Cost-Effectiveness of Antibiotics in Sacral Neuromodulation

IMPORTANCE: Preoperative antibiotics are currently recommended before sacral neuromodulation (SNM), but no guidelines exist for postoperative prophylaxis. OBJECTIVE: The objective of this study was to evaluate the cost-effectiveness of 3 antibiotic strategies for preventing SNM infections requiring explantation. STUDY DESIGN: A decision analysis model (TreeAge Pro) compared (1) intravenous preoperative and oral postoperative antibiotics (PrePostAbx), (2) intravenous preoperative antibiotics without postoperative antibiotics (PreAbxOnly), and (3) no antibiotics either preoperatively or postoperatively (NoAbx). Model inputs included SNM success/continuation, risk of antibiotic side effects, infection and explanation rates, and reimplantation±repeat infection. Modeled costs (2022 USD) included antibiotics ±side effects, explantation due to infection, and reimplantation. Effectiveness was reported as quality-adjusted life years (QALYs) over a 1-year horizon. Monte Carlo simulation (n=10,000) addressed uncertainty, and net monetary benefit (NMB) was used for comparison due to similar, nonnormally distributed QALYs. RESULTS: PrePostAbx had the highest median costs ($28,848), $25 more than PreAbxOnly ($28,823). NoAbx had the lowest costs ($28,784) and the highest QALY (0.95) when accounting for antibiotic side effects (PrePostAbx and PreAbxOnly QALY=0.91). In 70.2% of 10,000 iterations, NoAbx was dominant, with lower costs and higher QALYs. At a willingness-to-pay threshold of $100,000, NMBs were similar (PrePostAbx=$62,158; PreAbxOnly=$62,176; NoAbx=$66,216). Utilizing a baseline infection rate of 3.23%, NoAbx was preferred. However, if infection rates exceed 5%, NoAbx would no longer be cost-effective. CONCLUSIONS: For infection rates <5%, omitting antibiotics for SNM is preferred, offering the lowest costs and the highest quality of life. Although abandoning all antibiotics is potentially controversial, PreAbxOnly is cost-effective compared with PrePostAbx due to lower costs, reduced side effects, and reduced antimicrobial resistance.