Background. Selection of empiric antibiotics for urinary tract infections (UTIs) has become more challenging because of the increasing rates of multidrug-resistant Enterobacteriaceae (MDRE) infections. Methods. This retrospective study was conducted to determine antibiotic resistance patterns, risk factors, and appropriate empiric antibiotic selection for MDRE UTIs. Adult patients seen in the Emergency Department (ED) with Enterobacteriaceae UTIs during 2008-2009 were identified from review of microbiology records. MDRE were defined as organisms resistant to at least 3 categories of antibiotics. Results. There were 431 eligible patients; 83 (19%) had MDRE UTIs. Resistance rates for individual antibiotics among MDRE UTIs were significantly greater than non-MDRE UTIs: levofloxacin, 72% versus 14%; TMP-SMX, 77% versus 12%; amoxicillin-clavulanate, 35% versus 4%; nitrofurantoin, 21% versus 12%, and ceftriaxone, 20% versus 0%. All Enterobacteriaceae isolates were susceptible to ertapenem (MIC ≤ 2？mg/L). Independent risk factors for MDRE UTI were prior fluoroquinolone use within 3 months (adjusted odds ratio (aOR) 3.64; ), healthcare-associated risks (aOR 2.32; ), and obstructive uropathy (aOR 2.22; ). Conclusion. Our study suggests that once-daily intravenous or intramuscular ertapenem may be appropriate for outpatient treatment of ED patients with MDRE UTI. 1. Introduction Enterobacteriaceae are the most common cause of urinary tract infections (UTIs) in both community and healthcare settings. Selection of empiric antibiotic therapy for UTIs is therefore often based on the institutional susceptibility profiles of the Enterobacteriaceae [1]. Recent guidelines from the Infectious Diseases Society of America recommended that empiric antibiotic therapy for UTIs should be based on local resistance data, drug availability, and antibiotic intolerance/allergy history of treated patients [1, 2]. For uncomplicated cystitis, nitrofurantoin or trimethoprim-sulfamethoxazole (TMP-SMX, if local resistance ≤ 20%) can be used empirically, while fluoroquinolones, ceftriaxone, aminoglycosides, and carbapenems are appropriate for pyelonephritis and complicated UTIs. The increase in rates of antibiotic resistance among Enterobacteriaceae has posed challenges in choosing empiric regimens, especially when infections due to multidrug-resistant Enterobacteriaceae (MDRE) are suspected or endemic [3]. In the past decade, emerging resistance among the Enterobacteriaceae due to extended-spectrum beta-lactamases (ESBL) has been reported worldwide, including in Chicago [4]. In addition,
References
[1]
K. Gupta, T. M. Hooton, K. G. Naber et al., “International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the infectious diseases society of America and the European society for microbiology and infectious diseases,” Clinical Infectious Diseases, vol. 52, no. 5, pp. e103–e120, 2011.
[2]
T. M. Hooton, S. F. Bradley, D. D. Cardenas et al., “Diagnosis, prevention, and treatment of catheter-aassociated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious diseases society of America,” Clinical Infectious Diseases, vol. 50, no. 5, pp. 625–663, 2010.
[3]
G. V. Sanchez, R. N. Master, J. A. Karlowsky, and J. M. Bordon, “In vitro antimicrobial resistance of urinary Escherichia coli isolates among U.S. outpatients from 2000 to 2010,” Antimicrobial Agents and Chemotherapy, vol. 56, no. 4, pp. 2181–2183, 2012.
[4]
C. Qi, V. Pilla, J. H. Yu, and K. Reed, “Changing prevalence of Escherichia coli with CTX-M-type extended-spectrum β-lactamases in outpatient urinary E. coli between 2003 and 2008,” Diagnostic Microbiology and Infectious Disease, vol. 67, no. 1, pp. 87–91, 2010.
[5]
N. Gupta, B. M. Limbago, J. B. Patel, and A. J. Kallen, “Carbapenem-resistant enterobacteriaceae: epidemiology and prevention,” Clinical Infectious Diseases, vol. 53, no. 1, pp. 60–67, 2011.
[6]
K. K. Kumarasamy, M. A. Toleman, T. R. Walsh et al., “Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study,” The Lancet Infectious Diseases, vol. 10, no. 9, pp. 597–602, 2010.
[7]
D. L. Paterson, W.-C. Ko, A. Von Gottberg et al., “Antibiotic therapy for Klebsiella pneumoniae bacteremia: implications of production of extended-spectrum β-lactamases,” Clinical Infectious Diseases, vol. 39, no. 1, pp. 31–37, 2004.
[8]
F. M. Abrahamian, G. J. Moran, and D. A. Talan, “Urinary tract infections in the emergency department,” Infectious Disease Clinics of North America, vol. 22, no. 1, pp. 73–87, 2008.
[9]
T. C. Horan, M. Andrus, and M. A. Dudeck, “CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting,” The American Journal of Infection Control, vol. 36, no. 5, pp. 309–332, 2008.
[10]
10. American Thoracic Society and Infectious Diseases Society of America, “Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia,” American Journal of Respiratory and Critical Care Medicine, vol. 171, no. 4, pp. 388–416, 2005.
[11]
Clinical and Laboratory Standards Institute, “Performance standards for antimicrobial susceptibility testing. Nineteenth informational supplement. Approved standard M100-S19,” Clinical and Laboratory Standards Institute, Wayne, Pa, USA.
[12]
K. Cohen-Nahum, L. Saidel-Odes, K. Riesenberg, F. Schlaeffer, and A. Borer, “Urinary tract infections caused by multi-drug resistant proteus mirabilis: risk factors and clinical outcomes,” Infection, vol. 38, no. 1, pp. 41–46, 2010.
[13]
A.-P. Magiorakos, A. Srinivasan, R. B. Carey et al., “Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance,” Clinical Microbiology and Infection, vol. 18, no. 3, pp. 268–281, 2012.
[14]
G. A. Jacoby, “Epidemiology of extended-spectrum beta-lactamases,” Clinical Infectious Diseases, vol. 27, no. 1, pp. 81–83, 1998.
[15]
C. Gudiol, F. Tubau, L. Calatayud et al., “Bacteraemia due to multidrug-resistant gram-negative bacilli in cancer patients: risk factors, antibiotic therapy and outcomes,” Journal of Antimicrobial Chemotherapy, vol. 66, no. 3, pp. 657–663, 2011.
[16]
D. J. Diekema, B. J. BootsMiller, T. E. Vaughn et al., “Antimicrobial resistance trends and outbreak frequency in United States hospitals,” Clinical Infectious Diseases, vol. 38, no. 1, pp. 78–85, 2004.
[17]
P. H. A. Bours, R. Polak, A. I. M. Hoepelman, E. Delgado, A. Jarquin, and A. J. Matute, “Increasing resistance in community-acquired urinary tract infections in Latin America, five years after the implementation of national therapeutic guidelines,” International Journal of Infectious Diseases, vol. 14, no. 9, pp. e770–e774, 2010.
[18]
F. Jimenez-Cruz, A. Jasovich, J. Cajigas et al., “A prospective, multicenter, randomized, double-blind study comparing ertapenem and ceftriaxone followed by appropriate oral therapy for complicated urinary tract infections in adults,” Urology, vol. 60, no. 1, pp. 16–22, 2002.
[19]
K. M. Tomera, E. A. Burdmann, O. G. Pamo Reyna et al., “Ertapenem versus ceftriaxone followed by appropriate oral therapy for treatment of complicated urinary tract infections in adults: results of a prospective, randomized, double-blind multicenter study,” Antimicrobial Agents and Chemotherapy, vol. 46, no. 9, pp. 2895–2900, 2002.
[20]
V. Prakash, J. S. Lewis II, M. L. Herrera, B. L. Wickes, and J. H. Jorgensen, “Oral and parenteral therapeutic options for outpatient urinary infections caused by enterobacteriaceae producing ctx-m extended-spectrum β-lactamases,” Antimicrobial Agents and Chemotherapy, vol. 53, no. 3, pp. 1278–1280, 2009.
[21]
G. A. Jacoby and L. S. Munoz-Price, “The new beta-lactamases,” The New England Journal of Medicine, vol. 352, no. 4, pp. 380–391, 2005.
[22]
M. J. Schwaber, S. Klarfeld-Lidji, S. Navon-Venezia, D. Schwartz, A. Leavitt, and Y. Carmeli, “Predictors of carbapenem-resistant Klebsiella pneumoniae acquisition anions hospitalized adults and effect of acquisition on mortality,” Antimicrobial Agents and Chemotherapy, vol. 52, no. 3, pp. 1028–1033, 2008.
[23]
L. Johnson, A. Sabel, W. J. Burman et al., “Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates,” The American Journal of Medicine, vol. 121, no. 10, pp. 876–884, 2008.
[24]
D. L. Paterson, ““Collateral damage” from cephalosporin or quinolone antibiotic therapy,” Clinical Infectious Diseases, vol. 38, supplement 4, pp. S341–S345, 2004.
[25]
G. G. Zhanel, T. L. Hisanaga, N. M. Laing et al., “Antibiotic resistance in outpatient urinary isolates: final results from the North American Urinary Tract Infection Collaborative Alliance (NAUTICA),” International Journal of Antimicrobial Agents, vol. 26, no. 5, pp. 380–388, 2005.
