Infectious Disease

Urine culture, empirical antibiotics, most cost effective UTI strategy

September 10, 2021

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In most cases, a urine culture combined with empirical antibiotics is the most cost-effective strategy for urinary tract infections, the researchers said.

“We conducted this cost-benefit study because urinary tract infections are estimated to cost an estimated $ 1.6 billion annually in the United States and are an area of ​​health care availability that can be improved.” Rui Wang, MD, from the Department of Women’s Health at Hartford Hospital, Connecticut, said Healio. “We evaluated the cost effectiveness of several different UTI testing and treatment strategies, taking into account the societal costs of antibiotic resistance.”

WangR. et al. At J Obstet Gynecol. 2021; doi: 10.1016 / j.ajog.2021.08.014.

To determine the cost effectiveness of various UTI strategies, Wang and colleagues did Christine LaSala, MD, also from Hartford Hospital, designed a decision tree that would model four treatment approaches. This included empirical antibiotics first, followed by culture-directed antibiotics if symptoms persist; initial urine culture followed by culture directed antibiotics; Urine culture combined with empirical antibiotics followed by culture-directed antibiotics if symptoms persist; and initial symptomatic treatment, followed by culture-directed antibiotics if symptoms persist.

To address both patient and community concerns, Wang and LaSala developed three versions of their model with three different outcome measures: quality-adjusted life years (QALYs), symptom-free days, and antibiotic courses administered. The researchers modeled the societal cost of antibiotic resistance for each antibiotic regimen, analyzing the likelihood of urinary tract infection and the degree of antibiotic resistance from 0% to 100%. They also expanded their model to include patients who need a catheter to collect urine. The estimates of the model parameters were based “wherever possible” on medical literature, the researchers wrote.

The primary endpoint was the incremental cost-effectiveness ratio (ICER), which the researchers defined as the difference between strategies in mean costs divided by the difference in mean QALYs. A strategy was defined as “dominated” and therefore rejected if it was more costly and less effective than another strategy. Meanwhile, a strategy was “dominant” when it was less costly and more effective than any other strategy. A strategy was defined as cost-effective if it had an ICER below the willingness-to-pay threshold of $ 150,000 per QALY compared to another strategy. This threshold varied in the sensitivity analyzes.

According to the researchers, urine culture concurrently with empirical antibiotics under a baseline assumption of 20% antibiotic resistance was the most cost-effective strategy to maximize symptom-free days. It showed the lowest cost – $ 79.91 – and the highest effectiveness – 24.44 Quality Adjusted Life Days (QALDs). However, empirical antibiotics were the most cost-effective option when antibiotic resistance fell below 6%, while symptomatic treatment was the most cost-effective plan when resistance rose above 80%.

In the meantime, symptomatic treatment first was always the best strategy, followed by urine culture first to minimize antibiotic use with an average of 0.29 cycles administered. Sensitivity analyzes with other input parameters had no influence on the results on cost efficiency. When the researchers expanded their model to include a practice visit for catheterized urine samples, empirical antibiotics became the most cost-effective plan.

“The main finding is that in most cases, collecting urine cultures with empirical antibiotics was the best strategy,” said Wang. “This had a greater than 80% chance of being the most cost-effective strategy.

“It was cost effective to start only with empirical antibiotics when antibiotic resistance is very low – less than 6% – while starting only symptomatic treatment was cost effective when antibiotic resistance was very high – more than 80%,” says she added. “Our model can be used to guide testing and management plans for patients with sporadic UTIs or those with recurrent UTIs.”

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Victoria Scott, MD)

Victoria Scott, MD

This study examines a very important question about treating urinary tract infections in an age of rising antibiotic resistance and the growing recognition of the importance of antibiotic stewardship. Evidence that sending a urine culture concurrently with empirical antibiotics is both optimally cost-effective and maximizes symptom-free days for most patients with UTI symptoms should reassure providers to require urine testing in these patients rather than the historical strategy of empirical Antibiotics alone. It is also important for the authors to recognize that symptomatic treatment initially is the best strategy for situations where there is great concern about antibiotic resistance.

The next important step will be to assess patient satisfaction with this treatment strategy. As concerns about the prudent use of antibiotics grow in many patients, both on a personal and societal level, it is very likely that they will have an increased satisfaction with the evaluation of the urine culture for each episode of UTI symptoms.

Victoria Scott, MD

Cedars-Sinai Medical Center

Disclosure: Scott does not report any relevant financial information.

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