Tu H Y V, Pemberton J, Lorenzo A J, Braga L H
Division of Urology, St. Josephs Healthcare, Institute of Urology, 50 Charlton Avenue East, Room G344, Hamilton, Ontario, L8N 4A6, Canada; Division of Urology, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
J Pediatr Urol. 2015 Oct;11(5):247.e1-8. doi: 10.1016/j.jpurol.2015.04.031. Epub 2015 Jun 20.
For infants with hydronephrosis, continuous antibiotic prophylaxis (CAP) may reduce urinary tract infections (UTIs); however, its value remains controversial. Recent studies have suggested that neonates with severe obstructive hydronephrosis are at an increased risk of UTIs, and support the use of CAP. Other studies have demonstrated the negligible risk for UTIs in the setting of suspected ureteropelvic junction obstruction and have highlighted the limited role of CAP in hydronephrosis. Furthermore, economic studies in this patient population have been sparse.
This study aimed to evaluate whether the use of CAP is an efficient expenditure for preventing UTIs in children with high-grade hydronephrosis within the first 2 years of life.
A decision model was used to estimate expected costs, clinical outcomes and quality-adjusted life years (QALYs) of CAP versus no CAP (Fig. 1). Cost data were collected from provincial databases and converted to 2013 Canadian dollars (CAD). Estimates of risks and health utility values were extracted from published literature. The analysis was performed over a time horizon of 2 years. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty and robustness.
Overall, CAP use was less costly and provided a minimal increase in health utility when compared to no CAP (Table). The mean cost over two years for CAP and no CAP was CAD$1571.19 and CAD$1956.44, respectively. The use of CAP reduced outpatient-managed UTIs by 0.21 infections and UTIs requiring hospitalization by 0.04 infections over 2 years. Cost-utility analysis revealed an increase of 0.0001 QALYs/year when using CAP. The CAP arm exhibited strong dominance over no CAP in all sensitivity analyses and across all willingness-to-pay thresholds.
The use of CAP exhibited strong dominance in the economic evaluation, despite a small gain of 0.0001 QALYs/year. Whether this slight gain is clinically significant remains to be determined. However, small QALY gains have been reported in other pediatric economic evaluations. Strengths of this study included the use of data from a recent systematic review and meta-analysis, in addition to a comprehensive probabilistic sensitivity analysis. Limitations of this study included the use of estimates for UTI probabilities in the second year of life and health utility values, given that they were lacking in the literature. Spontaneous resolution of hydronephrosis and surgical management were also not implemented in this model.
To prevent UTIs within the first 2 years of life in infants with high-grade hydronephrosis, this probabilistic model has shown that CAP use is a prudent expenditure of healthcare resources when compared to no CAP.
对于肾积水婴儿，持续预防性使用抗生素（CAP）可能会减少尿路感染（UTI）；然而，其价值仍存在争议。最近的研究表明，患有严重梗阻性肾积水的新生儿发生UTI的风险增加，并支持使用CAP。其他研究表明，在疑似输尿管肾盂连接处梗阻的情况下，UTI的风险可忽略不计，并强调了CAP在肾积水中的作用有限。此外，针对这一患者群体的经济学研究较少。
本研究旨在评估使用CAP对于预防出生后2年内患有重度肾积水儿童的UTI是否是一项有效的支出。
采用决策模型来估计CAP与不使用CAP的预期成本、临床结局和质量调整生命年（QALY）（图1）。成本数据从省级数据库收集并换算为2013年加拿大元（CAD）。风险和健康效用值的估计值从已发表的文献中提取。分析在2年的时间范围内进行。进行单因素和概率敏感性分析以评估不确定性和稳健性。
总体而言，与不使用CAP相比，使用CAP成本更低，且健康效用仅有极小的增加（表）。CAP和不使用CAP在两年内的平均成本分别为1571.19加元和1956.44加元。使用CAP在2年内使门诊管理的UTI减少0.21例，需要住院治疗的UTI减少0.04例。成本效用分析显示，使用CAP时每年QALY增加0.0001。在所有敏感性分析和所有支付意愿阈值下，CAP组均显著优于不使用CAP组。
尽管每年QALY仅小幅增加0.0001，但在经济评估中使用CAP显示出显著优势。这种微小的增加在临床上是否具有显著意义仍有待确定。然而，在其他儿科经济学评估中也报告了QALY的小幅增加。本研究的优势包括使用了来自近期系统评价和荟萃分析的数据，以及全面的概率敏感性分析。本研究的局限性包括使用了生命第二年UTI概率的估计值和健康效用值，因为文献中缺乏这些数据。本模型中也未纳入肾积水的自然消退和手术治疗。
为预防出生后2年内患有重度肾积水婴儿的UTI，该概率模型表明，与不使用CAP相比，使用CAP是医疗资源的一项审慎支出。
