Identifying Disparities in Outpatient Antibiotic Prescribing for Urinary Tract Infections
Authors: Courtney Ashleah , Clemente Adriana Sarmiento , Dahl Steven , McMinn Caleb , Vance Mary Kathryn , Maples Holly 
Published: January 2025

Abstract

Corresponding Author: Ashleah Courtney, 1 Children’s Way, Slot 512-11, Little Rock, AR 72202, 501-912-0585, acourtney@uams.edu
Alternate Corresponding Author: Holly Maples, 1 Children’s Way, Slot 208, 501-658-6796, maplesholly@uams.edu
No conflicts of interest

Background
Disparities in antibiotic prescribing, especially within pediatrics, have been well-described. Most studies examine antibiotic prescribing as a whole or focus on acute upper respiratory tract infections, such as acute otitis media, sinusitis, and pharyngitis. However, literature describing disparities in prescribing for urinary tract infections (UTIs) remains limited. At our institution, antimicrobial stewardship interventions thus far have focused on optimizing empiric antibiotic selection for UTIs in the emergency department and inpatient settings, but no interventions have been made in the outpatient setting. The purpose of this study was to identify patient characteristics associated with cephalexin prescribing, which is recommended as empiric first-line at our institution, and with prescription durations &lt;10 days with hopes of identifying disparities and future targets for antimicrobial stewardship interventions.

Methods
This was a retrospective cross-sectional analysis of outpatient oral antibiotic prescriptions for UTIs from seven clinics at Arkansas Children’s Hospital between November 2017 and February 2024. Doxycycline and metronidazole prescriptions were excluded as these were presumed to be associated with sexually transmitted infections. For each outpatient prescription, patient data collected included gender, age, race, ethnicity, and insurance. Prescriptions were grouped by cephalexin and all other antibiotics, as well as ≥10 days and &lt;10 days. A multinomial logistic regression model was created utilizing age range, race/ethnicity, and insurance. Gender was not included in the model due to limited number of UTI prescriptions in male patients (n=101). All data analyses were conducted in SPSS (Version 27).

Results
A total of 1392 prescriptions were included in this analysis. Cephalexin accounted for 50.4% (n=701) of the prescriptions, while all other prescriptions accounted for 49.6% (n=691). Only 36.8% of the prescriptions were &lt;10 days in duration, while the remaining 63.2% (n=880) were ≥10 days. When comparing cephalexin to all other antibiotic prescriptions, patients in the 12-21 age range were 0.42 less likely to receive cephalexin when compared to the 6-11 age range (p=&lt;0.001). Black and patients with race defined as other were 1.51 and 1.93 more likely than white patients to receive cephalexin than other prescriptions, respectively (p=0.005 and p=&lt;0.001). Those with government insurance were 1.64 more likely to receive cephalexin when compared to self-pay (p=&lt;0.001). When comparing durations &lt;10 days and ≥10 days, those patients in the 12-21 age range were 3.53 more likely to receive durations &lt;10 days (p=&lt;0.001).

Conclusions
Cephalexin prescribing for UTIs was more likely in younger patients, in black patients and those with race defined as other, and in those with government insurance. Shorter antibiotic durations for UTIs were associated with older patients. Limitations of this study include inability to assess appropriateness of empiric antibiotic selection, especially in those patients with multiple recurrent UTIs, as well as relatively small sample size. Future work could include expansion of this data to include our community site in Northwest Arkansas as well as an analysis of state-wide data via the Medicaid claims database.