Fitch Ratings downgraded Owens & Minor Inc.'s long-term issuer default rating to B- from B+, while the outlook remains negative.

The Mechanicsville, Va.-based healthcare distributor's ratings reflect the uncertainty surrounding effectiveness of its strategy, its customer retention levels, revenue stability and the increasing reliance on debt for liquidity, according to the rating agency.

Fitch said the negative outlook reflects the company's significant increase in financial risk after the debt-backed $380 million acquisition of Byram Healthcare in 2017 and the $710 million acquisition of Avanos Medical Inc.'s surgical and infection prevention unit in 2018.

The rating agency expects Owens' leverage, or the investment strategy of using borrowed money, to remain at or above 6.0x through year-end 2019.

In addition, the outlook reflects expectations that Owens' will depend on debt as its main source of liquidity and that free cash flow will decline in 2019. Increased competition and accelerating pricing pressure in the company's core business also led to the outlook remaining negative.