In the United States, in rural and urban settings, most women with private health insurance are receiving inadequate treatment for their urinary tract infections (UTI), according to a new study.
Of the 670,450 women included in this survey, all with a diagnosis of uncomplicated UTI between the ages of 18 and 44, almost half received the wrong antibiotics and more than three quarters received the drug for a long time. (A UTI is declared ‘uncomplicated’ when the patient has no abnormalities or illnesses that could predispose him to more frequent infections.)
The results are largely consistent from place to place, although patients in more rural settings are more likely to be prescribed antibiotics for longer.
Throughout the study, from 2011 to 2015, there was only a slight improvement in prescriptions for appropriate antibiotics based on current clinical guidelines.
“Inadequate antibiotic prescriptions for uncomplicated urinary tract infections are prevalent and have serious consequences for the patient and society,” said epidemiologist Anne Mobley Butler of the University of Washington School of Medicine, St. Louis.
“The results of our study underscore the need for antimicrobial management interventions to improve outpatient antibiotic prescription, particularly in rural settings.”
The research was funded in part by several pharmaceutical companies, including Sanofi Pasteur, Pfizer and Merck. The results have been peer-reviewed and are largely in line 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 is not just a problem in the United States. Worldwide, urinary tract infections are one of the most common infections that lead to emergency care. In the UK, it is the second most common reason for prescribing antibiotics.
Taking the wrong antibiotic not only has worse results for the individual patient, but 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, it is estimated that 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 the number of deaths related to antibiotic-resistant urinary tract infections is difficult to establish due to a lack of research and monitoring, but some studies suggest that in US hospitals alone, there may be about 13,000 lives lost each year. And some people suffer from recurrent and resistant infections for years on end, with little or no relief.
In light of these emerging concerns, in 2010 the Society for Infectious Diseases of America (IDSA) and the European Society for Microbiology and Infectious Diseases updated their clinical practice guidelines. Based on the results of several studies, they now recommend several first-line antibiotic agents and durations to better treat UTIs, while minimizing the risk of antibiotic resistance.
This advice, however, is clearly not reaching doctors and health professionals. Many still prescribe antibiotics not recommended for inappropriate periods.
Finding out where the most inappropriate prescriptions are happening can help us target the areas where we need to improve adherence to antibiotic guidelines. In the United States, rural areas experience numerous health disparities compared to more urban areas, and yet this is the first large-scale study to assess how this impacts the treatment of UTI.
The authors are unsure as to why longer antibiotic treatments for urinary tract infections are especially prevalent in rural areas, but suggest that it may have to do with access to care and physician awareness. In rural areas, women may receive longer prescriptions to prevent future travel if treatment fails.
Studies also show that late-career doctors are more prevalent in rural areas and are more likely to prescribe antibiotics for longer, possibly because they have not heard of updated guidelines.
“The accumulation of evidence suggests that patients do better when we switch from broad-spectrum to narrow-spectrum and longer-term to shorter-term antibiotics,” explains Butler.
“Promoting optimal use of antimicrobials benefits the patient and society by preventing preventable adverse events, disrupting the microbiome and antibiotic-resistant infections.”
When up to 60 percent of women may suffer from a urinary tract infection at some point in their lives, it is clearly vital that treatment guidelines are best applied, especially as antibiotic resistance increases.
This particular study was based only on commercially insured individuals, which means that those who are uninsured or receive public insurance were not considered. Rural areas were also loosely defined, including small towns, as well as ‘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 doctors 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 made to reduce the inadequate prescription of antibiotics for uncomplicated UTI,” concludes the new article.
“Given the large number of inappropriate prescriptions annually in the United States, as well as the negative consequences for the patient and society of unnecessary exposure to antibiotics, antimicrobial management interventions are necessary to improve outpatient prescription of UTI antibiotics, particularly in rural environments. “
The study was published in Infection Control and Hospital Epidemiology.