How to Reduce the Overall Cost of a Urinary Tract Infection

UTI Costs Have Increased > 90% In The Last Decade

• Urinary tract infections (UTI) constitute one of the most common bacterial infections, with over 10.5 million office visits in the U.S. in 2007 alone.¹

• Hospitalizations for UTI increased dramatically: cases increased by 76% and incidence increased by 52% between 1998 and 2011.

• More than 436,437 patients were admitted to hospital with a primary diagnosis of UTI in 2011, at a cost of $9.7 billion. The mean real cost per case of UTI has increased by 90.8% between 2001 and 2011.²

Several studies have examined methods for providing appropriate infection management while reducing costs.^3–7 One approach might be to either reduce the length of hospitalization or to avoid hospitalization altogether. Two of the most important questions concern quality of care between home and hospital settings, and potential cost savings.

Keeping UTI Patients Out of the Hospital Reduces Costs of a UTI

Studies of UTI management commonly segregate patients into three groups:

• Community acquired UTI

• Health care acquired UTI

• Infection with ESBL-producing pathogens⁸

Hospital acquired Urinary tract Infection is generally more virulent and less susceptible to antimicrobial treatment.^9,10 Hospitalization, by itself, is considered a risk factor for antibiotic resistant UTI, and empiric treatment of hospital acquired UTI is different than that for community acquired cases.⁸ It may, therefore, be preferable to avoid hospitalization for UTI, altogether.

Keeping Patients at Home Saves as Much as $2,000 per Episode

Early hospital discharge and treatment only at home raise the question of quality of care in a home setting. While there is some evidence of overuse of UTI antibiotics associated with home care^8,11, patients treated at home realized psychological benefits, had similar outcomes, suffered fewer complications, and realized average cost savings of $2,399 per patient.¹²

Appropriate Use of UTI Antibiotics Keeps Patients at Home

One study examined whether cost savings could accrue from a careful assessment of antibiotic use in acute hospital wards. Their findings, partially reproduced in Table 1, support the conclusion that better antibiotic management results in cost reductions per patient, largely by reducing duration of hospitalization. Some costs may be shifted from hospital to community resources.¹³

Table 1.

Reproduced and revised from ¹³

Appropriate Use of UTI Antibiotics Reduces Antibiotic Resistance Rates

While antimicrobial therapy is only a small portion of total costs in hospital, a prolonged time to appropriate therapy increased costs without additional reimbursement.⁸ Inappropriate UTI antibiotic use is recognized as the primary selective pressure driving antibiotic resistance.¹⁴ Optimal management of UTI should direct treatment against patient-specific pathogens, while avoiding known antibiotic resistance, as expeditiously as possible.

A Tool to Reduce Overall Healthcare Costs Associated with a Urinary Tract Infection

Such an approach to determining definitive therapy for UTI is provided by the GUIDANCE test available from Pathnostics. GUIDANCE consists of two components: pathogen identification by PCR, and determination of antibiotic resistance.

• Infecting pathogens are identified using PCR. Most UTIs may be polymicrobial in nature, and polymicrobial infections often display enhanced virulence and increased antibiotic resistance.^15–17

• Antibiotic resistance is determined using two independent methods: genotyping of cultured pathogens and phenotyping of pathogen response to antibiotics. Tens of thousands of resistance genes have been discovered, impacting hundreds of antibiotics in hundreds of organisms.¹⁸ The presence of such resistance-conferring genes can be determined by genotyping. However, a resistant genotype may not fully describe the existing phenotype, especially in a polymicrobial environment.¹⁹ It is therefore necessary to fully phenotype pathogens, as well. We will delve into this topic in the next blog in our series.

With these two components, GUIDANCE can provide a swift diagnosis and therapy options that work the first time.

References

1. Flores-Mireles, A. L., Walker, J. N., Caparon, M. & Hultgren, S. J. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat. Rev. Microbiol. 13, 269–284 (2015).

2. Simmering, J. E., Tang, F., Cavanaugh, J. E., Polgreen, L. A. & Polgreen, P. M. The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open Forum Infect. Dis. 4, ofw281 (2017).

3. Turner, D. et al. Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial. BMJ 340, c346 (2010).

4. Bosmans, J. E. et al. Cost-effectiveness of different strategies for diagnosis of uncomplicated urinary tract infections in women presenting in primary care. PloS One 12, e0188818 (2017).

5. Mansour, A., Hariri, E., Shelh, S., Irani, R. & Mroueh, M. Efficient and cost-effective alternative treatment for recurrent urinary tract infections and interstitial cystitis in women: a two-case report. Case Rep. Med. 2014, 698758 (2014).

6. Rubin, N. & Foxman, B. The cost-effectiveness of placing urinary tract infection treatment over the counter. J. Clin. Epidemiol. 49, 1315–1321 (1996).

7. Eells, S. J., Bharadwa, K., McKinnell, J. A. & Miller, L. G. Recurrent urinary tract infections among women: comparative effectiveness of 5 prevention and management strategies using a Markov chain Monte Carlo model. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 58, 147–160 (2014).

8. Cardwell, S. M., Crandon, J. L., Nicolau, D. P., McClure, M. H. & Nailor, M. D. Epidemiology and economics of adult patients hospitalized with urinary tract infections. Hosp. Pract. 1995 44, 33–40 (2016).

9. Sievert, D. M. et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect. Control Hosp. Epidemiol. 34, 1–14 (2013).

10. Aguilar-Duran, S. et al. Community-onset healthcare-related urinary tract infections: comparison with community and hospital-acquired urinary tract infections. J. Infect. 64, 478–483 (2012).

11. Gee, M. E. et al. Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections. Consult. Pharm. J. Am. Soc. Consult. Pharm. 33, 105–113 (2018).

12. Leff, B. et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann. Intern. Med. 143, 798–808 (2005).

13. Gray, A., Dryden, M. & Charos, A. Antibiotic management and early discharge from hospital: an economic analysis. J. Antimicrob. Chemother. 67, 2297–2302 (2012).

14. Duane, S. et al. Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): protocol for a cluster randomized trial. Trials 14, 441 (2013).

15. Price, T. K. et al. The Clinical Urine Culture: Enhanced Techniques Improve Detection of Clinically Relevant Microorganisms. J. Clin. Microbiol. 54, 1216–1222 (2016).

16. Hilt, E. E. et al. Urine is not sterile: use of enhanced urine culture techniques to detect resident bacterial flora in the adult female bladder. J. Clin. Microbiol. 52, 871–876 (2014).

17. Rogers, G. B. et al. Revealing the dynamics of polymicrobial infections: implications for antibiotic therapy. Trends Microbiol. 18, 357–364 (2010).

18. Liu, B. & Pop, M. ARDB–Antibiotic Resistance Genes Database. Nucleic Acids Res. 37, D443-447 (2009).

19. Palmer, A. C. & Kishony, R. Understanding, predicting and manipulating the genotypic evolution of antibiotic resistance. Nat. Rev. Genet. 14, 243–248 (2013).