Antibiotic Prescribing Patterns and Guideline Concordance for Uncomplicated Urinary Tract Infections Among Adult Women in the US Military Health System

The most commonly diagnosed outpatient infection in the United States are urinary tract infections (UTIs). In 2011, increasing rate of antimicrobial resistance led the Infectious Diseases Society of America (IDSA) to update their international clinical practice guidelines for the treatment of acute uncomplicated cystitis in premenopausal women. As first-line therapy for optimal treatment of uncomplicated cystitis, the IDSA recommends nitrofurantoin, fosfomycin, trometamol, trimethoprimsulfamethoxazole, and pivmecillinam. Several studies have reported substantial discrepancies between clinical practice guidelines (guideline concordance) and antibiotic prescribing practices in different specialties. Numerous studies found that obstetricians and gynecologists are more likely to prescribe a first-line antibiotic compared with other clinicians in other specialties. Treatment patterns in the Military Health System (MHS) have not been studied. The Military Health System provides health care to 9.6 million beneficiaries and their families in 2 distinct settings: direct care through more than 350 military health facilities and via the US private sector care through civilian fee-for-service facilities. Comparing direct care and private sector care is a unique aspect of the MHS. There is no current specific requirement that hospitals have a specific outpatient or UTI protocol. The primary aim of this retrospective cross-sectional study was to assess the IDSA guideline-concordance rate among adult women with uncomplicated UTIs in the MHS treated with antibiotics. A secondary aim was to evaluate differences in IDSA guideline concordance rates between different clinician specialties. Health care claims data were obtained from the USMHS Data Repository, which contains comprehensive health care encounter and claims data for all military beneficiaries and their families. Approximately 50% of MHS beneficiaries are women, composing one of the largest cohorts of women in the United States under a single health care system. The beneficiary population of approximately 50% of women is considered to be demographically representative of the US population from 18 to 64 years. The patient population included 46,793 US women diagnosed with an uncomplicated UTI between October 1, 2017, and September 30, 2019. Excluded patients were women older than 50 years, those with International Classification of Diseases, Tenth Revision codes for the following conditions: current pregnancy, history of diabetes or of pyelonephritis, or any organ transplant, human immunodeficiency virus, or immunosuppression, or renal insufficiency or urinary tract abnormalities; and history of urologic procedures. The only antibiotics analyzed were received within 1 day after the diagnosis. As first-line therapy for an uncomplicated UTI, the IDSA recommends the following antibiotics: nitrofurantoin, trimethoprimsulfamethoxazole, fosfomycin, and pivmecillinam. The Infectious Diseases Society of America guideline concordance was defined as use of one of these antibiotic prescriptions. The IDSA guideline-concordance rates among women with uncomplicated UTIs were calculated as the number of cases receiving first-line guideline antibiotic therapy divided by the total number of cases for uncomplicated UTI. Most patients were aged 18 to 34 years (67.3%; 31,475-46,793), of White race (38.2%; 17,859-46,793]), and most had 1 UTI during the study period (85.9%; 40,225/46,793]). Most women received IDSA guideline-concordant treatment (91.0%; 42,583/ 46,793) and received care in the direct care setting (56.8%; 26,580/46,793). In comparison with obstetrics and gynecology, IDSA guideline-concordant treatment was more likely in internal medicine (adjusted odds ratio [aOR], 2.87; 95% CI, 2.73-3.03), family medicine (aOR, 1.81; 95% CI, 1.76-1.87), surgery (aOR, 1.51; 95% CI, 1.36-1.67), and emergency medicine (aOR, 1.36; 95% CI, 1.32-1.39) and less likely in urology (aOR, 0.40; 95% CI, 0.38-0.43). Only 3.4% of UTI treatments were within a surgical specialty. Private sector care had lower rates of IDSA guideline concordance compared with direct care (aOR, 0.63; 95% confidence interval of 0.62-0.64). In contrast to other studies, IDSA concordance rates for uncomplicated cystitis were higher than what has been previously reported with substantial variation among different specialties. Urology and obstetrics and gynecology had lower IDSA concordance rates. These findings provide more evidence on current antibiotic prescribing practices for uncomplicated UTIs in adult women.