Urinary tract infections (UTIs) are one of the most common complaints presenting to the ED and can be among the easiest cases to treat, but the costs many departments are incurring for this complaint are at least six times what they should be, says Ian Ahwah, MD, FACEP, Co-director of Emergency’s Physicians Medical Group’s Cost-Containment Program and the Assistant Director of Emergency Medicine at Brookside Hospital in San Pablo, CA.
When EPMG developed its Ambulatory Profiling Program, Ahwah and Laurel Hodgson, MD, FACEP, the group’s co-director of cost-containment, wrote detailed treatment guidelines for the 20 most common complaints presenting in the ED.
In the case of uncomplicated UTIs in non-pregnant female patientsthe majority of casesstudies have shown that laboratory urinalysis results have little impact on treatment decisions but can add up to $200 to the cost of the workup, Ahwah says.
They recommend a urine dipstick test followed by treatment with antibiotics if the test is positive.
"All you need to do is get their urine and put it into a dip analyzer. If it comes back positive for leuks or nitrites, go ahead and treat them," he explains. "You do not need to send them for a culture that may add $50-60, [and] you do not need a sensitivity, which may add another $200."
Ahwah notes that the urine must be from a "clean catch," and the physician must be able to rule out vaginitis.
The following chart, adapted from a table in EPMG’s Cost-Containment Manual, compares the cost of a "typical" UTI workup to their approach.
Typical Approach Cost-Effective Approach
Urinalysis $14.32 Dipstick U/A $7.50
Urine C&S $36.74
Rx Bactrim Rx Bactrim
10-day course $3.63 3-day course $1.09
OR Cipro $33.60
Total Cost: $54.69-84.66 Total Cost: $8.59
Cultures for UTIs are usually unnecessary because, in 90% of cases, they are caused by organisms from the Enterobacter family that are universally sensitive to Bactrim, he says.
A culture may be indicated in complicated UTIs, Ahwah notes, but a sensitivity test still may not affect management. Ordering a culture without sensitivity can reduce charges by up to 50% without a reduction in clinical effectiveness, he says.
Urine cultures may be indicated in patients who have symptoms but a negative dipstick, immunocompromised patients, children and the elderly, he says. (See chart on indications for urinalysis.)
Ahwah also recommends a shorter course of antibioticsa three-day course of Bactrim vs. a 10-day course.
"In the old days, we were all taught to use 10 days," he says. "New studies have shown that three days works just as well in young, non-pregnant females, the group most commonly infected with UTIs."
Prescribing a 10-day course of medication is also unrealistic because compliance drops significantly beyond five days.
"I don’t know about you, but I can’t take anything for 10 days, yet we still have a lot of physicians prescribing extremely long courses," he says.
A 10-day course of Bactrim may also result in a yeast infection in some patients."Now, you’ve treated the [original] infection, but you caused a complication. You give it for three days and you are less likely to get a yeast infection and you still clear up the UTI."
Physicians must also start paying attention to the cost of the medications they prescribe. Treating UTIs with fluoroquinolones, like Cipro, is effective but is much more expensive, Ahwah says.
"We as physicians don’t ever hear about how much it costs, and we need to," he says, noting that many insurance plans still don’t fully cover prescriptions. "Patients have to pay for their phone bill, their electric bill, and now, this medication. Pay attention to that."
EDs must begin to emphasize the most efficient and effective practices, both to control costs and provide the best care, he says. "Do what you have to do to make the appropriate diagnosis with the most efficient use of resources."
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