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Raphael E, Inamdar PP, Belmont C, Shariff-Marco S, Huang AJ, Chambers HF. Spatial clusters of extended-spectrum beta-lactamase-producing Escherichia coli causing community-onset bacteriuria due to repeat infections: cluster analysis from a large urban medical center, San Francisco, 2014-2020. Antimicrob Resist Infect Control 2023; 12:115. [PMID: 37858209 PMCID: PMC10588154 DOI: 10.1186/s13756-023-01320-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) may occur as outbreaks due to common-source exposures. Yet, it is currently unknown if they cluster geographically as would be expected as part of an outbreak. METHODS We collected electronic health record data on all patients living in San Francisco with culture-documented community-onset E. coli bacteriuria in a safety-net public healthcare system from January 2014 to March 2020 (diagnosed < 48 h after hospital admission or in outpatient clinical settings without a hospitalization in the past 90 days). We assessed the presence of spatial clusters of (1) ESBL-E. coli bacteriuria episodes, and (2) individuals with any ESBL-E. coli bacteriuria episode, with Global and Local Moran's I. We evaluated differences in prevalence of bacteriuria recurrence by ESBL-production by Poisson regression. RESULTS Out of 4,304 unique individuals, we identified spatial clusters of ESBL-E. coli bacteriuria episodes (n = 461) compared to non-ESBL-E. coli bacteriuria episodes (n = 5477; Global Moran's p < 0.001). Spatial clusters of individuals with any bacteriuria caused by ESBL-E. coli were not identified (p = 0.43). Bacteriuria recurrence was more likely to occur with ESBL-E. coli (odds ratio [OR] 2.78, 95% confidence interval [95% CI] 2.10, 3.66, p < 0.001), particularly after an initial ESBL-E. coli bacteriuria episode (OR 2.27, 95% CI 1.82, 2.83, p < 0.001). CONCLUSION We found spatial clusters of ESBL-E. coli bacteriuria episodes. However, this was partly explained by clustering within individuals more than between individuals, as having an ESBL-E. coli bacteriuria was associated with recurrence with ESBL-E. coli. These findings may help better tailor clinical treatment of patients with recurrent urinary tract infections after an initial episode caused by ESBL-E. coli.
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Affiliation(s)
- Eva Raphael
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Global Health and Clinical Sciences, 550 16th Street, Box 0560, San Francisco, CA, 94143, USA.
| | - Pushkar P Inamdar
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Cheyenne Belmont
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Salma Shariff-Marco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Alison J Huang
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Henry F Chambers
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Djim-Adjim-Ngana K, Mbiakop BW, Oumar LA, Munshili Njifon HL, Tchinda Fossi C, Enyegue ELE, Mouiche Mouliom MM, Fodouop Chegaing SP, Deweerdt L, Yanou NN, Nguinkal JA. Phenotypic characterization and epidemiology of extended-spectrum β-lactamase-producing Enterobacteriaceae strains from urinary tract infections in Garoua, Cameroon. Front Public Health 2023; 11:1187934. [PMID: 37457273 PMCID: PMC10343957 DOI: 10.3389/fpubh.2023.1187934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background and objectives The emergence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) is causing increased morbidity and mortality around the world as a result of therapeutic failures. ESBL-E are priority pathogens due to their multidrug resistance (MDR). In Northern Cameroon, ESBL-producing bacteria, particularly in urinary tract infections (UTIs), are being increasingly isolated. This study aimed to retrospectively determine the prevalence of multi-drug resistant ESBL strains isolated from UTIs in Northern Cameroon and to evaluate the effectiveness of the ATB UR Gallery of BioMérieux in diagnosing ESBL-E in clinical settings. Methods Standard microbiology protocols and statistical tools were utilized to identify ESBL-producing bacteria and characterize their phenotypic susceptibility and resistance profiles in the study population. Results Out of the 144 enterobacteria isolates successfully cultured, 59 (41%) were identified as MDR strains. The ATB UR EU gallery identified 33 (23%) multi-drug resistant ESBL-producing strains, while the double synergy test identified 35 strains without disc reconciliation and 38 strains after reconciliation. The most prevalent ESBL-E isolate was Escherichia coli, accounting for 77.1% of the isolates, followed by Klebsiella pneumoniae (20%) and Enterobacter aerogenes (2.9%). Additionally, the study revealed the emergence of Imipenem resistance (5.7%), a critical last-resort antibiotic. However, all ESBL strains were sensitive to Fosfomycin (FSF/FOS), demonstrating its potential as an effective therapeutic option. Moreover, 37% of the ESBL producers exhibited co-resistance to over 20 different antibiotics. Conclusion This study provides valuable insights into the prevalence and susceptibility patterns of ESBL-E associated with UTIs in Northern Cameroon. These insights emphasizes the importance of implementing appropriate treatment guidelines and antimicrobial stewardship measures to mitigate the spread and impact of MDR ESBL-producing strains on public health.
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Affiliation(s)
- Karyom Djim-Adjim-Ngana
- Centre for Research on Health and Priority Pathologies, Institute of Medical Research and Medicinal Plant Studies, Yaounde, Cameroon
- Department of Veterinary Public Health, School of Veterinary Medicine and Sciences, University of Ngaoundere, Ngaoundere, Cameroon
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
| | - Brunel W. Mbiakop
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
- Department of Biomedical Sciences, University of Ngaoundere, Ngaoundere, Cameroon
| | - Leila A. Oumar
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
| | | | - Cedric Tchinda Fossi
- Centre for Research on Medicinal Plants and Traditional Medicine, Institute of Medical Research and Medicinal Plant Studies, Yaounde, Cameroon
| | - Elisee L. Embolo Enyegue
- Centre for Research on Medicinal Plants and Traditional Medicine, Institute of Medical Research and Medicinal Plant Studies, Yaounde, Cameroon
| | - Mohamed M. Mouiche Mouliom
- Department of Veterinary Public Health, School of Veterinary Medicine and Sciences, University of Ngaoundere, Ngaoundere, Cameroon
| | | | - Louis Deweerdt
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
| | | | - Julien A. Nguinkal
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
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Raphael E, Inamdar PP, Belmont C, Shariff-Marco S, Huang A, Chambers H. Spatial clusters of extended-spectrum beta-lactamase-producing Escherichia coli causing community-onset bacteriuria due to repeat infections: cluster analysis from a large urban medical center, San Francisco, 2014-2020. RESEARCH SQUARE 2023:rs.3.rs-2949551. [PMID: 37292942 PMCID: PMC10246249 DOI: 10.21203/rs.3.rs-2949551/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) may occur as outbreaks due to common-source exposures. Yet, it is currently unknown if they cluster geographically as would be expected as part of an outbreak. Methods We collected electronic health record data on all patients living in San Francisco with culture-documented community-onset E. coli bacteriuria in a safety-net public healthcare system from January 2014 to March 2020 (diagnosed < 48 hours after hospital admission or in outpatient clinical settings without a hospitalization in the past 90 days). We assessed the presence of spatial clusters of (1) ESBL-E. coli bacteriuria episodes, and (2) individuals with any ESBL-E. coli bacteriuria episode, with Global and Local Moran's I. We evaluated differences in prevalence of bacteriuria recurrence by ESBL-production by Poisson regression. Results Out of 4,304 unique individuals, we identified spatial clusters of ESBL-E. coli bacteriuria episodes (n = 461) compared to non-ESBL-E. coli bacteriuria episodes (n = 5477; Global Moran's p < 0.001). Spatial clusters of individuals with any bacteriuria caused by ESBL-E. coli were not identified (p = 0.43). Bacteriuria recurrence was more likely to occur with ESBL-E. coli (odds ratio [OR] 2.78, 95% confidence interval [95% CI] 2.10, 3.66, p < 0.001), particularly after an initial ESBL-E. coli bacteriuria episode (OR 2.27, 95% CI 1.82, 2.83, p < 0.001). Conclusion We found spatial clusters of ESBL-E. coli bacteriuria episodes. However, this was partly explained by clustering within individuals more than between individuals, as having an ESBL-E. coli bacteriuria was associated with recurrence with ESBL-E. coli.
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A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance. J Glob Antimicrob Resist 2021; 28:18-29. [PMID: 34896337 DOI: 10.1016/j.jgar.2021.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Raphael E, Glymour MM, Chambers HF. Trends in prevalence of extended-spectrum beta-lactamase-producing Escherichia coli isolated from patients with community- and healthcare-associated bacteriuria: results from 2014 to 2020 in an urban safety-net healthcare system. Antimicrob Resist Infect Control 2021; 10:118. [PMID: 34380549 PMCID: PMC8359060 DOI: 10.1186/s13756-021-00983-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of infections caused by extended-spectrum beta-lactamase producing Escherichia coli (ESBL-E. coli) is increasing worldwide, but the setting in which this increase is occurring is not well defined. We compared trends and risk factors for ESBL-E. coli bacteriuria in community vs healthcare settings. METHODS We collected electronic health record data on all patients with E. coli isolated from urine cultures in a safety-net public healthcare system from January 2014 to March 2020. All analyses were stratified by healthcare-onset/associated (bacteriuria diagnosed > 48 h after hospital admission or in an individual hospitalized in the past 90 days or in a skilled nursing facility resident, N = 1277) or community-onset bacteriuria (bacteriuria diagnosed < 48 h after hospital admission or in an individual seen in outpatient clinical settings without a hospitalization in the past 90 days, N = 7751). We estimated marginal trends from logistic regressions to evaluate annual change in prevalence of ESBL-E. coli bacteriuria among all bacteriuria. We evaluated risk factors using logistic regression models. RESULTS ESBL-E. coli prevalence increased in both community-onset (0.91% per year, 95% CI 0.56%, 1.26%) and healthcare-onset/associated (2.31% per year, CI 1.01%, 3.62%) bacteriuria. In multivariate analyses, age > 65 (RR 1.88, CI 1.17, 3.05), male gender (RR 2.12, CI 1.65, 2.73), and Latinx race/ethnicity (RR 1.52, CI 0.99, 2.33) were associated with community-onset ESBL-E. coli. Only male gender (RR 1.53, CI 1.03, 2.26) was associated with healthcare-onset/associated ESBL-E. coli. CONCLUSIONS ESBL-E. coli bacteriuria frequency increased at a faster rate in healthcare-associated settings than in the community between 2014 and 2020. Male gender was associated with ESBL-E. coli bacteriuria in both settings, but additional risks-age > 65 and Latinx race/ethnicity-were observed only in the community.
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Affiliation(s)
- Eva Raphael
- Department of Epidemiology and Biostatistics , University of California, San Francisco, San Francisco, CA, USA.
- Department of Family and Community Medicine , University of California, San Francisco, San Francisco, CA, USA.
- Zuckerberg San Francisco General Hospital, 995 Potrero Avenue, Ward 83, San Francisco, CA, 94110, USA.
| | - M Maria Glymour
- Department of Family and Community Medicine , University of California, San Francisco, San Francisco, CA, USA
| | - Henry F Chambers
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Veeraraghavan B, Bakthavatchalam YD, Sahni RD. Oral Antibiotics in Clinical Development for Community-Acquired Urinary Tract Infections. Infect Dis Ther 2021; 10:1815-1835. [PMID: 34357517 PMCID: PMC8572892 DOI: 10.1007/s40121-021-00509-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/21/2021] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, 632004, India.
| | | | - Rani Diana Sahni
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, 632004, India
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Jia P, Zhu Y, Li X, Kudinha T, Yang Y, Zhang G, Zhang J, Xu Y, Yang Q. High Prevalence of Extended-Spectrum Beta-Lactamases in Escherichia coli Strains Collected From Strictly Defined Community-Acquired Urinary Tract Infections in Adults in China: A Multicenter Prospective Clinical Microbiological and Molecular Study. Front Microbiol 2021; 12:663033. [PMID: 34305831 PMCID: PMC8292957 DOI: 10.3389/fmicb.2021.663033] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/26/2021] [Indexed: 11/13/2022] Open
Abstract
Objective The objective of the study was to investigate the antimicrobial susceptibility and extended-spectrum beta-lactamase (ESBL) positive rates of Escherichia coli from community-acquired urinary tract infections (CA-UTIs) in Chinese hospitals. Materials and Methods A total of 809 E. coli isolates from CA-UTIs in 10 hospitals (5 tertiary and 5 secondary hospitals) from different regions in China were collected during the period 2016–2017 according to the strict inclusion criteria. Antimicrobial susceptibility testing was carried out by standard broth microdilution method. Isolates were categorized as ESBL-positive, ESBL-negative, and ESBL-uncertain groups according to the CLSI recommended phenotypic screening method. ESBL and AmpC genes were amplified and sequenced on ESBL-positive and ESBL-uncertain isolates. Results The antimicrobial agents with susceptibility rates of greater than 95% included imipenem (99.9%), colistin (99.6%), ertapenem (98.9%), amikacin (98.3%), cefmetazole (97.9%), nitrofurantoin (96%), and fosfomycin (95.4%). However, susceptibilities to cephalosporins (varying from 58.6% to 74.9%) and levofloxacin (48.8%) were relatively low. In the phenotypic detection of ESBLs, ESBL-positive isolates made up 38.07% of E. coli strains isolated from CA-UTIs, while 2.97% were ESBL-uncertain. Antimicrobial susceptibilities of imipenem, cefmetazole, colistin, ertapenem, amikacin, and nitrofurantoin against ESBL-producing E. coli strains were greater than 90%. The percentage of ESBL-producing strains was higher in male (53.6%) than in female patients (35.2%) (p < 0.001). CTX-M-14 (31.8%) was the major CTX-M variant in the ESBL-producing E. coli, followed by CTX-M-55 (23.4%), CTX-M-15 (17.5%), and CTX-M-27 (13.3%). The prevalence of carbapenem-resistant E. coli among CA-UTI isolates was 0.25% (2/809). Conclusion Our study indicated high prevalence of ESBL in E. coli strains from strictly defined community-acquired urinary tract infections in adults in China. Imipenem, colistin, ertapenem, amikacin, and nitrofurantoin were the most active antimicrobials against ESBL-positive E. coli isolates. blaCTX–M–14 is the predominant esbl gene in ESBL-producing and ESBL-uncertain strains. Our study indicated that the use of cephalosporins and fluoroquinolone needs to be restricted for empirical treatment of CA-UTIs in China.
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Affiliation(s)
- Peiyao Jia
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Zhu
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xue Li
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Timothy Kudinha
- School of Biomedical Sciences, Charles Sturt University, Orange, NSW, Australia.,NSW Health Pathology, Regional and Rural, Orange Hospital, Orange, NSW, Australia
| | - Yang Yang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ge Zhang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjia Zhang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingchun Xu
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiwen Yang
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Song JY, Yoo S, Lim TJ, Byun JH, Jo KJ, Kim HY, Park SE, Kim SH. Ampicillin-sulbactam monotherapy in infants with febrile urinary tract infections. Pediatr Int 2021; 63:430-435. [PMID: 32885532 DOI: 10.1111/ped.14454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/31/2020] [Accepted: 08/14/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cephalosporin is the most commonly used empirical agent for urinary tract infections (UTIs) in children. However, increasing use of cephalosporins can lead to an increase in resistant pathogens. This study therefore aims to investigate the effects of monotherapy with ampicillin-sulbactam as an alternative to cephalosporins. METHODS All 2- to 24-month-old patients who were hospitalized at Pusan National University Children's Hospital due to a first episode of a febrile UTI during the 2-year period from 2012 to 2014 were included in the study. The subjects were divided into two groups according to their empirical therapy (cefotaxime or ampicillin-sulbactam). We determined the patients' UTI pathogens and their antibiotic susceptibilities and compared the effectiveness and the occurrence of adverse effects of ampicillin-sulbactam and cephalosporin therapy. RESULTS Forty-six patients were treated with cefotaxime (group A) and 41 patients with ampicillin-sulbactam as the empirical antibiotic (group B). The most common pathogen in both groups was Escherichia coli, and antibiotic susceptibilities of the bacterial strains isolated from both groups were similar in ampicillin-sulbactam and cefotaxime. In addition, there was no significant difference in the duration of fever after treatment between the two groups (group A: 2.0 versus group B: 3.0, P = 0.331). There were no treatment failures and no recurrence in either group, even in patients with resistant pathogens. The most common side effect of the antibiotic agents was diarrhea. CONCLUSIONS Ampicillin-sulbactam could be an effective alternative to cephalosporin as empiric antibiotic for the treatment of first-episode UTI in patients under 24 months of age.
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Affiliation(s)
- Ji Yeon Song
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Sukdong Yoo
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Taek Jin Lim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Joung-Hee Byun
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Kyo Jin Jo
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Hye-Young Kim
- Department of Pediatrics, Pusan National University Hospital, Busan, Korea
| | - Su Eun Park
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
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9
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Raphael E, Chambers HF. Differential Trends in Extended-Spectrum Beta-Lactamase-Producing Escherichia coli Infections in Four Health Care Facilities in a Single Metropolitan Area: A Retrospective Analysis. Microb Drug Resist 2020; 27:154-161. [PMID: 32589493 DOI: 10.1089/mdr.2020.0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Prevalence of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-E. coli) is increasing worldwide, but greatly varies geographically. We compared the prevalence of ESBL-E. coli infections at four distinct health care facilities in San Francisco, California. Methods: Antimicrobial susceptibility reports were obtained for E. coli isolates from (1) a county hospital, (2) a public skilled nursing facility, (3) a university hospital, and (4) a Veterans Affairs (VA) Medical Center. We compared change in frequency of ESBL-E. coli and antimicrobial resistance to trimethoprim-sulfamethoxazole between 2012 and 2018. Results: From 2012 to 2018, frequency of ESBL-E. coli increased in urine and nonurine isolates from the county hospital (urine: 1.1% per year, 95% confidence interval [CI]: 0.5-1.6, p < 0.01; nonurine: 1.9% per year, 95% CI: 0.9-2.9, p < 0.01) and in urine isolates from the VA hospital (0.9% per year, 95% CI: 0.3-1.4, p < 0.01). The frequency of trimethoprim-sulfamethoxazole resistance fluctuated in all facilities. Conclusions: At the skilled nursing facility, the prevalence of ESBL-E. coli was highest, but remained stable over time, while the prevalence of ESBL-E. coli increased among urine and nonurine isolates at the county hospital and urine isolates at the VA hospital. The temporal trend of ESBL-E. coli infections, even within one city, varied by health care facility.
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Affiliation(s)
- Eva Raphael
- Department of Family and Community Medicine and University of California, San Francisco, San Francisco, California, USA
| | - Henry F Chambers
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Gajdács M, Ábrók M, Lázár A, Burián K. Differential epidemiology and antibiotic resistance of lactose-fermenting and non-fermenting Escherichia coli: Is it just a matter of taste? Biol Futur 2020; 71:175-182. [PMID: 34554531 DOI: 10.1007/s42977-020-00016-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/20/2020] [Indexed: 02/01/2023]
Abstract
Urinary tract infections (UTIs) are some of the most common infections affecting humans worldwide. Occurrence of atypical, lactose non-fermenting, biochemically "inactive" strains of E. coli in clinical material has been described in the literature, which may cause a significant diagnostic challenge. The present retrospective microbiological study was carried out using isolates and data collected between January 1, 2013, and December 31, 2017, at the Institute of Clinical Microbiology. n = 24,285 positive urine samples were noted during the study period, out of which, samples positive for either lac + and lac- E. coli were included in the analysis. E. coli represented n = 7075 (55.8% ± 4.6%) of outpatient and n = 4916 (42.4% ± 3.6%) of inpatient isolates. n = 401 (3.3%; 80.2 ± 14.6/year) lac- E. coli isolates were identified from urinary tract infections. The ratio of lac- E. coli isolates was significantly higher in outpatient samples (262 vs. 139). Resistance levels of lac- isolates for antibiotics commonly used for treating UTIs were significantly higher for both inpatient and outpatient isolates: norfloxacin, ciprofloxacin, fosfomycin and nitrofurantoin. It is essential to pay attention to the presence of lac- strains, and their omission from clinical material during diagnostic procedures may have significant consequences for epidemiological studies and therapy.
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Affiliation(s)
- Márió Gajdács
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, Eötvös Utca 6., Szeged, 6720, Hungary.
| | - Marianna Ábrók
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Semmelweis utca 6., Szeged, 6725, Hungary
| | - Andrea Lázár
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Semmelweis utca 6., Szeged, 6725, Hungary
| | - Katalin Burián
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Semmelweis utca 6., Szeged, 6725, Hungary.,Department of Medical Microbiology and Immunobiology, Faculty of Medicine, University of Szeged, Dóm tér 10., Szeged, 6720, Hungary
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11
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Kotb DN, Mahdy WK, Mahmoud MS, Khairy RMM. Impact of co-existence of PMQR genes and QRDR mutations on fluoroquinolones resistance in Enterobacteriaceae strains isolated from community and hospital acquired UTIs. BMC Infect Dis 2019; 19:979. [PMID: 31752702 PMCID: PMC6868749 DOI: 10.1186/s12879-019-4606-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 10/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fluoroquinolones are commonly recommended as treatment for urinary tract infections (UTIs). The development of resistance to these agents, particularly in gram-negative microorganisms complicates treatment of infections caused by these organisms. This study aimed to investigate antimicrobial resistance of different Enterobacteriaceae species isolated from hospital- acquired and community-acquired UTIs against fluoroquinolones and correlate its levels with the existing genetic mechanisms of resistance. METHODS A total of 440 Enterobacteriaceae isolates recovered from UTIs were tested for antimicrobial susceptibility. Plasmid-mediated quinolone resistance (PMQR) genes and mutations in the quinolone resistance-determining regions (QRDRs) of gyrA and parC genes were examined in quinolone-resistant strains. RESULTS About (32.5%) of isolates were resistant to quinolones and (20.5%) were resistant to fluoroquinolones. All isolates with high and intermediate resistance phenotypes harbored one or more PMQR genes. QnrB was the most frequent gene (62.9%) of resistant isolates. Co-carriage of 2 PMQR genes was detected in isolates (46.9%) with high resistance to ciprofloxacin (CIP) (MICs > 128 μg/mL), while co-carriage of 3 PMQR genes was detected in (6.3%) of resistant isolates (MICs > 512 μg/mL). Carriage of one gene only was detected in intermediate resistance isolates (MICs of CIP = 1.5-2 μg/mL). Neither qnrA nor qnrC genes were detected. The mutation at code 83 of gyrA was the most frequent followed by Ser80-Ile in parC gene, while Asp-87 Asn mutation of gyrA gene was the least, where it was detected only in high resistant E. coli isolates (MIC ≥128 μg/mL). A double mutation in gyrA (Lys154Arg and Ser171Ala) was observed in high FQs resistant isolates (MIC of CIP < 128 μg/mL). CONCLUSION FQs resistance is caused by interact between PMQR genes and mutations in both gyrA and parC genes while a mutation in one gene only can explain quinolone resistance. Accumulation of PMQR genes and QRDR mutations confers high resistance to FQs.
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Affiliation(s)
- Dalia Nabil Kotb
- Department of Microbiology and Immunology, Faculty of Medicine, Minia University, Minia, 61511, Egypt
| | - Wafaa Khairy Mahdy
- Department of Microbiology and Immunology, Faculty of Medicine, Minia University, Minia, 61511, Egypt
| | - Mahmoud Shokry Mahmoud
- Department of Microbiology and Immunology, Faculty of Medicine, Minia University, Minia, 61511, Egypt
| | - Rasha M M Khairy
- Department of Microbiology and Immunology, Faculty of Medicine, Minia University, Minia, 61511, Egypt.
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12
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Kim YJ, Lee JM, Cho J, Lee J. Change in the Annual Antibiotic Susceptibility of Escherichia coli in Community-Onset Urinary Tract Infection between 2008 and 2017 in a Tertiary Care Hospital in Korea. J Korean Med Sci 2019; 34:e228. [PMID: 31456383 PMCID: PMC6717241 DOI: 10.3346/jkms.2019.34.e228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/23/2019] [Indexed: 12/21/2022] Open
Abstract
The susceptibility of Escherichia coli from community onset urinary tract infection (UTI) was evaluated by dividing community onset UTI into the simple community acquired-UTI (CA-UTI) and healthcare associated UTI (HCA-UTI) groups for a period of 10 years. The susceptibility of E. coli to most antibiotics, except amikacin and imipenem, continued to decrease. In the CA-UTI group, the susceptibility to cefotaxime was 88% in 2015, but rapidly decreased to 79.3% in 2017. The susceptibility to cefepime and piperacillin-tazobactam were 88.8% and 90.5% in 2017, respectively. In the HCA-UTI group, the susceptibility to most antibiotics markedly decreased to less than 60% by 2017. The incidence of ESBL-producing E. coli increased to 23.3% in the CA-UTI group in 2017.
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Affiliation(s)
- Young Jun Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Jeong Mi Lee
- Department of Public Health, Wonkwang University College of Medicine, Iksan, Korea
| | - Jihyun Cho
- Department of Laboratory Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - JaeHoon Lee
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea.
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13
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Correlation of Antibiotic Resistance and Restriction Mapping of Plasmid DNA Isolated from E. coli Causing Urinary Tract Infection. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2019. [DOI: 10.22207/jpam.13.2.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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Michno M, Sydor A, Wałaszek M, Sułowicz W. Microbiology and Drug Resistance of Pathogens in Patients Hospitalized at the Nephrology Department in the South of Poland. Pol J Microbiol 2019; 67:517-524. [PMID: 30550238 PMCID: PMC7256703 DOI: 10.21307/pjm-2018-061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 11/30/2022] Open
Abstract
A retrospective study was conducted among 498 patients with urinary tract infections (UTI) referred to our department from January 2013 to December 2015. This study was performed to evaluate the etiology of UTI and the antibiotic susceptibility profile of Escherichia coli (E. coli) as the main etiological factor in different age groups. Urine samples were examined using standard microbiological methods. Three hundred sixty-three samples (72.9%) were identified as E. coli, of which 29 (8.0%) can produce extended-spectrum β-lactamases (ESBL). E. coli was highly sensitive to imipenem (100.0%), gentamicin (91.0%), nitrofurantoin (89.4%), amikacin (88.2%), piperacillin/tazobactam (87.0%) and cephalosporins (79.7–89.5%). Low sensitivity was found in relation to fluoroquinolones (60.3–70.4%). E. coli was least sensitive to ampicillin (30.2%) and amoxicillin/clavulanic acid (49.9%). We observed a significant fall in susceptibility level to piperacillin/tazobactam (68.4% vs. 88.8%; p = 0.017), amikacin (61.1% vs. 90.7%; p = 0.001), gentamicin (70.0% vs. 93.2%; p = 0.002), cefalexin (41.2% vs. 83.3%; p < 0.001), cefotaxime (63.6% vs. 89.4%; p = 0.002), ceftazidime (61.9% vs. 85.6%; p = 0.008), cefepime (73.7% vs. 91.1%; p = 0.025), ciprofloxacin (54.1% vs. 72.2%; p = 0.024) and norfloxacin (40.5% vs. 62.5%; p = 0.011) among patients with catheter-associated UTI (CAUTI) compared to those with non-CAUTI. A similar susceptibility profile was observed between different age groups. In the longevity, E. coli showed a higher sensitivity to cephalosporins than in the young-old group. E. coli susceptibility to fluoroquinolones was low, which excludes them as a first-line drug in our department. Nitrofurantoin may be used as an alternative drug to carbapenems. Monitoring of susceptibility pattern is of great importance.
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Affiliation(s)
- Mikołaj Michno
- Department of Internal Medicine, Nephrology and Dialysis Centre, Regional St Lukas Hospital , Tarnów , Poland
| | - Antoni Sydor
- Department of Internal Medicine, Nephrology and Dialysis Centre, Regional St Lukas Hospital , Tarnów , Poland
| | | | - Władysław Sułowicz
- Chair and Department of Nephrology, Jagiellonian University , Cracow , Poland
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15
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Ko JH, Kim SH, Kang CI, Cho SY, Lee NY, Chung DR, Peck KR, Song JH. Evaluation of a Carbapenem-Saving Strategy Using Empirical Combination Regimen of Piperacillin-Tazobactam and Amikacin in Hemato-Oncology Patients. J Korean Med Sci 2019; 34:e17. [PMID: 30636947 PMCID: PMC6327090 DOI: 10.3346/jkms.2019.34.e17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 10/14/2018] [Indexed: 11/20/2022] Open
Abstract
We implemented a carbapenem-saving strategy in hemato-oncology patients from 2013, using an empirical combination of piperacillin-tazobactam and amikacin for high-risk hemato-oncology patients with febrile neutropenia, who remain hemodynamically unstable > 72 hours despite initial cefepime treatment. All-cause mortality was not different between the two periods (6.54 and 6.57 deaths per 1,000 person-day, P = 0.926). Group 2 carbapenem use significantly decreased after strategy implementation (78.43 vs. 67.43 monthly days of therapy, P = 0.018), while carbapenem-resistant gram-negative bacilli did not show meaningful changes during the study period. Our carbapenem-saving strategy could effectively suppress carbapenem use without an increase of overall mortality.
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Affiliation(s)
- Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Si-Ho Kim
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Young Cho
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Dybowski BA, Zapała P, Bres-Niewada E, Zapała Ł, Miązek-Zapała N, Poletajew S, Młynarczyk G, Radziszewski P. Catheter-associated bacterial flora in patients with benign prostatic hyperplasia: shift in antimicrobial susceptibility pattern. BMC Infect Dis 2018; 18:590. [PMID: 30458721 PMCID: PMC6247620 DOI: 10.1186/s12879-018-3507-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 11/07/2018] [Indexed: 11/26/2022] Open
Abstract
Background Men with urinary retention secondary to benign prostatic hyperplasia (BPH) are prone to genitourinary infections. Physicians should be aware of the current antimicrobial susceptibility pattern in this population if empirical treatment is needed. The goal of this study was to evaluate variations in prevalence, composition and antimicrobial susceptibility of bacterial flora in men with indwelling catheters subjected to surgery for BPH in chosen time periods since 1994. Necessary changes in empirical therapy were also assessed. Methods All patients with indwelling catheters admitted to a single urological center for BPH surgery in the years 1994–1996, 2004–2006, and 2011–2015 were considered. Catheterization times and results of urine cultures from samples collected at admission were evaluated. Susceptibility for selected antimicrobials was compared separately for Gram negative and Gram positive species. For each agent and for their combinations effectiveness of empirical therapy was calculated dividing the number of patients with bacteriuria susceptible to the agents by the total number of patients with bacteriuria. Results Bacteriuria was present in 70% of 169, 72% of 132, and 69% of 156 men in the respective time periods. The incidence of Gram-positive strains increased from 10 to 37% (P < 0.001). Their susceptibility to amoxicillin/clavulanate was fluctuating (81, 61, 77%; P=NS). No vancomycin-resistant strain was present. Gram-negative flora composition was stable. Their susceptibility decreased to ciprofloxacin (70 to 53%; P = 0.01) and amoxicillin/clavulanate (56 to 37%; P < 0.01) while it increased to gentamycin (64 to 88%; P < 0.001) and co-trimoxazole (14 to 62%; P < 0.001); susceptibility to amikacin remained high (> 85%). Only two cases of resistance to carbapenems in 2004–2006 were found. In vitro effectiveness of amikacin + amoxicillin/clavulanate in empirical therapy was slowly decreasing (87 to 77%; P=NS). Imipenem was found the most effective single agent (90–95%) and its efficacy was even improved by adding vancomycin (97–98%). Conclusions Substantial rise in the incidence of Gram-positive species and fluctuations in antimicrobial susceptibility patterns were found. Empirical therapy of genitourinary infection in catheterized men with BPH should now involve antimicrobial agents effective both to Enterococci and Enterobacteriaceae. Periodic monitoring and publishing data on antimicrobial susceptibility for this population is necessary.
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Affiliation(s)
- Bartosz A Dybowski
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Piotr Zapała
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland.
| | - Ewa Bres-Niewada
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Łukasz Zapała
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Nina Miązek-Zapała
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Sławomir Poletajew
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Grażyna Młynarczyk
- Department of Medical Microbiology, Medical University of Warsaw, Chalubinskiego 5, 02-004, Warsaw, Poland
| | - Piotr Radziszewski
- Department of Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
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17
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Baziboroun M, Bayani M, Poormontaseri Z, Shokri M, Biazar T. Prevalence and Antibiotic Susceptibility Pattern of Extended Spectrum Beta Lactamases Producing Escherichia Coli Isolated from Outpatients with Urinary Tract Infections in Babol, Northern of Iran. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2018. [DOI: 10.1515/cipms-2018-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractReceived 08 November 2017 Accepted 15 February 2018 The incidence of community-acquired UTIs due to extended-spectrum beta-lactamase (ESBL) producing E. coli isolates, has increased worldwide and is considered a great problem in the treatment of infections. The aim of this study was to determine the prevalence of ESBL producing E. coli isolates in urine samples of outpatients in Babol, North of Iran. A total of 3 699 urine samples from outpatients referred to Yahyanejad Hospital, Babol, Iran, were collected during 15 months, from March 2016 to June 2017. The samples were processed for bacterial culture using conventional methods, while antimicrobial susceptibility testing for E. coli isolates was performed by the disc diffusion method. The prevalence of ESBL producing E. coli isolates were assessed by Double-Disc tests. Of 3699 tested sample, 201 samples showed the growth of pathogens and among them, 106 isolates (52/7%) were E. coli. The rate of ESBL producing E. coli isolates was 25/4%.The majority (81/5%) of the isolates were from females. High percent resistance was found against ceftazidime, cefotaxime, ceftriaxone, cefixime and ciprofloxacin, ranging from 61-100%, while the highest percent susceptibility was seen to meropenem, piperacillin- tazobactam (100%), followed by nitrofurantoin and amikacin (91%). The high prevalence of ESBL producing E. coli isolates from outpatients calls for the need to aware of this increasing resistance between uropathogens and update bacterial susceptibility data and to set up our empirical therapy accordingly.
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Affiliation(s)
- Mana Baziboroun
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol , I.R. Iran
| | - Masomeh Bayani
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol , I.R. Iran
| | - Zahra Poormontaseri
- Department of infectious disease, Fasa University of Medical Science, Fars , Iran
| | - Mehran Shokri
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol , I.R. Iran
| | - Tahmineh Biazar
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol , I.R. Iran
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