Economic burden of community-acquired antibiotic-resistant urinary tract infections: a systematic review and meta-analysis (Preprint)

BACKGROUND Antibiotic resistance (ABR) poses a major burden to global health and economic systems. ABR in community-acquired urinary tract infections (CA-UTIs) has become increasingly prevalent. Accurate estimates of the clinical and economic burden of ABR are needed to support medical resource prioritisation and cost-effectiveness evaluations of UTI interventions. OBJECTIVE This study aims to systematically synthesize the evidence in the economic costs associated with ABR in CA-UTIs, using published studies comparing the costs of antibiotic-susceptible and antibiotic-resistant cases. METHODS We searched PubMed, Ovid Medline and Embase, Cochrane Review Library, and Scopus databases. Studies published in English from 01 January 2012 to 31 January 2023 reporting the economic costs of ABR in CA-UTI of any microbe were included. Independent screening of title/abstracts and full texts were performed based on pre-specified criteria. Quality assessment was performed using the Integrated Quality Criteria for Review of Multiple Study Designs (ICROMS) tool. Data in UTI diagnosis criteria, patient characteristics, perspectives, resources costed, and patient and health economic outcomes, including mortality, hospital length of stay (LOS), and costs was extracted and analysed. Monetary costs were converted into 2023 USD. RESULTS This review included 15 studies with a total of 57,251 CA-UTI cases. All studies were from high- or upper middle-income countries. Fourteen (93%) studies took a health system perspective. Thirteen (87%) focused on hospitalised patients. Fourteen (93%) reported the UTI pathogens. E. coli, K. pneumoniae, and P. aeruginosa are the most prevalent organisms. Twelve (80%) studies reported mortality, of which, 7 reported increased mortality in the ABR group. Random effects meta-analyses estimated an odds ratio of 1.50 (95% CI: 1.29, 1.74) in the ABR CA-UTI cases. All 13 hospital-based studies reported LOS, of which, 11 reported significantly higher LOS in the ABR group. The meta-analysis of reported median LOS estimated a pooled excess LOS ranged from 1.50 days (95% CI: 0.71, 4.00) to 2.00 days (95% CI: 0.85, 3.15). The meta-analysis of reported mean LOS estimated a pooled excess LOS of 2.45 days (95% CI: 0.51 – 4.39). Eight (53%) studies reported costs in monetary terms, none discounted the costs. All these 8 studies reported higher medical costs spent treating patients with ABR CA-UTI in hospitals. The highest excess cost was observed in UTI caused by Carbapenem-resistant Enterobacteriaceae. No meta-analysis was performed for monetary costs due to heterogeneity. CONCLUSIONS ABR attributed to increased mortality, hospital LOS, and economic costs among the patients with CA-UTI. The findings of this review highlighted the scarcity of research in this area, particularly in patient morbidity and chronic sequelae and costs incurred in the community healthcare. Future research calls for cost-of-illness analysis of infections standardising therapy-pathogen combination comparators, medical resources, productivity loss, and intangible costs to be captured, and data from community sectors and low-resourced settings and countries. CLINICALTRIAL PROSPERO CRD42023374551