Advertisement

Role of antibiotic resistance in urinary tract infection management: a cost-effectiveness analysis

Published:August 18, 2021DOI:https://doi.org/10.1016/j.ajog.2021.08.014

      Background

      Urinary tract infections and recurrent urinary tract infections pose substantial burdens on patients and healthcare systems. Testing and treatment strategies are increasingly important in the age of antibiotic resistance and stewardship.

      Objective

      This study aimed to evaluate the cost effectiveness of urinary tract infection testing and treatment strategies with a focus on antibiotic resistance.

      Study Design

      We designed a decision tree to model the following 4 strategies for managing urinary tract infections: (1) empirical antibiotics first, followed by culture-directed antibiotics if symptoms persist; (2) urine culture first, followed by culture-directed antibiotics; (3) urine culture at the same time as empirical antibiotics, followed by culture-directed antibiotics, if symptoms persist; and (4) symptomatic treatment first, followed by culture-directed antibiotics, if symptoms persist. To model both patient- and society-level concerns, we built 3 versions of this model with different outcome measures: quality-adjusted life-years, symptom-free days, and antibiotic courses given. Societal cost of antibiotic resistance was modeled for each course of antibiotics given. The probability of urinary tract infection and the level of antibiotic resistance were modeled from 0% to 100%. We also extended the model to account for patients requiring catheterization for urine specimen collection.

      Results

      In our model, the antibiotic resistance rate was based either on the local antibiotic resistance patterns for patients presenting with sporadic urinary tract infections or on rate of resistance from prior urine cultures for patients with recurrent urinary tract infections. With the base case assumption of 20% antibiotic resistance, urine culture at the same time as empirical antibiotics was the most cost-effective strategy and maximized symptom-free days. However, empirical antibiotics was the most cost-effective strategy when antibiotic resistance was below 6%, whereas symptomatic treatment was the most cost-effective strategy when antibiotic resistance was above 80%. To minimize antibiotic use, symptomatic treatment first was always the best strategy followed by urine culture first. Sensitivity analyses with other input parameters did not affect the cost-effectiveness results. When we extended the model to include an office visit for catheterized urine specimens, empirical antibiotics became the most cost-effective option.

      Conclusion

      We developed models for urinary tract infection management strategies that can be interpreted for patients initially presenting with urinary tract infections or those with recurrent urinary tract infections. Our results suggest that, in most cases, urine culture at the same time as empirical antibiotics is the most cost-effective strategy and maximizes symptom-free days. Empirical antibiotics first should only be considered if the expected antibiotic resistance is very low. If antibiotic resistance is expected to be very high, symptomatic treatment is the best strategy and minimizes antibiotic use.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Foxman B.
        Epidemiology of urinary tract infections: incidence, morbidity, and economic costs.
        Am J Med. 2002; 113: 5S-13S
        • Foxman B.
        Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden.
        Infect Dis Clin North Am. 2014; 28: 1-13
        • Schappert S.M.
        • Rechtsteiner E.A.
        Ambulatory medical care utilization estimates for 2007.
        Vital Health Stat 13. 2011; 169: 1-38
        • Simmering J.E.
        • Tang F.
        • Cavanaugh J.E.
        • Polgreen L.A.
        • Polgreen P.M.
        The increase in hospitalizations for urinary tract infections and the associated costs in the United States, 1998-2011.
        Open Forum Infect Dis. 2017; 4: ofw281
        • Beerepoot M.A.
        • Geerlings S.E.
        • van Haarst E.P.
        • van Charante N.M.
        • ter Riet G.
        Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials.
        J Urol. 2013; 190: 1981-1989
        • Kronenberg A.
        • Bütikofer 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
        • Schmiemann G.
        • Kniehl E.
        • Gebhardt K.
        • Matejczyk M.M.
        • Hummers-Pradier E.
        The diagnosis of urinary tract infection: a systematic review.
        Dtsch Arztebl Int. 2010; 107: 361-367
        • World Health Organization
        Antimicrobial resistance. WHO Fact sheets.
        (Available at:) (Accessed March 1, 2020)
        • Ferry S.
        • Holm S.E.
        • Stenlund H.
        • Lundholm R.
        • Monsen T.J.
        Clinical and bacteriological outcome of different doses and duration of pivmecillinam compared with placebo therapy of uncomplicated lower urinary tract infection in women: the LUTIW project.
        Scan J Prim Health Care. 2007; 25: 49-57
        • Christiaens T.C.
        • De Meyere M.
        • Verschraegen G.
        • Peersman W.
        • Heytens S.
        • De Maeseneer J.M.
        Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women.
        Br J Gen Pract. 2002; 52: 729-734
      1. Healthcare blue book.
        (Available at:)
        https://healthcarebluebook.com/
        Date: 2020
        Date accessed: March 2, 2020
        • Michaelidis C.I.
        • Fine M.J.
        • Lin C.J.
        • et al.
        The hidden societal cost of antibiotic resistance per antibiotic prescribed in the United States: an exploratory analysis.
        BMC Infect Dis. 2016; 16: 655
        • Shrestha P.
        • Cooper B.S.
        • Coast J.
        • et al.
        Enumerating the economic cost of antimicrobial resistance per antibiotic consumed to inform the evaluation of interventions affecting their use.
        Antimicrob Resist Infect Control. 2018; 7: 98
        • Hirsch D.
        • Marlette S.
        • Bezdek T.
        • Orrange S.
        GoodRx, Inc.
        (Available at:)
        https://www.goodrx.com/
        Date: 2018
        Date accessed: May 3, 2018
        • Trading Economics
        United States average hourly wages.
        (Available at:)
        https://tradingeconomics.com/united-states/wages
        Date: 2020
        Date accessed: October 12, 2020
        • Fair Health Consumer
        Estimate your healthcare expenses.
        (Available at:)
        https://fairhealthconsumer.org/
        Date: 2020
        Date accessed: August 2, 2020
        • Skoglund E.
        • Dempsey C.J.
        • Chen H.
        • Garey K.W.
        Estimated clinical and economic impact through use of a novel blood collection device to reduce blood culture contamination in the emergency department: a cost-benefit analysis.
        J Clin Microbiol. 2019; 57: e01015-e01018
        • Bermingham S.L.
        • Ashe J.F.
        Systematic review of the impact of urinary tract infections on health-related quality of life.
        BJU Int. 2012; 110: E830-E836
      2. TreeAge Pro 2020, R2. TreeAge Software, Williamstown, MA. Available at: http://www.treeage.com. Accessed August 27, 2021.

        • Fenwick E.A.
        • Briggs A.H.
        • Hawke C.I.
        Management of urinary tract infection in general practice: a cost-effectiveness analysis.
        Br J Gen Pract. 2000; 50: 635-639
        • 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
        • Fihn S.D.
        Clinical practice. Acute uncomplicated urinary tract infection in women.
        N Engl J Med. 2003; 349: 259-266
        • Sadler S.
        • Holmes M.
        • Ren S.
        • Holden S.
        • Jha S.
        • Thokala P.
        Cost-effectiveness of antibiotic treatment of uncomplicated urinary tract infection in women: a comparison of four antibiotics.
        BJGP Open. 2017; 1bjgpopen17X101097
        • Turner D.
        • Little P.
        • Raftery J.
        • et al.
        Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial.
        BMJ. 2010; 340: c346