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Antibiotic Awareness Week 2023

U.S. Antibiotic Awareness Week is November 18th-24th. During this observance, SIDP is highlighting members who promote optimal antibiotic use and combat the threat of antibiotic resistance in impactful and innovative ways. This blog features Dr. Bethany A. Wattles, PharmD. 

Value of collecting health equity variables and opportunities to leverage electronic health record and claims data to evaluate health disparities and inequities 

Variations in antibiotic prescribing by patient age, geography, race/ethnicity, and other sociodemographic factors have been well-reported for over a decade.1–6 These findings have been described using a variety of data sources, most notably including electronic health record (EHR) data1,4,7,8 and healthcare claims data.6,9–11 A recent scoping review was performed to characterize inequities in antibiotic prescribing and use across healthcare settings in the US.12 Of the 61 studies included, none reported underlying drivers of inequities in antibiotic prescribing. In order to promote health equity in antimicrobial stewardship, we most move from describing variations in antibiotic utilization to understanding and reducing inequities.13

Antibiotic stewardship is designed to improve and measure the appropriate use of antibiotic agents; however, without careful consideration of health equity variables, these efforts are likely to fall short for our most vulnerable patient populations. EHR and claims data have been widely used to describe and measure progress in antibiotic use patterns. These data sources also include variables that may be indicators of inequities such as sex, race/ethnicity, insurance, and preferred language. Further, patient address can be used to determine rurality and neighborhood indices (e.g., Rural-Urban Continuum Codes,14 Rural-Urban Commuting Area Codes,15 Social Vulnerability Index,16 Area Deprivation Index,17 Child Opportunity Index18) to further identify social vulnerabilities. Antibiotic stewardship clinicians can and should incorporate health equity variables into antibiotic use tracking and reporting efforts, including evaluation of stewardship interventions. Additionally, clinicians and researchers with access to regional or national claims data, health information exchange networks, or all-payer claims databases have the potential to evaluate inequities on an even broader level.

Upon identifying any variations in antibiotic use by health equity variables, stewardship clinicians can partner with health equity colleagues to understand drivers of inequities. A number of research frameworks are available to conceptualize factors influencing health disparities,13,19 including a framework of factors contributing to inequities in antibiotic prescribing.12 Further, Cichon and colleagues recently published a review on inclusion, diversity, access and equity in antimicrobial stewardship which includes the following methods to reduce antimicrobial prescribing disparities: 1) Standardize equity monitoring tools; 2) Collect equity data on prescribing and provide prescriber feedback; 3) Develop guidelines to direct equitable access to new antimicrobials; and 4) Embrace health equity as part of the quality improvement mission.20 As noted in research frameworks, there are a variety of potential influences and outside variables reported within most healthcare data sources (e.g., access to care, cultural beliefs, patient-clinician interactions). However, data-driven assessment of antibiotic use with a health equity lens is an essential starting point that may lead to further exploration of inequities via quality improvement efforts, community-engagement, and/or mixed-methods research. 

Despite widespread, comprehensive hospital stewardship programs across the nation, the recent scoping review12 identified only 1 of 61 studies with documented inequities in antibiotic prescribing reported in an acute care setting.21 With minimal expansions to our existing structures of reporting antibiotic use, stewardship clinicians have the potential to lead the way in advocating and advancing the concept of pharmacoequity, a goal that ensures all individuals have access to the highest-quality medications required to manage their health needs.22

  1. Gerber JS, Prasad PA, Localio AR, Fiks AG, Grundmeier RW, Bell LM, et al. Racial differences in antibiotic prescribing by primary care pediatricians. Pediatrics 2013;131:677–84.
  2. Fleming-Dutra KE, Shapiro DJ, Hicks LA, Gerber JS, Hersh AL. Race, otitis media, and antibiotic selection. Pediatrics 2014;134:1059–66.
  3. oyal MK, Johnson TJ, Chamberlain JM, Casper TC, Simmons T, Alessandrini EA, et al. Racial and Ethnic Differences in Antibiotic Use for Viral Illness in Emergency Departments. Pediatrics 2017;140:.
  4. Seibert AM, Hersh AL, Patel PK, Matheu M, Stanfield V, Fino N, et al. Urgent-care antibiotic prescribing: An exploratory analysis to evaluate health inequities. Antimicrob Steward Healthc Epidemiol 2022;2:e184.
  5. Hicks LA, Bartoces MG, Roberts RM, Suda KJ, Hunkler RJ, Taylor TH Jr, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015;60:1308–16.
  6. Wattles BA, Vidwan NK, Feygin Y, Jawad KS, Creel LM, Smith MJ. Antibiotic prescribing to Kentucky Medicaid children, 2012-2017: Prescribing is higher in rural areas. J Rural Health 2022;38:427–32.
  7. Wattles BA, Jawad KS, Feygin YF, Stahl JD, Vidwan NK, Stevenson MD, et al. Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic. Antimicrob Steward Healthc Epidemiol 2022;2:e94.
  8. Wattles BA, Feygin Y, Jawad KS, Stevenson MD, Vidwan NK, Blatt DB, et al. Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children. J Pediatr 2023:113572.
  9. Wattles BA, Smith MJ, Feygin Y, Jawad KS, Bhadury S, Sun J, et al. Recurrent antibiotic use in Kentucky children with 6 years of continuous Medicaid enrollment. J Pediatric Infect Dis Soc 2022;11:492–7.
  10. Kilgore JT, Lanata MM, Willis JM, McCarthy MJ, Becker JB, Evans JE, et al. Utilization of West Virginia pediatric Medicaid claims data to guide outpatient antimicrobial stewardship interventions. J Pediatric Infect Dis Soc 2022;11:172–6.
  11. Dantuluri KL, Bruce J, Edwards KM, Banerjee R, Griffith H, Howard LM, et al. Rurality of residence and inappropriate antibiotic use for acute respiratory infections among young Tennessee children. Open Forum Infect Dis 2021;8:ofaa587.
  12. Kim C, Kabbani S, Dube WC, Neuhauser M, Tsay S, Hersh A, et al. Health equity and antibiotic prescribing in the United States: a systematic scoping review. Open Forum Infect Dis 2023.
  13. Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health 2006;96:2113–21.
  14. Rural-Urban Continuum Codes. Economic Research Service. n.d. URL:
  15. Rural-Urban Communting Area Codes. Economic Research Service, US Department of Agriculture. n.d. URL:
  16. Social Vulnerability Index. CDC-ATSDR. n.d. URL:
  17. Neighborhood Atlas. Center for Health Disparities Research. n.d. URL:
  18. Child Opportunity Index. Diversity Data Kids. n.d. URL:
  19. National Institute on Minority Health and Health Disparities (NIMHD). NIMHD Minority Health and Health Disparities Research Framework. 2022. URL: (Accessed May 31, 2023).
  20. Cichon CJ, Green EC, Hilker E, Marcelin JR. Inclusion, diversity, access, and equity in antimicrobial stewardship: where we are and where we are headed. Curr Opin Infect Dis 2023;36:281–7.
  21. Wurcel AG, Essien UR, Ortiz C, Fu X, Mancini C, Zhang Y, et al. Variation by race in antibiotics prescribed for hospitalized patients with skin and soft tissue infections. JAMA Netw Open 2021;4:e2140798.
  22. Essien UR, Dusetzina SB, Gellad WF. A policy prescription for reducing health disparities-achieving pharmacoequity. JAMA 2021;326:1793–4.

Bethany A. Wattles, PharmD

Bethany A. Wattles, PharmD, MHA – Assistant Professor of Pediatrics, Child and Adolescent Health Research Design and Support Unit (CAHRDS), University of Louisville School of Medicine

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