ORIGINAL ARTICLE
Nitrofurantoin Compares Favorably to Recommended Agents as Empirical Treatment of Uncomplicated Urinary Tract Infections in a Decision and Cost Analysis

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OBJECTIVE

To analyze the costs of nitrofurantoin use compared to those of other antibiotics recommended for treatment of uncomplicated urinary tract infection (UTI).

PATIENTS AND METHODS

We used a decision analysis model to perform cost-minimization and sensitivity analyses to determine the level of trimethoprim-sulfamethoxazole (TMP-SMX) and fluoroquinolone resistance that would favor the use of nitrofurantoin as a first-line empirical treatment of uncomplicated UTIs. The model used a program perspective to evaluate costs.

RESULTS

Nitrofurantoin was cost-minimizing when the prevalence of fluoroquinolone resistance exceeded 12% among uropathogens or the prevalence of TMP-SMX resistance exceeded 17%. On 2-way sensitivity analysis, variables that had a significant impact on our cost-minimization threshold included cost of antibiotics and probability of clinical cure with antibiotics.

CONCLUSION

From a payer perspective, nitrofurantoin appears to be a reasonable alternative to TMP-SMX and fluoroquinolones for empirical treatment of uncomplicated UTIs, especially given the current prevalence of antibiotic resistance among community uropathogens. On the basis of efficacy, cost, and low impact on promoting antimicrobial resistance, clinicians should consider nitrofurantoin as a reasonable alternative to TMP-SMX and fluoroquinolones for first-line therapy for uncomplicated UTIs.

Section snippets

PATIENTS AND METHODS

To determine the threshold level of TMP-SMX and fluoroquinolone resistance among community uropathogens that would make nitrofurantoin cost-minimizing, we employed a decision tree model using the DATA software (version 4.0, TreeAge Software, Williamstown, MA). The model is based on previous models of uncomplicated UTI treatment caused by Escherichia coli in women older than 18 years.10, 11, 12 All the models used a payer (program) perspective for the study. To obtain information on clinical

RESULTS

For the comparison of nitrofurantoin and fluoroquinolones, the sensitivity analysis demonstrated that, when the percentage of fluoroquinolone-resistant E coli exceeds 12%, empirical treatment with nitrofurantoin becomes cost-minimizing; below that level, fluoroquinolones are cost minimizing compared to nitrofurantoin (Figure 2). At the 12% fluoroquinolone resistance breakpoint, the mean total cost of empirical treatment of UTI with fluoroquinolones and nitrofurantoin was $159. When comparing

DISCUSSION

Using a cost-minimization model of empirical treatment of uncomplicated UTIs, we have performed, to our knowledge, the first decision analysis to explore the role of nitrofurantoin in empirical therapy for uncomplicated UTIs. In comparison with fluoroquinolones, nitrofurantoin was found to be cost-minimizing when the prevalence of fluoroquinolone-resistant E coli in the community reached 12%. In comparison with TMP-SMX, nitrofurantoin was cost-minimizing when E coli resistance to TMP-SMX was

CONCLUSION

Nitrofurantoin is an important treatment option for uncomplicated UTIs in the current era of increasing fluoroquinolone and TMP-SMX resistance among uropathogens. Nitrofurantoin is likely cost-minimizing compared with TMP-SMX in most areas of the United States and cost-competitive compared with generic ciprofloxacin. Our findings complement recent data that demonstrate that the efficacy and tolerability of nitrofurantoin are comparable with the efficacy and tolerability of TMP-SMX for treating

Acknowledgments

We thank Kalpana Gupta, MD, for her assistance with obtaining resistance data for nitrofurantoin and Samantha Eells, MPH, for her critical review of the submitted manuscript.

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  • Cited by (0)

    We acknowledge logistic support from the M01 RR 00425 grant to the General Clinic Research Center at Harbor-UCLA Medical Center.

    An earlier version of this article appeared Online First.

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