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