Worrisome high frequency of extended-spectrum beta-lactamase-producing Escherichia coli in community-acquired urinary tract infections: a case-control study

Prevalence and risk factors of extended-spectrum beta-lactamase producing E. coli causing urinary tract infections in Iceland during 2012-2021

PURPOSE

To investigate the association of potential risk factors for urinary tract infections (UTI) caused by E. coli producing ESBL vs. not producing ESBL in Iceland.

METHODS

Observational, case-control study including a cohort of 27,747 patients (22,800 females, 4,947 males; 1207 cases, 26,540 controls) of all ages with UTI caused by E. coli in 2012 to 2021 at the clinical microbiology laboratory covering about 2/3 of the Icelandic population. Clinical patient data was obtained from three national databases. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) as a measure of association between ESBL and exposure variables.

RESULTS

The proportion of samples with ESBL-producing E. coli increased during the study period, from 2.6% in 2012 to 7.6% in 2021 (p < 0.001). ESBL-positive strains were detected in 1207 individuals (4.4%), 905 females (4.0%) and 302 males (6.1%). The following risk factors were identified: Male sex, higher age, institution type (hospital, nursing home), hospital-associated UTI, Charlson comorbidity index score ≥ 3, history of cystitis or hospitalization in the past year, and prescriptions for certain antibiotics or proton pump inhibitors (PPIs: OR 1.51) in the past half year. The antibiotic associated with the highest risk was ciprofloxacin (OR 2.45).

CONCLUSION

The prevalence of UTIs caused by ESBL-producing E. coli has been increasing in Iceland. The strongest risk factors for ESBL production were previous antibiotic use, especially ciprofloxacin, and previous PPI use, both considered to be overprescribed. It is important to promote the prudent use of these drugs.

Risk factors for colonization with extended-spectrum cephalosporin-resistant and carbapenem-resistant Enterobacterales among hospitalized patients in Guatemala: An Antibiotic Resistance in Communities and Hospitals (ARCH) study

Objectives

The spread of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) has resulted in increased morbidity, mortality, and health care costs worldwide. To identify the factors associated with ESCrE and CRE colonization within hospitals, we enrolled hospitalized patients at a regional hospital located in Guatemala.

Methods

Stool samples were collected from randomly selected patients using a cross-sectional study design (March-September, 2021), and samples were tested for the presence of ESCrE and CRE. Hospital-based and household variables were examined for associations with ESCrE and CRE colonization using lasso regression models, clustered by ward (n = 21).

Results

A total of 641 patients were enrolled, of whom complete data sets were available for 593. Colonization with ESCrE (72.3%, n = 429/593) was negatively associated with carbapenem administration (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) and positively associated with ceftriaxone administration (OR 1.61, 95% CI 1.02-2.53), as was reported hospital admission within 30 days of the current hospitalization (OR 2.84, 95% CI 1.19-6.80). Colonization with CRE (34.6%, n = 205 of 593) was associated with carbapenem administration (OR 2.62, 95% CI 1.39-4.97), reported previous hospital admission within 30 days of current hospitalization (OR 2.58, 95% CI 1.17-5.72), hospitalization in wards with more patients (OR 1.05, 95% CI 1.02-1.08), hospitalization for ≥4 days (OR 3.07, 95% CI 1.72-5.46), and intubation (OR 2.51, 95% CI 1.13-5.59). No household-based variables were associated with ESCrE or CRE colonization in hospitalized patients.

Conclusion

The hospital-based risk factors identified in this study are similar to what has been reported for risk of health care-associated infections, consistent with colonization being driven by hospital settings rather than community factors. This also suggests that colonization with ESCrE and CRE could be a useful metric to evaluate the efficacy of infection and prevention control programs in clinics and hospitals.

Causative Microorganisms in Community-Acquired Urinary Tract Infections and Risk Factors for the Development of Infection with Extended-Spectrum β-Lactamase-Producing Species

Objective

This study aimed to determine the microorganisms grown in the urine cultures of patients followed up with the diagnosis of community-acquired urinary tract infection (CA-UTI), their antibiotic susceptibility, and the risk factors that cause extended-spectrum β-lactamase (ESBL) production in microorganisms.

Materials and Methods

Patients diagnosed with CA-UTI in the Yıldırım Beyazıt University City Hospital Infectious Diseases and Clinical Microbiology Clinic between February 2019 and February 2020 were prospectively analyzed. The microorganisms grown in the urine cultures and antibiotic susceptibility rates were examined. The clinical and demographic characteristics of the patients were compared in terms of the isolated agent producing ESBL.

Results

Escherichia coli (63.8%) and Klebsiella pneumoniae (22.0%) were the most common microorganisms detected in the urine cultures; the rate of those producing ESBL was 46.6%. Antibiotics with high resistance rates were ampicillin (74.2%), cefuroxime (49.6%), and ceftriaxone (49%). Male gender, complicating factors, immunosuppression, kidney transplantation and history of antibiotic use were determined as significant risk factors for ESBL production. Male gender, immunosuppression, and history of antibiotic use were also independent risk factors. ROC analysis of risk factors showed ESBL-producing bacteria were isolated at a high rate in patients having ≥3 risk factors.

Conclusion

The resistance rates in our study are quite high. Male gender, history of antibiotic use and immunosuppression status were found to be independent risk factors for ESBL positivity in patients with CA-UTI, and the more risk factors a patient has, the higher the risk of ESBL positivity.

Trends and predictors of antimicrobial resistance among patients with urinary tract infections at a tertiary hospital facility in Alexandria, Egypt: a retrospective record-based classification and regression tree analysis

BACKGROUND

The incidence of Antimicrobial Resistance (AMR) in uropathogens varies between countries and over time. We aim to study the patterns and potential predictors of AMR among patients with UTIs admitted to the Urology Department at Alexandria University Hospital.

METHODS

An observational retrospective record-based study was conducted on all patients admitted to the Urology department from October 2018 to October 2020. Data collected from patients' records included: demographic data, diagnosis on admission, history of chronic diseases, duration of hospital stay, insertion of a urinary catheter, duration of the catheter in days, history of the use of antibiotics in the previous three months, and history of urinary tract operations. If UTI was documented, we abstracted data about urine culture, use of antibiotics, results of urine cultures, type of organism isolated, and sensitivity to antibiotics. We conducted a multivariable logistic regression model. We performed Classification and Regression Tree Analysis (CART) for predicting risk factors associated with drug resistance among patients with UTI. Data were analyzed using SPSS statistical package, Version 28.0, and R software (2022).

RESULTS

This study encompassed 469 patients with UTIs. The most commonly isolated bacterium was Escherichia coli, followed by Klebsiella pneumoniae. Multidrug resistance (MDR) was found in 67.7% (149/220) of patients with hospital-acquired UTIs and in 49.4% (83/168) of patients with community-acquired UTIs. Risk factors independently associated with antimicrobial resistance according to logistic regression analysis were the use of antibiotics within three months (AOR = 5.2, 95% CI 2.19-12.31), hospital-acquired UTI (AOR = 5.7, 95% CI 3.06-10.76), diabetes mellitus (AOR = 3.8, 95% CI 1.24-11.84), age over 60 years (AOR = 2.9, 95% CI 1.27-6.72), and recurrent UTI (AOR = 2.6, 95% CI 1.08-6.20). Classification and regression tree (CART) analysis revealed that antibiotic use in the previous three months was the most significant predictor for developing drug resistance.

CONCLUSION

The study concluded a high level of antimicrobial resistance as well as significant MDR predictors among hospitalized patients with UTIs. It is vital to assess resistance patterns in our hospitals frequently to improve rational antibiotic treatment as well as to sustain antimicrobial stewardship programs and a rational strategy in the use of antibiotics. Empirical therapy for UTI treatment should be tailored to the potential pathogens' susceptibility to ensure optimal treatment. Strategic antibiotic use is essential to prevent further AMR increases. Further research should focus on suggesting new biological systems or designed drugs to combat the resistance of UTI pathogens.

Treating urinary tract infections in the era of antibiotic resistance

INTRODUCTION

Urinary tract infections (UTIs) are associated with 25-40% of antibiotics consumed in primary care and are, therefore, driving antibiotic resistance. The worldwide increase in antibiotic resistance especially in Escherichia coli has complicated the treatment choices for UTIs and absence of effective oral antibiotics may lead to increasing need for more effective treatments.

AREAS COVERED

In this review we focus on the importance of the correct diagnosis of UTI as based on proof of urinary pathogens in the urine and discuss diagnostic measures including microscopy, dipstick, and culture. Antibiotic treatment can often await diagnostic measures with pain relief such as ibuprofen. The risk of an uncomplicated UTI leading to pyelonephritis is low (1-2%) and presence of bacteria in the bladder leaves some time for the immune system to react. Three antibiotics are recommended as based on their activity, and low propensity to select for resistance, i.e. nitrofurantoin, fosfomycin, and pivmecillinam, and in general, 3-5 days of treatment will suffice.

EXPERT OPINION

Understanding the usual benign course of uUTIs can help reduce antibiotic treatment in many cases, e.g. starting treatment by pain relief and awaiting the course of infection without antibiotics. Better rapid tests in primary care are urgently needed to enforce such policies.

Factors Associated with Extended-spectrum β-lactamase-producing Enterobacteria Isolated from Respiratory Samples

Objective Although extended-spectrum β-lactamase (ESBL)-producing bacteria are a global threat, as they may cause respiratory infection, the factors associated with the isolation of these bacteria from sputum remain unclear. We therefore explored the factors related to ESBL-producing Klebsiella pneumoniae and Escherichia coli isolated from sputum samples. Patients and Methods This study included consecutive patients admitted to our department from 2010 to 2021 with K. pneumoniae or E. coli isolated from their sputum. The patients were categorized into ESBL-producing and non-ESBL-producing groups, and the factors associated with ESBL-producing bacteria isolation were assessed using a binomial logistic regression analysis. Results We included 82 patients, and ESBL-producing pathogens were isolated from 23 (28%). The usage rates of cephem [odds ratio (OR) 4.000, 95% confidence interval (CI) 1.402-11.409, p=0.010], quinolone (OR 2.961, 95% CI 1.097-7.996, p=0.032), and macrolide (OR 4.273, 95% CI 1.518-12.028, p=0.006) in the past year were significantly higher in the ESBL-producing group than in the non-ESBL-producing group. The multivariate analysis revealed that the applications of cephem (adjusted OR: 4.130, 95% CI: 1.233-13.830, p=0.021) and macrolide (adjusted OR: 6.365, 95% CI: 1.922-21.077, p=0.002) was independently associated with the isolation of ESBL-producing bacteria. Conclusions A history of cephem and macrolide use can be considered a risk factor for ESBL-producing bacteria isolation from sputum samples. Physicians need to consider these risk factors when determining antibiotics for the treatment of patients with respiratory infections.

Comprehensive assessment of holding urine as a behavioral risk factor for UTI in women and reasons for delayed voiding

BACKGROUND

Women of reproductive age group have greater predilection to urinary tract infections (UTI). Various risk factors increase the prevalence in women. Emergence of multidrug resistant uropathogens make clinical management of UTI challenging. Here we assess holding of urine as risk factor of UTI in women and reasons for delayed voiding. We also investigate the relationship between frequency of UTIs and overall behavioural features, menstrual hygiene and attitude of women towards their own health issues.

METHODS

A questionnaire based cross-sectional study was performed with 816 hostel residents with written consent. Self-reported data was statistically analysed using SPSS software. Urinalysis and urine culture were done for 50 women by random sampling to obtain the information on leading causative agents of UTI in the study population and their antimicrobial resistance profile.

RESULTS

The prevalence of UTI among the participants without risk factors was found to be 27.5 (95% CI: 24.4-30.7). Attitude of women towards their own personal health issues and use of public toilets showed a correlation with prevalence of infection. Delay in urination on habitual basis was found to be associated with UTI. Uropathogens isolated by random sampling were resistant to multiple drugs that are generally used to treat UTI.

CONCLUSIONS

Holding urine for long time had proven to be an important risk factor and amongst different reasons of holding urine, holding due to poor sanitary condition of public toilets was the most common. Higher frequency of self-reported UTIs is related to holding of urine, behavioural features and attitude of women.

From Pathophysiological Hypotheses to Case-Control Study Design: Resistance from Antibiotic Exposure in Community-Onset Infections

Antimicrobial resistance is a global public health concern, at least partly due to the misuse of antibiotics. The increasing prevalence of antibiotic-resistant infections in the community has shifted at-risk populations into the general population. Numerous case-control studies attempt to better understand the link between antibiotic use and antibiotic-resistant community-onset infections. We review the designs of such studies, focusing on community-onset bloodstream and urinary tract infections. We highlight their methodological heterogeneity in the key points related to the antibiotic exposure, the population and design. We show the impact of this heterogeneity on study results, through the example of extended-spectrum β-lactamases producing Enterobacteriaceae. Finally, we emphasize the need for the greater standardization of such studies and discuss how the definition of a pathophysiological hypothesis specific to the bacteria-resistance pair studied is an important prerequisite to clarify the design of future studies.

Carriage of ESBL-producing Enterobacterales in wastewater treatment plant workers and surrounding residents - the AWARE Study

To investigate whether wastewater treatment plant (WWTP) workers and residents living in close proximity to a WWTP have elevated carriage rates of ESBL-producing Enterobacterales, as compared to the general population. From 2018 to 2020, we carried out a cross-sectional study in Germany, the Netherlands, and Romania among WWTP workers (N = 344), nearby residents (living ≤ 300 m away from WWTPs; N = 431) and distant residents (living ≥ 1000 m away = reference group; N = 1165). We collected information on potential confounders via questionnaire. Culture of participants' stool samples was performed with ChromID®-ESBL agar plates and species identification with MALDI-TOF-MS. We used logistic regression to estimate the odds ratio (OR) for carrying ESBL-producing E. coli (ESBL-EC). Sensitivity analyses included stratification by country and interaction models using country as secondary exposure. Prevalence of ESBL-EC was 11% (workers), 29% (nearby residents), and 7% (distant residents), and higher in Romania (28%) than in Germany (7%) and the Netherlands (6%). Models stratified by country showed that within the Romanian population, WWTP workers are about twice as likely (aOR = 2.34, 95% CI: 1.22-4.50) and nearby residents about three times as likely (aOR = 3.17, 95% CI: 1.80-5.59) to be ESBL-EC carriers, when compared with distant residents. In stratified analyses by country, we found an increased risk for carriage of ESBL-EC in Romanian workers and nearby residents. This effect was higher for nearby residents than for workers, which suggests that, for nearby residents, factors other than the local WWTP could contribute to the increased carriage.

Antimicrobial Susceptibilities of Urinary Extended-spectrum β-lactamase Escherichia coli to Fosfomycin

Objectives

Escherichia coli (E. coli)-induced urinary tract infection (UTI) is a common infection associated with frequent use of antibiotics and the increase in global antibiotic resistances. We aimed to determine the susceptibility profile of extended-spectrum β-lactamase (ESBL) producing E. coli isolated from the urinary samples to fosfomycin and other antibiotics.

Methods

We retrospectively analyzed urine samples with ESBL-producing E. coli isolates obtained between January 2018 and December 2019 in the Microbiology Section, Salmaniya Medical Complex, Bahrain. We collected and analyzed all the E. coli urinary isolates' data and their antibiotic susceptibility patterns.

Results

The study included 3044 E. coli isolates with 50.6% obtained in 2018 and 49.4% in 2019; 38.1% (1161 isolates) were ESBL E. coli, and 0.7% (21 isolates) were carbapenem-resistant ^{Enterobacteriaceae} (CRE). There were 1161 (38.1%) isolates with ESBL-producing E. coli, with 37.3% isolated in 2018 and 39.0% isolated in 2019. The antibiotic susceptibility of ESBL-producing E. coli during the study period showed susceptibility to trimethoprim/sulfamethoxazole in 46.1% of isolates (50.2% in 2018 dropped to 41.9% in 2019), to ciprofloxacin in 49.0% of isolates (49.5% in 2018 dropped to 48.4% in 2019), to nitrofurantoin in 91.8% of isolates (94.3 in 2018 dropped to 89.3% in 2019), and to fosfomycin in 97.6% of isolates (98.8% in 2018 dropped to 96.3% in 2019).

Conclusions

ESBL-producing E. coli is an important cause of UTI in Bahrain. Fosfomycin is a very effective oral antimicrobial that retains high efficacy against ESBL-producing E. coli, which helps decrease the need for parenteral therapy and, consequently, hospitalization.

Antimicrobial Susceptibilities of Urinary Extended-spectrum β-lactamase Escherichia coli to Fosfomycin

OBJECTIVES

Escherichia coli (E. coli)-induced urinary tract infection (UTI) is a common infection associated with frequent use of antibiotics and the increase in global antibiotic resistances. We aimed to determine the susceptibility profile of extended-spectrum β-lactamase (ESBL) producing E. coli isolated from the urinary samples to fosfomycin and other antibiotics.

METHODS

We retrospectively analyzed urine samples with ESBL-producing E. coli isolates obtained between January 2018 and December 2019 in the Microbiology Section, Salmaniya Medical Complex, Bahrain. We collected and analyzed all the E. coli urinary isolates' data and their antibiotic susceptibility patterns.

RESULTS

The study included 3044 E. coli isolates with 50.6% obtained in 2018 and 49.4% in 2019; 38.1% (1161 isolates) were ESBL E. coli, and 0.7% (21 isolates) were carbapenem-resistant ^{Enterobacteriaceae} (CRE). There were 1161 (38.1%) isolates with ESBL-producing E. coli, with 37.3% isolated in 2018 and 39.0% isolated in 2019. The antibiotic susceptibility of ESBL-producing E. coli during the study period showed susceptibility to trimethoprim/sulfamethoxazole in 46.1% of isolates (50.2% in 2018 dropped to 41.9% in 2019), to ciprofloxacin in 49.0% of isolates (49.5% in 2018 dropped to 48.4% in 2019), to nitrofurantoin in 91.8% of isolates (94.3 in 2018 dropped to 89.3% in 2019), and to fosfomycin in 97.6% of isolates (98.8% in 2018 dropped to 96.3% in 2019).

CONCLUSIONS

ESBL-producing E. coli is an important cause of UTI in Bahrain. Fosfomycin is a very effective oral antimicrobial that retains high efficacy against ESBL-producing E. coli, which helps decrease the need for parenteral therapy and, consequently, hospitalization.

Local characteristics associated with higher prevalence of ESBL-producing Escherichia coli in community-acquired urinary tract infections: an observational, cross-sectional study

OBJECTIVES

The prevalence of ESBL-producing Escherichia coli (ESBL-E. coli) in community-acquired urinary tract infections (UTI) has been increasing worldwide since 2000, but with large geographical variations. The aim of this study was to determine whether the ESBL-E. coli rate in urine samples from individuals with community-acquired UTI was associated with the local socio-economic, environmental, agricultural and healthcare characteristics.

METHODS

This was a cross-sectional study in western France using data on antibiotic susceptibility of E. coli isolated from urine samples of individuals with community-acquired UTI analysed in non-hospital laboratories from 2015 to 2017. The ESBL-E. coli rate was calculated for each laboratory. Data on socio-economic characteristics, human antibiotic consumption, hospital bed density, animal farming density and percentage of agricultural land and surface water were retrieved at the municipality level and aggregated by study area. Their association with ESBL-E. coli prevalence was quantified using multivariate linear regression models with a backward selection.

RESULTS

From 358 291 E. coli isolates from urine samples tested in 92 laboratories, the mean ESBL-E. coli prevalence for the study period was 3.30%. In an adjusted model, the ESBL-E. coli rate was significantly (P < 0.05) and positively associated with the local percentage of people >65 years old, third-generation cephalosporin use (DDD/1000 inhabitants), number of hospital beds/km2, poultry density, pig density and percentage of agricultural land. Lower deprivation was associated with a higher ESBL-E. coli rate.

CONCLUSIONS

Several anthropogenic factors (primary care, hospitals and animal farming) are associated with the local ESBL-E. coli rate in community-acquired UTI. These results could contribute to improve risk management, including identification of at-risk patient groups.

Oral cephalosporin and β-lactamase inhibitor combinations for ESBL-producing Enterobacteriaceae urinary tract infections

ESBL-producing Enterobacteriaceae as uropathogens have given rise to a sizeable amount of global morbidity. Community and hospital surveillance studies continue to report increasing proportions of these organisms as causes of urinary tract infection (UTI). Due to limited treatment options and the presence of cross-resistance amongst oral antibiotics of different classes, patients often require IV therapy, thereby increasing healthcare costs and reducing the effectiveness of delivering healthcare. Oral cephalosporin antibiotics are well known for their ability to achieve high urinary concentrations, in addition to achieving clinical success for treatment of uncomplicated UTI with a drug-susceptible pathogen. Novel cephalosporin/β-lactamase inhibitor combinations have been developed and demonstrate good in vitro activity against ESBL-producing isolates. A pooled analysis of in vitro activity of existing oral cephalosporin/clavulanate combinations in ESBL-producing Enterobacteriaceae has shown MIC50s of 0.5-1, 0.125-1 and 0.25 mg/L for cefpodoxime, ceftibuten and cefixime, respectively. A novel cyclic boronic acid β-lactamase inhibitor, QPX7728, was able to produce MIC50 values of 0.5 and ≤0.06 mg/L when paired with cefpodoxime and ceftibuten, respectively. Other novel combinations, cefpodoxime/ETX0282 and ceftibuten/VNRX7145, have also demonstrated excellent activity against ESBL producers. Clinical trials are now awaited.

Community-Acquired, Extended-Spectrum β-Lactamase-Producing and Extensively Drug-Resistant Escherichia coli in a 28-Year-Old Pyelonephritis Patient Lacking Risk Factors

While Escherichia coli is a common cause of urinary tract infections and pyelonephritis, there are few documented cases of extended-spectrum β-lactamase (ESBL)-producing and extensively drug-resistant (XDR) isolates from the community resulting in infection requiring hospitalization, especially in individuals lacking risk factors. In the United States, exposure to ESBL-producing E. coli is typically nosocomial, whereas patients from developing countries often encounter ESBL-producing E. coli in the community through the consumption of contaminated food or water. Considering the rarity at which XDR E. coli isolates are encountered, there is also a scarcity of literature describing the successful treatment of ESBL-producing XDR E. coli. Here we present a case of an otherwise healthy 28-year-old female delicatessen worker infected with ESBL-producing and XDR E. coli without recent travel, antibiotic use, or healthcare contact, who required admission to the intensive care unit (ICU) with pyelonephritis and septic shock. Treatment with intravenous meropenem through a peripherally inserted central catheter (PICC) line at home was curative and follow up thereafter unremarkable. Given the patient’s lack of obvious exposure to and risk factors for an ESBL-producing XDR E. coli infection and the specific lack of risk factors for severe pyelonephritis requiring hospitalization, this case represents a unique addition to the literature and is of value to clinicians by describing successful treatment.

Impact of an antimicrobial stewardship and monitoring of infection control bundle in a surgical intensive care unit of a tertiary-care hospital in India

OBJECTIVES

Antimicrobial stewardship (AMS) in resource-limited settings lacks models that can be readily adapted to their settings. Here we discuss the impact of a combined strategy of AMS and monitoring of infection control practices in a tertiary-care centre of a developing country.

METHODS

This study was undertaken in the surgical unit of a tertiary-care hospital over an 8-month period. In the first 2 months (baseline phase), prospective audit and feedback alone was undertaken, while in the next 6 months (intervention phase) this was supplemented with strategies such as antimicrobial timeout, correction of doses and bundle approach for prevention of hospital-acquired infections.

RESULTS

A total of 337 patients were included (94 in the baseline phase and 243 in the intervention phase). There was a decrease in days of therapy per 1000 patient-days (1000PD) (1112.3 days vs. 1048.6 days), length of therapy per 1000PD (956 days vs. 936.3 days) and defined daily doses (DDD) per 1000PD for most antimicrobials. A decrease in double cover for Gram-negative infections (9.6% vs. 2.9%) but an increase in double anaerobic cover (4.2% vs. 7.4%) was observed. There was a decrease in the incidence of ventilator-associated pneumonia per 1000 ventilator-days in the intervention phase (46.4 vs. 35.4), whereas central line-associated bloodstream infections per 1000 central line-days remained the same (14.7 vs. 14.8).

CONCLUSION

This study shows that implementation of routine AMS activities with monitoring of infection control practices can help decrease overall antimicrobial use. With furtherance of measures to control infection, antimicrobial use may be further curtailed.

Risk Factors of Extended-Spectrum Beta-Lactamases-Producing Escherichia coli Community Acquired Urinary Tract Infections: A Systematic Review

Purpose

The prevalence of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) has been increasing worldwide since the early 2000s. E. coli is found in 70–90% of community-acquired urinary tract infections (CA-UTIs). We performed a systematic literature review to determine the risk factors for CA-UTI caused by ESBL-EC.

Methods

We searched the MEDLINE, Cochrane Library, Embase and Web of Science databases without language or date restriction up to March 2019. Two independent reviewers selected studies with quantified risk factors for CA-UTI due to ESBL-EC, and assessed their quality using the Newcastle-Ottawa Scale.

Results

Among the 5,597 studies identified, 16 observational studies (n=12,138 patients) met the eligibility criteria. The included studies were performed in various countries, and 14/16 were published after 2012. The most relevant risk factors for CA-UTI due to ESBL-EC identified were prior use of antibiotics (odds ratio (OR) from 2.2 to 21.4), previous hospitalization (OR: 1.7 to 3.9), and UTI history (OR: 1.3 to 3.8). Two risk factors were related to environmental contamination: travelling abroad, and swimming in freshwater.

Conclusion

Our findings could allow adapting empiric antibiotic treatments according to the patient profile. Further studies are needed to quantify the relationships between CA-UTI due to ESBL-EC and the environment.

Influence of primary care antibiotic prescribing on incidence rates of multidrug-resistant Gram-negative bacteria in hospitalised patients

PURPOSE

Use of antibiotics can give rise to the selection of resistant bacteria. It remains unclear whether antibiotic use in primary care can influence bacterial resistance incidence in patients when hospitalised. The aim of this study is to explore the impact of prior community antibiotic usage on hospital-detected multidrug-resistant Gram-negative (MRGN) incidence rate.

METHODS

This pharmacoepidemiological study was case-control in design, and was carried out in the Antrim Area Hospital (N. Ireland) in two phases. In phase 1, the controls were matched according to: age, gender, admission ward, date of admission, and age-adjusted Charlson co-morbidity index score. During the second phase, controls were selected randomly from the total population of admissions to the hospital over the 2-year study period.

RESULTS

In phase 1, multivariate analysis revealed that prior exposure to the second- and third-generation cephalosporins (p = 0.004) and fluoroquinolones (p = 0.023) in primary care was associated with an increased likelihood of MRGN detection in inpatients. In phase 2, an independent relationship between an increased risk of identification of MRGN, while hospitalised was associated with: prolonged hospitalisation (p < 0.001), being elderly (p < 0.001), being female (p = 0.007), and having genitourinary disease (p < 0.001).

CONCLUSION

This study provides clear evidence which supports the need to optimise antibiotic use in primary care to help reduce MRGN incidence in hospitalised patients.

Antibacterial effect evaluation of moxalactam against extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae with in vitro pharmacokinetics/pharmacodynamics simulation

Objectives

The aim of this study was to evaluate the bactericidal effects of moxalactam (MOX), cefotaxime (CTX), and cefoperazone/sulbactam (CFZ/SBT) against extended-spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae, using an in vitro pharmacokinetics (PK)/pharmacodynamics model.

Methods

Two clinical ESBL-producing strains (bla_CTX-M-15 positive E. coli 3376 and bla_CTX-M-14 positive K. pneumoniae 2689) and E. coli American Type Culture Collection (ATCC)25922 were used in the study. The PK Auto Simulation System 400 was used to simulate the human PK procedures after intravenous administration of different doses of MOX, CTX, and CFZ/SBT. Bacterial growth recovery time (RT) and the area between the control growth curve and bactericidal curves (IE) were employed to assess the antibacterial efficacies of all the agents.

Results

The minimum inhibitory concentrations of MOX, CTX, and CFZ/SBT against E. coli ATCC25922, 3376, and 2689 strains were 0.5, 0.5, 0.25; 0.06, >256, 256; and 0.5/0.5, 16/16, 32/32 mg/L. All the agents demonstrated outstanding bactericidal effects against E. coli ATCC25922 (RT >24 h and IE >120 log₁₀ CFU/mL·h⁻¹) with simulating PK procedures, especially in the multiple dose administration models. Against ESBL producers, CTX and CFZ/SBT displayed only weak bactericidal effects, and subsequent regrowth was evident. MOX exhibited potent antibacterial activity against all the strains tested. The values of effective parameters of MOX were much higher than those of CTX and CFZ/SBT (the bacterial RTs with the 3 agents were >24, <4, and <13 h, and the IEs were >110, <10, and <60 log₁₀ CFU/mL·h⁻¹, respectively).

Conclusion

MOX demonstrated excellent bactericidal effect, which is worthy of further exploration to serve as an alternative therapeutic agent against ESBL-producing Enterobacteriaceae.