Cost-Effectiveness of Antibiotic Prophylaxis Strategies for Transrectal Prostate Biopsy in an Era of Increasing Antimicrobial Resistance

• Published in: Value in health 2018-03, Vol.21 (3), p.310-317
• Main Authors: Lee, Kyueun, Drekonja, Dimitri M., Enns, Eva A.
• Format: Article
• Language: English
• Subjects: Aged; Anti-Bacterial Agents - administration & dosage; Anti-Bacterial Agents - economics; antibiotic prophylaxis; Antibiotic Prophylaxis - economics; Antibiotic Prophylaxis - methods; Antibiotic resistance; Antibiotics; Antimicrobial agents; Antimicrobial resistance; Biopsy; Biopsy - economics; Biopsy - methods; Ceftriaxone; Ciprofloxacin; Cohort Studies; Cost analysis; Cost-Benefit Analysis - methods; cost-effectiveness; Decision Support Techniques; directed antibiotic prophylaxis; Drug resistance; Drug Resistance, Microbial - drug effects; Drug Resistance, Microbial - physiology; Drug Therapy, Combination; Elderly men; fluoroquinolone resistance; Health Care Costs; Health care expenditures; Humans; Male; Men; Preventive medicine; Prophylaxis; Prostate; Prostate - drug effects; Prostate - pathology; Prostatic Neoplasms - diagnosis; Prostatic Neoplasms - economics; Quality adjusted life years; Sensitivity analysis; Susceptibility; transrectal prostate biopsy; Veterans; Willingness to pay
• ISSN: 1098-3015; 1524-4733
• DOI: 10.1016/j.jval.2017.08.3016

To determine the optimal antibiotic prophylaxis strategy for transrectal prostate biopsy (TRPB) as a function of the local antibiotic resistance profile. We developed a decision-analytic model to assess the cost-effectiveness of four antibiotic prophylaxis strategies: ciprofloxacin alone, ceftriaxone alone, ciprofloxacin and ceftriaxone in combination, and directed prophylaxis selection based on susceptibility testing. We used a payer’s perspective and estimated the health care costs and quality-adjusted life-years (QALYs) associated with each strategy for a cohort of 66-year-old men undergoing TRPB. Costs and benefits were discounted at 3% annually. Base-case resistance prevalence was 29% to ciprofloxacin and 7% to ceftriaxone, reflecting susceptibility patterns observed at the Minneapolis Veterans Affairs Health Care System. Resistance levels were varied in sensitivity analysis. In the base case, single-agent prophylaxis strategies were dominated. Directed prophylaxis strategy was the optimal strategy at a willingness-to-pay threshold of $50,000/QALY gained. Relative to the directed prophylaxis strategy, the incremental cost-effectiveness ratio of the combination strategy was $123,333/QALY gained over the lifetime time horizon. In sensitivity analysis, single-agent prophylaxis strategies were preferred only at extreme levels of resistance. Directed or combination prophylaxis strategies were optimal for a wide range of resistance levels. Facilities using single-agent antibiotic prophylaxis strategies before TRPB should re-evaluate their strategies unless extremely low levels of antimicrobial resistance are documented.