What is the Diagnostic Accuracy of Novel Urine Biomarkers for Urinary Tract Infection?

Background

Urinary tract infection (UTI) affects half of women at least once in their lifetime. Current diagnosis involves urinary dipstick and urine culture, yet both methods have modest diagnostic accuracy, and cannot support decision-making in patient populations with high prevalence of asymptomatic bacteriuria, such as older adults. Detecting biomarkers of host response in the urine of hosts has the potential to improve diagnosis.

Objectives

To synthesise the evidence of the diagnostic accuracy of novel biomarkers for UTI, and of their ability to differentiate UTI from asymptomatic bacteriuria.

Design

A systematic review.

Data Sources and Methods

We searched MEDLINE, EMBASE, CINAHL and Web of Science for studies of novel biomarkers for the diagnosis of UTI. We excluded studies assessing biomarkers included in urine dipsticks as these have been well described previously. We included studies of adult patients (≥16 years) with a suspected or confirmed urinary tract infection using microscopy and culture as the reference standard. We excluded studies using clinical signs and symptoms, or urine dipstick only as a reference standard. Quality appraisal was performed using QUADAS-2. We summarised our data using point estimates and data accuracy statistics.

Results

We included 37 studies on 4009 adults measuring 66 biomarkers. Study quality was limited by case-control design and study size; only 4 included studies had a prospective cohort design. IL-6 and IL-8 were the most studied biomarkers. We found plausible evidence to suggest that IL-8, IL-6, GRO-a, sTNF-1, sTNF-2 and MCR may benefit from more rigorous evaluation of their potential diagnostic value for UTI.

Conclusions

There is insufficient evidence to recommend the use of any novel biomarker for UTI diagnosis at present. Further evaluation of the more promising candidates, is needed before they can be recommended for clinical use.

Antimicrobial resistance patterns of bacterial pathogens recovered from the urine of patients at Canadian hospitals from 2009 to 2020

Objectives

To investigate in vitro susceptibility patterns of bacterial pathogens recovered from the urine of outpatients (isolates from outpatient clinics or emergency departments) and hospital inpatients across Canada from 2009 to 2020 as part of the CANWARD study.

Methods

Canadian hospital microbiology laboratories submitted bacterial pathogens cultured from urine to the CANWARD study coordinating laboratory on an annual basis (January 2009 to December 2020). Antimicrobial susceptibility testing was performed by CLSI broth microdilution, with MICs interpreted by current CLSI breakpoints.

Results

In total, 4644 urinary pathogens were included in this study. Escherichia coli was recovered most frequently (53.3% of all isolates), followed by Enterococcus faecalis, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa and Staphylococcus aureus. Together, these six species accounted for 84.2% of study isolates. Nitrofurantoin demonstrated excellent in vitro activity versus E. coli, with 97.6% of outpatient and 96.1% of inpatient isolates remaining susceptible. In contrast, E. coli susceptibility rates were lower for ciprofloxacin (outpatient 79.5%, inpatient 65.9%) and trimethoprim/sulfamethoxazole (outpatient 75.2%, inpatient 73.5%). The percentage of E. coli isolates that were phenotypically positive for ESBL production significantly increased from 4.2% (2009-11) to 11.3% (2018-20). A similar although less pronounced temporal trend was observed with ESBL-producing K. pneumoniae.

Conclusions

E. coli was the pathogen most frequently recovered from the urine of Canadian patients, and the proportion of isolates that were ESBL producers increased over time. Susceptibility data presented here suggest that ciprofloxacin and trimethoprim/sulfamethoxazole may be suboptimal for the empirical treatment of complicated urinary infections.

Antibiotic Resistance in COVID-19 with Bacterial Infection: Laboratory-Based Surveillance Study at Single Tertiary Hospital in Indonesia

Purpose

Coronavirus disease 2019 (COVID-19) is a new pandemic affecting the respiratory system and caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition to the increased use of antibiotics, the length of stay of hospitalized patients affects the risk of bacterial infections among the COVID-19 patients. However, this pandemic has interrupted antibiotic surveillance activity and led to an information gap about the prevalence and characteristics of bacterial infection. This study aims to describe the antibiotic resistance in COVID-19 patients with culture-proven bacterial infection using a laboratory-based surveillance approach.

Patients and Methods

A retrospective study with a cross-sectional design was conducted on adult patients that confirmed positive for COVID-19 according to the International Classification of Diseases 10th Revision (ICD-10). From March 2020 to October 2021, data were obtained from the hospital information system and merged with the culture and antibiotic susceptibility test from laboratory information system at Hasan Sadikin General Hospital. The outcome is the prevalence percentage of resistance to selected antibiotics in patients with COVID-19. The resistance percentage is considered high when equal to or more than 20%.

Results

There was 2786 adult patient confirmed for COVID-19 according to the ICD-10, and 26.3% (n = 733) of them submitted clinical specimen for culture. The prevalence of bacterial infection among COVID-19 patients was 16.4%, predominating Gram-negative bacteria (GNB). The respiratory specimen dominated the positive growth culture. The GNB were predominantly discovered among the respiratory and non-respiratory specimens. High range resistance to ampicillin-sulbactam (24–100%), ceftriaxone (22–81%), cefotaxime (22–73%) and ciprofloxacin (20–86%) are observed among the GNB.

Conclusion

There is high resistance to fluoroquinolone and cephalosporins in identified isolate, commonly used as the first-line empirical treatment for respiratory and non-respiratory infection in Indonesia. The continuous antibiotic surveillance is mandatory and crucial to prevent the long-term effects of the COVID-19 pandemic, particularly bacterial infection.

Evaluation of the French surveillance system for epidemiological surveillance of antimicrobial resistance in the community and nursing homes

Background

Antimicrobial resistance (AMR) has been widely recognized as a major public health issue, which can be addressed through effective AMR surveillance systems. In 2018, a national surveillance programme for AMR in the community and nursing homes called Mission PRIMO was established in France. It builds on an existing network called MedQual-Ville that had been monitoring AMR mainly in the west of France community since 2003.

Objectives and Methods

To evaluate the MedQual-Ville surveillance activities and to formulate practical recommendations for improvement, using a semi-quantitative evaluation framework called OASIS.

Results

The evaluation showed that MedQual-Ville is overall a well-performing surveillance system. Its major strengths rely on excellent coordination and internal communication with clinical laboratories that participate on a voluntary basis. Surveillance objectives and procedures are clear to all participants. Hence, the quality and reliability of the data being produced is very high. At this stage, the major area for improvement is representativeness, with poor coverage achieved in several densely populated areas. Besides, the utility and impact of surveillance data could be improved by strengthening communication towards end-users, especially local prescribers.

Conclusions

There is currently no European programme or guidance for AMR surveillance in the community and nursing homes. Our results partly fill this gap, by evaluating how surveillance is being performed in France and providing recommendations that could be applicable to other countries with similar health systems. This work also highlighted the relevance of OASIS for evaluation of surveillance systems in the human sector.

Antimicrobial resistance among bacteria isolated from urinary tract infections in females in Namibia, 2016-2017

Background

The emergence of antimicrobial resistance (AMR) among bacterial pathogens demands a local understanding of the epidemiological situation. This information is needed both for clinical treatment decision-making purposes as well as for the revision of current care guidelines. Clinical AMR data from Namibia is sparse, whilst urinary tract infections remain not only widespread but they disproportionally affect females. This paper aims to describe the national antimicrobial resistance situation of major bacterial uropathogens in females within the 14 Namibian regions.

Method

Retrospective countrywide information on clinical urine cultures performed in females in Namibia in 2016–2017 was obtained from the national public health laboratory, Namibia Institute of Pathology (NIP). The data set included both microbiological findings as well as antimicrobial susceptibility test (AST) results. The AST was done as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Resistance to 3rd generation cephalosporins was indicative of Extended Spectrum-ß-lactamase (ESBL) production. Data analysis was done with WHONET using expert interpretation rules.

Results

In total, 22,259 urinary cultures were performed, of which 13,673 (61.4%) were culture positive. Gram-negative bacterial species accounted for 72.6% of the findings. The most common pathogens identified were Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis. Most of these were from young females, with a median age ranging from 28 to 32 years for the various pathogens. Resistance to ampicillin was 77.7% in E. coli and 84.9% in K. pneumoniae. In E. coli, resistance to 1^st line empiric therapy antibiotic, nitrofurantoin, was below 13%, except for one region that showed 59.2% resistance. Resistance to third generation cephalosporin (3GC) was used as a proxy for ESBL production. By year 2017, 3GC resistance was 22%, 31.4% and 8.3% for E. coli, K. pneumoniae and P. mirabilis, respectively.

Conclusion

We report high resistance to ampicillin, quinolones and sulfamethoxazole-trimethoprim amongst E. coli. Resistance rates to third-generation cephalosporins was also concerningly high at 22%. Resistance to carbapenems was low. However, superiority of nitrofurantoin was found, which provides rational support for the usefulness of nitrofurantoin as an empiric therapy regimen for the treatment of urinary tract infections in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01066-2.

Computerized decision support system (CDSS) use for surveillance of antimicrobial resistance in urinary tract infections in primary care

BACKGROUND

Hospital-based surveillance of antimicrobial resistance may be irrelevant as a guide to antimicrobial use for urinary tract infections (UTIs) in primary care.

OBJECTIVES

To highlight the value of online computerized decision support systems (CDSS) in providing information on the surveillance of antimicrobial resistance in community-acquired UTIs.

METHODS

We collected the susceptibility profile for key antibiotics by type of UTI involving Escherichia coli from 2017 to 2020, using queries for UTI (Q-UTI) submitted to a French CDSS. We compared these results with those from the MedQual French surveillance system for community-acquired UTI and the European Antimicrobial Resistance Surveillance Network (EARS-NET) for invasive infections.

RESULTS

We collected 43 591 Q-UTI, of which 10 192 (23%) involved E. coli: 40% cystitis, 32% male-UTI, and 27% pyelonephritis. Resistance was 41.3% (95% CI, 40.3%-42.2%) for amoxicillin, 16.6% (95% CI, 15.9%-17.3%) for fluoroquinolones, 6.6% (95% CI, 6.1%-7.0%) for third-generation cephalosporins (3GC), and 5.7% (95% CI, 5.2%-6.1%) for aminoglycosides. Resistance to amoxicillin was lower than that reported in MedQual (42.7%, P value = 0.004), and in EARS-NET (55.2%, P value < 0.001). For fluoroquinolones, resistance was higher than in MedQual (12.0%, P value < 0.001) and EARS-NET (15.8%, P value = 0.041). In complicated pyelonephritis and male UTI, fluoroquinolone resistance peaked at ∼20%. For 3GC, all UTI had higher resistance than in MedQual (3.5%, P value < 0.001), but lower than in EARS-NET (9.5%, P value < 0.001). Aminoglycoside resistance was not reported by MedQual, and was lower than in EARS-NET (7.1%, P value < 0.001).

CONCLUSIONS

CDSS can inform prescribers in real-time about the ecology and surveillance of E. coli resistance in community-acquired UTI. In complicated upper UTIs, they can underline the risk of empirical use of fluoroquinolones and suggest preferential use of 3GC.

Improving empiric antibiotic prescribing in pediatric bloodstream infections: a potential application of weighted-incidence syndromic combination antibiograms (WISCA)

Background: Increasing antibiotic resistance to WHO-recommended first- and second-line treatments of pediatric sepsis requires adaptation of prescribing guidelines. We discuss the potential and limitations of a weighted-incidence syndromic combination antibiogram (WISCA) as a practical tool for incorporating local microbiology data when assessing empiric coverage of commonly used antibiotics.Research design and methods: A brief questionnaire of 18 clinically significant isolates from pediatric blood cultures (Jan-Dec 2018) was sent to a global network of pediatric hospitals in July 2019. Weighted coverage estimates of non-antipseudomonal third-generation cephalosporins (3GC) and meropenem were estimated using Monte-Carlo simulation for each site reporting >100 isolates.Results: 52 hospitals in 23 countries in 5 WHO regions responded to the questionnaire; 13 sites met the sample size requirement. The most common isolates were S. aureus, Klebsiella spp., E. coli and Enterococcus spp. Coverage of 3GC ranged from 39% [95%CrI: 34-43%] to 73% (two sites: [95%CrI: 65-80%]; [95%CrI: 68-86%]) and meropenem coverage ranged from 54% [95%CrI: 47-60%] to 88% [95%CrI:84-91%].Conclusions: A WISCA is a data-driven, clinically intuitive tool that can be used to compare empiric antibiotic regimens for pediatric sepsis using existing large datasets. The estimates can be further refined using more complex meta-analytical methods and patient characteristics.

Obtaining nasal and rectal swabs from general practice patients to assess carriage of antibiotic resistant microorganisms: a feasibility study

PURPOSE

The aim of this study was to assess the feasibility of obtaining nasal and rectal swabs from general practice patients for measuring carriage of antibiotic resistant microorganisms in an area in Rotterdam (the Netherlands) with low socioeconomic status and a large immigrant population.

METHODS

Data collection was from May to December 2017, in one general practice in Rotterdam. We asked adults (≥18 years) visiting the general practitioner (GP) with complaints not related to infections for one nasal and two rectal swabs and tested these for highly resistant microorganisms (HRMOs). Indicators for feasibility were recruitment rate, implementation and acceptation of data collection procedures by the participants.

RESULTS

We obtained a nasal swab from all included 234 patients and 164 (70%) also gave rectal swabs. On average, 3 out of 30 invited patients (10%) were recruited per day. The GPs considered the workload high to inform and refer to eligible patients for the study and did this inconsistently. Most participants experienced the rectal swab procedure as burdensome and preferred assistance of a medical assistant above self-swabbing. A monetary incentive increased the willingness to provide rectal swabs.

CONCLUSIONS

Obtaining (nasal and) rectal swabs from general practice patients for study purposes proved difficult. Lessons learnt from this feasibility study will help increase participation in HRMO prevalence studies among asymptomatic general practice patients.

Routine laboratory surveillance of antimicrobial resistance in community-acquired urinary tract infections adequately informs prescribing policy in England

Objectives

To assess whether resistance estimates obtained from sentinel surveillance for antimicrobial resistance (AMR) in community-acquired urinary tract infections (UTIs) differ from routinely collected laboratory community UTI data.

Methods

All patients aged ≥18 years presenting to four sentinel general practices with a suspected UTI, from 13 November 2017 to 12 February 2018, were asked to provide urine specimens for culture and susceptibility. Specimens were processed at the local diagnostic laboratory. Antibiotic susceptibility testing was conducted using automated methods. We calculated the proportion of Escherichia coli isolates that were non-susceptible (according to contemporaneous EUCAST guidelines) to trimethoprim, nitrofurantoin, cefalexin, ciprofloxacin and amoxicillin/clavulanic acid, overall and by age group and sex, and compared this with routine estimates.

Results

Sentinel practices submitted 740 eligible specimens. The specimen submission rate had increased by 28 specimens per 1000 population per year (95% CI 21-35). Uropathogens were isolated from 23% (169/740) of specimens; 67% were E. coli (113/169). Non-susceptibility of E. coli to trimethoprim was 28.2% (95% CI 20.2-37.7) on sentinel surveillance (33.4%; 95% CI 29.5-37.6 on routine data) and to nitrofurantoin was 0.9% (95% CI 0-5.7) (1.5%; 95% CI 0.7-3.0 on routine data).

Conclusions

Routine laboratory data resulted in a small overestimation in resistance (although the difference was not statistically significant) and our findings suggest that it provides an adequate estimate of non-susceptibility to key antimicrobials in community-acquired UTIs in England. This study does not support the need for ongoing local sentinel surveillance.

Antibiotic resistance in urinary tract infections: A re-visit after five years and experience over two sites

OBJECTIVE

The aim of this study was to repeat a previous audit, performed from 2009 to 2013, for the cohort of 2018 to determine how the resistance rates in urinary pathogens in women over 18 years of age have changed. A secondary aim of the study was to use resistance data from a different UK hospital in the same year to compare differences in resistance rates across different geographic locations.

STUDY DESIGN

This was a retrospective study of all positive urine cultures grown from female patients attending two different hospitals in the year 2018. Resistance patterns were analysed.

RESULTS

The resistance rate to co-amoxiclav continues to increase with amoxicillin retaining high resistance patterns. There are some significant differences in resistance patterns between the different locations.

CONCLUSION

Antimicrobial resistance is a significant problem in the UK particularly in antibiotics used to treat UTI. These patterns can vary across different geographical locations and over time; therefore, up-to-date knowledge of local anti-biotic resistance is essential when making an appropriate prescription choice.

Pathways to optimising antibiotic use in rural China: identifying key determinants in community and clinical settings, a mixed methods study protocol

INTRODUCTION

This study aims to investigate patterns of antibiotic treatment-seeking, describe current levels of and drivers for antibiotic use for common infections (respiratory tract and urinary tract infections) and test the feasibility of determining the prevalence and epidemiology of antimicrobial resistance (AMR) in rural areas of Anhui province, in order to identify potential interventions to promote antibiotic stewardship and reduce the burden of AMR in China.

METHODS AND ANALYSIS

We will conduct direct observations, structured and semistructured interviews in retail pharmacies, village clinics and township health centres to investigate treatment-seeking and antibiotic use. Clinical isolates from 1550 sputum, throat swab and urine samples taken from consenting patients at village and township health centres will be analysed to identify bacterial pathogens and ascertain antibiotic susceptibilities. Healthcare records will be surveyed for a subsample of those recruited to the study to assess their completeness and accuracy.

ETHICS AND DISSEMINATION

The full research protocol has been reviewed and approved by the Biomedical Ethics Committee of Anhui Medical University (reference number: 20170271). Participation of patients and doctors is voluntary and written informed consent is sought from all participants. Findings from the study will be disseminated through academic routes including peer-reviewed publications and conference presentations, via tailored research summaries for health professionals, health service managers and policymakers and through an end of project impact workshop with local and regional stakeholders to identify key messages and priorities for action.

Community acquired urinary tract infections among adults in Accra, Ghana

Background: Urinary tract infection (UTI) is one of the most common bacterial infectious diseases encountered in clinical practice, and accounts for significant morbidity and high medical costs. To reduce its public health burden, there is the need for local research data to address aspects of prevention and management of UTI. The aim of this study was to investigate community-acquired UTI among adults in Accra, Ghana, including the risk factors, etiological agents, and antibiotic resistance. Methods: This was a cross-sectional study involving 307 patients clinically diagnosed with UTI at the Korle Bu and Mamprobi polyclinics in Accra. Urine specimens were collected from the study participants and analyzed by culture, microscopy, and dipstick. The bacterial isolates were identified using standard microbiological methods and tested against a spectrum of antibiotics by the Kirby Bauer method. Multidrug resistant Enterobacteriaceae isolates were screened for Extended Spectrum β-lactamase (ESBL) production by the double disc method, and isolates that tested positive were analyzed by Polymerase Chain Reaction for ESBL genes. Demographic information and clinical history of study participants were collected. Results: Based on the criteria for laboratory confirmed UTI, 31 (10.1%) of the 307 specimens were positive and the main risk factor of UTI among the study participants was pregnancy (P=0.02, OR=2.43). The most common uropathogen isolated was Escherichia coli (48.9%), followed by Klebseilla sp. (16.1%). Prevalence of resistance was highest for Piperacillin (87.1%) and Amoxicillin+Clavulanic Acid (87.1%) and lowest for Amikacin (12.9%). Prevalence of multidrug resistance among the uropathogens was 80.1% (25) and the most common ESBL gene detected was CTX-M-15. Conclusion: Pregnant women constitute the key risk population of UTI in Accra, while Amikacin remains a suitable drug for the treatment of febrile UTI. The high prevalence of multidrug resistance among the uropathogens highlights the need for surveillance of antimicrobial resistance among these pathogens.

Assessment, management and prevention of urinary tract infections in men

While urinary tract infections (UTIs) are uncommon in healthy men aged under 50 years, their prevalence rises in men aged over 65 years. UTIs can be classified as uncomplicated or complicated. UTI in men is considered to be more complicated than in women, because it is often related to abnormalities of the urinary tract, such as prostatic enlargement or a urethral stricture. UTI is associated with a significant disease burden and cost to patients and healthcare organisations. It is one of the most common reasons for prescription of antibiotics in primary care; however, because antibiotic resistance is becoming increasingly widespread, it is essential that these drugs are used prudently. The main strategy for preventing UTIs in men is to avoid the use of indwelling catheters.

Stratification by demographic and clinical data of the antibiotic susceptibility of Escherichia coli from urinary tract infections of the community

Aim

To determine the patterns of antibiotic susceptibility of Escherichia coli strains isolated from adult patients with urinary tract infection (UTI), and to stratify the results by age and type of UTI to verify if there are statistically significant differences that can help physicians to prescribe better empirical antibiotherapy.

Design

Cross-sectional prospective study.

Location

Community of Getafe (Madrid). Primary care level.

Participants

100 E. coli strains, randomly chosen, isolated from the urine (10⁴–10⁵ cfu/ml) of different patients from primary care centers in the Getafe area.

Main measurements

The antibiotic susceptibility of the strains was evaluated and the results were stratified by age and type of UTI. The clinical and demographic data of the patients were analyzed, classifying each episode as complicated UTI or uncomplicated UTI.

Results

Strains isolated from patients with uncomplicated UTI showed significantly greater susceptibility than those of complicated UTI to amoxicillin (65.9% vs. 30.6%, p = 0.001), amoxicillin/clavulanic acid (95.5% vs. 77.6%, p = 0.013) and ciprofloxacin (81.8% vs. 63.3%, p = 0.047). In complicated UTI, susceptibility to ciprofloxacin was significantly greater in the ≤65 years age group compared to the older age group (78.3% vs. 50%, respectively, p = 0.041). In the rest of antibiotics, no statistically significant differences were obtained when comparing by age (≤65 years versus >65 years), both in uncomplicated and complicated UTI.

Conclusions

Clinical and demographic data of patients with UTI are of great importance in the results of the antibiotic susceptibility in E. coli. Antibiograms stratified by patient characteristics may better facilitate empirical antibiotic selection for UTI in primary care.

Antibiotic-Resistant E. coli in Uncomplicated Community-Acquired Urinary Tract Infection

BACKGROUND

Routine urine culture testing is not recommended for uncomplicated urinary tract infections (UTIs). As a result, the antibiotic resistance patterns or the organisms causing UTIs are not adequately reflected in routine data. We studied the sensitivity of Escherichia coli (E. coli) to trimethoprim (TMP) and to cotrimoxazole (i.e., trimethoprim/sulfamethoxazole, TMP/SMX) in community-acquired UTI and compared the findings with the resistance data of the Antimicrobial Resistance Surveillance System (ARS).

METHODS

General practitioners and internists in private practice prospectively recruited all of their adult patients with symptoms of a urinary tract infection from May 2015 to February 2016. Urine specimens from all patients were tested (including urine culture testing and antibiotic susceptibility) and infections were defined as uncomplicated or complicated UTIs.

RESULTS

1245 participants from 58 medical practices were enrolled in the study. Pathogenic organisms were found in the urine of 877 patients, of whom 74.5% had E. coli infections. Among the E.-coli-positive UTIs, 52.4% were classified as uncomplicated and 47.6% as complicated. The prevalence of E. coli that was resistant to TMP and to TMP/SMX in uncomplicated UTIs was 15.2% and 13.0%, respectively, compared to 25.3% and 24.4%, respectively, from all UTIs in ARS in 2015. Study participants who had previously taken antibiotics had the highest prevalence of E. coli resistance (30.9%), followed by those who had two or more UTIs within the past six months (28.9%).

CONCLUSION

E. coli with resistance to TMP was significantly less prevalent among the study patients with uncomplicated UTIs than in the routine data of the ARS. Accordingly, TMP should still be considered as an option for the treatment of uncomplicated UTIs. TMP/SMX is considered the agent of second choice because of its side effects. Surveillance systems based on routine data do not yield a representative sample for the evaluation of the resistance situation in patients with uncomplicated UTIs.

Global research output in antimicrobial resistance among uropathogens: A bibliometric analysis (2002-2016)

OBJECTIVES

Antimicrobial resistance (AMR) among uropathogens contributes to treatment failure. Research in AMR among uropathogens is important to establish treatment options. This study assessed global research trends in AMR among uropathogens.

METHODS

SciVerse Scopus was used to retrieve relevant documents for the period 2002-2016. Only journal articles were included in the analysis. Analysis of author keywords was carried out using VOSviewer.

RESULTS

A total of 1087 journal articles were retrieved with an h-index of 50. The number of publications increased noticeably in the past decade. Analysis of subject areas of retrieved documents showed that 275 (25.3%) articles were in molecular biology/genetics/microbiology/immunology, 197 (18.1%) were in pharmacological/therapeutic approaches for treatment of urinary tract infections and 615 (56.6%) were in epidemiology/public health. Terms such as multidrug-resistant and extended-spectrum β-lactamases (ESBLs) appeared more frequently in documents published in the period 2012-2016. The mean number of authors per article was 5.3. Most active authors in this field were from Japan. The USA ranked first with 148 documents (13.6%), followed by India (97; 8.9%) and Iran (84; 7.7%). The top productive institution was Tehran University of Medical Sciences (21 publications), followed by Kobe University in Japan (20 publications). The Journal of Antimicrobial Chemotherapy ranked first with 33 publications.

CONCLUSION

Research in AMR among uropathogens showed a noticeable increase in the past decade. Reports of increasing incidence of resistance among uropathogens were published from different parts of the world. Empirical therapy should be based on updated research in AMR.

Antibiotic use, knowledge and health literacy among the general population in Berlin, Germany and its surrounding rural areas

Objectives

Knowledge concerning antibiotic use in the general population is insufficient. The way health literacy is related to antibiotic use aside from knowledge needs further investigation. Our aim was to compare the levels of knowledge of antibiotics and health literacy in individuals who had taken antibiotics in recent years compared with those who not had taken antibiotics.

Methods

A population-based cross-sectional survey of 2,000 individuals aged 35 and older from Berlin, Germany and its surrounding rural and suburban areas (response rate 59%) with strata urban/rural, sex, age, and education. Computer-assisted personal interviews were conducted by external, trained interviewers during home visits. Knowledge, health literacy, and antibiotic use were assessed using standardized questionnaires.

Results

In all, 33.3% (666/2,000) of the participants indicated having had an antimicrobial therapy during the previous 12 months. Adjusting for sex, age, educational level and health literacy, individuals with four correct answers regarding antibiotics were 1.70 times and those with three correct answers 1.94 more likely to have had a history of recent antibiotic use than those who did not have any correct answers. Individuals with sufficient health literacy were 0.57 times less likely to have had a recent history of antibiotic use than individuals with insufficient health literacy.

Conclusion

Patients who have used antibiotics might have more knowledge as a result of their recent involvement with the topic of antibiotic use; health literacy may be a preventive mechanism to use antibiotics more critically. Besides improving the health knowledge of the general population and of vulnerable groups such as patients with low levels of health literacy, intervention strategies should focus on providers as well.

ESBL-producing Escherichia coli and Its Rapid Rise among Healthy People

Since around the 2000s, Escherichia coli (E. coli) resistant to both oxyimino-cephalosporins and fluoroquinolones has remarkably increased worldwide in clinical settings. The kind of E. coli is also identified in patients suffering from community-onset infectious diseases such as urinary tract infections. Moreover, recoveries of multi-drug resistant E. coli from the feces of healthy people have been increasingly documented in recent years, although the actual state remains uncertain. These E. coli isolates usually produce extended-spectrum β-lactamase (ESBL), as well as acquisition of amino acid substitutions in the quinolone-resistance determining regions (QRDRs) of GyrA and/or ParC, together with plasmid-mediated quinolone resistance determinants such as Qnr, AAC(6')-Ib-cr, and QepA. The actual state of ESBL-producing E. coli in hospitalized patients has been carefully investigated in many countries, while that in healthy people still remains uncertain, although high fecal carriage rates of ESBL producers in healthy people have been reported especially in Asian and South American countries. The issues regarding the ESBL producers have become very complicated and chaotic due to rapid increase of both ESBL variants and plasmids mediating ESBL genes, together with the emergence of various "epidemic strains" or "international clones" of E. coli and Klebsiella pneumoniae harboring transferable-plasmids carrying multiple antimicrobial resistance genes. Thus, the current state of ESBL producers outside hospital settings was overviewed together with the relation among those recovered from livestock, foods, pets, environments and wildlife from the viewpoint of molecular epidemiology. This mini review may contribute to better understanding about ESBL producers among people who are not familiar with the antimicrobial resistance (AMR) threatening rising globally.

Bacteriology in uncomplicated urinary tract infections in Norwegian general practice from 2001-2015

Background

Uncomplicated urinary tract infections in women are common, and urine samples from these patients are not routinely cultured. Empirical treatment is based on knowledge of resistance patterns for common uropathogens.

Aim

To evaluate the bacteriological findings and resistance patterns in urine samples from women with uncomplicated urinary tract infections, and to assess the relationship between antimicrobial use and resistance patterns from 2000–2015 in Norway.

Method

Bacteriology and resistance patterns were compared in 184 urine cultures from 2001, 406 urine cultures from 2010–2011 and 259 urine cultures from 2013–2015. Antibiotic use data from 2000–2015 were obtained from national databases.

Results

Escherichia coli (E. coli) was the main bacterial agent in 80% of the cultures. Staphylococcus saprophyticus (Staph. saprophyticus) represented 6–17%. For E. coli, resistance to mecillinam showed some variation but remained below 9%. There was negligible resistance to nitrofurantoin. Resistance to trimethoprim seemed to stabilise over the last 5 years at around 20%. Amoxicillin resistance had some variations, but remained stable around 30%. There was a steady rise in total consumption of selected antibiotics commonly used to treat urinary tract infections for the period 2000–2015.

Conclusion

Mecillinam and nitrofurantoin are both excellent first choices for empirical treatment of uncomplicated urinary tract infections. This study suggests that increasing resistance to trimethoprim challenges the rationale for its use as a first-line agent.

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

Objectives

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

Methods

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

Results

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

Conclusions

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