Lack of Health Insurance Coverage for Oral Vancomycin: It's Time to Tackle the Elephant in the Room

To the Editor—As a clinician in the front lines, taking care of elderly patients with severe and recurrent Clostridium difficile disease (CDI), I read with great interest Gerding and Johnson’s review, ‘‘Management of Clostridium difficile Infection: Thinking Inside and Outside the Box’’ [1]. I would like to point out the ‘‘elephant in the room’’ with respect to ‘‘in the box’’ management of CDI. Although vancomycin has been shown to be superior to metronidazole and remains the only US Food and Drug Administration (FDA)–approved antimicrobial for this serious infection, many of my patients’ outpatient vancomycin prescriptions are denied by Medicare and private prescription plans. In many cases, oral vancomycin is approved by the respective drug insurance plan, only after a time-consuming and irritating phone approval process. Not uncommonly, prescription plans pay only part of the tremendously elevated cost of vancomycin capsules, making this an unaffordable but essential medication for many patients. As Gerding and Johnson note, vancomycin has been shown to be superior for the treatment of CDI. Unlike metronidazole, a broad-spectrum antibiotic that achieves low stool concentrations and causes peripheral neuropathy, oral vancomycin results in