Economic Burden of Community-Acquired Antibiotic-Resistant Urinary Tract Infections: Systematic Review and Meta-Analysis.

Background: Antibiotic resistance (ABR) poses a major burden to global health and economic systems. ABR in community-acquired urinary tract infections (CA-UTIs) has become increasingly prevalent. Accurate estimates of ABR's clinical and economic burden are needed to support medical resource prioritization and cost-effectiveness evaluations of urinary tract infection (UTI) interventions. Objective: This study aims to systematically synthesize the evidence on the economic costs associated with ABR in CA-UTIs, using published studies comparing the costs of antibiotic-susceptible and antibiotic-resistant cases. Methods: We searched the PubMed, Ovid MEDLINE and Embase, Cochrane Review Library, and Scopus databases. Studies published in English from January 1, 2008, to January 31, 2023, reporting the economic costs of ABR in CA-UTI of any microbe were included. Independent screening of titles/abstracts and full texts was performed based on prespecified criteria. A quality assessment was performed using the Integrated Quality Criteria for Review of Multiple Study Designs (ICROMS) tool. Data in UTI diagnosis criteria, patient characteristics, perspectives, resource costs, and patient and health economic outcomes, including mortality, hospital length of stay (LOS), and costs, were extracted and analyzed. Monetary costs were converted into 2023 US dollars. Results: This review included 15 studies with a total of 57,251 CA-UTI cases. All studies were from high- or upper-middle-income countries. A total of 14 (93%) studies took a health system perspective, 13 (87%) focused on hospitalized patients, and 14 (93%) reported UTI pathogens. Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa are the most prevalent organisms. A total of 12 (80%) studies reported mortality, of which, 7 reported increased mortality in the ABR group. Random effects meta-analyses estimated an odds ratio of 1.50 (95% CI 1.29-1.74) in the ABR CA-UTI cases. All 13 hospital-based studies reported LOS, of which, 11 reported significantly higher LOS in the ABR group. The meta-analysis of the reported median LOS estimated a pooled excess LOS ranging from 1.50 days (95% CI 0.71-4.00) to 2.00 days (95% CI 0.85-3.15). The meta-analysis of the reported mean LOS estimated a pooled excess LOS of 2.45 days (95% CI 0.51-4.39). A total of 8 (53%) studies reported costs in monetary terms-none discounted the costs. All 8 studies reported higher medical costs spent treating patients with ABR CA-UTI in hospitals. The highest excess cost was observed in UTIs caused by carbapenem-resistant Enterobacterales. No meta-analysis was performed for monetary costs due to heterogeneity. Conclusions: ABR was attributed to increased mortality, hospital LOS, and economic costs among patients with CA-UTI. The findings of this review highlighted the scarcity of research in this area, particularly in patient morbidity and chronic sequelae and costs incurred in community health care. Future research calls for a cost-of-illness analysis of infections, standardizing therapy-pathogen combination comparators, medical resources, productivity loss, intangible costs to be captured, and data from community sectors and low-resource settings and countries.

Comparing costs associated with management of antibiotic-recalcitrant recurrent urinary tract infections for one year pre- and post-electrofulguration.

INTRODUCTION: To quantify and compare recurrent urinary tract infection costs between 1 year before and 1 year after electrofulguration. METHODS: Following IRB approval, a well-characterized cohort of non-neurogenic women with >3 symptomatic urinary tract infections (UTIs)/year, a negative upper and lower urinary tract evaluation, and inflammatory bladder lesions (cystitis) on office cystoscopy who underwent fulguration of these lesions was analyzed. Cost of visits, imaging, labs, and medications were summed for 1-year pre- and post-fulguration using the Medicare Physician Fee Schedule, local pharmacy pricing, and institutional expenses. Before fulguration, all patients underwent clinic visit, noninvasive flow study, and flexible cystoscopy, and post-fulguration, 6-week follow-up visit and 6-month cystoscopy. RESULTS: Ninety-three women met study criteria (mean age 64), with 100% 1-year follow-up. Before fulguration, 73% of patients used daily antibiotic suppression, 6% self-start antibiotics, and 5% postcoital prophylaxis. Some also used vaginal estrogens (17%), urinary analgesics (13%), and cranberry or d-mannose supplements (7%). At 1 year post-fulguration, 82% had 0-1 infections and no cystoscopy evidence of cystitis, while 14% required additional fulguration for new cystitis sites and recurrent infections. Patients had on average 0.7 infections in the 1-year post-fulguration, which was significantly lower than pre-fulguration (p < 0.05). Mean 1-year pre-fulguration cost was $1328 (median $1071, range $291-$5564). Mean 1-year post-fulguration cost was $617 (median $467, range $275-$4580). On average, post-fulguration costs were $710 lower than pre-EF (p < 0.05). CONCLUSION: For women with antibiotic-refractory recurrent urinary tract infections and cystoscopy evidence of cystitis, fulguration was associated with a significant reduction in UTI-related costs in the 1-year post-fulguration.

Disposable grasper-integrated flexible cystoscope for ureteral stent removal in transplanted patients; focus on feasibility, safety, and patient experience. Results and micro-cost analysis from a tertiary referral center.

INTRODUCTION & OBJECTIVES: To evaluate ureteral stent removal (SR) using a grasper-integrated disposable flexible cystoscope (giFC-Isiris ®, Coloplast ®) after kidney transplantation (KT), with a focus on feasibility, safety, patient experience, and costs. MATERIAL AND METHODS: All consecutive KT undergoing SR through giFC were prospectively enrolled from January 2020 to June 2023. Patient characteristics, KT and SR details, urine culture results, antimicrobial prescriptions, and the incidence of urinary tract infections (UTI) within 1 month were recorded. A micro-cost analysis was conducted, making a comparison with the costs of SR with a reusable FC and grasper. RESULTS: A total of 136 KT patients were enrolled, including both single and double KT, with 148 stents removed in total. The median indwelling time was 34 days [26, 47]. SR was successfully performed in all cases. The median preparation and procedure times were 4 min [3,5]. and 45 s[30, 60], respectively. The median Visual Analog Scale (VAS) score was 3 [1, 5], and 98.2% of patients expressed willingness to undergo the procedure again. Only one episode of UTI involving the graft (0.7%) was recorded. Overall, the estimated cost per SR procedure with Isiris ® and the reusable FC was 289.2€ and 151,4€, respectively. CONCLUSIONS: This prospective series evaluated the use of Isiris ® for SR in a cohort of KT patients, demonstrating feasibility and high tolerance. The UTI incidence was 0.7% within 1 month. Based on the micro-cost analysis, estimated cost per procedure favored the reusable FC.

Risk factors and economic burden for community-acquired multidrug-resistant organism-associated urinary tract infections: A retrospective analysis.

The spread of multidrug-resistant organisms (MDROs) has resulted in a corresponding increase in the incidence of urinary tract infections (UTIs). The risk factors and hospitalization burden for community-acquired MDRO-associated UTIs are discussed herein. This retrospective study included 278 patients with community-based MDRO-associated UTIs from January 2020 to January 2022. The MDRO (n = 139) and non-MDRO groups (n = 139) were separated based on drug susceptibility results. Community-based MDRO-associated UTIs mainly occurred in the elderly and frail patients with a history of invasive urinary tract procedures. The MDRO group imposed a greater economic burden compared to the non-MDRO group. Independent risk factors for community-based MDRO-associated UTIs were as follows: white blood cell (WBC) count > 10.0 × 109/L (OR = 2.316, 95% CI = 1.316-3.252; P = .018); ≥3 kinds of urinary tract obstructive diseases (OR = 1.720, 95% CI = 1.004-2.947; P = .048); use of 3rd generation cephalosporins (OR = 2.316, 95% CI = 1.316-4.076; P = .004); and a history of invasive urologic procedures (OR = 2.652, 95% CI = 1.567-4.487; P < .001). Days of hospitalization, antibiotic use, and bladder catheter use were significantly greater in the MDRO group than the non-MDRO group (P < .05).

Cost-effectiveness of methenamine hippurate compared with antibiotic prophylaxis for the management of recurrent urinary tract infections in secondary care: a multicentre, open-label, randomised, non-inferiority trial.

OBJECTIVES: To estimate the cost-effectiveness of methenamine hippurate compared with antibiotic prophylaxis in the management of recurrent urinary tract infections. DESIGN: Multicentre, open-label, randomised, non-inferiority trial. SETTING: Eight centres in the UK, recruiting from June 2016 to June 2018. PARTICIPANTS: Women aged ≥18 years with recurrent urinary tract infections, requiring prophylactic treatment. INTERVENTIONS: Women were randomised to receive once-daily antibiotic prophylaxis or twice-daily methenamine hippurate for 12 months. Treatment allocation was not masked and crossover between arms was allowed. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary economic outcome was the incremental cost per quality-adjusted life year (QALY) gained at 18 months. All costs were collected from a UK National Health Service perspective. QALYs were estimated based on responses to the EQ-5D-5L administered at baseline, 3, 6, 9, 12 and 18 months. Incremental costs and QALYs were estimated using an adjusted analysis which controlled for observed and unobserved characteristics. Stochastic sensitivity analysis was used to illustrate uncertainty on a cost-effectiveness plane and a cost-effectiveness acceptability curve. A sensitivity analysis, not specified in the protocol, considered the costs associated with antibiotic resistance. RESULTS: Data on 205 participants were included in the economic analysis. On average, methenamine hippurate was less costly (-£40; 95% CI: -684 to 603) and more effective (0.014 QALYs; 95% CI: -0.05 to 0.07) than antibiotic prophylaxis. Over the range of values considered for an additional QALY, the probability of methenamine hippurate being considered cost-effective ranged from 51% to 67%. CONCLUSIONS: On average, methenamine hippurate was less costly and more effective than antibiotic prophylaxis but these results are subject to uncertainty. Methenamine hippurate is more likely to be considered cost-effective when the benefits of reduced antibiotic use were included in the analysis. TRIAL REGISTRATION NUMBER: ISRCTN70219762.

Catheter-associated urinary tract infections (CAUTIs) and non-CAUTI hospital-onset urinary tract infections: Relative burden, cost, outcomes and related hospital-onset bacteremia and fungemia infections.

OBJECTIVE: To describe the relative burden of catheter-associated urinary tract infections (CAUTIs) and non-CAUTI hospital-onset urinary tract infections (HOUTIs). METHODS: A retrospective observational study of patients from 43 acute-care hospitals was conducted. CAUTI cases were defined as those reported to the National Healthcare Safety Network. Non-CAUTI HOUTI was defined as a positive, non-contaminated, non-commensal culture collected on day 3 or later. All HOUTIs were required to have a new antimicrobial prescribed within 2 days of the first positive urine culture. Outcomes included secondary hospital-onset bacteremia and fungemia (HOB), total hospital costs, length of stay (LOS), readmission risk, and mortality. RESULTS: Of 549,433 admissions, 434 CAUTIs and 3,177 non-CAUTI HOUTIs were observed. The overall rate of HOB likely secondary to HOUTI was 3.7%. Total numbers of secondary HOB were higher in non-CAUTI HOUTIs compared to CAUTI (101 vs 34). HOB secondary to non-CAUTI HOUTI was more likely to originate outside the ICU compared to CAUTI (69.3% vs 44.1%). CAUTI was associated with adjusted incremental total hospital cost and LOS of $9,807 (P < .0001) and 3.01 days (P < .0001) while non-CAUTI HOUTI was associated with adjusted incremental total hospital cost and LOS of $6,874 (P < .0001) and 2.97 days (P < .0001). CONCLUSION: CAUTI and non-CAUTI HOUTI were associated with deleterious outcomes. Non-CAUTI HOUTI occurred more often and was associated with a higher facility aggregate volume of HOB than CAUTI. Patients at risk for UTIs in the hospital represent a vulnerable population who may benefit from surveillance and prevention efforts, particularly in the non-ICU setting.

The clinical and economic evidence of the management of urinary tract infections by community pharmacists in women aged 16 to 65 years: a systematic review.

BACKGROUND: Many countries are experiencing an increased demand for health care and a shortage of health professionals in rural areas, impacting an individual's ability to receive timely treatment. The management of uncomplicated urinary tract infections by community pharmacists is usual practice in some regions of the United Kingdom and Canada, and Queensland, Australia. AIM: To systematically gather, assess, and synthesize the available peer-reviewed published literature on the management of uncomplicated UTIs by community pharmacists in women aged 16-65 years, provide an understanding of the clinical and economic evidence, while also identifying the essential components of interventions employed. METHOD: A systematic review was conducted to identify primary studies detailing interventions for the management of uncomplicated UTIs by community pharmacists. PubMed, PsycINFO, Scopus, Cochrane, CINAHL, EMBASE, and Web of Science were searched to February 2023. Non-primary and qualitative studies were excluded. Study details were recorded in a tailored data extraction form. The quality of studies was assessed using the Joanna Briggs Institute tools. RESULTS: Ten publications were included following review of 2129 records. High self-reported cure rates between 84 and 89% and referral rates of about 7% were reported. A single study found pharmacist management was cost effective compared to general practitioner management. No randomized controlled trials were found and papers were of variable quality. CONCLUSION: Preliminary evidence suggests pharmacist-led management of uncomplicated UTIs is safe and effective, however no firm conclusion can be provided since the methodologies reported in included studies have significant limitations.

A Cost Savings Analysis of Topical Estrogen Therapy in Urinary Tract Infection Prevention Among Postmenopausal Women.

INTRODUCTION: UTIs are some of the most common infections in geriatric patients, with many women experiencing recurrent infections after menopause. In the US, annual UTI-related costs are $2 billion, with recurrent infections creating a significant economic burden. Given the data published on topical estrogen in reducing the number of infections for postmenopausal women with recurrent UTI, we sought to evaluate how this would translate to cost savings. METHODS: We performed a systematic literature review of UTI reduction secondary to topical estrogen utilization in postmenopausal female patients. The cost per UTI was determined based on published Medicare spending on UTI per beneficiary, weighted on reported likelihood of complicated and resistant infections. For a patient with recurrent infections, topical estrogen therapy reported on average can reduce infections from 5 to 0.5 to 2 times per person per year. RESULTS: At a calculated cost per UTI of $1222, the reduction in UTI spending can range between $3670 and $5499 per beneficiary per year. Per-beneficiary spending on topical estrogen therapies was $1013 on average ($578-$1445) in 2020. After including the cost of the therapy, overall cost savings for topical estrogen therapies were $1226 to $4888 annually per patient. CONCLUSIONS: Topical estrogens are a cost-conscious way to improve the burden of UTI on postmenopausal women with the potential for billions of dollars in Medicare savings. System-wide efforts should be made to have these therapies available as prophylaxis for postmenopausal patients and to ensure they are affordable for patients.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis.

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

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.

Burden of illness in US hospitals due to carbapenem-resistant Gram-negative urinary tract infections in patients with or without bacteraemia.

BACKGROUND: Urinary tract infections (UTIs) are the most common infections caused by Gram-negative bacteria and represent a major healthcare burden. Carbapenem-resistant (CR) strains of Enterobacterales and non-lactose fermenting pathogens further complicate treatment approaches. METHODS: We conducted a retrospective analysis of the US Premier Healthcare Database (2014-2019) in hospitalised adults with a UTI to estimate the healthcare burden of Gram-negative CR UTIs among patients with or without concurrent bacteraemia. RESULTS: Among the 47,496 patients with UTI analysed, CR infections were present in 2076 (4.4%). Bacteraemia was present in 24.5% of all UTI patients, and 1.7% of these were caused by a CR pathogen. The most frequent CR pathogens were Pseudomonas aeruginosa (49.4%) and Klebsiella pneumoniae (14.2%). Patients with CR infections had a significantly longer hospital length of stay (LOS) (median [range] 8 [5-12] days vs 6 [4-10] days, P < 0.001), were less likely to be discharged home (38.4% vs 51.0%, P < 0.001), had a higher readmission rate (22.6% vs 13.5%, P < 0.001), and had greater LOS-associated charges (mean US$ 91,752 vs US$ 66,011, P < 0.001) than patients with carbapenem-susceptible (CS) infections, respectively. The impact of CR pathogens was greater in patients with bacteraemia (or urosepsis) and these CR urosepsis patients had a significantly higher rate of mortality than those with CS urosepsis (10.5% vs 6.0%, P < 0.001). CONCLUSIONS: Among hospitalised patients with UTIs, the presence of a CR organism and bacteraemia increased the burden of disease, with worse outcomes and higher hospitalisation charges than disease associated with CS pathogens and those without bacteraemia.

Device associated -health care associated infections monitoring, prevention and cost assessment at intensive care unit of University Hospital in Poland (2015-2017).

BACKGROUND: Device-associated health care-associated infections (DA-HAIs) in intensive care unit (ICU) patients constitute a major therapeutic issue complicating the regular hospitalisation process and having influence on patients' condition, length of hospitalisation, mortality and therapy cost. METHODS: The study involved all patients treated > 48 h at ICU of the Medical University Teaching Hospital (Poland) from 1.01.2015 to 31.12.2017. The study showed the surveillance and prevention of DA-HAIs on International Nosocomial Infection Control Consortium (INICC) Surveillance Online System (ISOS) 3 online platform according to methodology of the INICC multidimensional approach (IMA). RESULTS: During study period 252 HAIs were found in 1353 (549F/804M) patients and 14,700 patient-days of hospitalisation. The crude infections rate and incidence density of DA-HAIs was 18.69% and 17.49 ± 2.56 /1000 patient-days. Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI) and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 12.63 ± 1.49, 1.83 ± 0.65 and 6.5 ± 1.2, respectively. VAP(137) constituted 54.4% of HAIs, whereas CA-UTI(91) 36%, CLA-BSI(24) 9.6%.The most common pathogens in VAP and CA-UTI was multidrug-resistant (MDR) Acinetobacter baumannii (57 and 31%), and methicillin-resistant Staphylococcus epidermidis (MRSE) in CLA-BSI (45%). MDR Gram negative bacteria (GNB) 159 were responsible for 63.09% of HAIs. The length of hospitalisation of patients with a single DA-HAI at ICU was 21(14-33) days, while without infections it was 6.0 (3-11) days; p = 0.0001. The mortality rates in the hospital-acquired infection group and no infection group were 26.1% vs 26.9%; p = 0.838; OR 0.9633;95% CI (0.6733-1.3782). Extra cost of therapy caused by one ICU acquired HAI was US$ 11,475/Euro 10,035. Hand hygiene standards compliance rate was 64.7%, while VAP, CLA-BSI bundles compliance ranges were 96.2-76.8 and 29-100, respectively. CONCLUSIONS: DA-HAIs was diagnosed at nearly 1/5 of patients. They were more frequent than in European Centre Disease Control report (except for CLA-BSI), more frequent than the USA CDC report, yet less frequent than in limited-resource countries (except for CA-UTI). They prolonged the hospitalisation period at ICU and generated substantial additional costs of treatment with no influence on mortality. The Acinetobacter baumannii MDR infections were the most problematic therapeutic issue. DA-HAIs preventive methods compliance rate needs improvement.

Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs).

OBJECTIVE: Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. DESIGN: Retrospective case-control study. SETTING: Four academic medical centers. PATIENTS: Children aged 0-22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries. METHODS: Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0. RESULTS: Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005-$10,362) and $6,502 (95% CI, $2,261-$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, -$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022-$8,719). CONCLUSIONS: Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

Sustained decrease in urine culture utilization after implementing a reflex urine culture intervention: A multicenter quasi-experimental study.

Accurately diagnosing urinary tract infections (UTIs) in hospitalized patients remains challenging, requiring correlation of frequently nonspecific symptoms and laboratory findings. Urine cultures (UCs) are often ordered indiscriminately, especially in patients with urinary catheters, despite the Infectious Diseases Society of America guidelines recommending against routine screening for asymptomatic bacteriuria (ASB).1,2 Positive UCs can be difficult for providers to ignore, leading to unnecessary antibiotic treatment of ASB.2,3 Using diagnostic stewardship to limit UCs to situations with a positive urinalysis (UA) can reduce inappropriate UCs since the absence of pyuria suggests the absence of infection.4-6 We assessed the impact of the implementation of a UA with reflex to UC algorithm ("reflex intervention") on UC ordering practices, diagnostic efficiency, and UTIs using a quasi-experimental design.

Fabrication of Ultra-Pure Anisotropic Zinc Oxide Nanoparticles via Simple and Cost-Effective Route: Implications for UTI and EAC Medications.

The purposes of this work are to evaluate the antimicrobial, antibiofilm, anticancer, and antioxidant abilities of anisotropic zinc oxide nanoparticles (ZnO NPs) synthesized by a cost-effective and eco-friendly sol-gel method. The synthesized ZnO NPs were entirely characterized by UV-Vis, XRD, FTIR, HRTEM, zeta potential, SEM mapping, BET surface analyzer, and EDX elemental analysis. Antimicrobial and antibiofilm activities of ZnO NPs were investigated against multidrug-resistant (MDR) bacteria and yeast causing serious diseases like urinary tract infection (UTI). The anticancer activity was performed against Ehrlich ascites carcinoma (EAC). Additionally, antioxidant scavenging activity against 2,2-diphenyl-1-picrylhydrazyl (DPPH) was observed. The synthesized ZnO NPs exhibited an absorption peak at 385.0 nm characteristic to the surface plasmon resonance (SPR). Data obtained from HRTEM, SEM, and XRD confirmed the anisotropic crystalline nature of the prepared ZnO NPs with an average particle size of 68.2 nm. The calculated surface area of the prepared ZnO NPs was 10.62 m2/g and the porosity was 13.16%, while pore volume was calculated to be 0.013 cm3/g and the average pore size was about 3.10 nm. The prepared ZnO NPs showed promising antimicrobial activity against all tested UTI-causing pathogens. It showed a prominent antimicrobial capability against Candida tropicalis with a zone of inhibition (ZOI) reaching 22.4 mm, 13 mm ZOI for Bacillus subtilis, and 12.5 mm ZOI for Pseudomonas aeruginosa. Additionally, the prepared ZnO NPs showed enhanced biofilm repression of about 79.33%, 72.94%, and 33.68% against B. subtilis, C. tropicalis, and P. aeruginosa, respectively. Moreover, the prepared ZnO NPs had a powerful antioxidant property with 33.0% scavenging ability after applied DPPH assay. Surprisingly, upon ZnO NPs treatment, cancer cell viability reduced from 100 to 58.5% after only 24 h due to their unique antitumor activity. Therefore, according to these outstanding properties, this study could give insights for solving serious industrial, pharmaceutical, and medical challenges, particularly in the EAC and UTI medications.

Liquid gold: the cost-effectiveness of urine sample collection methods for young precontinent children.

BACKGROUND: Urinary tract infection (UTI) is a common childhood infection. Many febrile children require a urine sample to diagnose or exclude UTI. Collecting urine from young children can be time-consuming, unsuccessful or contaminated. Cost-effectiveness of each collection method in the emergency department is unknown. OBJECTIVE: To determine the cost-effectiveness of urine collection methods for precontinent children. METHODS: A cost-effectiveness analysis was conducted comparing non-invasive (urine bag, clean catch and 5 min voiding stimulation for clean catch) and invasive (catheterisation and suprapubic aspirate (SPA)) collection methods, for children aged 0-24 months in the emergency department. Costs included equipment, staff time and hospital bed occupancy. If initial collection attempts were unsuccessful subsequent collection using catheterisation was assumed. The final outcome was a definitive sample incorporating progressive dipstick, culture and contamination results. Average costs and outcomes were calculated for initial collection attempts and obtaining a definitive sample. One-way and probabilistic sensitivity analyses were performed. RESULTS: For initial collection attempts, catheterisation had the lowest cost per successful collection (GBP£25.98) compared with SPA (£37.80), voiding stimulation (£41.32), clean catch (£52.84) and urine bag (£92.60). For definitive collection, catheterisation had the lowest cost per definitive sample (£49.39) compared with SPA (£51.84), voiding stimulation (£52.25), clean catch (£64.82) and urine bag (£112.28). Time occupying a hospital bed was the most significant determinant of cost. CONCLUSION: Catheterisation is the most cost-effective urine collection method, and voiding stimulation is the most cost-effective non-invasive method. Urine bags are the most expensive method. Although clinical factors influence choice of method, considering cost-effectiveness for this common procedure has potential for significant aggregate savings.

Cost-effectiveness of prophylactic antibiotic use to prevent catheter-associated urinary tract infections.

PURPOSE: We evaluate the cost-effectiveness of prophylactic antibiotic use to prevent catheter-associated urinary tract infections. MATERIALS AND METHODS: A decision tree model was used to assess the cost-effectiveness of prophylactic antibiotics in preventing catheter-associated urinary tract infections for patients with a short-term indwelling urinary catheter. The model accounted for incidence of urinary tract infections with and without the use of prophylactic antibiotics, incidence of antibiotic-resistant urinary tract infections, as well as costs associated with diagnosis and treatment of urinary tract infections and antibiotic-resistant urinary tract infections. Costs were calculated from the health care system's perspective. We conducted one-way sensitivity analyses. RESULTS: The base case analysis showed that the use of prophylactic antibiotics is cost-saving in preventing catheter-associated urinary tract infections. The use of prophylactic antibiotics resulted in lower costs and higher quality-adjusted life-years compared with no prophylactic antibiotics. Sensitivity analyses showed that the optimal strategy changes to no prophylactic antibiotics when the incidence of urinary tract infections after prophylactic antibiotics exceeds 22% or the incidence of developing urinary tract infections without prophylactic antibiotics is less than 12%. Varying the costs of prophylactic antibiotics, urinary tract infection treatment, or antibiotic-resistant urinary tract infection treatment within a reasonable range did not change the optimal strategy. CONCLUSIONS: Prophylactic antibiotic use to prevent catheter-associated urinary tract infections is cost-effective under most conditions. These results were sensitive to the likelihood of developing catheter-associated urinary tract infections with and without prophylactic antibiotics. Our results are limited to the cost-effectiveness perspective on this clinical practice.

Direct medical costs of urinary tract infections by Gram-negative bacilli resistant to beta-lactams in a tertiary care hospital in Medellín, Colombia / Costos médicos directos de las infecciones del tracto urinario por bacilos Gram negativos resistentes a betalactámicos en un hospital de alta complejidad de Medellín, Colombia

Introduction: Urinary tract infections are very frequent in the hospital environment and given the emergence of antimicrobial resistance, they have made care processes more complex and have placed additional pressure on available healthcare resources. Objective: To describe and compare excess direct medical costs of urinary tract infections due to Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa resistant to beta-lactams. Materials and methods: A cohort study was conducted in a third level hospital in Medellín, Colombia, from October, 2014, to September, 2015. It included patients with urinary tract infections caused by beta-lactam-susceptible bacteria, third and fourth generation cephalosporin-resistant, as well as carbapenem-resistant. Costs were analyzed from the perspective of the health system. Clinical-epidemiological information was obtained from medical records and the costs were calculated using standard tariff manuals. Excess costs were estimated with multivariate analyses. Results: We included 141 patients: 55 (39%) were sensitive to beta-lactams, 54 (38.3%) were resistant to cephalosporins and 32 (22.7%) to carbapenems. The excess total adjusted costs of patients with urinary tract infections due to cephalosporin- and carbapenem-resistant bacteria were US$ 193 (95% confidence interval (CI): US$ -347-734) and US$ 633 (95% CI: US$ -50-1316), respectively, compared to the group of patients with beta-lactam sensitive urinary tract infections. The differences were mainly found in the use of broad-spectrum antibiotics such as meropenem, colistin, and fosfomycin. Conclusion: Our results show a substantial increase in the direct medical costs of patients with urinary tract infections caused by beta-lactam-resistant Gram-negative bacilli (cephalosporins and carbapenems). This situation is of particular concern in endemic countries such as Colombia, where the high frequencies of urinary tract infections and the resistance to beta-lactam antibiotics can generate a greater economic impact on the health sector.

Introducción. Las infecciones del tracto urinario son muy frecuentes en el ámbito hospitalario. Debido a la aparición de la resistencia antimicrobiana, la complejidad de los procesos de atención ha aumentado y, con ello, la demanda de recursos. Objetivo. Describir y comparar el exceso de los costos médicos directos de las infecciones del tracto urinario por Klebsiella pneumoniae, Enterobacter cloacae y Pseudomonas aeruginosa resistentes a betalactámicos. Materiales y métodos. Se llevó a cabo un estudio de cohorte en una institución de tercer nivel de Medellín, Colombia, entre octubre del 2014 y septiembre del 2015. Se incluyeron los pacientes con infección urinaria, unos por bacterias sensibles a los antibióticos betalactámicos, y otros por bacterias resistentes a las cefalosporinas de tercera y cuarta generación y a los antibióticos carbapenémicos. Los costos se analizaron desde la perspectiva del sistema de salud. La información clínico-epidemiológica se obtuvo de las historias clínicas y los costos se calcularon utilizando los manuales tarifarios estándar. El exceso de costos se estimó mediante análisis multivariados. Resultados. Se incluyeron 141 pacientes con infección urinaria: 55 (39 %) por bacterias sensibles a los betalactámicos, 54 (38,3 %) por bacterias resistentes a las cefalosporinas y 32 (22,7 %) por bacterias resistentes a los carbapenémicos. El exceso de costos totales ajustado de los 86 pacientes con infecciones del tracto urinario por bacterias resistentes a las cefalosporinas y a los carbapenémicos, fue de USD$ 193 (IC95% -347 a 734) y USD$ 633 (IC95% -50 a 1.316), respectivamente comparados con el grupo de 55 pacientes por bacterias sensibles a los betalactámicos. Las diferencias se presentaron principalmente en el uso de antibióticos de amplio espectro, como el meropenem, la colistina y la fosfomicina. Conclusión. Los resultados evidenciaron un incremento sustancial de los costos médicos directos de los pacientes con infecciones del tracto urinario por bacterias resistentes a las cefalosporinas o a los carbapenémicos. Esta situación genera especial preocupación en los países endémicos como Colombia, donde la alta frecuencia de infecciones del tracto urinario y de resistencia a los betalactámicos puede causar un mayor impacto económico en el sector de la salud.

A Payer Perspective of the Costs of Urinary Tract and Skin and Soft Tissue Infections in Adults with Diabetes and the Relationship to Oral Antidiabetic Medication Nonadherence.

BACKGROUND: Controlling costs and improving quality outcomes are important considerations of the triple aim in health care. Medication adherence to oral antidiabetic (OAD) medications is an outcome measure for those with diabetes. However, there is little research reporting the costs associated with OAD medication adherence among adults with diabetes and comorbid infections. OBJECTIVE: To provide nationally representative cost and utilization estimates from a payer perspective of 2 common comorbid infections: urinary tract infection (UTI) and skin and soft tissue infection (SSTI) among adults with diabetes in relation to OAD medication nonadherence to quantify cost per outcome. METHODS: A retrospective observational study for years 2010-2015 used longitudinal panel data in the public domain from the Medical Expenditure Panel Survey (MEPS). The study included individuals aged ≥ 18 years with diabetes (excluding gestational diabetes) who were prescribed OAD medications and then stratified by infection status, that is, without infection versus with UTI and/or SSTI. Outcomes measured included medication adherence, defined as medication possession ratio (MPR); treated prevalence of UTI and SSTI; and associated direct medical costs paid by insurers. RESULTS: 4,633 adults with diabetes were included; of those, 12% reported a UTI or SSTI, with the weighted sample representing 2.2 million U.S. residents. The mean MPR was 0.61 and 0.63 in the infection and noninfection groups, respectively. Less than 35% in each group were adherent to OAD medications. Having a UTI or SSTI increased the adjusted total health expenses by 53.7% (P < 0.001), but adherence to OAD medications did not significantly affect total health care costs. CONCLUSIONS: In adults with diabetes, a UTI or SSTI diagnosis did not influence medication adherence to OAD medication but increased health care utilization and costs significantly. DISCLOSURES: This study was supported by the Virginia Commonwealth University Presidential Research Quest Fund (PeRQ Fund). The authors have no financial conflicts of interest to disclose.