Cost-effectiveness of antibiotic treatment of uncomplicated urinary tract infection in women: a comparison of four antibiotics

Antibiotics efficacy in clinical and microbiological cure of uncomplicated urinary tract infection: a systematic review and network meta-analysis

PURPOSE

Fosfomycin has been used more frequently in managing uncomplicated urinary tract infections (UTIs) due to decreased compliance and increased multidrug-resistant bacteria. The aim of this network meta-analysis was to assess the efficacy of Fosfomycin compared to Nitrofurantoin, Trimethoprim-Sulfamethoxazole (TMP-SMX), and Ciprofloxacin in terms of clinical and microbiological cure alongside with other measurements.

MATERIALS AND METHODS

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). We included randomized control trials (RCTs) with uncomplicated UTI patients who received Fosfomycin, Nitrofurantoin, TMP-SMX, or Ciprofloxacin and reported the clinical or microbiological cure. We used Cochrane Risk of Bias Assessment Tool to assess the included studies' quality. R-software was used for all statistical analysis. We ranked all antibiotics using the netrank function which yielded P scores. Frequentist network meta-analysis was used to assess the efficacy of all outcomes.

RESULTS

We included 13 RCTs with a total number of 3856 patients that showed Fosfomycin ranked the highest among the other antibiotics with respect to clinical cure (P-score = 0.99) and microbiological cure (P-score = 0.99) while Ciprofloxacin ranked the lowest (P-score = 0.11 and 0.02, respectively). Moreover, Ciprofloxacin yielded the highest relapse rate (P-score = 1), whereas TMP-SMX had the lowest relapse rate (P-score = 0.07). As for the adverse events, Ciprofloxacin demonstrated the highest adverse events as opposed to Fosfomycin (P-score = 0.98 and 0.05, respectively).

CONCLUSION

The network meta-analysis demonstrated that Fosfomycin is the most effective antibiotic in treating uncomplicated UTIs with respect to clinical cure, microbiological cure, and adverse events profile.

Water intake and recurrent urinary tract infections prevention: economic impact analysis in seven countries

BACKGROUND

To estimate the economic impact of preventing urinary tract infections (UTI) by increasing water intake among women with recurrent UTI and low fluid intake across seven countries: France, United Kingdom, Spain, United States of America, Mexico, China and Australia.

METHODS

A Markov model was developed to compare costs and outcomes of UTIs associated with low fluid intake in women versus a strategy of primary prevention by increasing water intake. Model inputs were based on randomized controlled trial data which found that increasing water intake by 1.5 L/day decreased the risk of developing cystitis by 48% in women with low fluid intake and recurrent UTI. A time horizon of 10 years was used; outcomes were from the payer perspective and included both direct and indirect costs, reported in 2019 United States dollars ($). Discounting rates varied by country. Scenarios of increasing levels of compliance to the increased water intake strategy were evaluated.

RESULTS

The total cost of one UTI episode, including diagnostics, treatment and complications, ranged from $2164 (Mexico) to $7671 (Australia). Assuming 80% compliance with the increased water intake strategy over a 10-year time horizon, the number of UTIs prevented ranged from 435,845 (Australia) to 24150,272 (China), resulting in total savings of 286 million (Australia) to $4.4 billion (China). Across all countries, increased water intake resulted in lower cost and fewer UTIs compared with low water intake.

CONCLUSION

Preventing recurrent UTIs by increasing water intake would reduce both the clinical and economic burden associated with UTI. Public, healthcare professionals and patients should be made aware about the preventive positive impact of appropriate water intake on UTIs.

Real-Life Comparison of Fosfomycin to Nitrofurantoin for the Treatment of Uncomplicated Lower Urinary Tract Infection in Women

In this study, we compared the failure rates of fosfomycin and nitrofurantoin for uncomplicated urinary tract infections. We used Meuhedet Health Services’ large database to collect data on all female patients, older than 18 years, who were prescribed either antibiotic during 2013–2018. Treatment failure was a composite endpoint of hospitalization, emergency-room visit, IV antibiotic treatment, or prescription of a different antibiotic, within seven days of the initial prescription. Reinfection was considered when one of these endpoints appeared 8–30 days following the initial prescription. We found 33,759 eligible patients. Treatment failure was more common in the fosfomycin group than the nitrofurantoin group (8.16% vs. 6.87%, p-value < 0.0001). However, reinfection rates were higher among patients who received nitrofurantoin (9.21% vs. 7.76%, p-value < 0.001). Among patients younger than 40 years, patients treated with nitrofurantoin had more reinfections (8.68% vs. 7.47%, p value = 0.024). Treatment failure rates were mildly higher in patients treated with fosfomycin, despite having less reinfections. We suggest that this effect is related to a shorter duration of treatment (one vs. five days) and encourage clinicians to be more patient before declaring fosfomycin failure and prescribing another antibiotic.

Unmet Needs in Complicated Urinary Tract Infections: Challenges, Recommendations, and Emerging Treatment Pathways

While urinary tract infections (UTIs) are one of the most common types of infections globally, the wide variety of presentations and of severity of disease can make it difficult to manage. The definition for uncomplicated UTIs (uUTIs) is generally regarded as UTIs in healthy, non-pregnant women whereas all other UTIs are considered complicated. There is, however, a lack of consensus definition of complicated UTIs (cUTIs), leading to global differences in management. In addition, the patients who develop complicated UTIs generally have other comorbidities that warrant more urgent intervention. One of the biggest challenges in treating cUTIs is the rise of antimicrobial resistance (AMR). While there have been recent drug approvals for new antibiotic to treat these resistant organisms, a multidisciplinary approach, including regulatory frameworks, provider education and public awareness campaigns, is crucial to limiting unnecessary treatments for asymptomatic bacteriuria (ASB) and uUTIs that can ultimately lead to more severe infections.

A Cost-Effectiveness Analysis of Fosfomycin: A Single-Dose Antibiotic Therapy for Treatment of Uncomplicated Urinary Tract Infection

Nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX) and fosfomycin are first-line therapeutics for uncomplicated urinary tract infections (uUTI). While fosfomycin is the most expensive, it is also attractive due to its effectiveness against most uUTI-causing bacteria, limited risk of cross-resistance with other drugs, and single-dose delivery. In light of these competing attributes, a cost-effectiveness analysis can provide useful, standardized information about tradeoffs between fosfomycin and treatment alternatives. This paper assessed cost-effectiveness via incremental cost-effectiveness ratios (ICERs) that represented a drug’s incremental cost per additional uUTI case resolved with initial course of antibiotic therapy. The study setting was New Hampshire, USA. Total cost of treatment was lowest with TMP-SMX and highest with fosfomycin. ICERs were $84.53 and $78.59 for nitrofurantoin and $2264.29 and $2260.89 for fosfomycin under a payer and societal perspective, respectively. While no standard benchmark for our measure of cost-effectiveness exists, the high national prevalence of antibiotic stewardship efforts suggests that willingness-to-pay to increase the number of people who are successfully treated with an initial course of therapy is non-zero. Ultimately, fosfomycin may currently be considered a cost-effective option for treating uUTI in the US. As a recently off-patent drug, increased competition in the generic market may improve its cost-effectiveness in the future.

Cost-Effectiveness of a Sublingual Bacterial Vaccine for the Prophylaxis of Recurrent Urinary Tract Infections

<b><i>Introduction:</i></b> Recurrent urinary tract infections (rUTIs) affect 5–10% of women, resulting in an enormous healthcare and society burden. Uromune® is a polybacterial sublingual vaccine with an excellent clinical benefit in rUTI prophylaxis. This study assesses the impact of sublingual vaccination on healthcare resource use and expenditures associated with this pathology. <b><i>Methods:</i></b> A quasi-experimental, pretest-posttest, single center study including women with rUTI and vaccinated with Uromune® in real-life clinical practice was performed. Variables were the need of healthcare resources, collected prospectively during two follow-up years, and the rUTI-associated expenditure, calculated using the micro-costing methodology; these were compared before and after vaccination. <b><i>Results:</i></b> A total of 166 women {mean (standard deviation [SD]) urinary tract infection episodes/year 6.19 (2.15)} were included. After vaccination, annual consultations with a primary care physician (PCP) (43.9%), emergency room visits (71.8%), urinary analysis (90.0%), and ultrasound exams (35.6%) decreased compared to pre-vaccination (all <i>p</i> &#x3c; 0.001). Per patient consumption in antibiotics, PCP consultations, emergency room visits, and complementary exams significantly decreased (all <i>p</i> &#x3c; 0.02), resulting in a reduction in healthcare expenditure per patient/year from mean (SD) 1,001.1 (655.0) to 497.1 (444.4) EUR. <b><i>Conclusion:</i></b> Sublingual bacterial vaccination with Uromune® decreased healthcare resource use and associated expenditure in women with rUTI, representing an optimal strategy to reduce rUTI-associated healthcare and economic burden.

What is the evidence base of used aggregated antibiotic resistance percentages to change empiric antibiotic treatment? A scoping review

BACKGROUND

Antibiotic resistance requires continuous monitoring by experts to decide whether empiric antibiotic therapies (EAT) should be replaced by alternative antibiotics. The exact moment and criteria for this change is unclear and generally based on consensus between experts.

OBJECTIVES

This scoping review aims to identify from the literature the resistance thresholds used for a change in EAT and the criteria that they are based upon.

METHODS

Scoping review for which a comprehensive structured literature search was conducted. Rayyan, software for systematic reviews, was used for the screening of abstracts and titles.

DATA SOURCES

Pubmed and hand-searching of reference lists and grey literature.

ELIGIBILITY

Papers concerning any type of bacterial infectious disease and mentioning or defining antibiotic resistance thresholds for decision making purposes for EAT were included. The inclusion and analysis of articles was done by two researchers, any conflicts were resolved through discussion or by consulting a third reviewer.

RESULTS

We identified 3146 unique papers. Following title-abstract screening, 125 papers were comprehensively read, 16 papers included. The included papers gave thresholds for urinary tract infections, respiratory tract infections, meningitis, skin and soft tissue infections, gonorrhoea and bone and joint infections. Six criteria were found that were commonly used to base the thresholds on. These were: disease severity, efficacy of treatment, adverse drug events, risk of C. difficile infection, costs and increased resistance. The number of criteria used to define each threshold varied from 1 up to 6 criteria between papers.

CONCLUSIONS

The thresholds used for EATs are few, commonly based on expert opinion estimates and therefore can have broad ranges. Used criteria underlying reported thresholds are heterogenous and require standardization. Considering the rising trend in resistance there is a clear need for rigid tools to determine thresholds in order to support guideline development with the best and timely evidence.

Clinical Efficacy and Cost Analysis of Antibiotics for Treatment of Uncomplicated Urinary Tract Infections in the Emergency Department of a Tertiary Hospital in Saudi Arabia

Purpose

Uncomplicated urinary tract infections (uUTIs) are one of the main reasons for emergency department (ED) visits. Many antibiotics can be used for uUTI treatment. Currently, no data concerning uUTIs and cost-effectiveness have been reported in Saudi Arabia. This study aimed to investigate antibiotic and cost-effectiveness of beta-lactams, fluoroquinolones, and nitrofurantoin as first-line uUTI treatment.

Patients and Methods

This study was a retrospective cohort based on a five-arm comparative outcome analysis. A cost-effectiveness analysis and comparative group of uUTI treatments in the ED at King Abdulaziz Medical City (KAMC) in Saudi Arabia over a three-month follow-up period was done. The patient group consisted of those presenting to the ED with uUTIs who were treated initially with one of five antibiotics: (1) amoxicillin/clavulanic acid, (2) cefuroxime, (3) ciprofloxacin, (4) nitrofurantoin, or (5) norfloxacin. The main outcomes were effectiveness in terms of cure rates, symptom-free days (SFDs), and estimations of cost-effectiveness among this group.

Results

A total of 865 adult patients who presented with uUTIs were enrolled. Most patients (89.5%) completely recovered, whereas 10.5% of patients were readmitted to the ED with recurrent infections. Effectiveness in terms of the highest cure rate was observed with nitrofurantoin and amoxicillin/clavulanic acid (93.2% and 92.2%, respectively) followed by norfloxacin, cefuroxime, and ciprofloxacin; no significant differences in cure rates were found among these antibiotics. Antibiotic effectiveness in terms of SFDs showed that nitrofurantoin produced the longest SFD period (76 days) followed by amoxicillin/clavulanic acid (69 days). A cost-effectiveness analysis in terms of uUTI cure rates and number of SFDs indicated that nitrofurantoin presented the highest cost-effectiveness followed by amoxicillin/clavulanic acid, norfloxacin, ciprofloxacin, and cefuroxime.

Conclusion

A comparison of five antibiotics for uUTI treatment did not yield clinically significant differences in cure rates. Nitrofurantoin was more cost-effective than the other antibiotics.

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

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.

Fosfomycin and nitrofurantoin: classic antibiotics and perspectives

Antibiotics are essential molecules for the treatment and prophylaxis of many infectious diseases. However, drugs that combat microbial infections can become a human health threat due to their high and often indiscriminate consumption, considered one of the factors of antimicrobial resistance (AMR) emergence. The AMR crisis, the decrease in new drug development by the pharmaceutical industry, and reduced economic incentives for research have all reduced the options for treating infections, and new strategies are necessary, including the return of some traditional but "forgotten" antibiotics. However, prescriptions for these older drugs including nitrofurantoin and oral fosfomycin, have been based on the results of pioneer studies, and the limited knowledge generated 50-70 years ago may not be enough. To avoid harming patients and further increasing multidrug resistance, systematic evaluation is required, mainly for the drugs prescribed for community-acquired infections, such as urinary tract infections (UTI). Therefore, this review has the objective of reporting the use of two classic drugs from the nitrofuran and phosphonic acid classes for UTI control nowadays. Furthermore, we also explore new approaches used for these antibiotics, including new combination regimes for spectral amplification, and the prospects for reducing bacterial resistance in the fight against bacteria responsible for UTI.

Evaluation of efficacy and safety of fosfomycin versus nitrofurantoin for the treatment of uncomplicated lower urinary tract infection (UTI) in women - A systematic review and meta-analysis

Urinary tract infections (UTI) are among the most frequent medical conditions requiring outpatient treatment. Single dose oral fosfomycin (300 mg) and the older nitrofurantoin (100 mg for 5 days) have been found to be more effective than other first-line drugs in multiple studies. This systematic review and meta-analysis were carried out with the objective of evaluating their comparative efficacy and safety in the management of uncomplicated UTI. Two authors independently searched PubMed, Cochrane Central, Embase, and Google Scholar till Nov 2020 using MeSH terms and free text. Randomized controlled trials (RCTs) comparing both drugs for efficacy and safety in uncomplicated UTI in adult women were included. The primary outcome measures were microbiological and clinical cure rates. The search resulted in n = 663 studies out of which only four studies (three for treatment of uncomplicated UTI in women and one for asymptomatic bacteriuria in pregnancy) satisfied the selection criteria. No significant differences in clinical, (RR 0.95, 95% CI - 0.81, 1.12) and microbiological cure, (RR 0.96, 95% CI - 0.84, 1.08) were found within 4 weeks of treatment. The incidence of adverse events was found to be more in fosfomycin relative to the nitrofurantoin group (RR 1.05, 95% CI - 0.59, 1.87). Hence, single-dose fosfomycin presents a potentially useful and safe treatment option for the treatment of uncomplicated UTI in women and asymptomatic bacteriuria in pregnancy.

Adherence to recent antibiotic guidelines for acute uncomplicated cystitis

BACKGROUND

In 2017, the Centers for Disease Control and Prevention (CDC) published guidelines for treating acute uncomplicated cystitis (AUC) with nitrofurantoin (NTF), sulfamethoxazole-trimethoprim (SMX-TMP), or fosfomycin (FM) as appropriate first-line agents.

OBJECTIVE

To evaluate whether provider adherence to prescribing NTF, SMX-TMP, or FM has improved since the 2017 CDC guidelines were released, and to examine outcomes relative to the use of prescribing guidelines.

DATA SOURCE

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, and a systematic search for articles was conducted in the PubMed and Cochrane search engines using Boolean operators (AND, OR). The searches resulted in 56 published studies. After application of exclusion criteria, 11 peer-reviewed articles were ultimately included in this review.

CONCLUSION

The review showed prescribers' increasing efforts to adhering to antibiotic prescription guidelines for treating AUC, such as the 2017 CDC guidelines. The studies presented strong evidence that NTF, SMX-TMP, and FM are equally efficacious and cost-effective for treating AUC without concern for antibiotic resistance. Studies that referenced prescription guidelines and local antibiotic resistance yielded desired patient outcomes in bacterial and symptom resolution and cost-effectiveness.

IMPLICATIONS FOR PRACTICE

This article provides evidence and a platform for nurse practitioners to initiate collaborative efforts for structured AUC treatment guidelines in primary health care. To increase prescription adherence, electronic health records could be designed that would prompt prescribers to use updated local antibiotic resistance information and to use NTF, SMT-TMX, and FM as first-line agents.