Empirical therapy for uncomplicated urinary tract infections in an era of increasing antimicrobial resistance: a decision and cost analysis

Clin Infect Dis. 2001 Sep 1;33(5):615-21. doi: 10.1086/322603. Epub 2001 Jul 30.


Infectious Diseases Society of America guidelines state that uncomplicated urinary tract infections (UTIs) should be treated empirically with trimethoprim-sulfamethoxazole (TMP-SMZ), unless the community resistance among uropathogens exceeds 10%-20%, in which case a fluoroquinolone (FQ) should be used. However, the data to support this threshold are limited. We performed a cost-minimization and sensitivity analysis to determine what level of TMP-SMZ resistance in a community should trigger FQ use. The mean cost of empirical treatment with TMP-SMZ was US$92 when the proportion of resistant Escherichia coli was 0%, $106 when it was 20%, and $120 when it was 40%. The mean cost of empirical FQ treatment was $107 at current levels of FQ resistance. When >22% of E. coli in a community are TMP-SMZ-resistant, empirical FQ therapy becomes less costly than TMP-SMZ therapy. Treatment guidelines for empirical treatment of UTIs may need modification, and the threshold trigger for empirical FQ use should be raised to >20% TMP-SMZ resistance.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Anti-Infective Agents / therapeutic use
  • Anti-Infective Agents, Urinary / economics*
  • Anti-Infective Agents, Urinary / therapeutic use*
  • Computer Simulation
  • Cost Savings
  • Cost-Benefit Analysis
  • Costs and Cost Analysis
  • Decision Support Techniques
  • Decision Trees
  • Escherichia coli / isolation & purification
  • Escherichia coli Infections / drug therapy*
  • Escherichia coli Infections / economics
  • Fluoroquinolones
  • Humans
  • Microbial Sensitivity Tests
  • Practice Guidelines as Topic
  • Trimethoprim Resistance
  • Trimethoprim, Sulfamethoxazole Drug Combination / economics*
  • Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use*
  • Urinary Tract Infections / drug therapy*
  • Urinary Tract Infections / economics*


  • Anti-Infective Agents
  • Anti-Infective Agents, Urinary
  • Fluoroquinolones
  • Trimethoprim, Sulfamethoxazole Drug Combination