Does Where People Live Affect Antibiotic Prescribing Practices?

A new study presented at last month’s ID Week, showed that antibiotics were prescribed more frequently in the urban outpatient setting compared to rural settings.

“Overall, antibiotic prescriptions were more frequently prescribed within outpatient encounters at urban sites (175.4 per 1,000 patient encounters) compared to rural sites (145.4 per 1,000 patient encounters, p < 0.001),” the investigators wrote.

In terms of the reasoning for these findings, Kaylee Caniff, PharmD, BCIDP, assistant professor, Ferris State University, says there are no finite conclusions they found in their study, but she has some potential theories.

“Patient access and patient distance to care could influence who is seeking care,” Caniff said. “And then also resources available to providers. So at urban settings, it may be more likely that providers have access to stewardship resources and diagnostic resources that are influencing their prescribing practices that may be unavailable in rural settings.”

An important distinction in the prescribing was that it was done in concordance with guidelines the authors point out.

Study Parameters

They examined antibiotic prescribing patterns in Michigan's urban and rural outpatient settings to inform antimicrobial stewardship targets. This was part of the Collaboration to Harmonize Antimicrobial Registry Measure (CHARM) database, which was utilized to analyze antibiotic prescriptions and associated outpatient encounters from participating Michigan facilities from January 2020 until December 2024.

The healthcare facilities were categorized as rural or urban by ZIP code according to the US Census Bureau definition. Data collected included patient demographics, prescriber type, ICD-10 code, and antibiotic regimen, according to the investigators. And the appropriateness of antibiotic and dosing were assessed for concordance with diagnosis-specific guidelines as appropriate.

Another of the interesting findings from the study showed the difference in the types of clinicians in each of the settings.

“We found that there is a higher frequency of mid-level providers prescribing antibiotics at rural sites. And we don't really know where that gap is,” Caniff said. “So is that impacting our potential guideline concordance? Is there some gaps in education and training? Or is this more a reflection of practice structure and the patient volume that advanced practice providers are maybe seeing compared to urban settings, which could be seen more likely by physicians and resident physicians?

Although unknown, Caniff says they would like to continue to pursue this line of study to understand the findings better.

“What we're going to do next is really delve into these questions further to determine what is really influencing prescribing practice practices in urban and rural settings, and what are some confounders that might be at play here, for example, telemedicine,” she said. “It could be that there is much more telemedicine occurring in rural sites compared to urban sites. And telemedicine doesn't provide the prescriber with things like diagnostics or the physical exam that could potentially be playing a role in prescribing.”

Reference

Caniff K, et al. Examining Outpatient Antibiotic Prescribing Trends and Guideline Concordance Across Urban and Rural Healthcare Facilities. Presented at IDWeek 2025. October 19-22, 2025. Atlanta, GA.