Across the United States, in both rural and urban settings, most women with private health insurance are receiving inappropriate treatment for their urinary tract infections (UTIs), according to a new study.
Of the 670,450 women included in this research, all of whom had been diagnosed with uncomplicated UTIs between the ages of 18 and 44, nearly half received the wrong antibiotics and over three quarters were prescribed the medicine for too long. (A UTI is declared 'uncomplicated' when the patient has no abnormality or disease that could predispose them to more frequent infections.)
The results are largely consistent from location to location, although patients in more rural settings were more likely to be prescribed antibiotics for longer.
Over the course of the study, from 2011 to 2015, there was only a slight improvement in proper antibiotic prescriptions based on current clinical guidelines.
"Inappropriate antibiotic prescriptions for uncomplicated urinary tract infections are prevalent and come with serious patient- and society-level consequences," says epidemiologist Anne Mobley Butler from the Washington University School of Medicine, St. Louis.
"Our study findings underscore the need for antimicrobial stewardship interventions to improve outpatient antibiotic prescribing, particularly in rural settings."
The research was funded in part by several pharmaceutical companies, including Sanofi Pasteur, Pfizer, and Merck. The results were peer-reviewed and fall largely in line with the findings of previous studies, which suggest up to 60 percent of antibiotics prescribed in intensive care units are "unnecessary, inappropriate, or suboptimal".
Nor is this just a problem in the US. Around the world, UTIs are one of the most common infections leading to emergency room visits. In the United Kingdom, it's the second most common reason for prescribing antibiotics.
Not only does taking the wrong antibiotic have worse outcomes for the individual patient, longer prescriptions are not necessarily better and can cause bacteria to grow resistant, making recurrence more likely and future infections harder to treat.
Today, it's estimated one in three uncomplicated UTIs in women are resistant to the popular combined antibiotic drug Bactrim (sulfamethoxazole and trimethoprim), and one in five are resistant to five other common antibiotics.
An estimate of the number of deaths related to antibiotic-resistant UTIs is hard to establish due to a lack of research and monitoring, but some studies suggest that in US hospitals alone it could be around 13,000 lives lost per year. And some people suffer recurrent, resistant infections for years on end with little to no relief.
In light of these emerging concerns, in 2010 the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases updated their clinical practice guidelines. Based on results from various studies, they now recommend several first-line antibiotic agents and durations to best treat UTIs while minimizing the risk of antibiotic resistance.
That advice, however, is clearly not getting through to physicians and healthcare professionals. Many are still prescribing non-recommended antibiotics for improper durations.
Figuring out where the most inappropriate prescriptions are happening could help us target areas where we need to improve adherence to antibiotic guidelines. In the US, rural areas experience numerous health disparities compared to more urban areas, and yet this is the first large-scale study to evaluate how that impacts UTI treatment.
The authors are not sure why longer antibiotic treatments for UTIs are especially prevalent in rural areas, but suggest it could have to do with access to care and physician awareness. In rural areas, women may be given longer prescriptions to avoid future travel if that treatment fails.
Studies also show late-career physicians are more prevalent in rural locations and are more likely to prescribe antibiotics for longer, possibly because they have not heard of updated guidelines.
"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," explains Butler.
"Promoting optimal antimicrobial use benefits the patient and society by preventing avoidable adverse events, microbiome disruption, and antibiotic-resistant infections."
When up to 60 percent of women can suffer from a UTI at some point in their life, it's clearly vital that guidelines for treatment are better enforced, especially as antibiotic resistance increases.
This particular study was only based on commercially insured individuals, which means those who are uninsured or who receive public insurance were not considered. Rural areas were also loosely defined, including small towns as well as 'exurbs' on the edges of urban areas, and men, who also suffer from UTIs (albeit at a lower rate), were not included.
Future research should focus on filling these gaps, but in the meantime, the trend reinforces the idea that clinicians need to periodically review clinical practice guidelines, even for common conditions that they have been treating for years.
"In recent years, little effective progress has been achieved to reduce inappropriate antibiotic prescribing for uncomplicated UTI," the new paper concludes.
"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."
The study was published in Infection Control & Hospital Epidemiology.