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.
Abstract
Background
Identification of inappropriate antibiotic prescribing patterns is critical for designing antimicrobial stewardship programs. We sought to examine whether the risk of receipt of ...an inappropriate outpatient antibiotic prescription varied by rural-urban status among women with an uncomplicated urinary tract infection (UTI).
Methods
Using the IBM MarketScan Commercial Database, we identified U.S. women 18–44 years diagnosed with a new uncomplicated UTI and prescribed an oral antibiotic with activity against common uropathogens from April 2011 through June 2015. We classified first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin) as appropriate, non-first-line agents (fluoroquinolones and β-lactams) as inappropriate, and antibiotic duration as appropriate when the days’ supply was consistent with Infectious Diseases Society of America 2011 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.
Results
Of 670,450 women with uncomplicated UTI, 46.7% of antibiotic prescriptions were written for inappropriate agents and 76.1% for inappropriate durations (Figures 1 and 2). Use of inappropriate agents or durations did not change appreciably over the study period (2011–2013 vs. 2014–2015). Of 507,737 prescriptions with inappropriate duration, 501,496 (98.8%) were written for a days’ supply longer than recommended. Compared to urban women, rural women had similar risk of receipt of an inappropriate agent (adjusted risk ratio 0.99, 95% CI, 0.98–1.00) but were more likely to receive a prescription for an inappropriate duration (adjusted risk ratio 1.10, 95% CI, 1.09–1.11).
Figure 1. Distribution of antibiotic agent by rural-urban status
Figure 2. Distribution of the antibiotic prescription days’ supply by antibiotic agent and rural-urban status
Conclusion
Regardless of rural-urban status, the majority of antibiotic prescriptions for uncomplicated UTI were written for inappropriate agents and durations. Rural women were more likely to receive prescriptions with inappropriately long durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and reduce unnecessary exposure to antibiotics, particularly in rural settings.
Disclosures
Margaret A. Olsen, PhD, MPH, Merck (Grant/Research Support)Pfizer (Consultant, Grant/Research Support)
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