Recurrent urinary tract infections among women: comparative effectiveness of 5 prevention and management strategies using a Markov chain Monte Carlo model

Abstract

Background: Recurrent urinary tract infections (UTIs) are a common problem among women. However, comparative effectiveness strategies for managing recurrent UTIs are lacking.

Methods: We performed a systematic literature review of management of women experiencing ≥3 UTIs per year. We then developed a Markov chain Monte Carlo model of recurrent UTI for each management strategy with ≥2 adequate trials published. We simulated a cohort that experienced 3 UTIs/year and a secondary cohort that experienced 8 UTIs/year. Model outcomes were treatment efficacy, patient and payer cost, and health-related quality of life.

Results: Five strategies had ≥2 clinical trials published: (1) daily antibiotic (nitrofurantoin) prophylaxis; (2) daily estrogen prophylaxis; (3) daily cranberry prophylaxis; (4) acupuncture prophylaxis; and (5) symptomatic self-treatment. In the 3 UTIs/year model, nitrofurantoin prophylaxis was most effective, reducing the UTI rate to 0.4 UTIs/year, and the most expensive to the payer ($821/year). All other strategies resulted in payer cost savings but were less efficacious. Symptomatic self-treatment was the only strategy that resulted in patient cost savings, and was the most favorable strategy in term of cost per quality-adjusted life-year (QALY) gained.

Conclusions: Daily antibiotic use is the most effective strategy for recurrent UTI prevention compared to daily cranberry pills, daily estrogen therapy, and acupuncture. Cost savings to payers and patients were seen for most regimens, and improvement in QALYs were seen with all. Our findings provide clinically meaningful data to guide the physician-patient partnership in determining a preferred method of prevention for this common clinical problem.

Keywords: management; recurrent; urinary tract infection.

Figure 1.

Markov decision tree of urinary tract infection (UTI) outcomes among patients with recurrent UTIs. Abbreviations: Abx, antibiotic; FQ, fluoroquinolone; MD, physician; STI, sexually transmitted infection; Tx, treatment; UA, urinalysis; U Cx, urine culture; UTI, urinary tract infection.

Figure 2.

Study selection process and reasons for exclusion of references. In cases where articles fell into >1 category, the primary reason for exclusion is noted. Abbreviations: rUTI, recurrent urinary tract infection; TMP-SMX, trimethoprim-sulfamethoxazole; UTI, urinary tract infection.

Figure 3.

A–G, Results of decision analysis of management strategies for recurrent urinary tract infections (UTIs) from the payer perspective among women experiencing 3 UTIs per year. Abbreviations: QALD, quality-adjusted life-day; QALY, quality-adjusted life-year; Ref., reference group; USD, US dollars; UTI, urinary tract infection.

Figure 3 continued.

Figure 3 continued.

Figure 4.

A–G, Results of decision analysis of management strategies for recurrent urinary tract infections (UTIs) from the payer perspective among women experiencing 8 UTIs per year. Abbreviations: QALD, quality-adjusted life-day; QALY, quality-adjusted life-year; Ref., reference group; USD, US dollars; UTI, urinary tract infection.

Figure 4 continued.

Figure 4 continued.