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A cost-minimization analysis of treatment options for postmenopausal women with dysuria

      Background

      Empiric therapy for urinary tract infection is difficult in postmenopausal women because of the higher rates of confounding lower urinary tract symptoms and differential resistance profiles of uropathogens in this population.

      Objective

      The objective of the study was to determine the least costly strategy for treatment of postmenopausal women with the primary complaint of dysuria.

      Study Design

      We performed a cost minimization analysis modeling the following clinical options: (1) empiric antibiotic therapy followed by urine culture, (2) urinalysis with empiric antibiotic therapy only if positive nitrites and leukocyte esterase, or (3) waiting for culture prior to initiating antibiotics. For all strategies we included nitrofurantoin, trimethoprim/sulfamethoxazole, fosfomycin, ciprofloxacin, or cephalexin. Pathogens included Escherichia coli, Enterococcus faecalis, Klebsiella pneumonaie, or Proteus mirabalis. Pathogens, resistance, treatment success, and medication side effects were specific to postmenopausal women.

      Results

      Cost minimization modeling with TreeAge Pro assumed 73.4% of urinary tract infections were caused by Escherichia coli with 24.4% resistance to nitrofurantoin, trimethoprim/sulfamethoxazole. With our assumptions, empiric antibiotics with nitrofurantoin, trimethoprim/sulfamethoxazole was the least costly approach ($89.64/patient), followed by waiting for urine culture ($97.04/patient). Except for empiric antibiotics with fosfomcyin, empiric antibiotics was always less costly than using urinalysis to discriminate antibiotic use. This is due to the cost of urinalysis ($38.23), high rate of both urinary tract infection (91%), and positive urinalysis (69.3%) with dysuria in postmenopausal women and resultant high rate of antibiotic use with or without urinalysis. Options with fosfomycin were the most expensive because of the highest drug costs ($98/dose), and tornado analyses showed fosfomycin cost was the most impactful variable for model outcomes. Sensitivity analyses showed empiric fosfomycin became the least costly option if drug costs were $25.80, a price still more costly than almost all modeled baseline drug costs. This outcome was largely predicated on low resistance to fosfomycin. Conversely, ciprofloxacin was never the least costly option because of higher resistance and side effect cost, even if the drug cost was $0. We modeled 91% positive urine culture rate in postmenopausal women with dysuria; waiting for the urine culture prior to treatment would be the least costly strategy in a population with a predicted positive culture rate of <65%.

      Conclusion

      The least costly strategy was empiric antibiotics with nitrofurantoin and trimethoprim/sulfamethoxazole, followed by waiting on culture results. Local resistance patterns will have an impact on cost minimization strategies. Empiric fosfomycin would be least costly with reduced drug costs, even at a level at which drug costs were higher than almost all other antibiotics. In a population with high posttest probability of positive urine culture, urinalysis adds unnecessary cost. Antibiotic stewardship programs should continue efforts to decrease fluoroquinolone use because of high resistance, side effects, and increased cost.

      Key words

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      References

        • Foxman B.
        Epidemiology of urinary tract infections: incidence, morbidity, and economic costs.
        Am J Med. 2002; 113: 5s-13s
        • Foxman B.
        The epidemiology of urinary tract infection.
        Nat Rev Urol. 2010; 7: 653-660
        • Raz R.
        • Gennesin Y.
        • Wasser J.
        • et al.
        Recurrent urinary tract infections in postmenopausal women.
        Clin Infect Dis. 2000; 30: 152-156
        • Miotla P.
        • Romanek-Piva K.
        • Bogusiewicz M.
        • Markut-Miotla E.
        Antimicrobial resistance patterns in women with positive urine culture: does menopausal status make a significant difference?.
        Biomed Res Int. 2017; 2017: 4192908
        • Little P.
        • Turner S.
        • Rumsby K.
        • et al.
        Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women.
        Br J Gen Pract. 2010; 60: 495-500
        • FitzGerald M.
        • Mueller E.
        • Brubaker L.
        • Dalaza L.
        • Abraham T.
        • Schreckenberger P.
        Chronic lower urinary symptoms do not predict bacteriuria.
        Int J Gynaecol Obstet. 2008; 101: 302-303
        • Gupta K.
        • Hooton T.M.
        • Naber K.G.
        • et al.
        International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.
        Clin Infect Dis. 2011; 52: e103-e120
        • Bent S.
        • Saint S.
        The optimal use of diagnostic testing in women with acute uncomplicated cystitis.
        Am J Med. 2002; 113: 20s-28s
        • Dune T.J.
        • Price T.K.
        • Hilt E.E.
        • et al.
        Urinary symptoms and their associations with urinary tract infections in urogynecologic patients.
        Obstet Gynecol. 2017; 130: 718-725
        • Barry H.C.
        • Ebell M.H.
        • Hickner J.
        Evaluation of suspected urinary tract infection in ambulatory women: a cost-utility analysis of office-based strategies.
        J Fam Pract. 1997; 44: 49-60
        • McKinnell J.A.
        • Stollenwerk N.S.
        • Jung C.W.
        • Miller L.G.
        Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis.
        Mayo Clin Proc. 2011; 86: 480-488
        • Perrault L.
        • Dahan S.
        • Iliza A.C.
        • LeLorier J.
        • Zhanel G.G.
        Cost-effectiveness analysis of fosfomycin for treatment of uncomplicated urinary tract infections in Ontario.
        Can J Infect Dis Med Microbiol. 2017; 2017: 6362804
        • Huttner A.
        • Kowalczyk A.
        • Turjeman A.
        • et al.
        Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women: a randomized clinical trial.
        JAMA. 2018; 319: 1781-1789
        • Kronenberg A.
        • Butikofer L.
        • Odutayo A.
        • et al.
        Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial.
        BMJ. 2017; 359: j4784
      1. GoodRx.
        (Available At:)
        • Agency for Healthcare Research and Quality
        AHRQ Healthcare Cost and Utilization Project.
        Agency for Healthcare Research and Quality, Rockville (MD)2015
        • Van Pienbroek E.
        • Hermans J.
        • Kaptein A.A.
        • Mulder J.D.
        Fosfomycin trometamol in a single dose versus seven days nitrofurantoin in the treatment of acute uncomplicated urinary tract infections in women.
        Pharm World Sci. 1993; 15: 257-262
        • Stein G.E.
        Comparison of single-dose fosfomycin and a 7-day course of nitrofurantoin in female patients with uncomplicated urinary tract infection.
        Clin Ther. 1999; 21: 1864-1872
        • Brown P.
        • Ki M.
        • Foxman B.
        Acute pyelonephritis among adults: cost of illness and considerations for the economic evaluation of therapy.
        Pharmacoeconomics. 2005; 23: 1123-1142
        • Food and Drug Administration
        Food and Drug Administration Drug Safety Communication.
        (Available at:) (Accessed June 14, 2019)
      2. Markowitz MA, Wood LN, Raz S, Miller LG, Haake DA, Kim JH. Lack of uniformity among United States recommendations for diagnosis and management of acute, uncomplicated cystitis. Int Urogynecol J 2018 Aug 11. https://doi.org/10.1007/s00192-018-3750-z. [Epub ahead of print].

        • Fagan M.
        • Lindbaek M.
        • Grude N.
        • et al.
        Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living in nursing homes versus the elderly living at home: an observational study.
        BMC Geriatr. 2015; 15: 98
        • Schmiemann G.
        • Gagyor I.
        • Hummers-Pradier E.
        • Bleidorn J.
        Resistance profiles of urinary tract infections in general practice—an observational study.
        BMC Urol. 2012; 12: 33
        • Turner L.C.
        • Beigi R.
        • Shepherd J.P.
        • Lowder J.L.
        Utility of dipstick urinalysis in peri- and postmenopausal women with irritative bladder symptoms.
        Int Urogynecol J. 2014; 25: 493-497
        • Mody L.
        • Juthani-Mehta M.
        Urinary tract infections in older women: a clinical review.
        JAMA. 2014; 311: 844-854
        • Chu C.M.
        • Lowder J.L.
        Diagnosis and treatment of urinary tract infections across age groups.
        Am J Obstet Gynecol. 2018; 219: 40-51
      3. LabCorp.
        (Available at:)