Antimicrobial resistance in uropathogens and appropriateness of empirical treatment: a population-based surveillance study in Indonesia

Objectives

Urinary tract infections (UTIs) are a common reason for empirical treatment with broad-spectrum antibiotics worldwide. However, population-based antimicrobial resistance (AMR) prevalence data to inform empirical treatment choice are lacking in many regions, because of limited surveillance capacity. We aimed to assess the prevalence of AMR to commonly used antimicrobial drugs in Escherichia coli and Klebsiella pneumoniae isolated from patients with community- or healthcare-associated UTIs on two islands of Indonesia.

Methods

We performed a cross-sectional patient-based study in public and private hospitals and clinics between April 2014 and May 2015. We screened patients for symptoms of UTIs and through urine dipstick analysis. Urine culture and susceptibility testing were supported by telemicrobiology and interactive virtual laboratory rounds. Surveillance data were entered in forms on mobile phones.

Results

Of 3424 eligible patients, 3380 (98.7%) were included in the final analysis, and yielded 840 positive cultures and antimicrobial susceptibility data for 657 E. coli and K. pneumoniae isolates. Fosfomycin was the single oral treatment option with resistance prevalence <20% in both E. coli and K. pneumoniae in community settings. Tigecycline and fosfomycin were the only options for treatment of catheter-associated UTIs with resistance prevalence <20%, whilst the prevalence of resistance to meropenem was 21.3% in K. pneumoniae .

Conclusions

Patient-based surveillance of AMR in E. coli and K. pneumoniae causing UTIs indicates that resistance to the commonly available empirical treatment options is high in Indonesia. Smart AMR surveillance strategies are needed to inform policy makers and to guide interventions.

[Fosfomycin, an old antibiotic with new possibilities]

- Fosfomycin is a broad-spectrum antibiotic agent used orally for uncomplicated cystitis. The intravenous form of administration has recently been authorised in the Netherlands.- Thanks to its broad spectrum and extensive tissue penetration, fosfomycin offers possibilities for the treatment of infections in different organs.- Infections with multidrug-resistant bacteria pose a significant threat to public health. Many of these multidrug-resistant bacteria are sensitive to fosfomycin, which means fosfomycin may be an option for the treatment of infections with multidrug-resistant bacteria. - There is a lack of knowledge about the pharmacological properties of fosfomycin to establish a good dosing schedule. Knowledge is also lacking about the safety of fosfomycin and the extent of its tolerability in the treatment of different infections. - More research is needed before fosfomycin can be used in the battle against multidrug-resistant bacteria.

Fosfomycin for UTIs

Fosfomycin trometamol is a broad spectrum antibiotic recently marketed in the UK for the treatment of acute uncomplicated lower urinary tract infections (UTIs) in adults^1,2 and in adult and adolescent females.³ It is also indicated for prophylaxis in diagnostic and surgical transurethral procedures.^1-3 Fosfomycin was discovered in 1969 and the reference drug was first marketed as Monuril in France in 1986.^3,4 Although Monuril had UK marketing authorisation, it was never distributed in the UK. However, national guidance included the option of using unlicensed imported fosfomycin.^3,5,6 Branded and generic versions of fosfomycin are now available in the UK,^1-3,7 and here we review the evidence for their use in the treatment of UTIs.

Recurrent complicated urinary tract infection due to rare pathogen Sphingomonas paucimobilis: contamination or real deal?

Sphingomonas paucimobilis is an aerobic, oxidase-positive, yellow-pigmented, non-fermentative, Gram-negative opportunistic pathogen that rarely causes infections in humans. It is commonly found in nosocomial environments and, despite its low clinical virulence, it can be responsible for several different infections especially among patients with underlying disease. Here we describe a clinical case of a 46-year-old male paraplegic patient with a history of neurogenic bladder due to insulin-dependent diabetes mellitus and renal failure who was admitted to the urology clinic of a university hospital in Kirsehir, Turkey, with the complaints of urinary tract infection (UTI) including fever, chills, dysuria, abdominal and back pain. The urine culture was positive for Sphingomonas paucimobilis identified by the Vitek-2 system and the patient was successfully treated with oral co-trimoxazole 800/160 mg twice a day for ten days associated to cefixime and fosfomycin. A literature review of UTIs associated to Sphingomonas paucimobilis is reported as well.

[Complex treatment of chronic cystitis in women]

PURPOSE

Evaluation of the efficacy and safety of Phytolysin in complex treatment of female patients with chronic cystitis.

MATERIALS AND METHODS

40 women with chronic cystitis were examined from January 2016 to March 2016. Depending on the treatment, all patients were divided into two groups of 20 people. Main group of patients was treated with Fosfomycin (Monural) and Phytolysin. Control group of patients received monotherapy with fosfomycin.

RESULTS

The results were assessed at 1 and 2 months after initiation of therapy. Rapid normalization of the status and laboratory parameters, improvement of dynamics of the endoscopic view was observed in main group of patients.

CONCLUSION

The complex of biologically active substances contained in Phytolysin has antimicrobial, anti-inflammatory, antispasmodic, and immunomodulatory effects, promotes the normalization of urodynamics of lower urinary tract, reduces the risk of relapse of chronic recurrent cystitis. Thus, Phytolysin can be recommended as a component of complex therapy of exacerbations of chronic cystitis, as well as a drug for prevention of the disease in disease-free periods.

Whole-Genome Sequencing to Evaluate the Resistance Landscape Following Antimalarial Treatment Failure With Fosmidomycin-Clindamycin

Novel antimalarial therapies are needed in the face of emerging resistance to artemisinin combination therapies. A previous study found a high cure rate in Mozambican children with uncomplicated Plasmodium falciparum malaria 7 days after combination treatment with fosmidomycin-clindamycin. However, 28-day cure rates were low (45.9%), owing to parasite recrudescence. We sought to identify any genetic changes underlying parasite recrudescence. To this end, we used a selective whole-genome amplification method to amplify parasite genomes from blood spot DNA samples. Parasite genomes from pretreatment and postrecrudescence samples were subjected to whole-genome sequencing to identify nucleotide variants. Our data did not support the existence of a genetic change responsible for recrudescence following fosmidomycin-clindamycin treatment. Additionally, we found that previously described resistance alleles for these drugs do not represent biomarkers of recrudescence. Future studies should continue to optimize fosmidomycin combinations for use as antimalarial therapies.

TRIMETHOPRIM-SULFAMETHOXAZOLE RESISTANCE AND FOSFOMYCIN SUSCEPTIBILITY RATES IN UNCOMPLICATED URINARY TRACT INFECTIONS: TIME TO CHANGE THE ANTIMICROBIAL PREFERENCES

Urinary tract infections (UTIs) are among the most common bacterial infections in adult population. They are prevalent in all age groups both in women and men. Also, UTIs are the most frequent indication for empirical antibiotic treatment in emergency department. The aim of this study was to determine the antibiotic resistance rates in the treatment of uncomplicated UTIs. Adult patients admitted to emergency department with uncomplicated UTIs were included in this cross-sectional study. Mid-stream urine samples were obtained under sterile conditions and cultured quantitatively. After 24 hours, the samples showing 10(5) colony forming unit per milliliter (CFU/mL) were tested for antibiotic susceptibility. Resistance to fosfomycin-trometamol (FT), amoxicillin-clavulanic acid (AC), ciprofloxacin (CIP), trimethoprim-sulfamethoxazole (TMP-SMX) and cefpodoxime (CEF) was tested by Kirby-Bauer disc diffusion system. Escherichia (E.) coli accounted for the vast majority (93.4%) of the organisms isolated in the study. Among the E. coli positive patients, resistance to TMP-SMX was the most common antibiotic resistance. The E. coli species detected in our study group were least resistant to FT (2.4%). The resistance rates, especially to CEF, AC and CIP, were significantly higher in patients over 50 years of age. In conclusion, in the treatment of uncomplicated UTIs, TMP-SMX should be excluded from empirical treatment, while fosfomycin could be a viable option in all age groups.

A role for fosfomycin treatment in children for prevention of haemolytic-uraemic syndrome accompanying Shiga toxin-producing Escherichia coli infection

The role of antimicrobial therapy for Shiga toxin-producing Escherichia coli (STEC) infection has not been clearly defined. A prospective study identified antibiotic use as a significant risk factor for subsequent development of haemolytic-uraemic syndrome (HUS). However, early treatment with fosfomycin, a bacteriostatic antibiotic, resulted in a significantly decreased risk of HUS. The aim of this study was to evaluate a role of fosfomycin therapy in the development of HUS in children who contracted STEC infection. The study included 118 children who contracted a STEC infection between 1997 and 2013. A pre-defined questionnaire was utilised to collect patient information regarding age, sex, presenting symptoms (fever, abdominal pain, diarrhoea and bloody stool), results of stool culture examination, initial results of white blood cell counts and C-reactive protein (CRP), use of antibiotics, the timing of introduction of antibiotics, and complications including HUS. Of the 118 patients, 64 were diagnosed with HUS and the remaining 54 did not develop HUS. Multivariate analysis showed that three independent factors (age, initial values of CRP and use of fosfomycin) were significantly associated with the occurrence of HUS; of particular note, the adjusted odds ratio for use of fosfomycin was 0.15 (95% confidence interval 0.05-0.45). Use of fosfomycin within the first 5 days of illness may decrease the development of STEC-related HUS in children.

[Fosfomycin for urogenital tract infections: Advances in studies]

Fosfomycin (FOM) is an antibiotic with a small relative molecular weight (138.1) and a long half-life, and has a unique chemical structure and antibacterial mechanisms. It exerts a bactericidal activity by inhibiting the early synthesis of bacterial cell walls. It is also a broad-spectrum antibiotic with a good drug tolerance and compliance and a low pressure to bacterial resistance, but no cross-resistance with other antibiotics. Recent studies show the effectiveness of FOM in the treatment of acute uncomplicated urinary tract infections and urogenital tract infections as well, such as prostatitis and epididymitis. This review focuses on the clinical application of FOM in the treatment of infectious diseases of the urogenital tract.

Fosfomycin versus meropenem in bacteraemic urinary tract infections caused by extended-spectrum β-lactamase-producing Escherichia coli (FOREST): study protocol for an investigator-driven randomised controlled trial

INTRODUCTION

Finding therapeutic alternatives to carbapenems in infections caused by extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) is imperative. Although fosfomycin was discovered more than 40 years ago, it was not investigated in accordance with current standards and so is not used in clinical practice except in desperate situations. It is one of the so-called neglected antibiotics of high potential interest for the future.

METHODS AND ANALYSIS

The main objective of this project is to demonstrate the clinical non-inferiority of intravenous fosfomycin with regard to meropenem for treating bacteraemic urinary tract infections (UTI) caused by ESBL-EC. This is a 'real practice' multicentre, open-label, phase III randomised controlled trial, designed to compare the clinical and microbiological efficacy, and safety of intravenous fosfomycin (4 g/6 h) and meropenem (1 g/8 h) as targeted therapy for this infection; a change to oral therapy is permitted after 5 days in both arms, in accordance with predetermined options. The study design follows the latest recommendations for designing trials investigating new options for multidrug-resistant bacteria. Secondary objectives include the study of fosfomycin concentrations in plasma and the impact of both drugs on intestinal colonisation by multidrug-resistant Gram-negative bacilli.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Andalusian Coordinating Institutional Review Board (IRB) for Biomedical Research (Referral Ethics Committee), which obtained approval from the local ethics committees at all participating sites in Spain (22 sites). Data will be presented at international conferences and published in peer-reviewed journals.

DISCUSSION

This project is proposed as an initial step in the investigation of an orphan antimicrobial of low cost with high potential as a therapeutic alternative in common infections such as UTI in selected patients. These results may have a major impact on the use of antibiotics and the development of new projects with this drug, whether as monotherapy or combination therapy.

TRIAL REGISTRATION NUMBER

NCT02142751. EudraCT no: 2013-002922-21. Protocol V.1.1 dated 14 March 2014.

Daptomycin plus fosfomycin versus daptomycin monotherapy in treating MRSA: protocol of a multicentre, randomised, phase III trial

INTRODUCTION

Despite the availability of new antibiotics such as daptomycin, methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia continues to be associated with high clinical failure rates. Combination therapy has been proposed as an alternative to improve outcomes but there is a lack of clinical studies. The study aims to demonstrate that combination of daptomycin plus fosfomycin achieves higher clinical success rates in the treatment of MRSA bacteraemia than daptomycin alone.

METHODS AND ANALYSIS

A multicentre open-label, randomised phase III study. Adult patients hospitalised with MRSA bacteraemia will be randomly assigned (1:1) to group 1: daptomycin 10 mg/kg/24 h intravenous; or group 2: daptomycin 10 mg/kg/24 h intravenous plus fosfomycin 2 gr/6 g intravenous. The main outcome will be treatment response at week 6 after stopping therapy (test-of-cure (TOC) visit). This is a composite variable with two values: Treatment success: resolution of clinical signs and symptoms (clinical success) and negative blood cultures (microbiological success) at the TOC visit. Treatment failure: if any of the following conditions apply: (1) lack of clinical improvement at 72 h or more after starting therapy; (2) persistent bacteraemia (positive blood cultures on day 7); (3) therapy is discontinued early due to adverse effects or for some other reason based on clinical judgement; (4) relapse of MRSA bacteraemia before the TOC visit; (5) death for any reason before the TOC visit. Assuming a 60% cure rate with daptomycin and a 20% difference in cure rates between the two groups, 103 patients will be needed for each group (α:0.05, ß: 0.2). Statistical analysis will be based on intention to treat, as well as per protocol and safety analysis.

ETHICS AND DISSEMINATION

The protocol was approved by the Spanish Medicines and Healthcare Products Regulatory Agency (AEMPS). The sponsor commits itself to publishing the data in first quartile peer-review journals within 12 months of the completion of the study.

TRIAL REGISTRATION NUMBER

NCT01898338.

[Fosfomycin--its significance for treatment of diseases due to multidrug-resistant bacteria]

Fosfomycin is a bactericidal phosphonic acid derivative, which engages by inhibiting pyruvyltransferase at an early stage in the peptidoglycan synthesis. It shows a broad spectrum of activity that includes many multidrug-resistant gram-negative and gram-positive bacteria. Fosfomycin is active against most strains of Pseudomonas aeruginosa and several multidrug-resistant Enterobacteriaceae, e.g., Escherichia coli strains expressing extended spectrum beta-lactamases (ESBL) and Klebsiella pneumoniae strains with decreased susceptibilities to carbapenems. Most methicillin-resistant Staphylococcus aureus (MRSA) strains as well as enterococci with and without vancomycin resistance are also sensitive to fosfomycin. During the last decade, a variety of studies showed that fosfomycin is not only suitable for treating uncomplicated urinary tract diseases, but also for the treatment of many other diseases caused by bacterial pathogens with and without multidrug resistance. However, large controlled studies demonstrating the efficacy of the drug to treat diseases caused by multidrug-resistant bacteria are still missing. Considering the low number of antibacterial agents with good activity against multidrug-resistant bacteria, fosfomycin should be evaluated as an important antibiotic for the treatment of several severe illnesses due to these pathogens. However, because some multidrug-resistant bacteria are also resistant to fosfomycin, this agent should only be applied if the pathogen is sensitive to this drug. In addition, because rapid development of resistance cannot be excluded if fosfomycin will be applied alone, this drug should only be given in combination with other effective drugs for the treatment of serious systemic diseases due to multidrug-resistant bacterial pathogens.

[Some aspects of the treatment of persistent lower urinary tract infections in women]

Chronic recurrent cystitis in women is a major socio-economic problem. In the pathogenesis of recurrent infection, violations of mechanisms of innate immunity of the bladder mucosa, and the persistence of microorganisms play an important role. The study included 43 women (mean age 39.5±1.2 years) with persistent lower urinary tract infection. The mean duration of disease was 6.5±1.8 years. Depending on the therapy, patients were divided into two groups. Patients in Group 1 (n = 20) have received only fosfomycin trimetamol 3 g every 10 days for 3 months, patients in group 2 (n = 23) have received the drug viferon® (rectal suppositories) 1 million IU per rectum 2 times per day at intervals of 12 hours for 20 days in addition to antibiotic therapy at the same dosage. The inclusion of immunomodulator in the complex therapy of persistent lower urinary tract infections contributed to the reduction of relapse rate by 1.5 times, and reduction of the number of patients with relapses by 4 times.

High activity of Fosfomycin and Rifampin against methicillin-resistant staphylococcus aureus biofilm in vitro and in an experimental foreign-body infection model

Increasing antimicrobial resistance reduces treatment options for implant-associated infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We evaluated the activity of fosfomycin alone and in combination with vancomycin, daptomycin, rifampin, and tigecycline against MRSA (ATCC 43300) in a foreign-body (implantable cage) infection model. The MICs of the individual agents were as follows: fosfomycin, 1 μg/ml; daptomycin, 0.125 μg/ml; vancomycin, 1 μg/ml; rifampin, 0.04 μg/ml; and tigecycline, 0.125 μg/ml. Microcalorimetry showed synergistic activity of fosfomycin and rifampin at subinhibitory concentrations against planktonic and biofilm MRSA. In time-kill curves, fosfomycin exhibited time-dependent activity against MRSA with a reduction of 2.5 log10 CFU/ml at 128 × the MIC. In the animal model, planktonic bacteria in cage fluid were reduced by <1 log10 CFU/ml with fosfomycin and tigecycline, 1.7 log10 with daptomycin, 2.2 log10 with fosfomycin-tigecycline and fosfomycin-vancomycin, 3.8 log10 with fosfomycin-daptomycin, and >6.0 log10 with daptomycin-rifampin and fosfomycin-rifampin. Daptomycin-rifampin cured 67% of cage-associated infections and fosfomycin-rifampin cured 83%, whereas all single drugs (fosfomycin, daptomycin, and tigecycline) and rifampin-free fosfomycin combinations showed no cure of MRSA cage-associated infections. No emergence of fosfomycin resistance was observed in animals; however, a 4-fold increase in fosfomycin MIC (from 2 to 16 μg/ml) occurred in the fosfomycin-vancomycin group. In summary, the highest eradication of MRSA cage-associated infections was achieved with fosfomycin in combination with rifampin (83%). Fosfomycin may be used in combination with rifampin against MRSA implant-associated infections, but it cannot replace rifampin as an antibiofilm agent.

[Antibacterial therapy for acute cystitis in the age of growing pathogen resistance]

Acute cystitis refers to uncomplicated lower urinary tract infections, with the recurrence rates after the first cystitis episode being 50%. The basic treatment for the above diseases is antibacterial therapy, whose efficiency depends entirely on the right choice of a drug during initial empiric therapy. The paper gives the European Association of Urology guidelines and Russian guidelines, which are based on the results of both international (ARESC) and Russian (DARMIS) studies of urinary tract infection pathogens and their susceptibility to antibacterial drugs. Phosphomycin trometamol and furasidine potassium are the drugs of choice to treat acute cystitis in Russia now.

Fosfomycin for the treatment of prostate infection

A 69-year-old man with diabetes mellitus was diagnosed with a prostate abscess. Although the pathogen was fluoroquinolone-resistant Escherichia coli and the oral administration of trimethoprim-sulfamethoxazole was initiated, the infection recurred after three months. The antibiotic therapy was subsequently changed to intravenous fosfomycin, and the patient's condition promptly improved. Four weeks of fosfomycin therapy was successfully continued without any adverse events. In the era of antibiotic resistance, revival of forgotten drugs is an important issue for clinicians. Fosfomycin can be applied as an alternative option for prostate infections, considering the remaining susceptibility of multidrug-resistant pathogens to fosfomycin and the good pharmacokinetics of this drug in prostatic tissue.

[Efficiency of uroprofit in women with chronic cystitis]

From September 2011 to December 2011, 40 women aged 20-68 years with chronic cystitis were examined. All patients were divided into two groups of 20 people depending on the type of treatment. Control group of patients received monotherapy with fosfomycin (monural), main group of patients--complex therapy with fosfomycin and biologically active supplement uroprofit. The results were evaluated at 1 and 2 months after initiation of therapy. Before and after treatment, all patients were examined, including standard laboratory tests, uroflowmetry, cystometry, and cystoscopy. It was shown that patients in main group have a rapid normalization of clinical manifestations and laboratory parameters, improvement of dynamics of the endoscopic picture. Thus, uroprofit has antibacterial, anti-inflammatory action, contributes to the normalization of urodynamics of the lower urinary tract, reduces the risk of relapses of chronic cystitis and can be recommended as a component of the treatment of acute exacerbations of chronic cystitis, as well as a drug for the prevention of disease in the disease-free interval.

Pyelonephritis in pregnancy. How adequate is empirical treatment?

OBJECTIVE

To ascertain the adequacy of empirical antimicrobial treatment in pregnant women with acute pyelonephritis.

MATERIAL AND METHODS

We have conducted a retrospective observational study of women admitted to the hospital with acute pyelonephritis between May 2004 and April 2011. Patients were included if the results of urine cultures and susceptibility testing to antibiotics were available. Epidemiological, clinical, therapeutical and outcome variables were collected from chart review. We considered inappropriate empirical antimicrobial treatment (IEAT) as the occurrence of microorganism that were not effectively treated at the time when the causative microorganism and its antibiotic susceptibility were known.

RESULTS

Fifty women with appropriate microbiological data from a total of 93 cases of acute pyelonephritis were included in the study. The women's mean age was 26.4 years, and 58% were nulliparous. Pyelonephritis was developed in the 2nd and 3rd trimester in 88% of cases. Previous urinary tract infections were recorded in 34%. Escherichia coli was the most frequent microorganism (70%). The proportion of patients who received IEAT was 10%. Amoxicillin-clavulanate and cephalosporines were the most predominant antibiotics used, with a proportion of IEAT of 10.3% and 5.9%, respectively.

CONCLUSIONS

Pregnant women with pyelonephritis received IEAT in a small but significant number of cases. Amoxicillin-clavulante and cephalosporines were adequate in most cases. More studies are needed to define the clinical impact of IEAT on prognosis.

[Revival of selected well-tried antibiotics. Special features of the antiinfective agents penicillin G, fosfomycin, aztreonam and colistin]

Although a worldwide increasing incidence of bacterial infections with panresistant pathogens may need innovative antiinfective agents, no breakthrough developments can be expected in the near future. As a consequence, well-tried antibiotics like aztreonam, fosfomycin and colistin, are experiencing a clinical revival, particularly if they are used in an improved manner. Even penicillin G with its narrow spectrum of antimicrobial activity remains an important considerable agent of first choice in special indications compared to broad spectrum antiinfectives.

A randomized control trial between fosfomycin and cefuroxime as the antibiotic prophylaxis in knee arthroplasty

BACKGROUND

Antibiotic prophylaxis is used in all patient underwent total knee arthroplasty to prevent post operative infection which produced poor outcome. The suitable drug should be safe and good efficacy.

OBJECTIVE

To study safety and efficacy of fosfomicin and cefuroxime as antibiotic prophylaxis for total knee arthroplasty.

MATERIAL AND METHOD

The control trial was performed to find out efficacy and safety of fosfomycin as an antibiotic prophylaxis comparing to cefuroxime. There were 112 patients, 14 male and 98 female, with their ages ranged between 57 and 86 years. They were randomly divided into two groups, the fosfomycin group, 56 patients and the cefuroxime group, 56 patients. All patients underwent elective knee arthroplasty by the authors. The scheduled antibiotics were given perioperatively for 24 hours and all patients were followed-up for 6 months. Physical examination, skin temperature of the operated knee, radiograph and blood tests were carried out in the patients to monitor post operative infection, renal and liver disturbance.

RESULTS

One patient in the cefuroxime group had local wound infection which responded well to local treatment and administration of antibiotics. No patients had post operative infection at the 6 months follow-up. No patients had any complication and none had renal and liver function disturbance during the follow-up.

CONCLUSION

Comparing to cefuroxime,fosfomycin is safe and effective for the use as antibiotic prophylaxis in knee arthroplasty.