Disparities in Antibiotic Use & Access to Care in Older Women with Recurrent UTI

Objectives: Antibiotic overuse for urinary tract infection (UTI) drives antibiotic resistance. Lack of access to providers and labs could lead to unnecessary antibiotics (antibiotics prescribed in the absence of UTI symptoms or tests confirming UTI). This study aims to determine if socioeconomic factors are associated with antibiotic overuse and access to care in older women with recurrent UTI (rUTI).

Methods: We performed a retrospective chart review of female patients >65 years old with an ICD-10 diagnosis of rUTI. Women were included if they had received at least two antibiotic prescriptions in six months or three in one year. Symptom and antibiotic data were extracted for the three UTI episodes closest to the time of diagnosis of rUTI. An unnecessary antibiotic was defined as an antibiotic prescribed in the absence of urinary symptoms, negative urine culture, or negative pyuria. Empiric antibiotics prescribed with or without urine testing was also recorded. Area Deprivation Index (ADI) was used as a measure of socioeconomic conditions, and tertiles of ADI within the sample were used to group patients into high ADI (less advantaged) versus low ADI (more advantaged). We examined the association of ADI with patient variables (age, body mass index, race, ethnicity, comorbidities, and insurance type), antibiotic use, and access metrics (telephone calls, caregiver involvement) using Wilcoxon rank sum test, t-test, Chi-square, and Fisher’s exact test where appropriate (Table 1).

Results: In 100 older patients with rUTI, 32% were classified as less advantaged and 68% as more advantaged. Less advantaged patients were significantly more likely to be non-White (41% vs 6%, p< 0.001), speak a language other than English (6% vs 0%, p=0.037), and have comorbid urinary incontinence (47% vs 25%, p=0.029) and overactive bladder (50% vs 29%, p=0.045). Less advantaged patients were significantly more likely to have caregiver involvement (44% vs 24%, p=0.04) and less likely to send telephone messages (38% vs 60%, p=0.03) and electronic messages (19% vs 25%, p=0.488). The rate of unnecessary antibiotics was higher for less advantaged patients (66% vs 53%, p=0.232) and the rates of empiric antibiotics with concurrent urinary testing (69% vs 81%, p=0.179) and empiric antibiotics without concurrent testing (25% vs 32%, p=0.454) were lower for less advantaged patients but not statistically significant. There was no significant difference in time from symptom onset to testing or antibiotic prescription, or in rates of specialist care for rUTI between groups.

Conclusions: Less advantaged patients with rUTI are more likely to have coexisting conditions whose symptoms overlap with that of a UTI episode, which may affect antibiotic prescriptions for UTI symptoms. Less advantaged patients were less likely to contact their providers through telephone and electronic messages during an episode of UTI, indicating potential barriers with access to care.