According to a new study, most women with private health insurance in the United States, in both rural and urban areas, receive inappropriate treatment for their urinary tract infections (UTIs).
Of the 670,450 women enrolled in this study, all of whom had been diagnosed with uncomplicated UTIs between the ages of 18 and 44, nearly half were given the wrong antibiotics and more than three-quarters were overprescribed. (A urinary tract infection is declared ‘straightforward’ if the patient does not have an abnormality or disease that could predispose him to more frequent infections.)
The results are largely consistent from location to location, although patients in more rural settings would be more likely to be prescribed antibiotics.
Over the course of the study, from 2011 to 2015, there was only a slight improvement in appropriate antibiotic prescriptions based on current clinical guidelines.
“Incorrect antibiotic prescriptions for uncomplicated urinary tract infections are common and have serious consequences for the patient and society,” said epidemiologist Anne Mobley Butler of Washington University School of Medicine, St. Louis.
“The findings of our study underscore the need for antimicrobial stewardship interventions to improve antibiotic prescribing for outpatients, especially in rural areas.”
The research was funded in part by several pharmaceutical companies, including Sanofi Pasteur, Pfizer and Merck. The results were peer-reviewed and are largely consistent with the findings of previous studies, which suggest that up to 60 percent of antibiotics prescribed in intensive care units are “unnecessary, inappropriate, or suboptimal.”
This isn’t just a problem in the US, either. Around the world, UTIs are one of the most common infections leading to emergency room visits. In the UK, it is 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 become resistant, making recurrence more likely and future infections more difficult to treat.
Today, an estimated one in three uncomplicated UTIs in women is resistant to the popular combined antibiotic Bactrim (sulfamethoxazole and trimethoprim), and one in five is resistant to five other common antibiotics.
An estimate of deaths from antibiotic-resistant urinary tract infections is difficult to determine due to a lack of research and monitoring, but some studies suggest that approximately 13,000 lives per year can be lost in US hospitals alone. And some people suffer from recurring, resistant infections for years with little to no relief.
In light of these emerging concerns, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases updated their clinical practice guidelines in 2010. Based on the results of several studies, they now recommend different first-line antibiotics and duration to best treat UTIs while minimizing the risk of antibiotic resistance.
That advice is clearly not getting through to doctors and health care providers. Many still prescribe non-recommended antibiotics for an incorrect duration.
By figuring out where the most inappropriate prescriptions take place, we can focus on areas where we need to improve compliance with antibiotic guidelines. In the US, rural areas are experiencing numerous health inequalities compared to more urban areas, and yet this is the first large-scale study to evaluate how this affects UTI treatment.
The authors aren’t sure why longer antibiotic treatments for UTIs are especially prevalent in rural areas, but suggest this could be related to access to healthcare and physician education. In rural areas, women can be given longer prescriptions to avoid future travel if that treatment fails.
Studies also show that late career doctors are more likely to be in rural areas and prescribe antibiotics more often, possibly because they haven’t heard of updated guidelines.
“Accumulating evidence suggests that patients will have better outcomes if we switch prescribing from broad-acting to narrow-spectrum antibiotics and from longer to shorter durations,” explains Butler.
“Promoting optimal use of antimicrobials benefits patients and society by preventing avoidable side effects, microbiome disruption and antibiotic-resistant infections.”
When up to 60 percent of women may suffer from a UTI at some point in their lives, it is clearly vital that guidelines for treatment are better enforced, especially as antibiotic resistance increases.
This particular study was based on commercially insured persons only, meaning that those who are uninsured or who receive public insurance were not taken into account. Rural areas were also loosely demarcated, including small towns and ‘exurbs’ at 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 should periodically review clinical practice guidelines, even for common conditions they have been treating for years.
“In recent years, little effective progress has been made to reduce inappropriate antibiotic prescribing for uncomplicated UTI,” the new paper concludes.
“Given the vast amount of inappropriate prescriptions prescribed annually in the United States, as well as the negative patient and societal consequences of unnecessary antibiotic exposure, antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing, especially in rural environments. “
The study is published in Infection control and hospital epidemiology.