Clinical Context

Appropriate antibiotic prescribing as recommended by current guidelines is important for clinical and public health, as inappropriate antibiotic use is linked to increased risk for treatment failure, adverse events, antibiotic resistance, and healthcare costs. However, most antibiotic prescriptions for uncomplicated urinary tract infections (UTIs) are written for nonrecommended agents and durations and are therefore suboptimal.

The US Department of Health and Human Services prioritizes leveling of rural health disparities, but how these affect antibiotic treatment for UTIs has been previously undetermined.

Study Synopsis and Perspective

Women living in rural areas were significantly more likely than those in urban areas to receive inappropriate antibiotic prescriptions for UTIs, based on data from an observational cohort study of more than 600,000 women.

Uncomplicated UTIs are common among otherwise healthy women in the United States, and certain antibiotics are recommended as first-line therapy, write Abbye W. Clark, MD, from Washington University, St. Louis, and colleagues.

"However, most antibiotic prescriptions for uncomplicated UTIs are suboptimal because they are written for nonrecommended agents and durations," they note.

Addressing rural health disparities has become a focus in the United States, and previous studies of respiratory tract infections have shown differences in antibiotic prescribing based on geographic region; "however, no large-scale studies have evaluated rural-urban differences in inappropriate outpatient antibiotic prescribing for UTIs," they add.

In a study published in Infection Control & Hospital Epidemiology, the researchers identified 670,450 women aged 18-44 years who received oral antibiotics for uncomplicated UTIs between 2010 and 2015, using a commercial insurance database to determine diagnosis and antibiotic prescription information. Women were defined as urban if they lived in a metropolitan statistical area of at least 50,000 inhabitants (86.2%); all other women were defined as rural (13.8%). The median age was 30 years for both groups.

Overall, 46.7% of the women received prescriptions for inappropriate antibiotics and 76.1% received antibiotics for inappropriate durations.

Antibiotics and durations were defined as appropriate or inappropriate based on current clinical guidelines. "We classified first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole [TMP-SMX], and fosfomycin) as appropriate and non-first-line agents (fluoroquinolones and β-lactams) as inappropriate," the researchers write.

The regimens classified as appropriate duration were "nitrofurantoin 5-day regimen, TMP-SMX (including TMP monotherapy) 3-day regimen, fosfomycin 1-day regimen, fluoroquinolones 3-day regimen, and β-lactams 3-7-day regimens. All other regimens were classified as inappropriate duration," they note.

More Rural Women Receive Long-Duration Antibiotics

In a multivariate analysis, similar percentages of antibiotics for rural and urban women consisted of inappropriate agents (45.9% vs 46.9%, respectively) including use of fluoroquinolones (41.0% vs 41.7%) and β-lactams (4.8% vs 5.0%).

However, across all antibiotics, women in rural areas were more likely than women in urban areas to receive prescriptions for inappropriate durations (83.9% vs 74.9%; adjusted risk ratio, 1.10).

The percentage of women who received inappropriate antibiotic agents was not significantly different according to geographic region of the country.

From 2011 to 2015, the quarterly proportion of women overall who received inappropriate agents and antibiotics for inappropriate durations decreased slightly (from 48.5% to 43.7% and from 78.3% to 73.4%, respectively), the researchers note.

The study findings were limited by several factors including the potentially lenient definition of antibiotic duration, a study population that disproportionately oversampled from the South and undersampled from the West, use of ZIP codes to determine rural vs urban status, lack of data on race and income, and lack of access to urine culture results, the researchers note.

However, "our study identified rural-urban differences in antibiotic prescribing, including an actionable disparity in the duration of antibiotics that disproportionately affects women who live in rural locations," they write.

"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," they conclude.

Data Support Need for Education and Stewardship

"This manuscript provides valuable information to all women's health providers regarding the importance of antibiotic stewardship," David M. Jaspan, DO, and Natasha Abdullah, MD, from the Einstein Medical Center, Philadelphia, said in an interview. Whether urban or rural, more than 45% of the patients received inappropriate non-first-line treatment and 76% of the prescriptions were for an inappropriate duration (98.8% for longer durations than recommended, 1.2% for shorter durations), they emphasized.

"The potential negative impact of antibiotic resistance, coupled with the potential for increased side effects, should prompt providers to ensure that when treating uncomplicated UTIs in women, that the choice of treatment and the duration of treatment is tailored to the patient's needs," Dr. Jaspan and Dr. Abdullah said.

To improve antibiotic prescribing, especially at the local and regional level, "We encourage providers to familiarize themselves with local information as it pertains to known resistance when prescribing empiric treatment regimens for uncomplicated UTIs," they said.

The study was supported by the National Center for Advancing Translational Sciences at the National Institutes of Health. Lead author Dr Clark, as well as Dr Jaspan and Dr Abdullah, had no financial conflicts to disclose.

Infect Control Hosp Epidemiol. Published online February 24, 2021.^[1]

Clinical Implications

• Inappropriate antibiotic use for uncomplicated UTI is very common, and rural women are more likely to receive inappropriately long durations.
• Patient- and provider-level factors and local patterns of antibiotic resistance may explain rural-urban differences in use of appropriate antibiotic durations.
• Implications for the Health Care Team: The findings mandate antimicrobial stewardship interventions and interprofessional collaboration to improve outpatient UTI antibiotic prescribing.

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