Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses

Author:

Appaneal Haley J.123,Caffrey Aisling R.1234ORCID,Lopes Vrishali1,Dosa David125,LaPlante Kerry L.1235

Affiliation:

1. Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA

2. Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA

3. College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA

4. School of Public Health, Brown University, Providence, RI 02903, USA

5. Warren Alpert Medical School, Brown University, Providence, RI 02903, USA

Abstract

Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010–2020. Rural–urban status was determined using rural–urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010–2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02–1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18–1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.

Funder

A Health Services Research and Development (HSR&D) Career Development

Publisher

MDPI AG

Subject

Pharmacology (medical),Infectious Diseases,Microbiology (medical),General Pharmacology, Toxicology and Pharmaceutics,Biochemistry,Microbiology

Reference44 articles.

1. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009;Suda;J. Antimicrob. Chemother.,2013

2. Centers for Disease Control and Prevention (2022, October 26). Outpatient Antibiotic Prescriptions—United States, Available online: https://www.cdc.gov/antibiotic-use/pdfs/annual-report-2020-h.pdf.

3. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010–2011;Hersh;JAMA,2016

4. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–2009;Shapiro;J. Antimicrob. Chemother.,2014

5. Unnecessary Antibiotics for Acute Respiratory Tract Infections: Association With Care Setting and Patient Demographics;Barlam;Open Forum Infect. Dis.,2016

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