Prevalence of ESBL-producing Enterobacteriaceae in paediatric urinary tract infections: A systematic review and meta-analysis

Urinary Tract Infections among Febrile Infants in Qatar: Extended-Spectrum-Beta-Lactamase (ESBL)-Producing Versus Non-ESBL Organisms

BACKGROUND

The escalating prevalence of ESBL-producing Enterobacteriaceae in Qatar's pediatric population, especially in community-onset febrile urinary tract infections (FUTIs), necessitates a comprehensive investigation into this concerning trend.

RESULTS

Over the course of one year, a total of 459 infants were diagnosed and subsequently treated for UTIs. Cases primarily occurred in infants aged over 60 days, predominantly non-Qatari females born from term pregnancies. Notably, E. coli and K. pneumoniae were the most frequently identified organisms, accounting for 79.7% and 9.8% in the ESBL group and 57.2% and 18.7% in the non-ESBL group, respectively. Interestingly, hydronephrosis emerged as the most prevalent urological anomaly detected in both ESBL (n = 10) and other organism (n = 19) groups.

METHODS

In this retrospective cohort study conducted in Qatar, we meticulously evaluated the prevalence of pediatric FUTIs. Our study focused on febrile infants aged less than 1 year, excluding those with urine samples not obtained through a catheter.

CONCLUSIONS

E. coli and K. pneumoniae prevailed as the predominant causative agents in febrile children in Qatar, with hydronephrosis being identified as the most common urological anomaly. Moreover, our findings suggested that gentamicin served as a viable non-carbapenem option for hospitalized ESBL cases, while oral nitrofurantoin showed considerable promise for uncomplicated ESBL UTIs.

Association Between Antibiotic Duration and Recurrence of Urinary Tract Infection in the Neonatal Critical Care Unit

OBJECTIVES

Urinary tract infection (UTI) is the most common bacterial infection in infants. Current practice guidelines suggest a treatment duration of 7 to 14 days. Suboptimal therapy may increase the risk for recurrent UTIs leading to renal scarring and possibly chronic kidney disease. The primary objective is to evaluate the duration of therapy for UTIs and its association with the incidence of recurrent UTIs in a neonatal intensive care unit (NICU). The secondary objectives are to identify the risk factors and the most common organisms for recurrent UTIs.

METHODS

Patients were identified via the diagnosis codes for UTIs and were included if admitted to the NICU and if they received antibiotics prior to hospital discharge. Patients were divided into 2 groups: antibiotic treatment for 7 days or fewer and antibiotic treatment for greater than 7 days.

RESULTS

Eighty-six infants were included in the study. Twenty-six patients received antibiotics for 7 days or fewer, and 60 for more than 7 days. In the study, the median birth weight was 977 g and the median gestational age was 27.6 weeks. There was no significant difference in the rate of recurrent UTIs between the 2 groups (p = 0.66). However, in the subgroup analysis, the incidence was higher for patients receiving antibiotic therapy for fewer than 7 days versus 7 days (p = 0.03).

CONCLUSION

There was no difference in recurrence of UTI between treatment groups (≤7 days versus >7 days), and recurrence was seen in a higher percentage of patients with a urinary tract anomaly.

Piperacillin-Tazobactam versus Cefotaxime as Empiric Treatment for Febrile Urinary Tract Infection in Hospitalized Children

BACKGROUND

According to international pediatric urinary tract infection (UTI) guidelines, selecting ampicillin/sulbactam or amoxicillin/clavulanate is recommended as the first-line treatment for pediatric UTI. In Korea, elevated resistance to ampicillin and ampicillin/sulbactam has resulted in the widespread use of third-generation cephalosporins for treating pediatric UTIs. This study aims to compare the efficacy of piperacillin-tazobactam (TZP) and cefotaxime (CTX) as first-line treatments in hospitalized children with UTIs.

MATERIALS AND METHODS

The study, conducted at Jeju National University Hospital, retrospectively analyzed medical records of children hospitalized for febrile UTIs between 2014 and 2017. UTI diagnosis included unexplained fever, abnormal urinalysis, and the presence of significant uropathogens. Treatment responses, recurrence, and antimicrobial susceptibility were assessed.

RESULTS

Out of 323 patients, 220 met the inclusion criteria. Demographics and clinical characteristics were similar between TZP and CTX groups. For children aged ≥3 months, no significant differences were found in treatment responses and recurrence. Extended-spectrum beta-lactamase (ESBL)-positive strains were associated with recurrence in those <3 months.

CONCLUSION

In Korea, escalating resistance to empirical antibiotics has led to the adoption of broad-spectrum empirical treatment. TZP emerged as a viable alternative to CTX for hospitalized children aged ≥3 months with UTIs. Consideration of ESBL-positive strains and individualized approaches for those <3 months are crucial.

The risk factors, antimicrobial resistance patterns, and outcomes associated with extended-spectrum β-lactamases-Producing pathogens in pediatric urinary tract infection

BACKGROUND

Extended-spectrum β-lactamases-producing Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis (ESBL-producing-EKP) are an increasingly common cause of childhood urinary tract infection (UTI) worldwide. Recognizing the risk factors and antimicrobial resistance patterns may guide new management in this population.

METHODS

This is a retrospective cohort study of over 5 years in Taiwan (2017-2021). Inclusion criteria are hospitalized pediatric patients with the discharge diagnosis of UTI caused by E. coli, Klebsiella pneumoniae, or Proteus mirabilis. ESBL-producing-EKP and non-ESBL-producing-EKP UTI cases were reviewed for characteristics, urinary isolate antibiotics resistance, and clinical outcomes.

RESULTS

The incidence rate of ESBL-producing-EKP UTI increased over the study period (Overall incidence rate: 14.1 %, 46/327 patients). Recent antibiotic therapy in ≤6 months (X2 = 11.83, p < 0.01) and a preterm gestational history (X2 = 8.11, p < 0.05) were associated with an increased risk. The proportion of patients with these two risk factors for ESBL acquisition were 37.5 % (X2 = 9.08, p < 0.05). The co-resistance rate of ESBL-producing-EKP to other antimicrobial agents was 63.0 % for gentamicin, 56.5 % for trimethoprim-sulfamethoxazole, 52.2 % for ciprofloxacin, 4.3 % for amikacin, and 2.2 % for imipenem. The generalized linear model analysis identified a significantly longer length of stay (β: 2.85; 95 % confidence interval [CI]: 1.14-4.56; p < 0.01) and intensive care unit duration (β: 5.86; 95 % CI: 1.59-10.12; p < 0.01) among patients with ESBL-producing-EKP UTI.

CONCLUSION

Amikacin should be considered as an alternative antimicrobial choice beyond carbapenems for ESBL-producing-EKP UTI, especially in the context of carbapenem-resistant E. coli/Klebsiella pneumoniae (CRE/CRKP) emergence.

Phenotypic characterization of ESBL-producing urinary isolates of E. coli and Klebsiella spp. in a tertiary care children's hospital in Nepal

BACKGROUND

The production of extended-spectrum beta-lactamases (ESBLs) among uropathogens, particularly E. coli and Klebsiella spp., poses a severe public health concern. This study explored the epidemiology of ESBL-producing E. coli and Klebsiella spp. isolated from urine samples obtained at a tertiary care children's hospital in Nepal.

METHODS

A cross-sectional study was conducted from August 2016 to February 2017. A total of 745 clean catch urine samples were obtained from pediatric patients under the age of 13 and subjected to semiquantitative culture. E. coli and Klebsiella spp. were identified using standard laboratory protocols. Antibiotic susceptibility testing was performed using the Kirby-Bauer disc diffusion method, and ESBL producers were phenotypically identified using the combined disk method.

RESULTS

Among the bacterial isolates, E. coli predominated, accounting for 139 (81.8%) positive cases. Notably, E. coli showed high susceptibility to nitrofurantoin, with 117 (84.2%) isolates being susceptible. Meanwhile, K. pneumoniae showed high susceptibility to gentamicin, with 21 (91.3%) isolates being susceptible. Of the 163 isolates of E. coli and Klebsiella spp., 62 (38.0%) were identified as multidrug-resistant (MDR), with 42 (25.8%) confirmed as phenotypic ESBL producers. Remarkably, all 41 (100%) ESBL-producing E. coli isolates were susceptible to imipenem.

CONCLUSIONS

The prevalence of ESBL producers among E. coli and K. pneumoniae isolates from pediatric patients underscores the importance of antimicrobial stewardship. Nitrofurantoin and gentamicin emerge as effective empirical treatment choices against these pathogens in children. However, the high rates of multidrug resistance and ESBL production highlight the necessity for routine surveillance, and early detection strategies to manage such infections effectively.

Repurposing antibiotic resistance surveillance data to support treatment of recurrent infections in a remote setting

In northern Australia, a region with limited access to healthcare and a substantial population living remotely, antibiotic resistance adds to the complexity of treating infections. Focussing on Escherichia coli urinary tract infections (UTIs) and Staphylococcus aureus skin & soft tissue infections (SSTIs) captured by a northern Australian antibiotic resistance surveillance system, we used logistic regression to investigate predictors of a subsequent resistant isolate during the same infection episode. We also investigated predictors of recurrent infection. Our analysis included 98,651 E. coli isolates and 121,755 S. aureus isolates from 70,851 patients between January 2007 and June 2020. Following an initially susceptible E. coli UTI, subsequent recovery of a cefazolin (8%) or ampicillin (13%) -resistant isolate during the same infection episode was more common than a ceftriaxone-resistant isolate (2%). For an initially susceptible S. aureus SSTI, subsequent recovery of a methicillin-resistant isolate (8%) was more common than a trimethoprim-sulfamethoxazole-resistant isolate (2%). For UTIs and SSTIs, prior infection with a resistant pathogen was a strong predictor of both recurrent infection and resistance in future infection episodes. This multi-centre study demonstrates an association between antibiotic resistance and an increased likelihood of recurrent infection. Particularly in remote areas, a patient's past antibiograms should guide current treatment choices since recurrent infection will most likely be at least as resistant as previous infection episodes. Using population-level surveillance data in this way can also help clinicians decide if they should switch antibiotics for patients with ongoing symptoms, while waiting for diagnostic results.

The burden of hospital acquired infections and antimicrobial resistance

The burden of Hospital care-associated infections (HCAIs) is becoming a global concern. This is compounded by the emergence of virulent and high-risk bacterial strains such as "ESKAPE" pathogens - (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species), especially within Intensive care units (ICUs) that house high-risk and immunocompromised patients. In this review, we discuss the contributions of AMR pathogens to the increasing burden of HCAIs and provide insights into AMR mechanisms, with a particular focus on last-resort antibiotics like polymyxins. We extensively discuss how structural modifications of surface-membrane lipopolysaccharides and cationic interactions influence and inform AMR, and subsequent severity of HCAIs. We highlight some bacterial phenotypic survival mechanisms against polymyxins. Lastly, we discuss the emergence of plasmid-mediated resistance as a phenomenon making mitigation of AMR difficult, especially within the ICUs. This review provides a balanced perspective on the burden of HCAIs, associated pathogens, implication of AMR and factors influencing emerging AMR mechanisms.

Subgroup analysis of phase 2 study of ceftolozane/tazobactam in neonates and young infants with pyelonephritis

Ceftolozane/tazobactam is approved for the treatment of patients from birth to <18 y old with complicated urinary tract infections (cUTI). This post hoc analysis evaluated the safety, efficacy, and pharmacokinetics (PK) of ceftolozane/tazobactam compared with meropenem in neonates and young infants. NCT03230838 was a phase 2, randomized, active comparator-controlled, double-blind study of patients from birth to <18 y of age with cUTI, including pyelonephritis, given ceftolozane/tazobactam or meropenem in a 3:1 ratio. This subset analysis included only neonates and young infants < 3 mo of age. The microbiologic modified intent-to-treat population (mMITT) included 20 patients (ceftolozane/tazobactam, n = 14; meropenem, n = 6). All patients had pyelonephritis at baseline; two patients in each treatment group had bacteremia (overall 4/20, 20%). Escherichia coli was the most common baseline pathogen (overall 16/20, 80%). Safety and efficacy results were similar between treatment groups and consistent with the overall pediatric population. There were no serious drug-related adverse events (AEs), no discontinuations due to AEs, and no AEs leading to death in either treatment group. For the ceftolozane/tazobactam and meropenem treatment groups, clinical cure rates in the mMITT population were 92.9% and 100%, respectively. The population PK analysis of neonates and young infants demonstrated similar ceftolozane and tazobactam exposures to those of adults, achieving pharmacodynamic targets associated with clinical and microbiologic cure. Ceftolozane/tazobactam has a favorable safety profile and achieves high clinical cure and microbiologic eradication rates in neonates and young infants < 3 mo of age with cUTI and pyelonephritis. IMPORTANCE Extrapolation of antibacterial agent pharmacokinetics from adults to newborns and young infants may not be appropriate; similarly, the clinical manifestations of infectious diseases and outcomes following antibacterial treatment may not be similar. Ceftolozane/tazobactam is an antibacterial drug combination active against Pseudomonas aeruginosa and other multidrug-resistant gram-negative bacteria. A clinical study led to the approval for ceftolozane/tazobactam in patients from birth to 18 y of age who have complicated urinary tract infections, including those with serious kidney infections. Based on data collected during that clinical study, we compared newborns and young infants who were treated with ceftolozane/tazobactam (14 patients) and those who were treated with meropenem (6 patients). We found that ceftolozane/tazobactam treatment of newborns and young infants up to 3 mo of age who have complicated urinary tract infections demonstrated a favorable safety profile and high clinical cure and microbiologic eradication rates, similar to meropenem.

High Rates of ESBL-producing and Gentamycin-resistant Gram-negative Bacteria During the First Week of Life: A Multicenter Cross-sectional Study Among Infants Younger Than 2 Months With Urinary Tract Infection

INTRODUCTION

Reducing the risk of renal scarring in infants with urinary tract infection (UTI) necessitates timely and effective administration of antimicrobial treatment. The Israeli Medical Association recommends the empirical use of gentamicin and ampicillin for febrile infants younger than 2 months with suspected UTI. We aimed to assess the prevalence of Extended Spectrum Beta-Lactamase (ESBL)-producing and gentamicin-resistant Gram-negative UTI among infants younger than 2 months.

METHODS

A multicenter retrospective cross-sectional study of infants younger than 2 months with UTI who visited Clalit Health Services pediatric emergency departments between January 1, 2016, and December 31, 2021. The primary outcome measure was the prevalence of ESBL-associated and gentamicin-resistant UTI. The secondary outcome measure was the factors associated with such resistant bacteria.

RESULTS

Overall, 1142 infants were included. Sixty-five (5.7%) and 64 (5.6%) infants had gentamicin-resistant and ESBL-producing Gram-negative UTI, respectively. Forty-two percent of ESBL-associated UTI were gentamicin-resistant. Higher ESBL rates were found during first week of life (14.8% versus 4.1%-7.7%; P = 0.009). Similarly, higher rates of gentamicin resistance were found in this age group (11.2%). Admission rate to pediatric intensive care units (ICUs) was higher in infants with ESBL-associated UTI (9.8% versus 3.5%; P = 0.015). Gestational bacteriuria, previous neonatal ICU admission or gender were not associated with either gentamicin or ESBL-producing resistance.

CONCLUSIONS

Our findings support the current recommendations for empirical intravenous treatment. However, modification of the treatment protocol should be considered for infants younger than 7 days, who had higher rates of ESBL-producing and gentamicin-resistant Gram-negative UTI.

Carriage of β-lactamase and carbapenemase-producing Enterobacteriaceae in hospitalized patients at debre tabor comprehensive specialized hospital

Background

Antimicrobial resistance has remained global public health threat. Carriage with drug-resistant bacterial pathogens, particularly beta-lactamase and carbapenemase-producing Enterobacteriaceae is among the most concerning. The purpose of this study was to look into the magnitude, antimicrobial resistance patterns, and associated risk factors among hospitalized patients.

Methods

A facility-based cross-sectional study was conducted on 383 hospitalized patients at Debre Tabor Comprehensive Specialized Hospital between September 2022 and May 2023. A pre-tested structured questionnaire was used to collect sociodemographic and clinical data. The data on the etiologic agent was collected using standard bacteriological techniques. Briefly, stool specimens were collected aseptically into sterile, leak-proof stool cups. The stool sample was inoculated onto MacConkey agar and incubated aerobically at 37 °C for 24 h. The species isolation and antimicrobial resistance patterns were then performed adhering to bacteriological procedures. In the analysis, a p-value of <0.05 was considered statistically significant.

Results

There were 383 study participants, and men made up the majority (55.6%). The study participants' mean age was 33 ± 18 years. Three hundred and seventy-seven (88%) of the study's participants had no previous history of antibiotic use. There were 102 (26.6%) and 21 (5.5%) cases of gastrointestinal carriage caused by Enterobacteriaceae that produce beta-lactamase and carbapenemase, respectively. In total, 175 isolates of Enterobacteriaceae were detected. E. coli (n = 89) and K. pneumoniae (n = 51) were the most frequently recovered. In this study, 46 (79.3%) and 8 (13.8%) isolates of E. coli that produce beta-lactamase were resistant to ampicillin and amoxicillin/clavulanic acid, respectively. Furthermore, participants who had previously used antibiotics experienced a two-fold increase in exposure to gastrointestinal tract carriage by carbapenemase-producing Enterobacteriaceae [AOR, 95% CI (2.01, 1.06-2.98), p = 0.001].

Conclusions

The emergence of drug-resistant pathogens is a growing concern. An increase in the prevalence of drug-resistant infections in hospitalized patients is warranting further investigation.

Novel Beta Lactam Antibiotics for the Treatment of Multidrug-Resistant Gram-Negative Infections in Children: A Narrative Review

Infections due to carbapenem-resistant Enterobacterales (CRE) are increasingly prevalent in children and are associated with poor clinical outcomes, especially in critically ill patients. Novel beta lactam antibiotics, including ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, imipenem-cilastatin-relebactam, and cefiderocol, have been released in recent years to face the emerging challenge of multidrug-resistant (MDR) Gram-negative bacteria. Nonetheless, several novel agents lack pediatric indications approved by the Food and Drug Administration (FDA) and the European Medicine Agency (EMA), leading to uncertain pediatric-specific treatment strategies and uncertain dosing regimens in the pediatric population. In this narrative review we have summarized the available clinical and pharmacological data, current limitations and future prospects of novel beta lactam antibiotics in the pediatric population.

Safety and Efficacy of Ceftolozane/Tazobactam Versus Meropenem in Neonates and Children With Complicated Urinary Tract Infection, Including Pyelonephritis: A Phase 2, Randomized Clinical Trial

BACKGROUND

Ceftolozane/tazobactam, a cephalosporin-β-lactamase inhibitor combination, active against multidrug-resistant Gram-negative pathogens, is approved for treatment of adults with complicated urinary tract infections (cUTI). Safety and efficacy of ceftolozane/tazobactam in pediatric participants with cUTI, including pyelonephritis, were assessed.

METHODS

This phase 2 study (NCT03230838) compared ceftolozane/tazobactam with meropenem for treatment of cUTI in participants from birth to <18 years of age. The primary objective was safety and tolerability. Key secondary end points included clinical cure and per-participant microbiologic response rates at end of treatment (EOT) and test of cure (TOC) visits.

RESULTS

The microbiologic modified intent-to-treat (mMITT) population included 95 participants (ceftolozane/tazobactam, n = 71; meropenem, n = 24). The most common diagnosis and pathogen were pyelonephritis (ceftolozane/tazobactam, 84.5%; meropenem, 79.2%) and Escherichia coli (ceftolozane/tazobactam, 74.6%; meropenem, 87.5%); 5.7% (ceftolozane/tazobactam) and 4.8% (meropenem) of E. coli isolates were extended-spectrum β-lactamase-producers. Rates of adverse events were similar between treatment groups (any: ceftolozane/tazobactam, 59.0% vs. meropenem, 60.6%; drug-related: ceftolozane/tazobactam, 14.0% vs. meropenem, 15.2%; serious: ceftolozane/tazobactam, 3.0% vs. meropenem, 6.1%). Rates of clinical cure for ceftolozane/tazobactam and meropenem at EOT were 94.4% and 100% and at TOC were 88.7% and 95.8%, respectively. Rates of microbiologic eradication for ceftolozane/tazobactam and meropenem at EOT were 93.0% and 95.8%, and at TOC were 84.5% and 87.5%, respectively.

CONCLUSIONS

Ceftolozane/tazobactam had a favorable safety profile in pediatric participants with cUTI; rates of clinical cure and microbiologic eradication were high and similar to meropenem. Ceftolozane/tazobactam is a safe and effective new treatment option for children with cUTI, especially due to antibacterial-resistant Gram-negative pathogens.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae related urinary tract infection in adult cancer patients: a multicenter retrospective study, 2015-2019

BACKGROUND

The aim of this study was to investigate the prevalence and risk factors of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae related urinary tract infections (UTI) in adult cancer patients.

METHODS

We conducted a retrospective study of three cancer hospitals centered on Cancer Hospital of Chinese Academy of Medical Sciences from 2015 to 2019. The clinical characters, risk factors and antimicrobial susceptibility of ESBL-producing Enterobacteriaceae UTI in adult cancer patients were described and analyzed.

RESULTS

A total of 4967 specimens of UTI were evaluated, of which 909 were positive. After excluding multiple infection bacteria, non-conforming strains, inconsistent pathological information, no drug sensitivity test or medical records, 358 episodes remained. Among them, 160 episodes belonged to ESBL-producing Enterobacteriaceae, while 198 were classified into non-ESBL group. The prevalence of ESBL UTI circled around 39.73 to 53.03% for 5 years. Subgroup analysis by tumor type revealed that 62.5% of isolates from patients with urological tumors were ESBL positive. Multivariate analysis showed that tumor metastasis (OR 3.41, 95%CI 1.84-6.30), urological cancer (OR 2.96, 95%CI 1.34-6.53), indwelling catheter (OR 2.08, 95%CI 1.22-3.55) and surgery or invasive manipulation (OR 1.98, 95%CI 1.13-3.50) were the independent risk factors. According to antimicrobial sensitivity, meropenem, imipenem and piperacillin/tazobactam were the most commonly used antibiotics for ESBL-producing Enterobacteriaceae UTI.

CONCLUSIONS

In view of the high prevalence, clinicians should be alert to the occurrence of ESBL UTI, especially for patients with urological cancer or metastatic tumors. Regular replacement of urinary catheters, reduction of unnecessary invasive operations and selection of appropriate antibiotics are the necessary conditions to deal with the occurrence of ESBL UTI in adult cancer patients.

Magnitude and associated factors of bacterial urinary tract infections among paediatric patients in Arba Minch, southern Ethiopia

Bacterial urinary tract infections (UTI) commonly occur in children; if left untreated, they may result in severe consequences such as uro-sepsis and renal damage. This study aimed to determine the bacterial profile, antimicrobial susceptibility patterns and associated factors among paediatric patients suspected of urinary tract infections in Arba Minch General Hospital (AMGH). An institution-based cross-sectional study was conducted from 01 October 2020 to 31 January 2021. A convenient sampling technique was used to recruit the participants; data were collected using a pre-tested questionnaire. To quantify the bacteria (as per the Kass count, >10⁵CFU/ml), midstream urine samples were streaked onto bacteriological media. Isolates were identified by following standard procedures. The antibiotic susceptibility test was performed as per the Kirby-Bauer disc diffusion technique. Data were analyzed using SPSS software. Out of the 246 children included, 38 (15.4%) were found to be positive for significant bacteriuria. Isolates of Escherichia coli, 9/38 (23.7%), and Staphylococcus aureus, 9/38 (23.7%), were the most predominant. The majority of Gram-negative bacterial (GNB) isolates showed resistance towards amoxicillin-clavulanate (89.5%), ampicillin (84.6%), and ceftazidime (81%). Likewise, 76.9 and 76.5% of Gram-positive bacteria (GPB), respectively, had shown resistance towards co-trimoxazole and tetracycline. Multi-drug and extensively drug resistance were detected respectively in the case of 68.4 and 15.8% of the total isolates; ESBL production was found in 57.1% of GNB, whereas 55.6% of S. aureus were methicillin-resistant S. aureus (MRSA). The process of un-circumcision was significantly associated with UTI [(adjusted odds ratio= 3.578; 95% confidence interval: 1.263 - 10.13; p=0.016)].

Pediatric community acquired urinary tract infections due to extended-spectrum beta-lactamase versus non-extended-spectrum beta-lactamase producing bacteria

BACKGROUND

This study aimed to evaluate the demographics, clinical characteristics, risk factors, and antibiotic resistance of pediatric community-acquired urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing and non-ESBL-producing uropathogens.

METHODS

This retrospective study was conducted at a tertiary care hospital in Saudi Arabia, among children aged between 0 and 14 years, with a culture-proven diagnosis of community-acquired UTI between February 2019 and September 2021. Patients were divided into two groups based on whether or not their UTI was caused by ESBL-producing bacteria.

RESULTS

A total of 383 patients with community-acquired UTI were evaluated. Escherichia coli was detected in 72.6% of cultures. Extended-spectrum beta-lactamase-producing organisms were responsible for 35.7% of UTI episodes. Of these 69% and 31% were caused by E. coli and Klebsiella pneumoniae, respectively. There were no significant differences between the two groups with regard to clinical presentation or urine analysis. The resistance rates in the ESBL-producing group were 39.4% for amoxicillin/clavulanic acid, 65.7% for ciprofloxacin, 72.3% for co-trimoxazole, 32.8% for nitrofurantoin, 21.2% for gentamicin, and 0.7% for amikacin and carbapenems. In the non-ESBL-producing group, it was 22.4% for amoxicillin/clavulanic acid, 22.4% for ciprofloxacin, 38.2% for co-trimoxazole, 23.6% for nitrofurantoin, 6.1% for gentamicin, and zero for amikacin and carbapenems. The presence of renal abnormalities (p = 0.014) and male gender (p = 0.026) were determined to be independent risk factors for ESBL UTIs.

CONCLUSIONS

Recognizing risk factors and antibiotic resistance for ESBL-producing bacteria may aid in tailoring an antibiotic regimen for pediatric patients at high risk of ESBL-UTIs.

Temporal Changes in Extended Spectrum β-Lactamase Producing Organisms in Acute Care Surgery

BACKGROUND

Extended-spectrum β-lactamase (ESBL) producing organisms are resistant to a wide range of broad-spectrum antibiotics, and their emergence is a significant driving force of antibiotic resistance. Most South-Asian countries have become hotspots for antibiotic resistance, so specifics of ESBL data are critical to tackling antibiotic resistance. We present the temporal changes in ESBL-producing organisms cultured in our tertiary care referral centre.

METHODS

Over a year, a historical cohort analysis was carried out at our tertiary care referral centre in Southeast Asia. Samples from patients presenting with acute surgical conditions were sent for culture and sensitivity. The phenotype of all specimens was checked using the combination disc method. Antimicrobial susceptibilities to various antibiotics were also checked as per CLSI (Clinical and Laboratory Standard Institute) guidelines.

RESULTS

Specimens from 170 patients were analysed. The mean age was 44.73±19.89 years, and there was a female predominance of 62%. The most common organisms were Escherichia coli (70%), Klebsiella pneumoniae (18%), and Pseudomonas aeruginosa (16%). The percentage of ESBL-producing organisms was 54.7%, which is significantly higher than in previous reports. Widespread resistance was found against commonly used antibiotics, including co-amoxiclav (81.9%), ceftriaxone (75%), ciprofloxacin (47%), and levofloxacin (35.7%). Sensitivities to combination antibiotics like piperacillin-tazobactam (79.2% sensitive), cefoperazone-sulbactam (84.3% sensitive), and imipenem-cilastatin (91.1% sensitive) were also noted to be falling.

CONCLUSION

The incidence of ESBL-producing organisms continues to increase at an alarming rate, which mandates strict antibiotic stewardship and amendments to local guidelines.

A Case-Control Study Evaluating Risk Factors and Outcomes of Hospitalized Children With ESBL-UTI

Urinary tract infections (UTIs) are among the most common causes of hospitalization in children, with a rising prevalence of extended-spectrum beta-lactamase-producing organisms (ESBL). The purpose of this study was to identify risk factors and treatment outcomes of children with ESBL-UTI. A retrospective case-control study of hospitalized children was performed from July 2014 till December 2017. Medical records from patients with a positive urine culture were reviewed and included in the study if they met criteria for UTI. Cases were defined as ESBL-UTI, while controls were defined as non-ESBL-UTI patients. This study confirmed that there are certain risk factors, such as previous UTI, recent antibiotic use, urinary tract abnormalities, recent hospital admission, and nonrenal comorbidities, that are associated with ESBL-UTI. Most of the patients with ESBL-UTI responded to discordant antibiotics. Other significant outcomes in patients with ESBL-UTI included a longer length of stay and longer intravenous antibiotic therapy.

Clinical features and treatment strategies of febrile urinary tract infection caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae in children: a multicenter retrospective observational study in Japan

OBJECTIVES

The incidence of infections caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria has increased. This study aimed to clarify the risk factors and treatment strategies for febrile urinary tract infection (fUTI) caused by ESBL-producing bacteria in Japanese children.

METHODS

A retrospective observational study was conducted in 21 hospitals among children aged <16 years diagnosed with an fUTI between 2008 and 2017. Clinical data of children with fUTI caused by ESBL-producing and non-ESBL-producing bacteria were compared.

RESULTS

Of the 2049 cases of fUTI, 147 (7.2%) were caused by ESBL-producing bacteria. Children in the ESBL group were more likely to have a history of recent antibiotic use or prophylactic antibiotic use, and experience recurrent UTIs (P <0.001) compared with those in the non-ESBL group. Of the 124 cases of fUTI due to ESBL-producing bacteria that were reviewed, 20 and 100 had concordant and discordant antibiotic use, respectively, and four had unknown antibiotic susceptibility. The median time from the start of treatment to fever resolution was 24 hours and did not differ significantly by therapy group (P = 0.39).

CONCLUSION

ESBL-producing bacteria should be considered in children with recurrent UTIs and recent antibiotic use. Most children with fUTI experience clinical improvement regardless of the choice of antibiotic.

Management of Pediatric Urinary Tract Infections: A Delphi Study

Urinary tract infection (UTI) is one of the most common infectious diseases in the pediatric population and represents a major cause of antibiotic consumption and hospitalization in children. Considering the ongoing controversies on the management of pediatric UTI and the challenges due to increasing antimicrobial resistance, the aim of the present study was to evaluate the level of agreement on UTI management in pediatric age in Emilia-Romagna Region, Italy, and to assess on the basis of recent studies whether there is the need to change current recommendations used by primary care pediatricians, hospital pediatricians, and pediatric surgeons in everyday clinical practice to possibly improve outcomes. This consensus provides clear and shared indications on UTI management in pediatric age, based on the most updated literature. This work represents, in our opinion, the most complete and up-to-date collection of statements on procedures to follow for pediatric UTI, in order to guide physicians in the management of the patient, standardize approaches, and avoid abuse and misuse of antibiotics. Undoubtedly, more randomized and controlled trials are needed in the pediatric population to better define the best therapeutic management in cases with antimicrobial resistance and real usefulness of long-term antibiotic prophylaxis.

Trends and risk factors of extended-spectrum beta-lactamase urinary tract infection in Chinese children: a nomogram is built and urologist should act in time

BACKGROUND

To investigate the etiological characteristics and risk factors of extended-spectrum beta-lactamase (ESBL) urinary tract infection (UTI) and construct a corresponding nomogram to predict the probability of ESBL(+) UTI.

METHODS

We retrospectively reviewed the records among patients experiencing UTI events in Chongqing Medical University Affiliated Children's Hospital from 1994 and 2019.

RESULTS

A total of 854 patients with UTI were evaluated and ESBL-producing bacteria increased significantly. Significant potential risk factors of ESBL-UTI were congenital urological abnormalities, vesicoureteral reflux, neurologic disorder, age <12 months, fever and previous use of antibiotics. On logistic regression analysis, neurological disorder (OR =8, 95% CI: 1.845-34.695) and antibiotics administration in the last 3 months (OR =4.764, 95% CI: 3.114-7.289) were identified as an independent significant risk factor for ESBL-UTI. The nomogram generated was well calibrated for all predictions of ESBL+ probability, and the accuracy of the model nomogram measured by Harrell's C statistic (C-index) was 0.741.

CONCLUSIONS

The current situation of multiple bacterial antibiotic resistance has become a worrisome issue in UTI and early identification of ESBL production is important in terms of appropriate treatment and effective infection control. We may choose broad-spectrum antibiotics as empirical antibiotics for UTI among children with neurological disease and used antibiotic in the last three months.

Comparative genomic analysis of ESBL-producing Escherichia coli from faecal carriage and febrile urinary tract infection in children: a prospective multicentre study

Background

The reliability of ESBL-producing Escherichia coli (ESBL-Ec) faecal carriage monitoring to guide probabilistic treatment of febrile urinary tract infection (FUTI) in children remains unclear.

Objectives

To compare the genomic characteristics of ESBL-Ec isolates from faecal carriage and FUTI to assess their correlation and identify a FUTI-associated virulence profile.

Methods

We conducted a prospective multicentre hospital and ambulatory-based study. We analysed the genotypes and virulence factors of both faecal and FUTI ESBL-Ec by whole genome sequencing. Correlations were assessed by non-parametric Spearman coefficient and virulence factors were assessed by chi-squared tests with Bonferroni correction.

Results

We included 218 ESBL-Ec causing FUTI and 154 ESBL-Ec faecal carriage isolates. The most frequent ST was ST131 (44%) in both collections. We found high correlation between carriage and ESBL-Ec FUTI regarding genes/alleles (rho = 0.88, P < 0.0001) and combinations of virulence genes, MLST and serotypes (rho = 0.90, P < 0.0001, rho = 0.99, P = 0.0003, rho = 0.97, P = 0.005 respectively). Beside this strong correlation, we found five genes that were significantly associated with FUTI (papC, papGII, hlyC, hek and traJ). The strongest association with FUTI was found with adhesin gene allele papGII (54% in FUTI versus 16% in carriage) and for papGII and gene traJ alone or in combination (63% versus 24%).

Conclusions

The genomic profile of ESBL-Ec causing FUTI in children strongly correlates with faecal carriage isolates except for a few genes. The presence of papGII and/or traJ in a previously identified carriage strain could be used as a marker of uropathogenicity and may guide the empirical antimicrobial choice in subsequent FUTI.

Impact of Third-Generation Cephalosporin Resistance on Recurrence in Children with Febrile Urinary Tract Infections

Background: The purpose of this study was to investigate the association between third-generation cephalosporin resistance and urinary tract infection (UTI) recurrence in patients who underwent voiding cystourethrogram (VCUG). Methods: In this retrospective study, data were obtained from hospitalized pediatric patients who had a first febrile UTI episode and subsequently underwent VCUG. Information based on VCUG was mandatory to identify the presence of vesicoureteral reflux (VUR). A multivariable logistic model was used to identify the risk factors for recurrence. Recurrence was divided into early (90-day) and late (1-year), and sensitivity analyses were performed according to each definition. The estimates of all the statistical models were internally validated using bootstrap samples. Results: A total of 210 patients were included, and the overall recurrence rate of UTI was 26.2% (55 of 210). Third-generation cephalosporin resistance was a significant risk factor for early recurrence (odds ratio: 2.79 [1.08–7.20]) but not for late recurrence. Sensitivity analyses showed that third-generation cephalosporin resistance was a significant risk factor for 60-day recurrence but not for 180-day recurrence. A VUR grade ≥ 3 was identified as a consistent risk factor for both early and late recurrence. Conclusions: Third-generation cephalosporin resistance was a significant risk factor for the early recurrence of pediatric UTI in patients who underwent VCUG.

Mass Spectrometry-Based Detection of Beta Lactam Hydrolysis Enables Rapid Detection of Beta Lactamase Mediated Antibiotic Resistance

OBJECTIVE

Antibiotic resistance by beta lactamase expression is a serious and growing threat. We aimed to determine whether beta-lactamase activity is detectable in urine specimens to enable faster identification of resistance.

METHODS

Urine specimens from patients with extended spectrum beta lactamase (ESBL)-expressing urinary infections were incubated with beta lactam antibiotics. Beta lactam hydrolysis was determined by mass spectrometry methods.

RESULTS

Ceftriaxone hydrolysis was observed in 45 of 45 ESBL-containing specimens from patients not treated with a beta lactamase inhibitor before specimen collection. Ceftriaxone hydrolysis was not observed in 108 of 108 non-ESBL-containing specimens. Spiking studies show that beta lactam hydrolysis can be observed within 30 minutes. Beta lactam hydrolysis is evidenced by mass spectrometry preceded by either liquid chromatography or matrix-assisted laser desorption ionization specimen processing methods.

CONCLUSION

Clinically significant beta lactamase activity is detectable directly from urine specimens. The described methods would enable the detection of beta lactam resistance 24 to 48 hours sooner than culture based methods.

Integron detection for prediction of trimethoprim/sulfamethoxazole susceptibility in children with Enterobacterales urinary tract infections

Objectives

In some countries, third-generation cephalosporins (3GCs) serve as first-line therapy in children with urinary tract infections (UTIs). However, their use may contribute to the emergence of antibiotic resistance, notably among Gram-negative bacteria (GNB). Integrons are bacterial genetic elements involved in antibiotic resistance in GNB. Their absence is associated with &gt;97% susceptibility to trimethoprim/sulfamethoxazole in adults infected with GNB. The objective of this study was to examine the value of integron detection directly from urine samples as a predictive marker of resistance to trimethoprim/sulfamethoxazole in children with GNB-related UTIs.

Methods

Children admitted to the Limoges University Hospital’s paediatric emergency department between February 2018 and March 2019 with a suspicion of UTI were eligible for the study. Only confirmed cases presenting a positive urine culture with unique GNB were retained for further study analyses. Integrons were detected directly from urines using real-time PCR.

Results

The data of 72 patients were analysed and integrons were detected in 15 urine samples. The negative predictive value of integron detection for resistance to trimethoprim/sulfamethoxazole was 100% as all of the GNB (all were Enterobacterales) isolated from patients with no integrons detected in their urine samples were susceptible to trimethoprim/sulfamethoxazole.

Conclusions

The detection of integrons in cases of paediatric patients with suspected UTI could help limit 3GC empirical use and empower an empirical first-line strategy better tailored to the needs of each patient.

Risk factors for cefazolin-resistant febrile urinary tract infection in children

BACKGROUND

Febrile urinary tract infection (fUTI) is a common bacterial infection among children. This study investigated the risk factors for fUTI caused by cefazolin-resistant bacteria in children.

METHODS

The medical records of patients with fUTI hospitalized between April 2014 and March 2020 were retrospectively analyzed. The patients were divided into two groups based on the cefazolin susceptibility of the infection-causing bacteria: cefazolin-resistant and cefazolin-susceptible groups.

RESULTS

The records of 80 patients were evaluated. The median age was 5.0 months (range 0.5-119.4 months). Cefazolin-susceptible bacteria were detected in 60 patients (75.0%). Significant differences were noted between the cefazolin-resistant and cefazolin-susceptible groups regarding UTI-related antimicrobial prophylaxis and recurrence of UTI within 3 months (P = 0.0318 and P = 0.00876, respectively). However, no significant differences were observed between these two groups regarding renal anomalies, or UTI history. Logistic regression analysis revealed that the recurrence of UTI within 3 months was an independent, significant risk factor for cefazolin-resistant fUTI (odds ratio 3.81, 95% confidence interval: 1.07-13.5, P = 0.0388). Six patients who were empirically treated with antibiotics ineffective against the infection-causing bacteria recovered from fever before these antibiotics were switched to those effective against the infection-causing bacteria.

CONCLUSIONS

In children, a recurrence of UTI within 3 months is a risk factor for fUTI caused by cefazolin-resistant bacteria. Recognizing these risk factors before initiating fUTI treatment in children may support treatment with narrower-spectrum antibiotics, such as first-generation cephalosporins (e.g., cefazolin).

Antibiotic Resistance in Paediatric Febrile Urinary Tract Infections

Febrile urinary tract infection (UTI) is currently considered the most frequent cause of serious bacterial illness in children in the first 2 years of life. UTI in paediatrics can irreversibly damage the renal parenchyma and lead to chronic renal insufficiency and related problems. To avoid this risk, an early effective antibiotic treatment is essential. Moreover, prompt treatment is mandatory to improve the clinical condition of the patient, prevent bacteraemia, and avoid the risk of bacterial localization in other body sites. However, antibiotic resistance for UTI-related bacterial pathogens continuously increases, making recommendations rapidly outdated and the definition of the best empiric antibiotic therapy more difficult. Variation in pathogen susceptibility to antibiotics is essential for the choice of an effective therapy. Moreover, proper identification of cases at increased risk of difficult-to-treat UTIs can reduce the risk of ineffective therapy. In this review, the problem of emerging antibiotic resistance among pathogens associated with the development of paediatric febrile UTIs and the best potential solutions to ensure the most effective therapy are discussed. Literature analysis showed that the emergence of antibiotic resistance is an unavoidable phenomenon closely correlated with the use of antibiotics themselves. To limit the emergence of resistance, every effort to reduce and rationalise antibiotic consumption must be made. An increased use of antibiotic stewardship can be greatly effective in this regard.

Synergistic Effect of Glycyrrhizic Acid and ZnO/Palygorskite on Improving Chitosan-Based Films and Their Potential Application in Wound Healing

The synergistic effect of chitosan (CS), glycyrrhizic acid (GA) and ZnO/palygorskite (ZnO/PAL) as potential wound dressing was evaluated in the form of films by the solution casting method. The nanocomposite films were well-characterized with ATR-FTIR, XRD and SEM to explore the interactions between CS, GA and ZnO/PAL. Physical, mechanical and antibacterial properties of the nanocomposite films were systematically investigated for their reliability in end-up utilization. Importantly, it was found that the presence of PAL in the films provided enhanced mechanical properties, whereas CS, GA and ZnO supplied a broad-spectrum antibacterial activity, especially for drug-resistant bacteria such as ESBL-E. coli and MRSA. Overall, this research demonstrated that the prepared films can be a promising candidate for wound-care materials.

Contamination rates of different methods of urine culture collection in children: A retrospective cohort study

AIM

Urinary tract infection is a common cause of paediatric morbidity. However, there is no consensus on the default method for urine culture collection in children. This study aimed to examine the contamination rates of different urine collection methods.

METHODS

This was a retrospective cohort study in a paediatric emergency department. Data were collected from electronic health records on all children whose urine culture samples were obtained in the paediatric emergency department between March 2018 and March 2019. Different methods of urine collection included the midstream (MS) method, clean catch (CC), transurethral bladder catheterisation and suprapubic aspiration. Contamination rates and positive urine culture rates were calculated and compared for sex, age, and collection method.

RESULTS

Urine culture samples were collected from 1507 children. There were 284 (18.8%) cultures that were positive with significant growth and 52 (3.5%) that were defined as 'contaminated'. The contamination rates for the midstream method in toilet-trained children were 1.6% (10/609), 4.9% (17/348) for CC in pre-continent children, 4.9% (25/515) for transurethral bladder catheterisation and 0% (0/35) (P = 0.006) for suprapubic aspiration. There was no significant difference in contamination rates of urine cultures collected by CC and catheterisation in the compared groups. The rates of positive cultures in the subgroup of children with high suspicion for Urinary tract infection were also found to be similar.

CONCLUSIONS

Our study shows that CC is non-inferior to catheterisation for collecting urine cultures in young children.

Paediatric Enterobacteriaceae infections in hospitalised children in Durban, KwaZulu-Natal

Background

Community-acquired Gram-negative Enterobacteriaceae infections in malnourished and HIV-infected hospitalised children are not well documented and are of concern because of increasing antibiotic resistance and limited available treatment options. This study describes the clinical characteristics and outcomes of hospitalised children with positive Enterobacteriaceae cultures.

Method

A retrospective chart review of children with Gram-negative Enterobacteriaceae infections was performed in King Edward VIII Hospital, a referral hospital in Durban, KwaZulu-Natal. Standard descriptive and analytical statistics, including regression analysis, were performed to determine the clinical characteristics associated with Enterobacteriaceae infections in children hospitalised in the study period.

Results

Of all hospitalised children in the study period, 207 (3.5%) had positive cultures for Enterobacteriaceae isolates, with Escherichia coli 109 (44.5%) and Klebsiella spp. 59 (24.1%) making up most of the infections. Urine (126; 58%) followed by stool (34; 14.8%) and blood (35; 14.0%) were the commonest samples that yielded positive cultures. Diarrhoeal hospitalisations especially posed a higher risk for Enterobacteriaceae infections. Severe acutely malnourished and HIV-infected children were at higher risk. These comorbidities were independently associated with an increased risk of Enterobacteriaceae infection. Prolonged hospitalisation and increased risk of death were also associated with Enterobacteriaceae infection.

Conclusion

Enterobacteriaceae infections were common in hospitalised children and posed an increased risk, especially in malnourished and HIV-infected children. Further studies investigating the relationships between diarrhoea, urinary tract infections and Enterobacteriaceae infections are needed.

Management and Outcomes in Children with Third-Generation Cephalosporin-Resistant Urinary Tract Infections

BACKGROUND

Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs.

METHODS

We conducted a multisite retrospective cohort study of children <18 years presenting to acute care at 5 children's hospitals and a large managed care organization from 2012 to 2017 with a third-generation cephalosporin-resistant UTI from Escherichia coli or Klebsiella spp. Long parenteral therapy was ≥3 days and short/no parenteral therapy was 0-2 days of concordant parenteral antibiotics. Discordant therapy was antibiotics to which the pathogen was non-susceptible. Relapse was a UTI from the same organism within 30 days.

RESULTS

Of the 482 children included, 81% were female and the median age was 3.3 years (interquartile range: 0.8-8). Fifty-four children (11.2%) received long parenteral therapy (median duration: 7 days). Predictors of long parenteral therapy included age <2 months (adjusted odds ratio [aOR] 67.3; 95% confidence interval [CI]: 16.4-275.7), limited oral antibiotic options (aOR 5.9; 95% CI: 2.8-12.3), and genitourinary abnormalities (aOR 5.4; 95% CI: 1.8-15.9). UTI relapse occurred in 1 of the 54 (1.9%) children treated with long parenteral therapy and in 6 of the 428 (1.5%) children treated with short/no parenteral therapy (P = .57). Of the 105 children treated exclusively with discordant antibiotics, 3 (2.9%, 95% CI: 0.6%-8.1%) experienced UTI relapse.

CONCLUSIONS

Long parenteral therapy was associated with age <2 months, limited oral antibiotic options, and genitourinary abnormalities. UTI relapse was rare and not associated with duration of parenteral therapy. For UTIs with limited oral options, further research is needed on the effectiveness of continued discordant therapy.

Prevalence of Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Ethiopia: A Systematic Review and Meta-Analysis

Background

Antimicrobial resistance especially caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has become a global public health concern. Globally, these isolates have remained the most important causes of several infections and associated mortality. Their rapid spread in Ethiopia is associated with a lack of regular surveillance and antibiotic stewardship programs. Isolates of ESBL-PE from different regions of Ethiopia were searched exhaustively. However, published data regarding the pooled estimate of ESBL-PE are not conducted in Ethiopia. For this reason, we systematically reviewed laboratory-based studies to summarize the overall pooled prevalence of the isolates recovered from various human specimens.

Methods

An exhaustive literature search was carried out using the major electronic databases including PubMed, Web of Science, MEDLINE, EMBASE, CINAHL, Google Scholar, Cochrane Library, Scopus, and Wiley Online Library to identify potentially relevant studies without date restriction. Original articles which address the research question were identified, screened, and included using the PRISMA follow diagram. Data extraction form was prepared in Microsoft Excel, and data quality was assessed by using 9-point Joanna Briggs Institute critical appraisal tools. Then, data were exported to STATA 16.0 software for analyses of pooled estimation of outcome measures. Estimation of outcome measures at 95% confidence interval was performed using Der-Simonian-Laird's random-effects model. Finally, results were presented via text, figures, and tables.

Results

A comprehensive electronic database literature search has yielded a total of 86 articles. Among the total, 68 original articles were excluded after the review process. A total of 18 studies with 1191 bacterial isolates recovered from 7919 various clinical samples sizes were included for systematic review and meta-analysis. In this study, the pooled prevalence of ESBL-PE was 18% (95% CI: 9–26). Nine out of the total (50%) reviewed articles were studied using the combination disk test. Likewise, E. coli and K. pneumoniae (50% both) were the predominant isolates of ESBL-PE in addition to other isolates such as Salmonella spp. and Shigella spp.

Conclusion

This meta-analysis has shown a low pooled estimate of ESBL-PE in Ethiopia.

No significant difference between ceftriaxone and cefotaxime in the emergence of antibiotic resistance in the gut microbiota of hospitalized patients: A pilot study

BACKGROUND

Ceftriaxone and cefotaxime share a similar antibacterial spectrum and similar indications but have different pharmacokinetic characteristics. Ceftriaxone is administered once daily and 40% of its clearance is by biliary elimination, whereas cefotaxime requires three administrations per day and shows less than 10% biliary elimination. The high biliary elimination of ceftriaxone suggests a greater impact of this antibiotic on the gut microbiota than cefotaxime. The objective of this study was to compare the impact of ceftriaxone and cefotaxime on the gut microbiota.

METHODS

A prospective clinical trial was performed that included 55 patients treated with intravenous ceftriaxone (1 g/24 h) or cefotaxime (1 g/8 h) for at least 3 days. Three fresh stool samples were collected from each patient (days 0, 3, and 7 or at the end of intravenous treatment) to assess the emergence of third-generation cephalosporin (3GC)-resistant Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, Pseudomonas aeruginosa, toxigenic Clostridioides difficile, and vancomycin-resistant enterococci.

RESULTS

The emergence of 3GC-resistant gram-negative enteric bacilli (Enterobacteriaceae) (5.9% vs 4.7%, p > 0.99), Enterococcus spp, and non-commensal microorganisms did not differ significantly between the groups. Both antibiotics reduced the counts of total gram-negative enteric bacilli and decreased the cultivable diversity of the microbiota, but the differences between the groups were not significant.

CONCLUSION

No significant difference was observed between ceftriaxone and cefotaxime in terms of the emergence of resistance.

Impact of Antibiotic Prescribing Patterns on Susceptibilities of Uropathogens in Children below 24 Months Old

Monitoring regional antibiotic resistance patterns of uropathogens are important for deciding suitable empirical antibiotics for urinary tract infections (UTIs) in children. This study aimed to investigate regional differences in antimicrobial susceptibility patterns of E. coli and Klebsiella spp. in children below 24 months old, diagnosed with their first episode of UTI, and to find factors associated with an increased risk for UTI caused by extended-spectrum β-lactamase (ESBL)-producing uropathogens. This was a retrospective cohort study of children diagnosed between 2011 and 2017 in four different hospitals located in four different regions of South Korea; regions A, B, C, and D. The government’s big data repository was used to acquire data on regional antibiotic prescriptions. The pooled antimicrobial susceptibilities of E. coli and Klebsiella spp. (n = 2044) were as follows: ampicillin–sulbactam (61.0%), 3rd generation cephalosporin (3C) (82.8%), and trimethoprim–sulfamethoxazole (72.0%). Multivariate analysis showed that children diagnosed at hospital A (OR, 1.8; 95% confidence interval [CI], 1.2–2.6; P = 0.002) and every year that increased in the study period (OR, 1.1; 95% CI, 1.1–1.2; P < 0.001) were factors associated with an increased risk for UTIs with ESBL-producers. Regions A and B had significantly higher amounts of oral 3Cs prescribed compared to regions C and D (P = 0.009), which correlate with hospitals in the regions that had higher proportions of UTIs with ESBL-producing uropathogens (A and B vs. C and D, P < 0.001). Therefore, children in certain regions are at a higher risk for UTIs caused by ESBL-producers compared to other regions, which correlate with regions that had higher amounts of oral 3Cs prescribed.

Treatment and Outcomes of Children With Febrile Urinary Tract Infection Due to Extended Spectrum Beta-lactamase-producing Bacteria in Europe: TOO CUTE Study

BACKGROUND

The prevalence of extended-spectrum beta-lactamase producing Εnterobacteriaceae (ESBL-PE) is increasing globally. ESBL-PE are an important cause of urinary tract infections (UTIs) in children. We aimed to characterize the clinical presentation, treatment and outcomes of childhood UTI caused by ESBL-PE in Europe.

METHODS

Multicenter retrospective cohort study. Children 0 to 18 years of age with fever, positive urinalysis and positive urine culture for an ESBL-PE uropathogen, seen in a participating hospital from January 2016 to July 2017, were included.

MAIN OUTCOME MEASURES

Primary outcome measure: day of defervescence was compared between (1) initial microbiologically effective treatment (IET) versus initial microbiologically ineffective treatment (IIT) and (2) single initial antibiotic treatment versus combined initial antibiotic treatment.

SECONDARY OUTCOME MEASURES

Clinical and microbiologic failure of initial treatment.

RESULTS

We included 142 children from 14 hospitals in 8 countries. Sixty-one children had IET and 77 IIT. There was no statistical difference in time to defervescence for effective/ineffective groups (P = 0.722) and single/combination therapy groups (P = 0.574). Two of 59 (3.4%) and 4/66 (6.1%) patients exhibited clinical failure during treatment (P = 0.683) when receiving IET or IIT, respectively. Eight of 51 (15.7%) receiving IET and 6/58 (10.3%) receiving IIT patients (P = 0.568) had recurring symptoms/signs suggestive of a UTI. Recurrence of a UTI occurred 15.5 days (interquartile range, 9.0-19.0) after the end of treatment.

CONCLUSIONS

Time to defervescence and clinical failure did not differ between IET/IIT groups. Non-carbapenem beta-lactam antibiotics may be used for the empiric treatment of ESBL febrile UTIs, until susceptibility testing results become available.

First UTI episode in life in infants <1 year of age: Epidemiologic, clinical, microbiologic and disease recurrence characteristics

BACKGROUND

To examine the epidemiologic and microbiologic characteristics of first and recurrent UTI in young infants.

METHODS

A retrospective study of all infants <1 year hospitalized during 2014-2017 with their first UTI and followed during their first year of life.

RESULTS

191 infants were enrolled; 69 (36.12%) patients were <2 months and 32 (16.8%) developed R-UTI during the follow-up. The five most common uropathogens were Escherichia coli, Klebsiella spp., Enterococcus spp., Proteus mirabilis and Staphylococcus aureus. High resistance rates were recorded for ampicillin, amoxicillin/clavulanic acid, TMP/SMX, cefuroxime, ceftriaxone, piperacillin/tazobactam and gentamicin among E. coli and Klebsiella spp.; 29.15% E. coli and 42.9% Klebsiella spp. were ESBL-positive. 53.2% of recurrent UTI (R-UTI) episodes were diagnosed within 2 months after the initial UTI episode. E. coli (40.6%) and Klebsiella spp. (37.55) were the most frequent R-UTI pathogens. Twenty-five (78.1%) R-UTIs were caused by recurrent uropathogens representing new infections. Antibiotic resistance rates at recurrence were similar to those at initial UTI, except for a significant increase in E. coli and Klebsiella spp. resistance to piperacillin/tazobactam.

CONCLUSION

We reported high antibiotic resistance rates to major antibiotic classes used in UTI treatment. Most R-UTI episodes were caused by uropathogens different than those isolated at the initial UTI episode and were caused by highly-resistant organisms. Our findings require frequent monitoring and possible modification of the empiric and prophylactic antibiotic therapy protocols in use. As a result of our findings, the protocol for initial empiric treatment of infants with suspicion of UTI was modified by changing gentamicin to amikacin in the treatment of infants <2 months of life and amikacin monotherapy (intravenous or intramuscular) was introduced as first-line therapy for infants >2 months of life.

Trends in Antimicrobial Susceptibility of Escherichia coli Isolates in a Taiwanese Child Cohort with Urinary Tract Infections between 2004 and 2018

The aim of this study was to investigate the annual incidence of Escherichia coli isolates in urinary tract infections (UTIs) and the antimicrobial resistance of the third-generation cephalosporin (3GCs) to E. coli, including the factors associated with the resistance in hospitalized children in Taiwan. A large electronic database of medical records combining hospital admission and microbiological data during 2004–2018 was used to study childhood UTIs in Taiwan. Annual incidence rate ratios (IRR) of E. coli in children with UTIs and its resistant rate to the 3GCs and other antibiotics were estimated by linear Poisson regression. Factors associated with E. coli resistance to 3GCs were assessed through multivariable logistic regression analysis. E. coli UTIs occurred in 10,756 unique individuals among 41,879 hospitalized children, with 92.58% being community associated based on urine culture results reported within four days after the hospitalization. The overall IRR E. coli UTI was 1.01 (95% confidence interval (CI) 0.99–1.02) in community-associated (CA) and 0.96 (0.90–1.02) in healthcare-associated infections. The trend in 3GCs against E. coli increased (IRR 1.18, 95% CI 1.13–1.24) over time in CA-UTIs. Complex chronic disease (adjusted odds ratio (aOR), 2.04; 95% CI, 1.47–2.83) and antibiotics therapy ≤ 3 months prior (aOR, 1.49; 95% CI, 1.15–1.94) were associated with increased risk of 3GCs resistance to E. coli. The study results suggested little or no change in the trend of E. coli UTIs in Taiwanese youths over the past 15 years. Nevertheless, the increase in 3GCs-resistant E. coli was substantial. Interventions for children with complex chronic comorbidities and prior antibiotic treatment could be effective in reducing the incidence of 3GCs-resistant E. coli in CA-UTIs in this region and more generally.

Multidrug-resistant and extended-spectrum beta-lactamase-producing uropathogens in children in Bhaktapur, Nepal

Background

The emergence of multidrug-resistant (MDR) and extended-spectrum beta-lactamase (ESBL)-producing uropathogens has complicated the treatment of urinary tract infections (UTI). Paediatric UTI is a common illness, which if not treated properly, may lead to acute and long-term complications, such as renal abscess, septicaemia, and renal scarring. This study aimed to determine the prevalence of MDR and ESBL-producing uropathogens among children.

Methods

During the study period (April 2017–April 2018), midstream urine samples were collected following aseptic procedures from children < 16 years in Siddhi Memorial Hospital. Standard culture and biochemical tests were performed to identify uropathogens and antimicrobial susceptibility test was done by modified Kirby-Bauer disc diffusion method following Clinical and Laboratory Standard Institute (CLSI) guidelines. ESBL-producing uropathogens were screened by ceftazidime (30 μg) and cefotaxime (30 μg) discs, and confirmed by the combination disc tests: ceftazidime + clavulanic acid (30/10 μg) or cefotaxime + clavulanic acid (30/10 μg) as recommended by CLSI.

Results

We processed 5545 non-repeated urine samples from the children with symptoms of UTI. A significant growth of uropathogens was observed in 203 samples (3.7%). The median age of the children was 24 months (interquartile range (IQR), 12–53 months). Escherichia coli (n = 158, 77.8%) and Klebsiella pneumoniae (n = 30, 14.8%) were common among the uropathogens. Among them, 80.3% were resistant to amoxycillin and 51.2% were resistant to cotrimoxazole. Most of them were susceptible to amikacin, nitrofurantoin, and ofloxacin. MDR was detected in 34.5% (n = 70/203) and ESBL producers in 24.6% (n = 50/203) of them. The proportion of MDR isolates was higher in children < 5 years (n = 59/153, 38.6%) than children ≥ 5 years (n = 11/50, 22%) (P = 0.03).

Conclusions

Nitrofurantoin, ofloxacin, and amikacin can be used for the empirical treatment for UTI in children in Bhaktapur, Nepal. MDR and ESBL-producing uropathogens are prevalent; this warrants a continuous surveillance of antimicrobial resistance.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

A Rare Case of Pyonephrosis in an Infant Induced by Extended-Spectrum Beta-Lactamase-Producing Klebsiella pneumoniae

Pyonephrosis is a rare condition in both adult and pediatric population. Here, the author presents a rare case of pyonephrosis induced by extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a 12-month-old girl presenting with a picture of urosepsis. The patient presented with febrile urinary tract infection and was unresponsive to intravenous meropenem. Physical examination revealed huge, firm and irregular right renal swelling. Ultrasound and computed tomography imaging revealed severely hydronephrotic right kidney, and laboratory investigations showed elevated C-reactive protein level (22.9 mg/dl). Emergency percutaneous nephrostomy tube was inserted, pus was drained (20 ml) and intravenous vancomycin and amikacin were started. Her general condition improved, and urine culture was negative. Functional assessment with dimercaptosuccinic acid renal scan revealed that the split renal function was 5% on the right and 95% on the left side, and the bladder outline was smooth with no reflux in voiding cystourethrogram. A right nephrectomy was done a week later using the anterior subcostal approach. The postoperative course was smooth. Histopathological examination was diagnostic for xanthogranulomatous pyelonephritis. No adverse events were reported in the follow-up over 12 months. It can be concluded that a high degree of suspicion, rapid initiation of appropriate antibiotics and drainage of pus are crucial in the management of pyonephrosis.

Potential Perinatally Acquired Extended Spectrum β-Lactamase Escherichia coli Urinary Tract Infection in an Infant

Extended-spectrum β-lactamases (ESBL) are produced mainly by members of the Enterobacteriaceae family and confer resistance to most β-lactam antibiotics. Because of limited treatment options, ESBL infections are typically more challenging to treat resulting in poor outcomes, increased complications, and mortality. Because ESBL-producing organisms are primarily seen in critically ill patients, along with those patients having prolonged hospital stays, extensive courses of antimicrobials, and/or use of invasive medical devices (i.e., urinary catheters, central venous lines, or endotracheal tubes), guidelines regarding the management of ESBL-producing organisms in the pediatric population are scant. A review of current recommended treatment options for infections caused by ESBL-producing organisms centers on the use of carbapenems, with some supportive literature regarding the utility/effectiveness of other non-β-lactam therapy. We present a case report of an 8-month-old female diagnosed with a urinary tract infection due to ESBL-producing Escherichia coli successfully treated with sulfamethoxazole/trimethoprim. Multidrug resistant infections in pediatric patients without risk factors remains an important field of study because these unique infections may pose a problem when choosing an effective empiric antimicrobial therapy.

2019 Update on Pediatric Medical Overuse: A Systematic Review

IMPORTANCE

Medical overuse is common in pediatrics and may lead to unnecessary care, resource use, and patient harm. Timely scrutiny of established and emerging practices can identify areas of overuse and empower clinicians to reconsider the balance of harms and benefits of the medical care that they provide. A literature review was conducted to identify the most important areas of pediatric medical overuse in 2018.

OBSERVATIONS

Consistent with prior methods, a structured MEDLINE search and manual table of contents review of selected pediatric journals for the 2018 literature was conducted identifying articles pertaining to pediatric medical overuse. The structured MEDLINE search consisted of a PubMed search for articles with the Medical Subject Headings term health services misuse or medical overuse or article titles containing the term unnecessary, inappropriate, overutilization, or overuse. Articles containing the term overuse injury or overuse injuries were excluded, along with articles not published in English and those not constituting original research. The same search was performed using Embase with the additional Emtree term unnecessary procedure. Each article was evaluated by 3 independent raters for quality of methods, magnitude of potential harm, and number of patients potentially harmed. Ten articles were identified based on scores and appraisal of overall potential harm. This year's review identified both established and emerging practices that may warrant deimplementation. Examples of such established practices include antibiotic prophylaxis for urinary tract infections, routine opioid prescriptions, prolonged antibiotic courses for latent tuberculosis, and routine intensive care admission and pharmacologic therapy for neonatal abstinence syndrome. Emerging practices that merit greater inspection and discouragement of widespread adoption include postdischarge nurse-led home visits, probiotics for gastroenteritis, and intensive cardiac screening programs for athletes.

CONCLUSIONS AND RELEVANCE

This year's review highlights established and emerging practices that represent medical overuse in the pediatric setting. Deimplementation of disproven practices and careful examination of emerging practices are imperative to prevent unnecessary resource use and patient harm.

Enhanced quantitative urine culture technique, a slight modification, in detecting under-diagnosed pediatric urinary tract infection

Objectives

The pediatric urinary tract infection (UTI) often remains under-diagnosed or neglected owing to non-specific clinical presentations, patients failing to describe the actual situation and of clinical practice in diagnosis. The study was aimed to determine the etiologies of UTI in children with enhanced quantitative urine culture (EQUC) technique.

Results

Of enrolled 570 pediatric urine samples, the significant growth positivity was higher in EQUC 92 (16.15%) compared to standard urine culture (SUC) 73 (12.80%) technique. 20.6% of the significant isolates as detected with EQUC were missed on the SUC technique. The age group, in range 1–4 years, was more prone to the infection, where E. coli was the commonest pathogen. EQUC detected, probably all isolates, contributing UTI i.e. multidrug-resistant (MDR), extensive drug-resistant (XDR), and extended-spectrum β-lactamase (ESBL) producers, as some of them skipped on the SUC technique. Of total organisms isolated from EQUC, 46% were ESBL producer, 56.5% were MDR, and 1.4% were XDR. However, 40.5% ESBL, 44% MDR but no XDR detected on SUC. Hence a simple modification on conventional culture protocol could be a crucial modification for the detection of etiologies, contributing UTI, and hence to reduce inapt antimicrobial burden.

Urinary tract infection caused by extended-spectrum β-lactamase-producing bacteria: Risk factors and antibiotic resistance

BACKGROUND

The aim of this study was to investigate the risk factors for acquisition of extended spectrum β-lactamase (ESBL)-producing bacteria in community-acquired urinary tract infection (UTI) and to evaluate their antimicrobial resistance.

METHODS

The medical records of hospitalized children were retrospectively evaluated. Children with ESBL-producing bacteria UTI were matched with controls with non-ESBL-producing bacteria UTI of the same age and gender.

RESULTS

A total of 243 patients with community-acquired UTI in a 5 year period were evaluated, of whom 46% had UTI caused by ESBL bacteria. Seventy-seven cases were matched with 77 controls. There were no significant differences in the clinical presentation between the two groups apart from a longer hospital stay in the ESBL group (9.1 ± 5.5 days vs 8.0 ± 4.4 days, P = 0.013). Significant potential risk factors for ESBL-UTI were previous use of antibiotics in the last 3 months, previous hospitalization in the last 3 months, history of recurrent UTI, and presence of renal anomalies. On logistic regression analysis, history of previous hospitalization in the last 3 months (OR, 3.83; 95%CI: 1.49-9.84) was identified as an independent significant risk factor for ESBL-UTI. There was a significantly higher resistance to amoxicillin-clavulanate, amikacin, gentamycin and quinolones in the ESBL group compared with the control group.

CONCLUSION

Recognizing the risk factors for ESBL-UTI helps to identify the high-risk cases and enables proper management.

Direct molecular detection of amoxicillin-susceptible E. coli in urine samples from children with suspected urinary tract infection: A potential tool to improve antibiotic stewardship and patient care

BACKGROUND

Rapid detection of amoxicillin-susceptible Escherichia coli (ASEC) urinary tract infections (UTIs) could have a significant impact on patient care and improve antibiotic stewardship. This is especially true for infants and children, for whom antibiotic choices are more limited than for adults.

METHODS

A real-time polymerase chain reaction (PCR) uniplex panel for detection of ASEC using PCR assays for E. coli and five resistance genes (bla _TEM, bla _SHV, bla _OXA, bla _CTX-M, and bla _CMY) and an internal control was designed. PCR was then performed directly on pediatric urine samples using an inhibitor-resistant DNA polymerase. The main outcome measure was the performance of the PCR panel (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], accuracy) for the detection of ASEC. ASEC samples were defined as those that were E. coli PCR positive and PCR negative for all five resistance genes. PCR results were compared with the reference standard for culture and susceptibility testing.

RESULTS

Two hundred and six urine samples with pyuria (>10 white blood cells/high power field) were tested with the PCR panel. Two samples showed PCR inhibition (1%). For ASEC detection, the PCR panel showed a sensitivity of 91.53% (95% CI 81.32% to 97.19%), specificity of 98.21% (95% CI 90.45% to 99.95%), PPV of 98.18% (95% CI 88.54% to 99.74%), NPV of 91.67% (95% CI 82.61% to 96.22%), and accuracy of 94.78% (95% CI 88.99% to 98.06%).

CONCLUSIONS

This PCR method could potentially enable amoxicillin or ampicillin to be used in a greater proportion of children with E. coli UTIs, improving antibiotic stewardship.

Safety and Efficacy of Ceftazidime-Avibactam in the Treatment of Children ≥3 Months to <18 Years With Complicated Urinary Tract Infection: Results from a Phase 2 Randomized, Controlled Trial

BACKGROUND

Ceftazidime-avibactam is effective and well tolerated in adults with complicated urinary tract infection (cUTI), but has not been evaluated in children with cUTI.

METHODS

This single-blind, multicenter, active-controlled, phase 2 study (NCT02497781) randomized children ≥3 months to <18 years with cUTI (3:1) to receive intravenous (IV) ceftazidime-avibactam or cefepime for ≥72 hours, with subsequent optional oral switch. Total treatment duration was 7-14 days. Primary objective was assessment of safety. Secondary objectives included descriptive efficacy and pharmacokinetics. A blinded observer determined adverse event (AE) causality and clinical outcomes up to the late follow-up visit (20-36 days after the last dose of IV/oral therapy).

RESULTS

In total, 95 children received ≥1 dose of IV study drug (ceftazidime-avibactam, n = 67; cefepime, n = 28). The predominant baseline Gram-negative uropathogen was Escherichia coli (92.2%). AEs occurred in 53.7% and 53.6% patients in the ceftazidime-avibactam and cefepime groups, respectively. Serious AEs occurred in 11.9% (ceftazidime-avibactam) and 7.1% (cefepime) patients. One serious AE (ceftazidime-avibactam group) was considered drug related. In the microbiologic intent-to-treat analysis set, favorable clinical response rates >95% were observed for both groups at end-of-IV and remained 88.9% (ceftazidime-avibactam) and 82.6% (cefepime) at test-of-cure. Favorable per-patient microbiologic response at test-of-cure was 79.6% (ceftazidime-avibactam) and 60.9% (cefepime).

CONCLUSIONS

Ceftazidime-avibactam was well tolerated in children with cUTI, with a safety profile consistent with that of adults with cUTI and of ceftazidime alone, and appeared effective in children with cUTI due to Gram-negative pathogens.

Antibiotic Use and Resistance Pattern in Ethiopia: Systematic Review and Meta-Analysis

BACKGROUND

In the last decades, medicines have had an unprecedented positive effect on health, leading to reduced mortality and disease burden and consequently to an improved quality of life. The rapid and ongoing spread of antimicrobial-resistant organisms threatens our ability to successfully treat a growing number of infectious diseases. In the absence of the development of new generations of antibiotic drugs, appropriate use of existing antibiotics is needed to ensure the long-term availability of effective treatment for bacterial infections. Irrational use of antibiotics is an ongoing global public health problem that deserves more attention. This review is conducted to evaluate the prevalence of inappropriate antibiotic utilization and resistance to antibiotics in Ethiopia.

METHODS

Electronic search in PubMed/MEDLINE and Google was used to find published literature with reference lists of relevant articles searched manually. Titles and abstracts were initially screened for eligibility. The full texts of articles judged to be eligible were reviewed if they meet the inclusion criteria. Data were extracted on important variables like the sample size, region of the study, the inappropriate antibiotic use, bacterial detection rate, multidrug resistance pattern, and more other variables. Microsoft Excel was used for data extraction. Quantitative analysis was performed using STATA version 11.

RESULTS

The electronic searches identified 193 articles of which 33 were found eligible. The random-effects model was used to provide point estimates (with 95% confidence interval (CI)) of bacterial detection rate, inappropriate antibiotic use, and multidrug resistance rate to account for heterogeneity. The pooled bacteria detection rate was 29.1 with 95% CI (16.6-41.7). The pooled prevalence of multidrug resistant strains identified was 59.7% (95% CI: 43.5-75.9). The pooled estimate of inappropriate antibiotic use was 49.2% (95% CI: 32.2-66.2). The pooled proportion of self-antibiotic prescription was 43.3% (95% CI: 15.7-70.9). Other reasons for inappropriate antibiotic use included a wrong indication, wrong duration, improper route of administration, use of leftover antibiotics from a family member, and immature discontinuation of antibiotics.

CONCLUSION AND RECOMMENDATIONS

Inappropriate antibiotic use is a huge problem in Ethiopia, and many bacteria were resistant to commonly used antibiotics and similarly, multidrug-resistant bacterial strains are numerous. Appropriate antibiotic use should be ensured by prohibiting over-the-counter sale of antibiotics and strengthening antimicrobial stewardship.