The Clinical Significance of High Antimicrobial Resistance in Community-Acquired Urinary Tract Infections

Degree of awareness and practices on urinary tract infections: A study of Sri Lankan school teachers selected from a chronic kidney disease high-prevalent setting

OBJECTIVE

As key stakeholders in educational settings, teachers' awareness on Urinary Tract Infections (UTI) will ultimately enhance its management in schools and community. This study aimed to assess the level of knowledge, attitudes, and practices (KAP) on UTIs among teachers in Sri Lanka.

MATERIALS AND METHODS

Conveniently selected 373 school teachers were assessed using a pre-tested questionnaire. Each of the individual was scored and categorized as either satisfactory or poor. Descriptive statistics and chi-square tests were performed to describe the outcomes.

RESULTS

Around 80% of respondents demonstrated awareness regarding the microbial origin of UTIs, while 42% possessed knowledge of women's increased susceptibility to UTIs. Over 90% of participants had favorable attitudes toward drinking adequate amounts of water, personal hygiene, and consulting doctors for UTI symptoms. Each inquiry demonstrated significant disparities between individuals with satisfactory and poor attitudes (p = 0.000), with over 95% adhered to effective hygiene practices as a preventive measure against UTIs. The demographics of the participants did not show any significance over the KAP results of the study (p < 0.05).

CONCLUSIONS

The study revealed satisfactory levels of awareness and favorable attitudes among respondents on UTIs. However, there is a further need for increased awareness, specifically regarding the risk factors associated with UTIs.

Uropathogenic E. coli and Hybrid Pathotypes in Mexican Women with Urinary Tract Infections: A Comprehensive Molecular and Phenotypic Overview

Uropathogenic Escherichia coli (UPEC) is the main cause of urinary tract infections (UTIs) and carries virulence and resistance factors often found in mobilizable genetic elements, such as plasmids or pathogenicity islands (PAIs). UPEC is part of the extraintestinal pathogenic E. coli (ExPEC), but hybrid strains possessing both diarrheagenic E. coli (DEC) and ExPEC traits, termed "hypervirulent", present a significant health threat. This study assessed the prevalence of UPEC PAIs, ExPEC sequence types (ST), DEC genes, carbapenemase and extended-spectrum β-lactamase (ESBL) phenotypes, resistance genotypes, and plasmids in 40 clinical isolates of UPEC. Results showed that 72.5% of isolates had PAIs, mainly PAI IV536 (53%). ESBL phenotypes were found in 65% of β-lactam-resistant isolates, with 100% of carbapenem-resistant isolates producing carbapenemase. The predominant ESBL gene was blaCTX-M-2 (60%), and the most common resistance gene in fluoroquinolone and aminoglycoside-resistant isolates was aac(6')Ib (93%). Plasmids were present in 57% of isolates, and 70% belonged to the ST131 clonal group. Molecular markers for DEC pathotypes were detected in 20 isolates, with 60% classified as hybrid pathotypes. These findings indicate significant pathogenic potential and the presence of hybrid pathotypes in E. coli UTI clinical isolates in the Mexican population.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Laboratory Tests, Bacterial Resistance, and Treatment Options in Adult Patients Hospitalized with a Suspected Urinary Tract Infection

Patients treated for systemic urinary tract infections commonly have nonspecific presentations, and the specificity of the results of the urinalysis and urine cultures is low. In the following narrative review, we will describe the widespread misuse of urine testing, and consider how to limit testing, the disutility of urine cultures, and the use of antibiotics in hospitalized adult patients. Automated dipstick testing is more precise and sensitive than the microscopic urinalysis which will result in false negative test results if ordered to confirm a positive dipstick test result. There is evidence that canceling urine cultures if the dipstick is negative (negative leukocyte esterase, and nitrite) is safe and helps prevent the overuse of urine cultures. Because of the side effects of introducing a urine catheter, for patients who cannot provide a urine sample, empiric antibiotic treatment should be considered as an alternative to culturing the urine if a trial of withholding antibiotic therapy is not an option. Treatment options that will decrease both narrower and wider spectrum antibiotic use include a period of watching and waiting before antibiotic therapy and empiric treatment with antibiotics that have resistance rates > 10%. Further studies are warranted to show the option that maximizes patient comfort and safety.

Therapeutic strategies for uncomplicated cystitis in women

Uncomplicated cystitis is affecting many women of all ages and has a great impact on the quality of life, especially in women suffering from recurrent, uncomplicated cystitis. By far the most frequent uropathogen, E. coli, may have acquired increasing resistance against a variety of oral antibiotics, which may differ between countries and regions. Therefore, local resistance data are important to be considered. On the other hand, non-antibiotic therapy has also become an option which should be discussed and offered to the patient. In patients suffering from recurrent uncomplicated cystitis, individual risk factors and possible behavioral changes should first be taken into account. Non-antimicrobial prophylactic strategies shown to be successful in well-designed clinical studies are the next options. Long term antibiotic prophylaxis, however, should only be considered as a last option. For some of those patients self-diagnosis and self-treatment may be suitable, e.g. by using a recognized questionnaire.

Current state of research on the clinical benefits of herbal medicines for non-life-threatening ailments

Herbal medicines are becoming increasingly popular among patients because they are well tolerated and do not exert severe side effects. Nevertheless, they receive little consideration in therapeutic settings. The present article reviews the current state of research on the clinical benefits of herbal medicines on five indication groups, psychosomatic disorders, gynecological complaints, gastrointestinal disorders, urinary and upper respiratory tract infections. The study search was based on the database PubMed and concentrated on herbal medicines legally approved in Europe. After applying defined inclusion and exclusion criteria, 141 articles were selected: 59 for psychosomatic disorders (100% randomized controlled trials; RCTs), 20 for gynecological complaints (56% RCTs), 19 for gastrointestinal disorders (68% RCTs), 16 for urinary tract infections (UTI, 63% RCTs) and 24 for upper respiratory tract infections (URTI) (79% RCTs). For the majority of the studies, therapeutic benefits were evaluated by patient reported outcome measures (PROs). For psychosomatic disorders, gynecological complaints and URTI more than 80% of the study outcomes were positive, whereas the clinical benefit of herbal medicines for the treatment of UTI and gastrointestinal disorders was lower with 55%. The critical appraisal of the articles shows that there is a lack of high-quality studies and, with regard to gastrointestinal disorders, the clinical benefits of herbal medicines as a stand-alone form of therapy are unclear. According to the current state of knowledge, scientific evidence has still to be improved to allow integration of herbal medicines into guidelines and standard treatment regimens for the indications reviewed here. In addition to clinical data, real world data and outcome measures can add significant value to pave the way for herbal medicines into future therapeutic applications.

Impact of antibiotic intake on the incidence of extended-spectrum β-lactamase-producing Enterobacterales in sub-Saharan Africa: results from a community-based longitudinal study

OBJECTIVES

The global prevalence of intestinal extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) is approximately 17% in communities, with significant variations among regions. This longitudinal study aimed to assess the impact of antibiotic intake on the incidence of intestinal ESBL-PE in Ghanaian pharmacy customers outside of hospitals.

METHODS

Screening for ESBL-PE was performed in four independent pharmacies in Kumasi, Ghana, using rectal swabs and an ESBL-PE-selective medium. Pharmacy customers purchasing antibiotics were recruited, and those buying non-antibiotic drugs served as controls. Participants who were negative for ESBL-PE provided follow-up swabs for up to 28 days.

RESULTS

At baseline, 302 (75%) of 404 participants were colonized with ESBL-PE. Sixty-three participants who were negative for ESBL-PE at baseline received per-protocol follow-up, including 28 individuals who took antibiotics and 35 controls. The cumulative proportions of ESBL-PE in the antibiotics and control groups were 71% (20/28) and 54% (19/35) at the first follow-up (p 0.258), 86% (24/28) and 80% (28/35) at the second follow-up (p 0.741) and 86% (24/28) and 94% (33/35) at the third follow-up (p 0.393), respectively.

DISCUSSION

The rate of intestinal ESBL-PE carriage among pharmacy customers outside of hospitals was higher than expected at baseline and further increased during the 28 days of follow-up, irrespective of antibiotic intake. This alarming finding needs to be considered in the antibiotic treatment of outpatients and emphasizes the urgent need for improved prevention strategies, development of new antibiotic drugs and potential future elimination strategies. Further longitudinal studies on ESBL-PE in African communities, also outside of pharmacy settings, are required.

Uropathogenic Escherichia coli in Mexico, an Overview of Virulence and Resistance Determinants: Systematic Review and Meta-analysis

BACKGROUND

Urinary tract infections (UTI) are one of the most common pathologies in Mexico and the majority are caused by uropathogenic Escherichia coli (UPEC). UPEC possesses virulence and resistance determinants that promote UTI development and affect diagnosis and treatment. This study aims to systematically review published reports of virulence genes, antibiotic resistance, and phylogenetic groups prevalent in clinical isolates of UPEC in the Mexican population.

METHODS

Systematic review with meta-analysis was performed following PRISMA guidelines. Articles in both English and Spanish were included. Total prevalence with a 95% confidence interval of each characteristic was calculated. Heterogeneity between studies and geographical areas was assessed by the Cochran Q test (Q), I-square (I²), and H-square (H²). Egger's test was used for risk of bias in publications and asymmetry evaluations.

RESULTS

Forty-two articles were analyzed. The most prevalent virulence genes were ecp (97.25%; n = 364) and fimH (82.34%; n = 1,422), which are associated with lower UTI, followed by papGII (40.98%; n = 810), fliC (38.87%; n = 319), hlyA (23.55%; n = 1,521), responsible for with upper UTI. More than 78.13% (n = 1,893) of the isolates were classified as multidrug-resistant, with a higher prevalence of resistance to those antibiotics that are implemented in the basic regimen in Mexico. The most frequently reported Extended Spectrum β-Lactamase (ESBL) was CTX-M-1 (55.61%; n = 392), and the predominant phylogroup was B2 (35.94%; n = 1,725).

CONCLUSION

UPEC strains are responsible for a large portion of both lower and upper UTI in Mexico, and their multi-drug resistance drastically reduces the number of therapeutic options available.

Characteristics of Hospitalized Adults With Recurrent Urinary Tract Infection Due to Extended Spectrum Beta-Lactamase Producing Escherichia coli in a Tertiary Center in Saudi Arabia

BACKGROUND

The increase in extended-spectrum β-lactamase (ESBL) producing microbes in recent years represents a major challenge.

AIM

To study the risk factors for urinary tract infections (UTIs) caused by ESBL-producing Escherichia coli in patients requiring hospitalization for treatment.

MATERIALS AND METHOD

Electronic health records were used to identify 616 inpatients over the age of 18 who had UTI symptoms and/or signs and an ESBL-producing E. coli strain cultured on urine culture between January 1 and December 31, 2018. The electronic health care records of these patients were searched to identify those patients with previous UTIs due to an ESBL-producing E. coli grown on urine culture. Patients with cancer or those taking prophylactic antibiotics or immunosuppression were excluded.

RESULT

Risk factors for the acquisition of ESBL-producing E. coli included male sex (P = 0.0032), age over 66 years (P < 0.0001), renal stones (P = 0.0021), urology intervention within six months of presentation (P = 0.0360), pressure sores (P = 0.0002), feeding tubes (P = 0.0076), and urinary catheter (P = 0.0023). Comorbidities (e.g., diabetes mellitus and duration of antibiotic therapy were not associated with an increased risk of recurrence of ESBL-producing E. coli UTI (P = 0.4680, P = 0.3826, respectively).

CONCLUSION

Antimicrobial stewardship programs may have reduced the development of antimicrobial resistance in E. coli. However, the recognition of risk factors for UTI caused by ESBL-producing E. coli may facilitate the early detection of high-risk cases and guide treatment decisions. This can improve patient outcomes while decreasing the length of the hospital stay.

Increasing rates of extended-spectrum B-lactamase-producing Escherichia coli and Klebsiella pneumoniae in uncomplicated and complicated acute pyelonephritis and evaluation of empirical treatments based on culture results

Increasing rates of extended-spectrum beta-lactamase (ESBL) producing E. coli and K. pneumoniae over time made empirical treatment complicated. Knowing local antimicrobial resistance patterns of common pathogens can make it easier to decide on empirical antibiotics. We aimed to investigate the prevalence and risk factors of ESBL positivity of E. coli and K. pneumoniae strains in uncomplicated and complicated pyelonephritis acquired in community and healthcare associations and to evaluate the appropriateness of empirical treatment. Adult patients hospitalized with diagnosis of community-acquired or healthcare-associated uncomplicated/complicated pyelonephritis initiated empirical antimicrobial therapy were included in the study. Appropriateness of empirical treatment at 48-72 h based on culture results and treatment modifications were evaluated. A total of 369 uncomplicated (94) and complicated (275) episodes of pyelonephritis were evaluated. The most common agents were E. coli (71.0%) and K. pneumoniae (17.7%), and the ESBL-production rate was 64.4%, and higher in healthcare-associated pyelonephritis (P 0.013). Being of healthcare-associated infection, previous antibiotic use, and presence of urinary catheters were independent risk factors for ESBL-producing E. coli and K. pneumoniae (P 0.009, < 0.001, and 0.024, respectively). The treatment inappropriateness was mostly associated with use of ceftriaxone (56.3%) (P < 0.001). Treatment has escalated in 41.5% of ceftriaxone-initiated patients, in only 8.8% and 9.5% ertapenem and piperacillin-tazobactam-initiated patients, respectively. ESBL-production rates are quite high even in community-acquired infections. The use of broad-spectrum antibiotics covering ESBL-producing pathogens to increase the appropriateness of empirical treatment and then narrowing treatment based on culture results appears a better and life-saving choice.

Combating antimicrobial resistance with cefiderocol for complicated infections involving the urinary tract

Cefiderocol is a unique siderophore cephalosporin antimicrobial agent that has shown promise in treating complicated urinary tract infections (cUTI). Urinary tract infections are commonly diagnosed infections with risk increasing with age and prevalence more common in women. cUTI poses a risk of recurrence and is more likely to be associated with antibiotic-resistant bacteria. The Food and Drug Administration approved cefiderocol for use as a last-line option in the treatment of cUTI including pyelonephritis. Cefiderocol has activity against all forms of carbapenemases due to its ability to overcome the mechanisms of carbapenemase resistance. Because of this, resistance to cefiderocol is unlikely to occur. Studies show cefiderocol is well tolerated among younger patients and patients greater than 65 years of age, the latter making up most of the study population. Renal dose adjustments are recommended. Dose adjustment in the presence of hepatic impairment is not recommended, as hepatic clearance represents a minor elimination pathway for cefiderocol. The ability of cefiderocol to overcome multiple resistance mechanisms makes it a novel choice in combating multidrug-resistant bacteria in the treatment of cUTI.

A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are a common problem in women. Management is mainly based on empirical prescribing, but there are concerns about overtreatment and antimicrobial resistance (AMR), especially in patients with recurrent uUTIs.

METHODS

A multidisciplinary panel of experts met to discuss diagnosis, treatment, prevention, guidelines, AMR, clinical trial design, and the impact of COVID-19 on clinical practice.

RESULTS

Symptoms remain the cornerstone of uUTI diagnosis, and urine culture is necessary only when empirical treatment fails, or rapid recurrence of symptoms or AMR is suspected. Specific antimicrobials are first-line therapy (typically nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam; dependent on availability and local resistance data). Fluoroquinolones are not first-line options for uUTIs due primarily to safety concerns, but also rising resistance rates. High-quality data to support most non-antimicrobial approaches are lacking. Local AMR data specific to community-acquired uUTIs are needed, but representative information is difficult to obtain; instead, identification of risk factors for AMR can provide a basis to guide empirical antimicrobial prescribing. The COVID-19 pandemic has impacted management of uUTIs in some countries and may have long-lasting implications for future models of care.

CONCLUSIONS

The management of uUTIs in women can be improved without increasing complexity, including simplified diagnosis, and empirical antimicrobial prescribing based on patient characteristics, including review of recent antimicrobial use and past pathogen resistance profiles, drug availability, and guidelines. Current data for non-antimicrobial approaches are limited. The influence of COVID-19 on telehealth could provide an opportunity to enhance patient care in the long term.

Antimicrobial susceptibility testing profiles of ESBL-producing Enterobacterales isolated from hospital and community adult patients in Blantyre, Malawi

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Extended-spectrum β-lactamase (ESBL) strains are an increasingly global health issue

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ESBL-Enterobacteriaceae isolates affected 64% of inpatients and 36% of outpatients

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ESBL-E isolates had high antimicrobial resistance; most were multi-drug resistant

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Surveillance systems are needed to monitor antimicrobial resistance in Malawi

Objective

There is a paucity of data on antimicrobial resistance (AMR) in Malawi. Here we present a study of AMR of extended-spectrum β-lactamases-producing Enterobacterales (ESBL-E) isolated from hospital and community settings in Blantyre, Malawi.

Design and Methods

A cross-sectional study was conducted between March and November 2020, involving 403 adult participants aged ≥18 years. Screening for ESBL-E was performed using CHROMagar ESBL medium. Production of ESBLs was confirmed by a combination disk test method. Antimicrobial susceptibility was tested using the agar disk diffusion method in accordance with the Clinical Laboratory Standards Institute's 2019 guidelines.

Results

The mean resistance rate of ESBL-E to antimicrobial agents tested was 49.2% (range from 1.4%–92%). The highest resistance rates were observed for trimethoprim-sulfamethoxazole (92%), amoxicillin and ceftriaxone (79%), doxycycline (75%) and gentamicin (72%). Carbapenems (meropenem and imipenem) were highly active against isolates. The overall rate of multi-drug resistant (MDR) ESBL-E was 47%. The highest MDR was found in Yersinia enterocolitica (51%) and the least in Serratia spp. (40%).

Conclusions

We found a high resistance rate of ESBL-E isolates to antimicrobial agents; the majority were MDR. Surveillance systems are recommended to monitor AMR in Malawi.

Oral Antibiotics in Clinical Development for Community-Acquired Urinary Tract Infections

The treatment of urinary tract infections (UTIs) has been complicated by the emergence of multidrug-resistant, β-lactamase-expressing pathogens. As a result of the limited treatment options, patients often require hospitalization and intravenous therapy. In essence, a strong unmet need for oral antibiotics, active against extended-spectrum β-lactamase (ESBL) uropathogens has emerged. Oral carbapenems (tebipenem and sulopenem) and oral cephalosporin/β-lactamase inhibitor combinations are in various stages of clinical development for the treatment of uncomplicated and complicated UTI. Tebipenem, if approved, will be the first oral treatment for complicated UTI while sulopenem will be for uncomplicated UTI. The β-lactamase inhibitors ETX0282, VNRX7145, ARX1796, and QPX7728 are combined with cefpodoxime proxetil or ceftibuten that achieve favorable exposures in urine compared to other uropathogen-active oral cephalosporins. The combination ceftibuten-QPX7728 has potential broad-spectrum coverage against carbapenemase producers including metallo β-lactamase producers. Other novel combinations, namely cefpodoxime/ETX0282, ceftibuten/VNRX-7145, and ceftibuten/ARX1796, have also demonstrated excellent activity against Klebsiella pneumoniae carbapanemase (KPC) and OXA-48-like producers. All these agents, upon their arrival for commercial use, would strengthen the outpatient therapy.

Amidochelocardin Overcomes Resistance Mechanisms Exerted on Tetracyclines and Natural Chelocardin

The reassessment of known but neglected natural compounds is a vital strategy for providing novel lead structures urgently needed to overcome antimicrobial resistance. Scaffolds with resistance-breaking properties represent the most promising candidates for a successful translation into future therapeutics. Our study focuses on chelocardin, a member of the atypical tetracyclines, and its bioengineered derivative amidochelocardin, both showing broad-spectrum antibacterial activity within the ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) panel. Further lead development of chelocardins requires extensive biological and chemical profiling to achieve favorable pharmaceutical properties and efficacy. This study shows that both molecules possess resistance-breaking properties enabling the escape from most common tetracycline resistance mechanisms. Further, we show that these compounds are potent candidates for treatment of urinary tract infections due to their in vitro activity against a large panel of multidrug-resistant uropathogenic clinical isolates. In addition, the mechanism of resistance to natural chelocardin was identified as relying on efflux processes, both in the chelocardin producer Amycolatopsis sulphurea and in the pathogen Klebsiella pneumoniae. Resistance development in Klebsiella led primarily to mutations in ramR, causing increased expression of the acrAB-tolC efflux pump. Most importantly, amidochelocardin overcomes this resistance mechanism, revealing not only the improved activity profile but also superior resistance-breaking properties of this novel antibacterial compound.