Antimicrobial resistance among uropathogens in the Asia-Pacific region: a systematic review

Antibiotic susceptibility patterns of bacterial uropathogens at a private tertiary hospital in Uganda: a retrospective study

BACKGROUND

Urinary tract infections are disproportionately prevalent in low- and middle-income countries, where a significant portion of the population relies on over the counter and self-prescriptions to manage symptoms. This practice has contributed to a concerning shift in antimicrobial resistance trends, among the most recommended treatments.

METHODS

A cross-sectional retrospective study was conducted at Mengo Hospital's medical laboratory, utilizing data from the hospital management system between January 2019 and July 2023. A total of 1,091 urine samples were collected and cultured on Cysteine Lactose Electrolyte Deficient agar. Of the samples analyzed, 476 showed significant bacteria growth (> 105 colony-forming units). Organisms were identified using Gram staining and other biochemical techniques. Antibiotic susceptibility testing was performed using the Kirby-Bauer disc diffusion method. Data was entered into Microsoft Excel, cleaned, and analyzed using STATA 15.0.

RESULTS

Among the 476 records with bacterial growth, 74.8% were females. The highest incidence of infection occurred in individuals aged 50 years and above (31.7%). The most isolated bacterial organisms were Gram-negative Escherichia coli (39.5%) and Gram-positive Staphylococcus aureus (25.6%). E.coli was most isolated among females (78.2%, p < 0.0001). Imipenem (83.9%), amikacin (72%), and nitrofurantoin (65.5%) were the antimicrobial agents to which isolated bacteria exhibited the highest sensitivity. Conversely, bacteria showed highest resistance to ciprofloxacin and ofloxacin of 65.5% and 64.5%, respectively.

CONCLUSIONS

The increasing resistance of uropathogens to commonly prescribed and affordable antibiotics is a growing concern. Ciprofloxacin, a widely used empirical treatment, has shown a significant shift towards resistance, highlighting the need for healthcare facilities to utilize bacteriology laboratories for culture and antimicrobial susceptibility testing, and surveillance to inform standard treatment guidelines.

Travel to low- and middle-income countries and travellers' diarrhoea increase risk of mismatching antimicrobial therapy for urinary tract infection

BACKGROUND

Travel to low- and middle-income countries (LMICs) increases the risk of urinary tract infections (UTIs), including those caused by extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE). Focusing on international travel, we explored resistance profiles of urinary ESBL-PE and non-ESBL-PE isolates in a low antimicrobial resistance prevalence country and factors associated with UTI treatment failure.

METHODS

During 2015-19, we recruited 18-65-year-old individuals with recent ESBL-PE UTI and a respective cohort of those with non-ESBL-PE UTI to complete questionnaires on symptoms, antibiotic therapies and treatment failure risk factors. We compared uropathogens' resistance profiles amongst patients with or without LMIC travel history and conducted multivariable analyses to identify factors contributing to mismatching antimicrobial treatment (uropathogen resistant to the initial antimicrobial used) and clinical failure.

RESULTS

Amongst non-ESBL-PE UTI patients (n = 187), trimethoprim resistance was more common in isolates from individuals with recent LMIC travel (8/19, 42.1%) compared to those without (30/167, 18.0%) [odds ratio (OR) 3.3, compatibility interval (CI) 95% 1.2-9.0]. ESBL-PE isolates (n = 130) showed no differences in resistance profiles with respect to LMIC travel history.In the group non-ESBL-PE UTI, risk factors included microbiological mismatching recent LMIC travel [adjusted odds ratio (AOR) 3.6, CI 95% 1.0-12.7] and travellers' diarrhoea (AOR 7.1, CI 95% 1.1-45.6); no factors were significantly associated with mismatching in the group ESBL-PE UTI. As risk factors for clinical failure, in the group non-ESBL-PE UTI, we identified microbiological mismatching (AOR 15.2, CI 95% 4.0-57.9), and renal/bladder disease (AOR 5.2, CI 95% 1.1-23.2), and in the group ESBL-PE UTI, microbiological mismatching (AOR 8.1, CI 95% 2.6-24.7).

CONCLUSIONS

LMIC travel increases the risk of nonmatching empiric antimicrobials, concurring with increased trimethoprim resistance rates amongst the non-ESBL-PE isolates. Our data suggest that UTI patients with recent LMIC travel should not be empirically treated with trimethoprim and, when possible, urinary culturing is warranted.

Current access, availability and use of antibiotics in primary care among key low- and middle-income countries and the policy implications

INTRODUCTION

Antimicrobial resistance (AMR) poses a significant threat, particularly in low- and middle-income countries (LMICs), exacerbated by inappropriate antibiotic use, access to quality antibiotics and weak antimicrobial stewardship (AMS). There is a need to review current evidence on antibiotic use, access, and AMR, in primary care across key countries.

AREAS COVERED

This narrative review analyzes publications from 2018 to 2024 regarding access, availability, and use of appropriate antibiotics.

EXPERT OPINION

There were very few studies focussing on a lack of access to antibiotics in primary care. However, there was considerable evidence of high rates of inappropriate antibiotic use, including Watch antibiotics, typically for minor infections, across studied countries exacerbated by patient demand. The high costs of antibiotics in a number of LMICs impact on their use, resulting in short courses and sharing of antibiotics. This can contribute to AMR alongside the use of substandard and falsified antibiotics. Overall, limited implementation of national action plans, insufficient resources, and knowledge gaps affects sustainable development goals to provide routine access to safe, effective, and appropriate antibiotics.

CONCLUSIONS

There is a clear need to focus health policy on the optimal use of essential AWaRe antibiotics in primary care settings to reduce AMR in LMICs.

Analysis of the Distribution Characteristics and Changes of Drug Resistance of Pathogens in Patients with Urinary Tract Infection Across Southwest China From 2019 to 2023

Objective

To analyze the changes in the distribution and drug resistance of pathogenic bacteria causing urinary tract infections in Southwest China from 2019 to 2023, and to provide an accurate scientific basis for empirical clinical use.

Methods

The identification results and drug susceptibility tests of non-duplicate pathogens isolated from urine samples of patients in Sichuan region from 2019 to 2023 were retrospectively analyzed. The results obtained were interpreted with reference to CLSI M100-33th and analyzed with WHONET 5.6 software.

Results

A total of 247295 strains of pathogens were detected, including 188551 gram-negative strains (76.2%). The positive rate of female patients (56.8%) was significantly higher than that of male patients (43.2%). The top five most common urinary pathogens were Escherichia coli (50.5%), Enterococcus faecium (11.5%), Klebsiella pneumoniae (8.5%), Enterococcus faecalis (6.5%), and Proteus mirabilis (2.9%). The resistance rate of E.coli to levofloxacin, cefotaxime and ceftriaxone was higher (>50%) and had a certain upward trend. The resistance rates of Klebsiella pneumoniae to imipenem and meropenem increased from 7.8% and 9.6% in 2019 to 11.6% and 13.2% in 2023, respectively, much higher than the resistance rates of E. coli to carbapenem antibiotics (<2%). E. coli, K. pneumoniae and E. cloacae still maintained high activity against tigecycline and polymyxin B. The drug resistance rate of Acinetobacter baumannii to imipenem and meropenem was more than 27.4%. The resistance rates of Enterococcus faecium and Enterococcus faecalis to vancomycin, teicoplanin and linezolid were lower than 3.4%. There was an increasing trend in the detection of CRE-KPN among multidrug-resistant bacteria, and a slight decreasing trend in CRPA and CRAB.

Conclusion

The main pathogens of urinary tract infections were E. coli, E. faecium and K. pneumoniae. The drug resistance rates of main clinically isolated bacteria in urine samples showed a diverse trend. Antibiotics should be rationally selected based on the resistance patterns of the pathogens. At the same time, with the continuous detection of multi-drug resistant bacteria VRE and CRE, we have a long way to go in future drug resistance monitoring.

Characteristics and antibiotic resistance patterns of urinary tract isolates in hospitalized and non-hospitalized patients: a cross-sectional study in Khartoum, Sudan

BACKGROUND

Urinary tract infections (UTIs) are widespread worldwide impacting society, economics, and healthcare systems. The rise of antibiotic resistance in both hospital and community settings has further complicated UTI management. This study aims to assess the epidemiologic distribution and microbiologic classification of UTI-causing microorganisms, as well as their resistance patterns.

METHODS

This cross-sectional descriptive study was conducted at the National Public Health Laboratories in Khartoum, Sudan. Urine samples were collected from three hospitals from September to December 2021, and 65 bacterial isolates were recovered from patients with clinical symptoms of UTI. Bacterial identification and antimicrobial susceptibility testing were performed using standard bacteriological methods and Kirby-Bauer's disc diffusion method. Genotyping for Extended Spectrum Beta-Lactamase (EsβL) production was conducted using multiplex PCR.

RESULTS

Of the 65 bacterial isolates, 27 (41.5%) were community-acquired UTI patients (C-UTIs), and 38 (58.5%) were hospital acquired UTI patients (H-UTIs). Males were more commonly affected by H-UTIs (68.4%), while females represented the majority among C-UTIs (85.2%). Gram-negative bacteria were predominant in urinary isolates (81.54%), with Escherichia coli being the most common organism (49.1%). Gram-positive organisms accounted for 18.46% of isolates, with Enterococcus spp. being the most prevalent. In-vitro susceptibility analysis revealed that meropenem was the most effective antibiotic in Gram-negative isolates (77.4%), while nitrofurantoin was the most effective in Gram-positive isolates (91.67%). EsβL production was detected in 11/23 (47.8%) of the tested isolates with Escherichia coli being the most common ESβL producer.

CONCLUSION

This study highlights the pattern of antibiotic-resistant bacteria in UTIs and their significance. Continuous monitoring, development of local antibiograms, and implementation of surveillance programs are essential for guiding empirical antibiotic use and managing UTIs effectively, especially in resource-limited settings like Sudan.

Insights into durability against resistance from the antibiotic nitrofurantoin

Nitrofurantoin has shown exceptional durability against resistance over 70 years of use. This longevity stems from factors such as rapid achievement of therapeutic concentrations, multiple physiological targets against bacteria, low risk of horizontal gene transfer, and the need to acquire multiple mutations to achieve resistance. These combined features limit resistance emergence and spread of nitrofurantoin resistance. We propose nitrofurantoin as an exemplar for developing other durable treatments.

Trends in Antimicrobial Resistance of Uropathogens Isolated from Urinary Tract Infections in a Tertiary Care Hospital in Dhaka, Bangladesh

Background/Objectives: Urinary tract infection (UTI) is a prevalent microbial infection in medical practise, leading to significant patient morbidity and increased treatment costs, particularly in developing countries. This retrospective study, conducted at a tertiary care hospital in Dhaka, Bangladesh, aims to examine the antimicrobial resistance (AMR) patterns of uropathogens and evaluate whether these patterns are influenced by demographic factors such as gender, age, or patient status. Methods: Standard microbiological techniques were used to identify uropathogens, and AMR patterns were determined using the Kirby-Bauer disc diffusion method. Results: Out of 6549 urine samples, 1001 cultures were positive. The infection was more prevalent in females compared to males. The incidence of UTIs in children aged 0-10 years accounted for 12.59% of the total cases, with this age group also exhibiting the highest rate of polymicrobial infections. Among the bacterial uropathogens, 71.19% of isolates were multidrug resistant (MDR) and 84.27% were resistant to at least one antibiotic. Escherichia coli (n = 544, 73.90% MDR) and Klebsiella species (n = 143, 48.95% MDR) were the most common Gram-negative uropathogens, while Enterococcus species (n = 78, 94.87% MDR) was the predominant Gram-positive isolate in this study. Our results indicate that most uropathogens showed resistance against ceftazidime, followed by cefuroxime, trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, and netilmicin. Moderate levels of resistance were observed against ciprofloxacin, levofloxacin, aztreonam, and cefpodoxime. Conclusions: Amikacin was observed to be effective against Gram-negative uropathogens, whereas cefixime was more active against Gram-positive microorganisms, such as Enterococcus species. Moreover, a principal coordinate analysis (PCoA) depicted no significant influence of gender, patient status, or age on AMR patterns. For the continued usefulness of most antibiotics, periodic analysis of the AMR patterns of uropathogens can help assess the rise of MDR bacteria, and therefore guide the selection of appropriate antibiotic treatment strategies.

Impact of lactoferrin supplementation on cotrimoxazole pharmacokinetics: A preliminary clinical investigation

Background and purpose

Cotrimoxazole, a commonly prescribed antibiotic, has substantial resistance, especially in Indonesia, with its uropathogenic resistance reaching 67% in 2017. Although cotrimoxazole has been suggested to be co-administered with lactoferrin to enhance its antibacterial effectiveness and this practice has been widely adopted since the Covid-19 pandemic, the impact of lactoferrin on the pharmacokinetics of cotrimoxazole remains relatively unknown. This study aims to conduct a preliminary clinical investigation into the impact of lactoferrin supplementation on the pharmacokinetics of cotrimoxazole, focusing on the elimination rate and excretion of unchanged drug in urine.

Experimental approach

This study employed a blinded, cross-over, single-dose pharmacokinetics investigation, which included five healthy volunteers as participants. In the initial period, the first group received cotrimoxazole (80 mg trimethoprim and 400 mg sulfamethoxazole) along with a lactoferrin-containing supplement, while the second group only received cotrimoxazole. Subsequently, after a washout period, the conditions were reversed. Urine sampling was conducted at intervals from 0 to 24 hours post-medication, and drug levels in the urine were determined using high-performance liquid chromatography.

Key results

The population-based pharmacokinetic analysis revealed that the optimal model was the one-compartment model with first-order elimination and proportional residual error.

Conclusion

The findings show that the administration of lactoferrin-containing supplements did not significantly influence the covariate model and, therefore, did not alter the pharmacokinetics parameter of cotrimoxazole in urine with a single administration, implying that lactoferrin did not cause drug interaction problems when given simultaneously.

The Prevalence of Multidrug-Resistant Escherichia coli in Chennai and Whole Genome Sequence Analysis of Carbapenem-Resistant Escherichia coli ST410

The current study evaluates antibiotic susceptibility and Extended Spectrum β-Lactamase (ESBL) production of 557 Escherichia coli isolates obtained from clean catch midstream urine samples using VITEK 2 compact automated microbial identification system. Different classes of drugs were used to determine the Minimum inhibitory concentration (MIC). In our study, 50.45% of isolates were ESBL producers. There is a higher incidence of UTI in females (77.4%) than in males (22.6%). The isolates reveal a high percentage of resistance to antibiotics like nalidixic acid (89.59%), ampicillin (75.76%), ticarcillin (73.43%), cefalotin (67.68%), cefixime (65.17%), ciprofloxacin (58.35%) and ceftriaxone (56.37%). An increased susceptibility pattern was observed for the isolates against drug classes like fosfomycin (98.03%) and nitrofurantoin (91.02%). Among the isolates, 395 (70.91%) were classified as Multidrug-resistant organisms based on the resistance pattern observed against three or more classes of antibiotics. One of the isolates resistant to fluoroquinolones, penicillins, penicillins along with β-lactamase inhibitor, aminoglycosides, third-generation cephalosporins and carbapenems was subjected to Whole genome sequencing (WGS). WGS data revealed the isolate to be a high-risk clone ST410, which contains antimicrobial-resistance genes (blaTEM-1B, blaCTX-M-15, blaNDM-5, aac(3)-IId, armA, gyrA(p.S83L), gyrA(p.D87N)) conferring resistance to β-lactam, cephalosporins, carbapenem, aminoglycoside and fluoroquinolone class of antibiotics. The core genome MLST was carried out using BacWGSTdb to assess the global phylogenetic relationship of the genome sequence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12088-023-01125-1.

The emotional impact of uncomplicated urinary tract infections in women in China and Japan: a qualitative study

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are one of the most common community-acquired infections, particularly among women. Common symptoms of UTI include dysuria, urinary urgency and increased frequency, and lower abdominal pain. With appropriate treatment, symptoms may resolve in a few days. However, there is a lack of research on the emotional impact of this disease. We conducted a qualitative, interview-based study to gain a greater understanding of the emotional impact of uUTIs in women in China and Japan.

METHODS

A qualitative, exploratory, in-depth, interview-based study was conducted between 19 November 2020 and 25 February 2021. Women aged ≥ 18 years who experienced ≥ 1 uUTI and received antibiotic treatment in the past year were eligible for inclusion. Participants must have experienced ≥ 1 of the following symptoms during a uUTI episode: urinary urgency, frequency, dysuria, or lower abdominal/suprapubic pain. Participants who reported back pain or fever (indicative of complicated UTI) were excluded. Participants with recurrent or sporadic UTIs were included, with specific screening criteria used to ensure capture of both groups. Following a screening call, a structured, in-depth telephone interview (~ 30 min in duration) was conducted by three female external moderators trained in qualitative interviewing, assisted by an interview guide. Interviews were analysed individually and thematically, with the results presented within the identified themes.

RESULTS

A total of 65 women with uUTI completed the in-depth telephone interview: 40 (62%) from China and 25 (38%) from Japan. Participants reported that the symptoms of uUTI affected multiple aspects of their lives, and described feelings of embarrassment, frustration, guilt, dread, and loneliness associated with symptoms that interfered with relationships, work and daily activities, and sleep. Participants reported seeking healthcare from several different points of contact, from local pharmacies to hospitals.

CONCLUSIONS

Our analysis highlights the profound emotional impact of uUTIs in women in China and Japan, and the journey these participants take before their initial interaction with a healthcare professional. These insights emphasise the need to better understand the full impact of uUTI, and the role of healthcare professionals in improved patient education and support.

Antimicrobial Resistance in Streptococcus pneumoniae before and after the Introduction of Pneumococcal Conjugate Vaccines in Brazil: A Systematic Review

Streptococcus pneumoniae causes serious illnesses, such as pneumonia, bacteremia, and meningitis, mainly in immunocompromised individuals and those of extreme ages. Currently, pneumococcal conjugate vaccines (PCVs) are the best allies against pneumococcal diseases. In Brazil, the 10-valent and 13-valent PCVs have been available since 2010, but the threat of antimicrobial resistance persists and has been changing over time. We conducted a systematic review of the literature with works published since 2000, generating a parallel between susceptibility data on isolates recovered from colonization and invasive diseases before and after the implementation of PCVs for routine childhood use in Brazil. This systematic review was based on the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Literature Reviews and Meta-Analyses (PRISMA) guidelines. Despite the inclusion of PCVs at a large scale in the national territory, high frequencies of non-susceptibility to important drugs used in pneumococcal diseases are still observed, especially penicillin, as well as increasing resistance to macrolides. However, there are still drugs for which pneumococci have a comprehensive sensitivity profile.

Evaluation of Two Tests for the Rapid Detection of CTX-M Producers Directly in Urine Samples

Infections caused by extended-spectrum β-lactamase-producing Enterobacterales have increased rapidly and are mainly attributed to the production of CTX-M enzymes. This study evaluated the NG-Test® CTX-M MULTI lateral flow assay (CTX-M LFA) and the Rapid ESBL NP® test (ESBL NP test) for rapid detection of CTX-M-producing Enterobacterales directly in midstream urine (MSU) samples. Testing was performed on 277 clinical MSU samples in a hospital microbiology laboratory from November 2022 to January 2023; 60 of these samples (30 positive for ESBL producers and 30 positive for non-ESBL producers) were tested retrospectively after the identification and susceptibility results were obtained, and 217 samples were tested prospectively immediately after a Gram stain showing the presence of Gram-negative bacilli. The results were compared against phenotypic detection of ESBL and molecular testing as the reference methods. Overall, 67 of the 277 samples were culture-positive for ESBL-producing Enterobacterales. PCR for the blaCTX-M gene was positive for all ESBL-producing Enterobacterales isolates. All CTX-M LFA results were interpretable, while three of the ESBL NP test results were noninterpretable. The sensitivity of the CTX-M LFA (100%, 95% CI 94.6-100%) was higher than that of the ESBL NP test (86.6%, 95% CI 76.0-93.7%). Both tests had high specificities (CTX-M LFA, 99.1%, 95% CI 96.6-99.9% and ESBL NP test, 100%, 95% CI 98.2-100%). In conclusion, both the CTX-M LFA and the ESBL NP test can deliver rapid results that could improve antimicrobial stewardship for urinary tract infections.

Patterns of Drug Resistance and Bacterial Pathogen Distribution in Patients with Urinary Tract Infections in the Jiaxing Region from 2020 to 2022

Background

Urinary tract infections (UTIs) and the antibiotic resistance of pathogenic bacteria pose severe threats to public health in the current healthcare environment.

Objective

The purpose of this study was to assess the frequency distribution of bacterial pathogens causing UTIs as well as the characteristics of antibiotic susceptibility and resistance.

Methods

The retrospective study was conducted on 32,391 samples of midstream urine culture from January 1, 2020, to December 31, 2022, in Jiaxing. Bacteria were cultivated on blood agar and identified using MALDI-TOF, and their susceptibility to different antibiotics was assessed using the Kirby-Bauer disk diffusion method and drug sensitivity reaction cards. The SPSS 22 software was used for data analysis. Bivariate logistic regression was used to analyze the risk factors for multidrug resistance.

Results

The total number of positive growth samples was 5378 (16.6%), including 3206 females (59.6%) and 2172 males (40.4%). The four most common urinary pathogens were Escherichia coli (39.2%), Enterococcus faecalis (12.4%), Klebsiella pneumoniae (7.6%), and Enterococcus faecium (7.6%). As far as antibiotic resistance was concerned, Escherichia coli had a greater than 50% resistance rate to ampicillin (76.1%), ciprofloxacin (58.6%), and levofloxacin (51.2%). The multidrug resistance rate was high (41.8%). Low levels of resistance were seen to ertapenem (0.1%), imipenem (0.7%), meropenem (0.7%), piperacillin/tazobactam (0.7%), and nitrofurantoin (1.8%). Klebsiella pneumoniae was highly sensitive to ertapenem (100%). The resistance rates to nitrofurantoin, ceftriaxone, and ciprofloxacin were 37.4%, 37.1%, and 35.1%, respectively. Up to 41% of Escherichia coli strains and 26% of Klebsiella pneumoniae strains produced extended-spectrum lactamases (ESBL). Two species of enterococci were highly sensitive to tigecycline and linezolid (100%), and a small number of norvancomycin-resistant strains (0.2%/two strains) were found.

Conclusion

Escherichia coli and Enterococcus faecium were the most common urinary pathogens in this study. The isolated pathogens showed different sensitivity patterns. Antibiotics should be selected reasonably according to the sensitivity mode of pathogenic bacteria to effectively treat and prevent urinary tract infections.

Potentiality of Actinomycetia Prevalent in Selected Forest Ecosystems in Assam, India to Combat Multi-Drug-Resistant Microbial Pathogens

Actinomycetia are known for their ability to produce a wide range of bioactive secondary metabolites having significant therapeutic importance. This study aimed to explore the potential of actinomycetia as a source of bioactive compounds with antimicrobial properties against multi-drug-resistant (MDR) clinical pathogens. A total of 65 actinomycetia were isolated from two unexplored forest ecosystems, namely the Pobitora Wildlife Sanctuary (PWS) and the Deepor Beel Wildlife Sanctuary (DBWS), located in the Indo-Burma mega-biodiversity hotspots of northeast India, out of which 19 isolates exhibited significant antimicrobial activity. 16S rRNA gene sequencing was used for the identification and phylogenetic analysis of the 19 potent actinomycetia isolates. The results reveal that the most dominant genus among the isolates was Streptomyces (84.21%), followed by rare actinomycetia genera such as Nocardia, Actinomadura, and Nonomuraea. Furthermore, seventeen of the isolates tested positive for at least one antibiotic biosynthetic gene, specifically type II polyketide synthase (PKS-II) and nonribosomal peptide synthetases (NRPSs). These genes are associated with the production of bioactive compounds with antimicrobial properties. Among the isolated strains, three actinomycetia strains, namely Streptomyces sp. PBR1, Streptomyces sp. PBR36, and Streptomyces sp. DBR11, demonstrated the most potent antimicrobial activity against seven test pathogens. This was determined through in vitro antimicrobial bioassays and the minimum inhibitory concentration (MIC) values of ethyl acetate extracts. Gas chromatography-mass spectrometry (GS-MS) and whole-genome sequencing (WGS) of the three strains revealed a diverse group of bioactive compounds and secondary metabolite biosynthetic gene clusters (smBGCs), respectively, indicating their high therapeutic potential. These findings highlight the potential of these microorganisms to serve as a valuable resource for the discovery and development of novel antibiotics and other therapeutics with high therapeutic potential.

High Resistance to Antibiotics Recommended in Standard Treatment Guidelines in Ghana: A Cross-Sectional Study of Antimicrobial Resistance Patterns in Patients with Urinary Tract Infections between 2017-2021

Management of urinary tract infections is challenged by increasing antimicrobial resistance (AMR) worldwide. In this study, we describe the trends in antimicrobial resistance of uropathogens isolated from the largest private sector laboratory in Ghana over a five-year period. We reviewed positive urine cultures at the MDS Lancet Laboratories from 2017 to 2021. The proportions of uropathogens with antimicrobial resistance to oral and parenteral antimicrobials recommended by the Ghana standard treatment guidelines were determined. The proportion of multi-drug resistant isolates, ESBL and carbapenemase-producing phenotypes were determined. Of 94,134 urine specimens submitted for culture, 20,010 (22.1%) were culture positive. Enterobacterales was the most common group of organisms, E. coli (70.6%) being the most common isolate and Enterococcus spp. the most common gram-positive (1.3%) organisms. Among oral antimicrobials, the highest resistance was observed to ciprofloxacin (62.3%) and cefuroxime (60.2%) and the least resistance to fosfomycin (1.9%). The least resistance among parenteral antimicrobials was to meropenem (0.3%). The highest multi-drug resistance levels were observed among Klebsiella spp. (68.6%) and E. coli (64.0%). Extended-spectrum beta-lactamase (ESBL) positivity was highest in Klebsiella spp. (58.6%) and E. coli (50.0%). There may be a need to review the Ghana standard treatment guidelines to reflect increased resistance among uropathogens to recommended antimicrobials.

Limited Therapeutic Options in Mexico for the Treatment of Urinary Tract Infections

The rise in antimicrobial resistance (AMR) has complicated the management of urinary tract infections (UTIs). The objective of this study was to evaluate the antimicrobial susceptibility patterns of Escherichia coli and Klebsiella pneumoniae. Design: prospective observational study. Bacteria were classified as susceptible or resistant to ampicillin-sulbactam, amikacin, gentamicin, ciprofloxacin, norfloxacin, nitrofurantoin, trimethoprim-sulfamethoxazole (TMP/SMZ), ertapenem, meropenem, and fosfomycin. The sensitivity to fosfomycin and chloramphenicol was evaluated by the disk diffusion method. Statistical analysis: the chi-square test and Fisher’s exact test were used to compare differences between categories. A p value < 0.05 was considered statistically significant. Isolates were collected from January 2019 to November 2020 from 21 hospitals and laboratories. A total of 238 isolates were received: a total of 156 E. coli isolates and 82 K. pneumoniae isolates. The majority were community-acquired infections (64.1%). Resistance was >20% for beta-lactams, aminoglycosides, fluoroquinolones, and TMP/SMZ. For E. coli isolates, resistance was <20% for amikacin, fosfomycin, and nitrofurantoin; for K. pneumoniae, amikacin, fosfomycin, chloramphenicol, and norfloxacin. All were susceptible to carbapenems. K. pneumoniae isolates registered a higher proportion of extensively drug-resistant bacteria in comparison with E. coli (p = 0.0004). In total, multidrug-resistant bacteria represented 61% of all isolates. Isolates demonstrated high resistance to beta-lactams, fluoro-quinolones, and TMP/SMZ.

Compliance to Guidelines in Prescribing Empirical Antibiotics for Individuals with Uncomplicated Urinary Tract Infection in a Primary Health Facility of Ghana, 2019-2021

Increasing trends in antimicrobial resistance among uropathogens call for rational use of empirical antibiotics for managing uncomplicated urinary tract infections (UTIs). In Ghana, standard treatment guidelines (STGs) for UTI recommend oral ciprofloxacin or cefuroxime for 5-7 days in females and 10-14 days in males. We conducted a cross-sectional audit using electronic medical records (EMR) to assess compliance to the STGs among adults (≥18 years) with uncomplicated UTIs diagnosed in a primary health facility between October 2019 and October 2021. Among 3717 patients, 71% were females and all had complete prescription details in the EMR. Of all the patients, 83% were prescribed empirical antibiotics, of whom 88% received oral ciprofloxacin or cefuroxime. Only 68% were prescribed antibiotics for the correct duration, which was significantly lower among males (10%) compared to females (90%). Among patients who received antibiotics, 60% were prescribed in line with the STGs. The results call for feedback to physicians about poor compliance to STGs with duration of antibiotic prescribed. Recommendations on 10-14 days duration of antibiotics for males needs to be reassessed and necessary amendments to STGs can be made. Leveraging the well-established EMR system, a real-time audit-feedback mechanism can be instituted to improve compliance with STGs.

Risk Factors for Community-Acquired Urinary Tract Infections Caused by Multidrug-Resistant Enterobacterales in Thailand

The dissemination of multidrug-resistant Enterobacterales (MDRE) in community settings is becoming a great concern. This study aimed to assess the incidence and risk factors associated with community-acquired urinary tract infections (CA-UTIs) caused by MDRE. A prospective case−control study was undertaken among patients with UTIs visiting an outpatient department in Phitsanulok Province, Thailand. Urine samples were collected and screened to include only patients with Enterobacterales infections. Risk factors were analyzed by multivariate logistic regression analysis. Of the 284 patients with CA-UTIs, 25.7% (n = 73) and 74.3% (n = 211) were positive for MDRE (case) and non-MDRE (control), respectively. Being a farmer was identified as an independent risk factor for MDRE-associated CA-UTIs (adjusted odds ratio = 3.101; 95% confidence interval = 1.272−7.564; p = 0.013). A total of 309 Enterobacterales isolates were recovered, and Escherichia coli was the most frequently detected (86.4%). The highest resistance rate was observed for ampicillin (67.0%), followed by ciprofloxacin (34.0%) and cotrimoxazole (32.7%), while resistance to third-generation cephalosporins (cefotaxime, ceftriaxone) and levofloxacin remained <20%. Resistance to ampicillin−gentamicin−cotrimoxazole was the most common pattern among MDRE isolates. Interestingly, we detected a colistin-resistant Enterobacter cloacae harboring mcr-9 (colistin MIC = 16 µg/mL). mcr-9 was transferable at high frequency (4.5 × 10−4) and resided on IncF plasmid. This study demonstrates that being a farmer is a risk factor for MDRE-associated CA-UTIs. Interestingly, this is the first report to identify mcr-9-positive E. cloacae from a Thai patient in the community.

Risk factors for carriage of antimicrobial-resistant bacteria in community dwelling-children in the Asia-Pacific region: a systematic review and meta-analysis

Background

Antimicrobial resistance is an increasingly important issue in public health as antibiotics are overused. Resistance to antimicrobial agents can pose significant challenges to infection treatment.

Objectives

To evaluate risk factors associated with carriage of antimicrobial-resistant (AMR) bacteria in children in the Asia-Pacific region to consolidate evidence for future implementation of antibiotic prescribing practice.

Methods

Three electronic databases-PubMed, EMBASE and Cochrane Library-were searched. Observational studies that investigated the risk factors for carriage of MRSA, penicillin-resistant Streptococcus pneumoniae, ESBL-producing Escherichia coli and Klebsiella pneumoniae among the paediatric population in community settings in the Asia-Pacific region were considered eligible. Summary statistics from the identified studies were pooled using meta-analyses.

Results

From the 4145 search results, 25 papers were included in this review. Sixteen papers were included in the meta-analysis based on reported risk factors. Young age of 2-6 months compared with children aged 7-60 months (OR 2.74, 95% CI: 1.75-4.29), antibiotic use within the past 3 months (OR 2.65, 95% CI: 1.70-4.12), daycare attendance (OR 1.49, 95% CI: 1.17-1.91) and hospital admission within the past 3 months (OR 3.43, 95% CI: 2.13-5.51) were found to be significant risk factors for AMR bacterial carriage, whilst breastfeeding (OR 0.69, 95% CI: 0.60-0.81) and concurrent colonization of S. pneumoniae (OR 0.59, 95% CI: 0.38-0.91) are protective factors.

Conclusions

The findings support that there are a number of significant risk factors associated with carriage of AMR bacteria in the Asia-Pacific paediatric population. To combat antimicrobial resistance in the future, these risk factors should be considered, and measures taken to mitigate associated carriage.

High multidrug resistance in urinary tract infections in a tertiary hospital, Kathmandu, Nepal

SETTING:

Tribhuvan University Teaching Tertiary Care Hospital, Kathmandu, Nepal, May–October 2019.

OBJECTIVE:

1) To describe the bacteriological profile, 2) to identify the antimicrobial resistance (AMR) pattern, and 3) to find the demographic characteristics associated with the presence of bacterial growth and multidrug resistance (MDR) in adult urine samples undergoing culture and drug susceptibility testing.

DESIGN:

This was a hospital-based, cross-sectional study using routine laboratory records.

RESULTS:

Among 11,776 urine samples, 16% (1,865/11,776) were culture-positive, predominantly caused by Escherichia coli (1,159/1,865; 62%). We found a high prevalence of resistance to at least one antibiotic (1,573/1,865; 84%) and MDR (1,000/1,865; 54%). Resistance to commonly used antibiotics for urinary tract infections (UTIs) such as ceftazidime, levofloxacin, cefepime and ampicillin was high. Patients aged ⩾60 years (adjusted prevalence ratio [aPR] 1.6, 95% CI 1.4–1.7) were more likely to have culture positivity. Patients with age ⩾45 years (45–59 years: aPR 1.5, 95% CI 1.3–1.7; ⩾60 years: aPR 1.4, 95% CI 1.2–1.6), male sex (aPR 1.3, 95% CI 1.2–1.5) and from inpatient settings (aPR 1.4, 95% CI 1.2–1.7) had significantly higher prevalence of MDR.

CONCLUSION:

Urine samples from a tertiary hospital showed high prevalence of E. coli and MDR to routinely used antibiotics, especially among inpatients. Regular surveillance and application of updated antibiograms are crucial to monitor the AMR situation in Nepal.