Advertisement

Cost-effectiveness of bacteriuria screening before urogynecologic surgery

Published:December 16, 2021DOI:https://doi.org/10.1016/j.ajog.2021.11.1375

      Background

      Currently, there is controversy over who requires preoperative screening for bacteriuria in the urogynecologic population and whether treating asymptomatic bacteriuria reduces postoperative urinary tract infection rates.

      Objective

      To evaluate the cost-effectiveness of selective, universal, and no preoperative bacteriuria screening protocols in women undergoing surgery for prolapse or stress urinary incontinence.

      Study Design

      A simple decision tree model was created from a societal perspective to evaluate cost and effectiveness of 3 strategies to prevent postoperative urinary tract infection: (1) a universal protocol where all women undergoing urogynecologic surgery are screened for bacteriuria and receive preemptive treatment if bacteriuria is identified; (2) a selective protocol, where only women with a history of recurrent urinary tract infection are screened and treated for bacteriuria; and (3) a no-screening protocol, where no women are screened for bacteriuria. Our primary outcome was the incremental cost-effectiveness ratio, calculated in cost per quality-adjusted life-years. Secondary outcomes were the number of urine cultures, postoperative urinary tract infections, and pyelonephritis associated with each strategy. Costs were derived from the Centers for Medicare & Medicaid Services, Healthcare Cost and Utilization Project, and Medical Expenditure Panel Survey. Clinical estimates were derived from published literature and data from a historic surgical cohort. Quality-of-life-associated utilities for urinary tract infection (0.73), pyelonephritis (0.66), and antibiotic use (0.964) were derived from the published literature using the HALex scale, reported directly by affected patients. One-way sensitivity analyses were performed over the range of reported values.

      Results

      In the base case scenario, selective screening is more costly (no screen: $101.69, selective: $101.98) and more effective (no screen: 0.096459 quality-adjusted-life-year, selective: 0.096464 quality-adjusted-life-year) than no screening, and is cost-effective, with an incremental cost-effectiveness ratio of $49,349 per quality-adjusted-life-year. Both selective screening and no screening dominate universal screening in being less costly (universal: $111.92) and more effective (universal: 0.096446 quality-adjusted-life-year), with a slightly higher rate of postoperative urinary tract infection (no screen: 17.1%, selective: 16.9%, universal: 16.6%). In 1-way sensitivity analyses, selective screening is no longer cost-effective compared with no screening when the cost of a urine culture exceeds $12, cost of a preoperative urinary tract infection exceeds $93, the cost of a postoperative urinary tract infection is below $339, the specificity of a urine culture is less than 96%, or preoperative bacteriuria rates in those without symptoms but a history of recurrent urinary tract infection is <23%. Universal screening only becomes cost-effective when the postoperative urinary tract infection rate increases to >50% in those without risk factors and untreated preoperative bacteriuria. When compared with no screening, selective screening costs an additional $104 per urinary tract infection avoided and $2607 per pyelonephritis avoided. Compared with selective screening, universal screening costs $4609 per urinary tract infection avoided and $115,223 per pyelonephritis avoided.

      Conclusion

      Implementation of a selective preoperative bacteriuria protocol is cost-effective in most scenarios and associated with only a <1% increase in the 30-day postoperative urinary tract infection rate. No screening is cost-effective when cost of a preoperative urinary tract infection is high and the rate of preoperative bacteriuria in those without risk factors is low.

      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

        • Sutkin G.
        • Alperin M.
        • Meyn L.
        • Wiesenfeld H.C.
        • Ellison R.
        • Zyczynski H.M.
        Symptomatic urinary tract infections after surgery for prolapse and/or incontinence.
        Int Urogynecol J. 2010; 21: 955-961
        • Hill A.J.
        • Walters M.D.
        • Unger C.A.
        Perioperative adverse events associated with colpocleisis for uterovaginal and posthysterectomy vaginal vault prolapse.
        Am J Obstet Gynecol. 2016; 214: 501.e1-501.e6
        • Wei J.T.
        • Nygaard I.
        • Richter H.E.
        • et al.
        A midurethral sling to reduce incontinence after vaginal prolapse repair.
        N Engl J Med. 2012; 366: 2358-2367
        • Barber M.D.
        • Brubaker L.
        • Burgio K.L.
        • et al.
        Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial.
        JAMA. 2014; 311: 1023-1034
        • Vigil H.R.
        • Mallick R.
        • Nitti V.W.
        • Lavallée L.T.
        • Breau R.H.
        • Hickling D.R.
        Risk factors for urinary tract infection following mid urethral sling surgery.
        J Urol. 2017; 197: 1268-1273
        • Nygaard I.
        • Brubaker L.
        • Chai T.C.
        • et al.
        Risk factors for urinary tract infection following incontinence surgery.
        Int Urogynecol J. 2011; 22: 1255-1265
        • Dieter A.A.
        • Amundsen C.L.
        • Visco A.G.
        • Siddiqui N.Y.
        Treatment for urinary tract infection after midurethral sling: a retrospective study comparing patients who receive short-term postoperative catheterization and patients who pass a void trial on the day of surgery.
        Female Pelvic Med Reconstr Surg. 2012; 18: 175-178
        • Anger J.T.
        • Litwin M.S.
        • Wang Q.
        • Pashos C.L.
        • Rodríguez L.V.
        Complications of sling surgery among female Medicare beneficiaries.
        Obstet Gynecol. 2007; 109: 707-714
        • Lightner D.J.
        • Wymer K.
        • Sanchez J.
        • Kavoussi L.
        Best practice statement on urologic procedures and antimicrobial prophylaxis.
        J Urol. 2020; 203: 351-356
        • Polin M.R.
        • Edenfield A.L.
        • Dieter A.A.
        • Amundsen C.L.
        • Visco A.G.
        • Weidner A.C.
        Predictrs of positive preoperative urine cultures in asymptomatic women undergoing urogynecologic surgery.
        Clin. Obstet Gynaecol Reprod Med. 2015; 1: 47-50
        • Polin M.R.
        • Kawasaki A.
        • Amundsen C.L.
        • Weidner A.C.
        • Siddiqui N.Y.
        Do mixed-flora preoperative urine cultures matter?.
        South Med J. 2017; 110: 426-429
        • Chung C.P.
        • Kuehl T.J.
        • Harris S.K.
        • et al.
        Incidence and risk factors of postoperative urinary tract infection after uterosacral ligament suspension.
        Int Urogynecol J. 2012; 23: 947-950
        • Fok C.S.
        • McKinley K.
        • Mueller E.R.
        • et al.
        Day of surgery urine cultures identify urogynecologic patients at increased risk for postoperative urinary tract infection.
        J Urol. 2013; 189: 1721-1724
        • Cai T.
        • Verze P.
        • Palmieri A.
        • et al.
        Is preoperative assessment and treatment of asymptomatic bacteriuria necessary for reducing the risk of postoperative symptomatic urinary tract infections after urologic surgical procedures?.
        Urology. 2017; 99: 100-105
        • Gallegos Salazar J.
        • O’Brien W.
        • Strymish J.M.
        • Itani K.
        • Branch-Elliman W.
        • Gupta K.
        Association of screening and treatment for preoperative asymptomatic bacteriuria with postoperative outcomes among US veterans.
        JAMA Surg. 2019; 154: 241-248
        • Chong J.T.
        • Klausner A.P.
        • Petrossian A.
        • et al.
        Pre-procedural antibiotics for endoscopic urological procedures: initial experience in individuals with spinal cord injury and asymptomatic bacteriuria.
        J Spinal Cord Med. 2015; 38: 187-192
        • Geller E.J.
        • Siddiqui N.Y.
        • Wu J.M.
        • Visco A.G.
        Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy.
        Obstet Gynecol. 2008; 112: 1201-1206
        • Richter H.E.
        • Albo M.E.
        • Zyczynski H.M.
        • et al.
        Retropubic versus transobturator midurethral slings for stress incontinence.
        N Engl J Med. 2010; 362: 2066-2076
        • Albo M.E.
        • Richter H.E.
        • Brubaker L.
        • et al.
        Burch colposuspension versus fascial sling to reduce urinary stress incontinence.
        N Engl J Med. 2007; 356: 2143-2155
        • Nicolle L.E.
        • Gupta K.
        • Bradley S.F.
        • et al.
        Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2019; 68: 1611-1615
        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
        • Chu C.M.
        • Lowder J.L.
        Diagnosis and treatment of urinary tract infections across age groups.
        Am J Obstet Gynecol. 2018; 219: 40-51
        • American College of Surgeons
        User guide for the 2019 ACS NSQIP participant use data file.
        (Available at:) (Accessed January 15, 2019)
        • 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
        • American College of Obstetricians and Gynecologists
        ACOG Practice Bulletin No. 91: treatment of urinary tract infections in nonpregnant women.
        Obstet Gynecol. 2008; 111: 785-794
        • European Association of Urology, European Association of Urology
        Urologic infections.
        (Available at:)
        https://uroweb.org/guideline/urological-infections/#1
        Date: 2020
        Date accessed: October 24, 2021
      1. ACOG Practice Bulletin No. 195: prevention of infection after gynecologic procedures.
        Obstet Gynecol. 2018; 131: e172-e189
        • Bent S.
        • Nallamothu B.K.
        • Simel D.L.
        • Fihn S.D.
        • Saint S.
        Does this woman have an acute uncomplicated urinary tract infection?.
        JAMA. 2002; 287: 2701-2710
        • Fihn S.D.
        Clinical practice. Acute uncomplicated urinary tract infection in women.
        N Engl J Med. 2003; 349: 259-266
        • 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
        • Dass A.K.
        • Lo T.S.
        • Khanuengkitkong S.
        • Tan Y.L.
        Bacteriuria and safety of female urodynamic studies.
        Int Urogynecol J. 2013; 24: 677-682
        • Cameron A.P.
        • Campeau L.
        • Brucker B.M.
        • et al.
        Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient.
        Neurourol Urodyn. 2017; 36: 915-926
        • Centers for Medicare and Medicaid Services
        Clinical Laboratory fee schedule.
        (Available at:)
      2. Centers for Medicaid and Medicare. Services.
        (Available at:)
        • US Bureau of labor statistic
        Occup Employ Wages.
        (Available at:)
        https://www.bls.gov/oes/current/oes291141.htm
        Date: 2018
        Date accessed: August 8, 2019
        • Wolters Kluwer
        Medi-span average wholesale acquisition cost pricing.
        (Available at:)
        • Shepherd J.P.
        • Jones K.A.
        • Harmanli O.
        Is antibiotic prophylaxis necessary before midurethral sling procedures for female stress incontinence? A decision analysis.
        Int Urogynecol J. 2014; 25: 227-233
        • Internal Revenue Services
        IRS Releases 2019 standard mileage rates.
        (Available at:)
        • GoodRx
        GoodRx.com.
        (Available at:)
        https://www.goodrx.com/
        Date: 2011
        Date accessed: October 31, 2019
        • Agency for Healthcare Research and Quality
        MEPS summary tables: medical Conditions, 2016 and later.
        (Available at:)
        https://www.meps.ahrq.gov/mepstrends/home/index.html
        Date: 2019
        Date accessed: October 31, 2019
      3. Health care cost and utilization project (HCUP). Free Health Care Statistics.
        (Available at:)
        https://hcupnet.ahrq.gov/#setup
        Date: 2019
        Date accessed: May 24, 2019
        • Gold M.R.
        • Franks P.
        • McCoy K.I.
        • Fryback D.G.
        Toward consistency in cost-utility analyses: using national measures to create condition-specific values.
        Med Care. 1998; 36: 778-792
        • 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
        • Bradley M.S.
        • Beigi R.H.
        • Shepherd J.P.
        A cost-minimization analysis of treatment options for postmenopausal women with dysuria.
        Am J Obstet Gynecol. 2019; 221: 505.e1-505.e7
        • Talan D.A.
        • Stamm W.E.
        • Hooton T.M.
        • et al.
        Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial.
        JAMA. 2000; 283: 1583-1590
        • 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
        • Foxman B.
        • Barlow R.
        • D’Arcy H.
        • Gillespie B.
        • Sobel J.D.
        Urinary tract infection: self-reported incidence and associated costs.
        Ann Epidemiol. 2000; 10: 509-515
        • Haylen B.T.
        • Lee J.
        • Husselbee S.
        • Law M.
        • Zhou J.
        Recurrent urinary tract infections in women with symptoms of pelvic floor dysfunction.
        Int Urogynecol J Pelvic Floor Dysfunct. 2009; 20: 837-842
        • Walter F.G.
        • Knopp R.K.
        Urine sampling in ambulatory women: midstream clean-catch versus catheterization.
        Ann Emerg Med. 1989; 18: 166-172
        • 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
        • Unger C.A.
        • Walters M.D.
        • Ridgeway B.
        • Jelovsek J.E.
        • Barber M.D.
        • Paraiso M.F.
        Incidence of adverse events after uterosacral colpopexy for Uterovagial and posthysterectomy vault prolapse.
        Am J Obstet Gynecol. 2015; 212: 603.e1-603.e7
        • Brubaker L.
        • Norton P.A.
        • Albo M.E.
        • et al.
        Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study.
        Am J Obstet Gynecol. 2011; 205: 498.e1-498.e6
        • Dieter A.A.
        • Amundsen C.L.
        • Edenfield A.L.
        • et al.
        Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial.
        Obstet Gynecol. 2014; 123: 96-103
        • Sanders G.D.
        • Neumann P.J.
        • Basu A.
        • et al.
        Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second Panel on Cost-Effectiveness in Health and Medicine.
        JAMA. 2016; 316: 1093-1103
        • Husereau D.
        • Drummond M.
        • Petrou S.
        • et al.
        Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.
        BJOG. 2013; 120: 765-770
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; 371: 796-797
        • Erickson P.
        Evaluation of a population-based measure of quality of life: the Health and Activity Limitation Index (HALex).
        Qual Life Res. 1998; 7: 101-114
        • deShazo R.D.
        • Kemp S.F.
        Allergic reactions to drugs and biologic agents.
        JAMA. 1997; 278: 1895-1906
        • Alves C.
        • Mendes D.
        • Marques F.B.
        Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis.
        Eur J Clin Pharmacol. 2019; 75: 1431-1443
        • Agency for Healthcare Research and Quality
        MEPS summary tables: medical Conditions, 1996–2015.
        (Available at:)
        https://www.meps.ahrq.gov/mepstrends/hc_cond/
        Date: 2019
        Date accessed: October 31, 2019
        • Xu J.
        • Sobel J.D.
        Antibiotic-associated vulvovaginal candidiasis.
        Curr Infect Dis Rep. 2003; 5: 481-487
        • Xu J.
        • Schwartz K.
        • Bartoces M.
        • Monsur J.
        • Severson R.K.
        • Sobel J.D.
        Effect of antibiotics on vulvovaginal candidiasis: a MetroNet study.
        J Am Board Fam Med. 2008; 21: 261-268
        • Moo-Young J.A.
        • Suarez E.A.
        • Adamson A.S.
        Distance to pharmacy and risk of medication primary nonadherence.
        Dermatol Online J. 2018; 24: 18-22
        • Lam O.
        • Broderisk B.
        • Toor S.
        How far Americans live from the closest Hospital differs by Community type. Pew Research Center.
        (Available at:)
        • Syed S.T.
        • Sharp L.K.
        • Kim Y.
        • et al.
        Relationship between medication adherence and distance to dispensing pharmacies and prescribers among an urban Medicaid population with diabetes mellitus.
        Pharmacotherapy. 2016; 36: 590-597
        • Ward G.
        • Jorden R.C.
        • Severance H.W.
        Treatment of pyelonephritis in an observation unit.
        Ann Emerg Med. 1991; 20: 258-261
        • Czaja C.A.
        • Scholes D.
        • Hooton T.M.
        • Stamm W.E.
        Population-based epidemiologic analysis of acute pyelonephritis.
        Clin Infect Dis. 2007; 45: 273-280
        • Halfhill T.R.
        Tom’s inflation calculator.
        (Available at:) (Accessed March 14, 2020)
        • 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
        • Choosing wisely
        Five Things Phys Patients Should Quest.
        (Available at:)