— Both uncalled-for drugs and prolonged treatment durations, large-scale review finds
by Charles Bankhead, Senior Editor, MedPage Today February 26, 2021

A majority of women with uncomplicated urinary tract infections (UTIs) received inappropriate antibiotics or continued treatment beyond the recommended duration, a review of almost 700,000 cases showed.

Overall, 46.7% of patients received prescriptions for inappropriate antibiotics and 76.1% had inappropriately long duration of treatment. The frequency of inappropriate antibiotic agents was similar between urban and rural patients, but women in rural areas were significantly more likely to continue antibiotic therapy beyond the recommended treatment duration.

“Given the large quantity of inappropriate prescriptions annually in the United States, as well as the negative patient- and society-level consequences of unnecessary exposure to antibiotics, antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing, particularly in rural settings,” Anne M. Butler, PhD, of Washington University in St. Louis, and co-authors wrote in their study online in Infection Control & Hospital Epidemiology.

“Existing recommendations for the promotion of outpatient antibiotic stewardship include establishing personal and policy commitment to change, reporting progress, and enhancing education around best practices. Future research is needed to effectively identify, disseminate, and implement guideline-concordant antibiotic prescribing in rural settings,” the team said.

The key takeaway from the study centers on antibiotic stewardship, not the apparent urban-rural practice variation, said Brian R. Stork, MD, of the University of Michigan School of Medicine and West Short Urology in Muskegon.

“Clinicians and patients need to do a better job of working together to follow evidence-based antibiotic prescribing practices,” Stork, a spokesperson for the American Urological Association, told MedPage Today. “Regardless of whether we’re urban physicians or rural physicians, we all have to think carefully about our prescribing patterns and being more antibiotic-stewardship conscious.”

Urban-rural practice variations are often more nuanced than portrayed in academic studies, he continued. In rural areas, primary care providers treat most UTIs. Patients might have to travel long distances to see a urology or infectious disease specialist, whereas such specialists are more available in urban areas.

In addition, rural providers may not have ready access to laboratory testing, including urinalysis, and different types of providers may follow different recommendations for treating UTIs.

Rural medicine also has inherent differences in the approach to clinical practice, as compared with medical practice in urban settings.

“My concern about the study is that people will look at it and think rural physicians aren’t doing a good job,” said Stork. “People need to realize that the practice of rural medicine is different. For example, if I had a patient with a urinary tract infection during corn harvest season, I would probably treat that patient with a longer course of antibiotics and keep that patient in the field, harvesting the crops, feeding the family, rather than err on the side of undertreating and really affecting the patient’s livelihood.”

The study had its genesis in the recognition that inappropriate antibiotic use is associated with increased risk of treatment failure, adverse events, and antibiotic resistance, as well as increased costs, Butler and co-authors noted. Uncomplicated UTIs in women account for about 10.5 million ambulatory visits a year in the U.S. and are one of the most common reasons for outpatient antibiotic use by otherwise healthy women.

The Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESMID) have recommended first-line antibiotic agents and durations for UTI. However, most prescriptions for UTIs are for nonrecommended antibiotics and treatment durations.

Several recent studies have documented urban-rural practice variations in respiratory tract and pediatric infections, but no large-scale studies had evaluated urban-rural variations in outpatient antibiotic prescribing for UTIs, Butler and co-authors noted.

For the study, they examined urban-rural differences in the risk of inappropriate antibiotic use by agent and duration for uncomplicated UTIs in women. Data for the study came from a health insurance and prescription database.

The investigators defined urban areas as those included in standard metropolitan statistical areas and rural areas as all others. Appropriate antibiotics and treatment durations were determined from the IDSA-ESMID recommendations.

The analysis included 670,450 women treated for uncomplicated UTI during 2010-2015. Urban areas accounted for 86.2% of the study population. Rural and urban patients had a median age of 30. Rural patients were more likely to reside in the South and Midwest, and their infections were more likely to be diagnosed by family physicians, pediatricians, or nonphysicians.

Consistent with previous studies, the data showed that almost half of the patients received inappropriate antibiotics, and three fourths continued treatment beyond the recommended duration. The frequency of inappropriate antibiotic prescriptions was similar between urban (46.9%) and rural (45.9%) patients and did not vary substantially from one drug or drug class to another.

The rate of inappropriate prescribing declined over the study period from 48.5% in mid-2011 to 43.7% by mid-2015. The rate decreased among urban (48.8% to 43.5%) and rural (46.6% to 44.8%) patients. By multivariable analysis, rural patients had a slightly lower likelihood of receiving inappropriate agents (RR 0.98, 95% CI 0.98-0.99) versus urban patients.

The frequency of inappropriate treatment duration also decreased, from 78.3% in mid-2011 to 73.4% in mid-2015. The rate of decline was greater among urban patients (77.1% to 72.0%) as compared with rural patients (85.1% to 83.2%). A multivariable analysis showed that rural patients were 10% more likely to be treated for an inappropriately prolonged duration (95% CI 1.10-1.10).