Antimicrobial resistance of uropathogens in women with acute uncomplicated cystitis from primary care settings

Escherichia coli Resistance to Fluoroquinolones in Community-Acquired Uncomplicated Urinary Tract Infection in Women: a Systematic Review

Antibiotic resistance is a threat to public health, and uncomplicated urinary tract infections (uUTIs) are an example of this concern. This systematic review (International Prospective Register of Systematic Reviews [PROSPERO] ID: CRD42020156674) is the first to determine the prevalence of Escherichia coli resistance to fluoroquinolones in women with community-acquired uUTI. PubMed and Embase searches were conducted; 38 studies fulfilled eligibility criteria and were included in the systematic review. Within Europe, ciprofloxacin resistance in E. coli isolates varied between countries and increased in some from 2006 to 2008 and 2014 to 2016, specifically in the United Kingdom (0.5% to 15.3%), Germany (8.7% to 15.1%), and Spain (22.9% to 30.8%), although methodologies and settings were often not comparable. In Asia, there was a substantial increase in ciprofloxacin resistance during 2008 to 2014 from 25% to more than 40%. In North America, resistance to ciprofloxacin also increased between 2008 and 2017, from 4% to 12%. Data exploring different age groups did not show a consistent relationship with resistance, whereas two studies found that fluoroquinolone resistance was higher in postmenopausal women than premenopausal women. One study indicated a link between fluoroquinolone resistance and uUTI recurrence. These findings may have implications for the empirical treatment of uUTI with fluoroquinolones globally, but more data are needed to fully understand regional situations and impact patient management.

Prevalence of antibiotic susceptibility and resistance of Escherichia coli in acute uncomplicated cystitis in Korea: Systematic review and meta-analysis

BACKGROUND

The aim of this study is to determine the prevalence of antibiotic susceptibility and resistance of Escherichia coli Escherichia coli (E coli) in female uncomplicated cystitis in Korea using meta-analysis.

METHODS

A cross-search of the literature was performed with MEDLINE for all relevant data published before October 2015 and EMBASE from 1980 to 2015, the Cochrane Library, KoreaMed, RISS, KISS, and DBPia were also searched. Observational or prospective studies that reported the prevalence of antimicrobial susceptibility and resistance of E coli were selected for inclusion. No language or time restrictions were applied. We performed a meta-analysis using a random effects model to quantify the prevalence of antimicrobial susceptibility and resistance of E coli.

RESULTS

Ten studies were eligible for the meta-analysis, which together included a total of 2305 women with uncomplicated cystitis. The overall resistance rate to antibiotics was 0.28 (95% confidence interval [CI]: 0.25, 0.32). The pooled resistance rates were 0.08 (95% CI: 0.06, 0.11) for cephalosporin, 0.22 (95% CI: 0.18, 0.25) for fluoroquinolone (FQ), and 0.43 (95% CI: 0.35, 0.51) for trimethoprim/sulfamethoxazole (TMP/SMX). Regression analysis showed that resistance to FQ is increasing (P = 0.014) and resistance to TMP/SMX is decreasing (P = 0.043) by year. The generation of cephalosporin was not a significant moderator of differences in resistance rate.

CONCLUSION

The resistance rate of FQ in Korea is over 20% and is gradually increasing. Although the resistance rate of TMP/SMX is over 40%, its tendency is in decreasing state. Antibiotic strategies used for the treatment of uncomplicated cystitis in Korea have to be modified.

Quinolone resistance and ornithine decarboxylation activity in lactose-negative Escherichia coli

Quinolones and fluoroquinolones are widely used to treat uropathogenic Escherichia coli infections. Bacterial resistance to these antimicrobials primarily involves mutations in gyrA and parC genes. To date, no studies have examined the potential relationship between biochemical characteristics and quinolone resistance in uropathogenic E. coli strains. The present work analyzed the quinolone sensitivity and biochemical activities of fifty-eight lactose-negative uropathogenic E. coli strains. A high percentage of the isolates (48.3%) was found to be resistant to at least one of the tested quinolones, and DNA sequencing revealed quinolone resistant determining region gyrA and parC mutations in the multi-resistant isolates. Statistical analyses suggested that the lack of ornithine decarboxylase (ODC) activity is correlated with quinolone resistance. Despite the low number of isolates examined, this is the first study correlating these characteristics in lactose-negative E. coli isolates.

Pharmacological and Non-pharmacological Treatment Options for Depression and Depressive Symptoms in Hemodialysis Patients

Depression is a mental disorder with a high prevalence among patients with end stage renal disease (ESRD). It is reported that depression afflicts approximately 20-30% of this patient population, being associated, amongst other, with high mortality rate, low adherence to medication and low perceived quality of life. There is a variety of medications known to be effective for the treatment of depression but due to poor adherence to treatment as well as due to the high need for medications addressing other ESRD comorbidities, depression often remains untreated. According to the literature, depression is under-diagnosed and undertreated in the majority of the patients with chronic kidney disease. In the current review the main pharmacological and non-pharmacological approaches and research outcomes for the management of depressive symptoms in hemodialysis patients are discussed.

A clinical decision rule identifies risk factors associated with antimicrobial-resistant urinary pathogens in the emergency department: a retrospective validation study

BACKGROUND

Identifying patients at high risk for multidrug-resistant urinary tract infections (UTIs) is important for guiding empirical antimicrobial therapy. Clinical risk factors associated with antimicrobial-resistant urinary pathogens and the derivation of a simple clinical decision rule could help define health care-associated UTI.

OBJECTIVE

To derive a simple clinical decision rule to identify clinical risk factors associated with antimicrobial-resistant urinary pathogens.

METHODS

This was a retrospective case-control study of all emergency department (ED) patients from July 1, 2011, to July 1, 2012, who presented to the ED with UTI and a positive urine culture. Candidate risk factors were collected retrospectively from medical record review. We compared differences in patient characteristics stratified by the presence of an antimicrobial-resistant urinary pathogen.

RESULTS

A total of 360 patients with UTI had a positive, noncontaminated urine culture during the study period. About 6.7% of patients (n = 24) had a multidrug-resistant (MDR) urinary infection. Logistic regression modeling identified 3 clinical factors associated with the identification of a MDR pathogen: male sex, chronic hemodialysis, and nursing home residence. A scoring system was created to identify patients with MDR pathogens. Test characteristics were calculated using bootstrapping for internal validation, with a sensitivity of 74.7% (95% CI = 55.1%-91.3%) and specificity of 85.1% (95% CI = 77.8%-86.2%), positive likelihood ratio of 4.3, and a negative likelihood ratio of 0.3.

CONCLUSIONS

Clinical factors can be used to identify UTI patients at high risk of MDR urinary pathogens.

Prevalence and risk factors for trimethoprim-sulfamethoxazole-resistant Escherichia coli among women with acute uncomplicated urinary tract infection in a developing country

BACKGROUND

Prospective studies from developing countries that have investigated risk factors for trimethoprim-sulfamethoxazole (TMP-SMX)-resistant Escherichia coli in women with uncomplicated urinary tract infection (UTI) remain scarce.

METHODS

Women with acute uncomplicated UTI were enrolled prospectively. Urine was sent for antimicrobial susceptibility testing. Logistic regression analysis was used to identify risk factors for TMP-SMX resistance.

RESULTS

Of 405 participants, 229 (56.5%) had bacteriuria (mean age 31.9 ± 9.5 years). In the previous 12 months, 77 (33.6%) had experienced at least one UTI episode and 106 (46.3%) reported antimicrobial use. The most common uropathogens were E. coli (75.8%) and Staphylococcus saprophyticus (8.9%). For the 179 E. coli, resistance rates were highest for ampicillin (64.3%) and TMP-SMX (41.3%). Resistance to cephalosporins, nitrofurantoin, and fluoroquinolones was much lower compared with the hospital laboratory-based surveillance data. Risk factors for TMP-SMX resistance were UTI in the last 6 months (odds ratio 2.22; p = 0.04) and the number of UTI episodes in the past year (odds ratio 2.06; p = 0.004). The number of UTI episodes (adjusted odds ratio 2.21; p = 0.02) remained significant on multivariate analysis.

CONCLUSIONS

TMP-SMX resistance was high. Number of previous UTI episodes was associated with increased risk of resistance; prior antimicrobial use was not. Hospital antibiograms should be used with caution when treating uncomplicated UTI.

[Treatment practice of acute cystitis on the basis of national prescription data]

INTRODUCTION

Urinary tract infections are one of the common diseases in the primary health care.

AIM

To analyse patterns of ambulatory antibiotic use in acute cystitis.

METHOD

Antibiotic use data was based on national-level prescription turnovers. Patterns of antibiotic use were evaluated by prescribing quality indicators. The content of different national guidelines for treatment of acute cystitis and adherence to these guidelines were also evaluated.

RESULTS

For the treatment of acute cystitis quinolones were used predominantly. Norfloxacin (26%) and ciprofloxacin (19%) were prescribed most commonly. The use of internationally recommended agents such as sulphonamides, nitrofurans and fosfomycin shared 15%, 7% and 2%, respectively. The average adherence rate to national guidelines was 66% and certain weak points (e.g. controversial content) of the national guidelines were also identified.

CONCLUSIONS

Antibiotic use in acute cystitis seems to be suboptimal in Hungary. Considering actual local antibiotic resistance patterns, a new national guideline should be worked out for acute cystitis treatment.

Antimicrobial resistance among Enterobacteriaceae in South America: history, current dissemination status and associated socioeconomic factors

South America exhibits some of the higher rates of antimicrobial resistance in Enterobactericeae worldwide. This continent includes 12 independent countries with huge socioeconomic differences, where the ample access to antimicrobials, including counterfeit ones, coexists with ineffective health systems and sanitation problems, favoring the emergence and dissemination of resistant strains. This work presents a literature review concerning the evolution and current status of antimicrobial resistance threats found among Enterobacteriaceae in South America. Resistance to β-lactams, fluoroquinolones and aminoglycosides was emphasized along with description of key epidemiological studies that highlight the success of specific resistance determinants in different parts of the continent. In addition, a discussion regarding political and socioeconomic factors possibly related to the dissemination of antimicrobial resistant strains in clinical settings and at the community is presented. Finally, in order to assess the possible sources of resistant bacteria, we compile the current knowledge about the occurrence of antimicrobial resistance in isolates in South American' food, food-producing animals and off-hospitals environments. By addressing that intensive intercontinental commerce and tourism neutralizes the protective effect of geographic barriers, we provide arguments reinforcing that globally integrated efforts are needed to decelerate the emergence and dissemination of antimicrobial resistant strains.

Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injection

OBJECTIVE

To determine the effect of repeated intermittent use of topical antibiotics after intravitreal injections on conjunctival bacterial flora and antibiotic resistance.

DESIGN

Cross-sectional case-control study.

PARTICIPANTS AND CONTROLS

A total of 80 eyes of 40 patients were enrolled (40 study eyes, 40 control eyes). Patients were enrolled with unilateral exudative age-related macular degeneration who had received at least 3 prior intravitreal injections with use of postinjection topical antibiotics. Patients had received an average of 7 (range, 3-13) intravitreal injections before enrollment.

METHODS

At the time of enrollment, the inferior fornix of the treated eye was swept with a culture swab before use of povidone iodine; the inferior fornix of the fellow eye was also cultured and served as a control. The culture and sensitivity data from the study and control eyes were analyzed.

MAIN OUTCOME MEASURES

The rate of antibiotic resistance among the conjunctival bacterial flora of the study eyes and control eyes.

RESULTS

A total of 80 eyes of 40 patients were enrolled in the study; 29 patients used trimethoprim/polymyxin B drops, and 11 patients used fluoroquinolone drops after each injection. A total of 58 bacterial colonies were isolated from 50 eyes. There were no significant differences in bacterial species or culture positivity rates between study and control eyes. Coagulase-negative staphylococcus accounted for 41 of the 58 bacterial colonies (71%). There was a 63.6% resistance rate to fluoroquinolones among study eyes compared with 32.1% among control eyes (P < 0.05). In the subset of 11 study eyes using fluoroquinolone drops for 4 days after injection, there was an 87.5% resistance rate compared with 25.0% in matched control eyes (P = 0.04). There was no significant difference in trimethoprim resistance rates between study and control eyes: Four of 14 study eyes (28.6%) showed resistance compared with 5 of 18 control eyes (27.7%) (P = 1.0).

CONCLUSIONS

Use of fluoroquinolone drops after intravitreal injection leads to increased rates of resistance among conjunctival flora. Repeated use of topical fluoroquinolones after intravitreal injections may have a detrimental effect on eye health by breeding resistance in the bacterial flora.