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Most women receive inappropriate treatment for uncomplicated UTIs

Nearly half of women with uncomplicated urinary tract infections (UTIs) received the wrong antibiotics and almost three-quarters received prescriptions for longer than necessary, with inappropriately long treatment durations more common in rural areas, according to a US study of private insurance claims data.

"Inappropriate antibiotic prescriptions for uncomplicated urinary tract infections are prevalent and come with serious patient- and society-level consequences," said Dr Anne Mobley Butler, lead author of the study and assistant professor of medicine and surgery at Washington University School of Medicine in St Louis. "Our study findings underscore the need for antimicrobial stewardship interventions to improve outpatient antibiotic prescribing, particularly in rural settings."

Researchers studied insurance claims data for 670,400 women ages 18 to 44 who received an outpatient diagnosis of uncomplicated urinary tract infection between April 2011 and June 2015. They identified filled antibiotic prescriptions, assessed adherence to clinical guidelines, and compared rural and urban antibiotic usage patterns.

Rural patients were more likely to receive a prescription for an inappropriately long duration of therapy than urban patients, according to an analysis of geographic data from the claims database. While use of both inappropriate antibiotic choice and inappropriate duration of prescriptions declined slightly over the study period, inappropriate prescriptions continued to be common with 47% of prescriptions written for antibiotics outside guideline recommendations and 76% for an inappropriate duration, nearly all of which were longer than recommended.

"Accumulating evidence suggests that patients have better outcomes when we change prescribing from broad-acting to narrow-spectrum antibiotics and from longer to shorter durations," Butler said. "Promoting optimal antimicrobial use benefits the patient and society by preventing avoidable adverse events, microbiome disruption, and antibiotic-resistant infections."

Clinicians should periodically review clinical practice guidelines, even for common conditions, to determine the ideal antibiotic and treatment duration, Butler said. Auditing outpatient antibiotic prescribing patterns and periodic feedback to healthcare provider helps remind clinicians of the best practices and improves antibiotic prescribing.

However, additional research should be performed to understand and ultimately improve rural outpatient antibiotic prescribing practices for urinary tract infections and other common conditions.

Possible explanations for study findings, which are consistent with other research reflecting rural disparities, may be that rural providers may not be as aware of current antibiotic treatment guidelines. In addition, urban providers who treat rural patients may prescribe longer antibiotic durations because of distance-to-care barriers in case symptoms persist. Further research is needed to identify reasons for higher inappropriate prescribing in rural settings.


Study details
Rural–urban differences in antibiotic prescribing for uncomplicated urinary tract infection

Abbye W Clark, Michael J Durkin, Margaret A Olsen, Matthew Keller, Yinjiao Ma, Caroline A O’Neil, Anne M Butle

Published in Infection Control & Hospital Epidemiology on 24 February 2021

To examine rural–urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI).
Observational cohort study.
Using the IBM MarketScan Commercial Database (2010–2015), we identified US commercially insured women aged 18–44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural–urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural–urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural–urban status.
Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10–1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural–urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty.
Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.


[link url=""]Society for Healthcare Epidemiology of America material[/link]


[link url=""]Infection Control & Hospital Epidemiology study (Open access)[/link]

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