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A Cost Minimization Analysis of Treatment Options for Postmenopausal Women With Dysuria

The most common type of bacterial infection seen in an outpatient setting is urinary tract infection (UTI). In the United States, the overall lifetime prevalence of UTIs in women is greater than 50%. Urinary tract infections account for at least $2.6 billion annual costs. Compared with premenopausal women, in premenopausal womenmuch less is known about factors predisposing to UTIs and how best to treat these infections. Urinary tract infections in older women are especially difficult to treat because of increased variation and antibiotic resistance to the uropathogens that cause UTIs. Evidence in recent studies suggests that the presence of frequency and urgency of urination in women seeking urogynecologic care does not confirm a culture-based UTI diagnosis. Urinary tract infection can be detected more readily by the presence of dysuria, which more effectively discriminates UTI-positive and UTI-negative individuals. Empiric therapy with antibiotics is a commonly accepted practice for premenopausal women presenting with UTI symptoms, first doing urinalysis, or waiting on urine culture results for treatment. However, empiric therapy for UTI in postmenopausal women may not be beneficial because of high rates of concurrent confounding lower urinary tract symptoms unrelated to infection and differential resistance profiles of uropathogens in this population. The least costly management strategy for postmenopausal women with dysuria is unclear. The aim of this cost-minimization analysis was to determine the least costly treatment strategy for postmenopausal women with a primary complaint of dysuria. Cost-minimization analysis was performed using a decision-tree model for the following clinical options: (1) empiric antibiotic therapy followed by confirmatory urine culture, (2) urinalysis with empiric antibiotic therapy only if urinalysis is positive for nitrites and leukocyte esterase, or (3) waiting for culture results before initiating antibiotics. The likelihood of effectiveness was assumed to be equal for all antibiotics used in this study. Cost variables were assessed in an attempt to show how much less expensive an antibiotic would need to be or how high an antibiotic resistance percentage would have to be to favor a different treatment strategy. Drug costs were estimated, based on recommended dosage for treatment of UTI in recent clinical guidelines. Five different antibiotic regimens were included in the final model for all strategies: nitrofurantoin, trimethoprim/ sulfamethoxazole (TMP/SMX), fosfomycin, ciprofloxacin, or cephalexin. Pathogens included were those typically present in postmenopausal women: Escherichia coli, Escherichia faecalis, Klebsiella pneumoniae, or Proteus mirabilis. The model accounted for pathogens, resistance, treatment success, and medication adverse effects—all of which were specific to postmenopausal women. The cost minimizationmodel assumed that 73.4%ofUTIswere caused byE. coli, and therewas 24.4% resistance to TMP/SMX. The least costly treatment strategy was empiric antibiotics with TMP/SMX ($89.64/patient), followed by waiting for results of urine culture ($97.04/patient). With the exception of empiric antibiotic therapy with fosfomycin, empiric antibiotics were always less costly than using urinalysis results to determine the need for antibiotics. This is due to high rate of UTI (91%), positive urinalysis (69.3%) with dysuria in postmenopausal women, and resultant high rate of antibiotic use with or without urinalysis as well as cost of urinalysis ($38.23). The most expensive option was fosfomycin because of its high drug costs ($98/dose) and tornado analyses showing that cost of this medication was the most impactful variable for model outcomes. With sensitivity analyses, empiric fosfomycin became the least costly option if drug costs were $25.80, which was still more costly than almost all modeled baseline drug costs. This outcome was largely predicated by low resistance to fosfomycin. Conversely, sensitivity analysis showed that even if the cost of ciprofloxacin was $0, this medication was never the least costly option because of its higher resistance and adverse effect costs. Modeling a 91% positive urine culture rate in postmenopausal women with dysuria, waiting for culture results prior to treatment would be the least costly option in a population if the pretest probability of a positive urine culture rate was assumed to be less than 65%. In conclusion, these findings show that in a population of postmenopausal women with dysuria the least costly strategy is empiric antibiotics with TMP/SMX, followed by waiting on culture results prior to initiation of antibiotic therapy. Cost Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. 470 Obstetrical and Gynecological Survey minimization strategies will be impacted by local resistance patterns. It is commonly accepted that local resistance patterns should guide empiric antibiotic therapy choices for UTI. In postmenopausal women with dysuria, who have a high pretest probability of a UTI, urinalysis adds unnecessary cost. Empiric fosfomycin would be the least costly option because of its low resistance, favorable adverse effect profile, and single-dose treatment if the drug cost was lower. This drug was the least costly option for empiric therapy in a recent cost-minimization analysis in Canada where the cost of this drug is low. However, the high cost of fosfomycin in the United States makes it the most costly option for empiric therapy with sensitivity analysis. The model demonstrates that using fluoroquinolones was never the least costly option because of high resistance rates, adverse effects, and increased cost. Fluoroquinolones should not be prescribed for uncomplicated UTIs when there are other treatment options.