title: Empirical therapy for uncomplicated urinary tract infections in an era of increasing antimicrobial resistance: a decision and cost analysis.
abstract: Infectious Diseases Society of America guidelines state that uncomplicated urinary tract infections (UTIs) should be treated empirically with trimethoprim-sulfamethoxazole (TMP-SMZ), unless the community resistance among uropathogens exceeds 10%-20%, in which case a fluoroquinolone (FQ) should be used. However, the data to support this threshold are limited. We performed a cost-minimization and sensitivity analysis to determine what level of TMP-SMZ resistance in a community should trigger FQ use. The mean cost of empirical treatment with TMP-SMZ was US$92 when the proportion of resistant Escherichia coli was 0%, $106 when it was 20%, and $120 when it was 40%. The mean cost of empirical FQ treatment was $107 at current levels of FQ resistance. When >22% of E. coli in a community are TMP-SMZ-resistant, empirical FQ therapy becomes less costly than TMP-SMZ therapy. Treatment guidelines for empirical treatment of UTIs may need modification, and the threshold trigger for empirical FQ use should be raised to >20% TMP-SMZ resistance.
authors.affiliation: Division of Infectious Diseases, Harbor-University of California Los Angeles Medical Center, Torrance, CA 90509, USA.
authors.forename: T P
authors.initials: TP
authors.lastname: Le
authors.forename: L G
authors.initials: LG
authors.lastname: Miller
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use; D000892:Anti-Infective Agents, Urinary / Q000191:economics* / Q000627:therapeutic use*; D003198:Computer Simulation; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000188:drug therapy* / Q000191:economics; D024841:Fluoroquinolones; D006801:Humans; D008826:Microbial Sensitivity Tests; D017410:Practice Guidelines as Topic; D014296:Trimethoprim Resistance; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000191:economics* / Q000627:therapeutic use*; D014552:Urinary Tract Infections / Q000188:drug therapy* / Q000191:economics*
chemical_list: D000890:Anti-Infective Agents; D000892:Anti-Infective Agents, Urinary; D024841:Fluoroquinolones; D015662:Trimethoprim, Sulfamethoxazole Drug Combination