The additional costs of antibiotics and re-consultations for antibiotic-resistant Escherichia coli urinary tract infections managed in general practice

https://doi.org/10.1016/j.ijantimicag.2008.08.027Get rights and content

Abstract

The emergence of antibiotic resistance is a major threat to public health. In the UK, most antibiotics are prescribed in general practice but the extra costs to general practice of resistant infections have not previously been well described. We compared the costs of treating patients presenting with resistant Escherichia coli urinary tract infections (UTIs) (resistant to ampicillin, trimethoprim or at least one antibiotic) with the costs of treating patients with UTIs that were sensitive to all six tested antibiotics (ampicillin, trimethoprim, amoxicillin/clavulanic acid, cefalexin, ciprofloxacin and nitrofurantoin) with regard to re-consultations and antibiotics prescribed. There were significantly higher antibiotic costs (mean extra antibiotic cost £1.19/€1.75), re-consultation costs (£2.42/€3.55) and total costs (£3.62/€5.31) for patients whose infections were resistant to at least one antibiotic compared with those with sensitive infections even after accounting for potentially confounding factors. Although these per-patient costs may appear small, they do not take into account the full additional costs of resistant UTIs in the community and, given the high prevalence of UTIs, the overall costs to the health service are substantial.

Introduction

The emergence of antibiotic resistance is a major threat to public health. Direct and indirect use of antibiotics are among the main contributors to the development of resistance [1]. In secondary care, antibiotic resistance increases the length of hospital stay [2], mortality [3] and costs [2], but the consequences for general practice are less clear [4].

In the UK, 80% of antibiotic consumption is through prescriptions from general practitioners (GPs) in primary care [5]. The management of antibiotic-resistant infections in primary care is not well described in the literature. GPs often view the problem as a ‘public health issue’, remote from their prescribing decisions for their individual patients [6]. Qualitative studies have identified a number of factors influencing GPs’ decisions to prescribe antibiotics, but concerns about antimicrobial resistance are generally a secondary consideration or are not taken into account at all [7]. Whilst some GPs are concerned about the development of resistance, the associated costs are seldom considered. This may be due to the lack of information on the impact of antibiotic resistance for general practice and, in particular, the excess costs incurred [8].

Urinary tract infections (UTIs) are one of the commonest bacterial infections managed in general practice, accounting for between 1% and 3% of all general practice consultations [9]. We recently found that resistant Escherichia coli UTIs are symptomatic for longer and cause increased workload in general practice [10]. Whilst we did not attempt to quantify the full costs to general practice associated with resistant E. coli UTIs, additional analysis of the data collected allows an estimation of these costs.

The aim of this report was therefore to estimate the extra costs to the UK National Health Services (NHS) of additional re-consultations and additional antibiotics owing to treating antibiotic-resistant compared with sensitive E. coli UTIs in general practice.

Section snippets

Materials and methods

Ten GP practices from the former Bro Taf Health Authority in South East Wales, UK, were recruited. These practices were geographically dispersed and were shown to be representative of all practices in the area in terms of antibiotic-prescribing rates, number of registered patients and indicators of social deprivation. Patients consulting with clinically suspected UTI from 17 July 2002 to 31 March 2004 were identified and approached to participate in the study. Those who agreed to participate

Results

A total of 932 patients with UTIs completed questionnaires in the original study. Of these, 865 had complete data on resistance status and all potential confounders and had their medical records checked. In total, 347 infections were resistant to ampicillin (40.1%), 148 were resistant to trimethoprim (17.1%) and 389 were resistant to at least one antibiotic (45.0%).

Table 1 shows the mean (standard deviation) total cost per patient and separately for re-consultations and antibiotics costs. Table

Discussion

Overall, patients presenting with an antibiotic (ampicillin)-resistant E. coli UTI incurred mean general practice costs that were £3.64 (€5.34) (95% CI £0.84–6.24/€1.23–9.15) higher than those for patients whose infections were sensitive to all six antibiotics assessed in the study. For patients with infections resistant to trimethoprim, the extra cost was £11.21 (€16.45) (95% CI £7.27–15.97/€10.67–23.43).

Whilst these extra costs may appear small, these estimates must be regarded as minima for

Conclusion

Although on a per-case basis the extra costs to general practice of antibiotic-resistant UTIs were relatively small, the high incidence of this infection suggests that the overall cost of resistance in common infections managed in the community can be substantial. The estimates derived in this study can be used in economic evaluations of alternative strategies for treating UTIs.

Acknowledgments

The authors thank the patients who gave us their time; the GPs, practice managers and practice staff for maintaining their support throughout the study period; Dr A. Howard and colleagues at the laboratories for undertaking the work in addition to their routine work; and Mrs S. Horan, our research nurse, who conducted the interviews and liaised with practices.

Funding: The original study was funded by the Wellcome Trust (grant number GR064010MA).

Competing interests: None declared.

Ethical approval

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