nih.gov/pubmed/29020328 #ASHP18 @julie_justo "If that’s not impressive, I don’t know what is. 1 retro study so biases for sure, but still compelling data."
Can you give a #cdiff talk & not mention #kefir? @julie_justo making #twitterless Kevin Garey proud discussing this 🍓wonder. Not perfect data, but interesting for sure. This is a potential counseling point for our pts. help diversify & reconstitute a healthy microbiome! #ASHP18
.@julie_justo closes out the debate (and really, the FID > for recurrence argument) by stating: "let's be real... just give me the 💩, please." FMT data promising and our patients have other options aside from exceedingly expensive FID #ASHP18
.@TimbrookTT with the rebuttal. The "FID for everyone" concern would be less of an issue if we improved #cdiff testing #ASHP18
.@TimbrookTT also points out that risk scores, while helpful, are not a panacea. All risk scores need validated at local institutions. Lots of heterogeneity. #ASHP18
And with his final slide.... @TimbrookTT asks @julie_justo if she would treat her beloved colleague, fellow @sidpharm and @accpinfdprn member Dr. @BBookstaver_USC, with VAN over FID? Justo quickly replies-- she sure would. #ASHP18
.@julie_justo rebuttal and closing arguments include incremental cost-effectiveness ratio data and real-world fidaxomicin use data with mixed results, noting it is difficult to predict the impact of expanding FID use at your institution #ASHP18
This marks the end of the debate. Audience poll = 💯in favor of vancomycin, however EXCELLENT discussion on both sides. Amazing job @TimbrookTT @julie_justo and if you missed it, check out this debate from @BWDionne and @PharmerMeg as well:
