Magnesium sulphate for fetal neuroprotection: a cost-effectiveness analysis.

BACKGROUND: The aim of this study was to assess the cost-effectiveness of administering magnesium sulphate to patients in whom preterm birth at < 32+0 weeks gestation is either imminent or threatened for the purpose of fetal neuroprotection. METHODS: Multiple decision tree models and probabilistic sensitivity analyses were used to compare the administration of magnesium sulphate with the alternative of no treatment. Two separate cost perspectives were utilized in this series of analyses: a health system and a societal perspective. In addition, two separate measures of effectiveness were utilized: cases of cerebral palsy (CP) averted and quality-adjusted life years (QALYs). RESULTS: From a health system and a societal perspective, respectively, a savings of $2,242 and $112,602 is obtained for each QALY gained and a savings of $30,942 and $1,554,198 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is imminent. From a health system perspective and a societal perspective, respectively, a cost of $2,083 is incurred and a savings of $108,277 is obtained for each QALY gained and a cost of $28,755 is incurred and a savings of $1,494,500 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is threatened. CONCLUSIONS: Administration of magnesium sulphate to patients in whom preterm birth is imminent is a dominant (i.e. cost-effective) strategy, no matter what cost perspective or measure of effectiveness is used. Administration of magnesium sulphate to patients in whom preterm birth is threatened is a dominant strategy from a societal perspective and is very likely to be cost-effective from a health system perspective.

Uncomplicated urinary tract infection in women. Current practice and the effect of antibiotic resistance on empiric treatment.

OBJECTIVE: To review treatment recommendations for empiric therapy of uncomplicated urinary tract infection (uUTI) in light of evolving antibiotic resistance and to consider use of guidelines to promote optimal practice. QUALITY OF EVIDENCE: PubMed was searched and additional relevant references were identified by reviewing articles found in the search. Guidelines were identified through discussion with family practitioners. Level of evidence was assessed for recommendations. MAIN MESSAGE: Many women have uUTIs. The treatment approach is usually empiric antimicrobial therapy without obtaining pretherapy cultures. Trimethoprim-sulfamethoxazole is standard first-line empiric treatment. While resistance to this drug is increasing, it remains only about 10% in community-acquired Escherichia coli in Canada. Concerns about increased resistance have contributed to greater use of fluoroquinolones, but widespread empiric use of this class of medications might promote resistance to fluoroquinolones. Hence, fluoroquinolones should not be considered first-line therapy. While guidelines for treatment of uUTIs have been developed, their usefulness is compromised by their conflicting recommendations. CONCLUSION: Trimethoprim-sulfamethoxazole and nitrofurantoin remain first-choice empiric therapy for uUTIs. Development of guidelines relevant to family physicians and community education programs that incorporate local susceptibility patterns are important strategies for promoting optimal practice.