Increased resistance to first-line agents among bacterial pathogens isolated from urinary tract infections in Latin America: time for local guidelines?

Incidence and antimicrobial profile of extended-spectrum β-lactamase producing gram-negative bacterial isolates: An in-vitro and statistical analysis

OBJECTIVES

There is an extensive incidence of extended-spectrum beta-lactamases (ESBLs), principally in the hospital environment across the world. The present study was designed to discover the frequency of ESBL-production among the clinical isolates of Escherichia coli, Klebsiella pneumonia, and Pseudomonas aeruginosa. The study also focused on determining their liability to the selected antimicrobials.

METHODS

Two hundred ten (210) clinical specimens were tested for the occurrence of ESBL using the double-disc synergy test. The molecular, physicochemical, absorption, distribution, metabolism, excretion, and toxicity were checked through an online server.

RESULTS

Among the screened clinical isolates, E. coli (n=44), K. pneumonia (n=34) and P. aeruginosa (n=14) were ESBL markers. The ESBL producing isolates exhibited co-resistance to diverse categories of antibiotics. It was observed that all the ESBL-producing isolates were sensitive towards imipenem and faropenem with minimal proportion of resistance.

CONCLUSION

The imipenem and faropenem can be recommended as the drugs of selection due to a lesser amount of resistance as compared to other antibiotics in this study.

Challenges facing drug utilization research in the Latin American region

PURPOSE

The International Society of Pharmacoepidemiology (ISPE) in collaboration with the Latin America Drug Utilization Research Group (LatAm DURG), the Medicines Utilization Research in Africa (MURIA) group, and the Uppsala Monitoring Center, is leading an initiative to understand challenges to drug utilization research (DUR) in the Latin American (LatAm) and African regions with the goal of communicating results and proposing solutions to these challenges in four scientific publications. The purpose of this first manuscript is to identify the main challenges associated with DUR in the LatAm region.

METHODS

Drug utilization (DU) researchers in the LatAm region voluntarily participated in multiple discussions, contributed with local data and reviewed successive drafts and the final manuscript. Additionally, we carried out a literature review to identify the most relevant publications related to DU studies from the LatAm region.

RESULTS

Multiple challenges were identified in the LatAm region for DUR including socioeconomic inequality, access to medical care, complexity of the healthcare system, limited investment in research and development, limited institutional and organization resources, language barriers, limited health education and literacy. Further, there is limited use of local DUR data by decision makers particularly in the identification of emerging health needs coming from social and demographic transitions.

CONCLUSIONS

The LatAm region faces challenges to DUR which are inherent in the healthcare and political systems, and potential solutions should target changes to the system.

Breaking the frontiers of cosmetology with antimicrobial peptides

Antimicrobial peptides (AMPs) are mostly endogenous, cationic, amphipathic polypeptides, produced by many natural sources. Recently, many biological functions beyond antimicrobial activity have been attributed to AMPs, and some of these have attracted the attention of the cosmetics industry. AMPs have revealed antioxidant, self-renewal and pro-collagen effects, which are desirable in anti-aging cosmetics. Additionally, AMPs may also be customized to act on specific cellular targets. Here, we review the recent literature that highlights the many possibilities presented by AMPs, focusing on the relevance and impact that this potentially novel class of active cosmetic ingredients might have in the near future, creating new market outlooks for the cosmetic industry with these molecules as a viable alternative to conventional cosmetics.

[[Resistance profile of uropathogens in patients with diabetes in Quito, Ecuador, a disturbing panorama]]

Señor Editor: Las infecciones del tracto urinario (ITU) se encuentran entre las infecciones bacterianas más comunes y los pacientes con diabetes tienen mayor riesgo de sufrirlas. Aunque el espectro de agentes etiológicos es reducido y predecible, los mecanismos y tasas de resistencia a antimicrobianos han aumentado, lo que dificulta el tratamiento empírico.

High Prevalence of CTX-M-1-Like Enzymes in Urinary Isolates of Escherichia coli in Guayaquil, Ecuador

Escherichia coli is one of the major causes of urinary tract infections in primary healthcare, and treatment is more complicated due to the increase in antibiotic resistance. Extended-spectrum β-lactamases are the most common mechanism of resistance against third-generation cephalosporin, and CTX-M-like are among the most prevalent. The aim of our work is to investigate the prevalence of bla_CTX-M in isolates of E. coli obtained from samples of patients without previous known contact with the hospital. Ninety-four E. coli isolates with resistance to third-generation cephalosporin were collected between 2008 and 2013 in Guayaquil, Ecuador. Polymerase chain reaction, followed by sequencing, was performed to identify the type of bla_CTX-M-Like. Enterobacterial repetitive intergenic consensus (ERIC)-PCR was carried out to determine the clonal relationship between isolates. These results show an increase in resistance to third-generation cephalosporin from 10.58% to 23.96%. CTX-M-15 was the most prevalent mechanism of resistance being that the isolates were not clonal. Overall, these results show an increase in antibiotic resistance in the community over time, suggesting that more precise antibiotic stewardship needs to be implemented to control the dissemination of antibiotic-resistant bacteria in this region.

Bacteriological profile and antimicrobial susceptibility patterns of urine culture isolates from patients in Ndjamena, Chad

Introduction

Bacteriological profile and antimicrobial susceptibility patterns of urine culture isolates were determined among patients in the Ndjamena General Hospital, a National Reference centre.

Methods

A cross-sectional study was carried out from July to November 2014. Six hundred and sixty patients were enrolled, to whom a cytobacteriological examination of urine was prescribed. Urine was collected and cultured. Bacterial identification and antimicrobial susceptibility patterns were performed using Vitek 2 compact automated system.

Results

216 isolates were recovered from patients (age range: 10-90 years). E. coli was the pathogen frequently cultured 128 (59.3%) followed by K. pneumonia 28 (13.0%). Bacteriuria was more present in inpatients (70.4%) compared to outpatients (29.6%). High antibiotic-resistance rate (> 60%) of the total isolates was observed with ampicillin, ciprofloxacin and cephalosporins. Imipeneme (94.9%) displayed satisfactory activity against bacteria isolates. ESBLs phenotype was present in 68/105 (64.7%) of betalactamine resistant isolates. AAC(3)-I and AAC(6’)-I enzymes were found respectively in 16/36 (44.4%) and 20/36 (55.6%) of aminoglycosides resistant isolates. Resistance of isolates to quinolones was mainly due to an association of target modification (gyrA and parC), porin reduction and/or efflux mechanisms and was present in 107/213 (49%) of quinolones resistant isolates.

Conclusion

E. coli is the predominant uropathogen isolated in our setting and there are antibiotic-resistant uropathogens among the studied population. Therefore, routine surveillance of bacterial uropathogens to common used antibiotics must be a continuous process so as to provide physicians with up to date information about the local data of antimicrobial resistance.

Drug-resistant gram-negative uropathogens: A review

Urinary tract infection(UTI) caused by Gram-negative bacteria is the second most common infectious presentation in community medical practice. Approximately 150 million people are diagnosed with UTI each year worldwide. Drug resistance in Gram-negative uropathogens is a major global concern which can lead to poor clinical outcomes including treatment failure, development of bacteremia, requirement for intravenous therapy, hospitalization, and extended length of hospital stay. The mechanisms of drug resistance in these bacteria are important due to they are often not identified by routine susceptibility tests and have an exceptional potential for outbreaks. Treatment of UTIs depends on the access to effective drugs, which is now threatened by antibiotic resistant Gram-negative uropathogens. Although several effective antibiotics with activity against highly resistant Gram-negatives are available, there is not a unique antibiotic with activity against the high variety of resistance. Therefore, antimicrobial susceptibility tests, correlation between clinicians and laboratories, development of more rapid diagnostic methods, and continuous monitoring of drug resistance are urgent priorities. In this review, we will discuss about the current global status of drug-resistant Gram-negative uropathogens and their mechanisms of drug resistance to provide new insights into their treatment options.

Clarithromycin-Based Triple Therapy is Still Useful as an Initial Treatment for Helicobacter pylori Infection in the Dominican Republic

AbstractHelicobacter pylori antibiotic susceptibility in the Dominican Republic has not been monitored. We assessed H. pylori antibiotic susceptibility in the Dominican Republic, and analyzed H. pylori mutations associated with antibiotic resistance. We recruited 158 dyspeptic patients in Santo Domingo and used agar dilution to test susceptibility to five antibiotics. Polymerase chain reaction-based sequencing was used to assess gyrA, gyrB, rdxA, frxA, and 23S rRNA mutations; next-generation sequencing was used to identify other metronidazole resistance-associated genes. Among 64 H. pylori strains isolated, we identified two (3.1%), one (1.6%), and no strains with clarithromycin, amoxicillin, and tetracycline resistance, respectively. Moreover, high frequency of metronidazole resistance (53/64, 82.8%) was observed, whereas levofloxacin resistance is emerging (23/64, 35.9%). We identified many rdxA and frxA mutations in metronidazole-resistant strains, but no synergistic effect was apparent. We revealed novel mutations in dppA, dppB, fdxA, and fdxB, irrespective of rdxA and frxA mutations. Novel mutations at Ser-14 of trx1 and Arg-221 of dapF were associated with different levels of metronidazole resistance. Most levofloxacin-resistant strains had a substitution at Asn-87 of gyrA, including the strain with the highest levofloxacin resistance, whereas only three substitutions were found at Ser-479 of gyrB with no synergistic effect. Besides the 23S rRNA A2142G mutation, we observed another mutation at T1958G in both clarithromycin-resistant strains. We confirmed high metronidazole and levofloxacin resistance associated with genetic mutations in the Dominican Republic. However, prevalence of clarithromycin resistance was low, suggesting that standard clarithromycin-based triple therapy remains useful as initial treatment of H. pylori infection.

Infecções comunitárias do trato urinário: prevalência e susceptibilidade aos antimicrobianos na cidade de Florianópolis

Objetivo: Determinar a frequência de isolamento dos uropatógenos e avaliar o perfil de sensibilidade antimicrobiana in vitro das bactérias isoladas em uroculturas de pacientes ambulatoriais atendidos em Florianópolis no ano de 2014, correlacionando tais dados com sexo e idade do paciente. Métodos: Estudo observacional, descritivo do tipo transversal, que incluiu uroculturas positivas de pacientes ambulatoriais realizadas em um único laboratório seguindo a mesma metodologia. Realizaram-se análises de estatísticas descritivas e testes de associação entre as variáveis classificatórias: sexo, idade, agente etiológico e sensibilidade aos antimicrobianos. Resultados: Foram registradas 1035 uroculturas positivas, das quais 89,66% de pacientes femininas. Microrganismos Gram-negativos foram os patógenos mais isolados, com destaque para a Escherichia coli (77,10%), principal agente causal. Proteus mirabilis foi significativamente mais prevalente no sexo masculino e o principal microrganismo isolado nas uroculturas dos meninos de 1 a 5 anos. A E. coli foi significativamente mais prevalente no sexo feminino e apresentou o perfil mais amplo de resistência. Evidenciaram-se diferenças estatisticamente significativas nas resistências às fluoroquinolonas entre os gêneros, com maiores prevalências de resistência em homens e entre as faixas etárias, com maior resistência entre idosos. Conclusões: Idade e sexo são variáveis determinantes na frequência de isolamento dos uropatógenos e na prevalência da susceptibilidade antimicrobiana; e os microrganismos mais prevalentes já não respondem satisfatoriamente a parte dos antimicrobianos amplamente utilizados. É fundamental que o médico considere tais informações no momento da decisão terapêutica e preze pelo uso racional dos antimicrobianos, sobretudo aqueles de largo espectro como as fluoroquinolonas.

Temporal trends and risks factors for antimicrobial resistant Enterobacteriaceae urinary isolates from outpatients in Guadeloupe

BACKGROUND

Urinary tract infections are bacterial infections most commonly encountered in the community. The resistance rate of uropathogens to commonly prescribed antibiotics has increased worldwide but there are no published data concerning the resistance of strains isolated from community-acquired UTI in Guadeloupe. To assess the susceptibility patterns of Enterobacteriaceae strains isolated from outpatients in Guadeloupe we conducted a prospective study from December 2012 to May 2014 among outpatients consulting at private and public laboratories for urine analysis. Risk factors for E. coli resistance to amoxicillin, third-generation cephalosporin, and ciprofloxacin were also determined. To study the trends of E. coli resistance rates over the past 10 years, data on the susceptibility patterns of E. coli from 2003 to 2014 were also collected from three major laboratories for a retrospective study.

RESULTS

During the prospective study, we isolated 1293 bacterial strains from the urine of outpatients presenting for urine analysis. The most commonly isolated bacteria were E. coli (57 %) and Klebsiella pneumoniae (15.5 %). Thirty seven per cent of the E. coli strains were resistant to amoxicillin. Resistance rates to third generation cephalosporin were low for E. coli and other Enterobacteriaceae (3.1 and 12.2 % respectively) and mostly due to the presence of an Extended Spectrum Beta-lactamase. Resistance to cotrimoxazole and ciprofloxacin was moderate (17.8 and 15.6 % respectively). However, the resistance rate of E. coli to ciprofloxacin has significantly increased during the last 10 years. Risk factors were consistent with previously reported data, especially for the increasing ciprofloxacin resistance with age.

CONCLUSION

General practitioners in Guadeloupe need to be better informed to favor the prescription of fosfomycin-trometamol to reduce the risk of resistance to fluoroquinolones.

ANTIBIOTIC RESISTANCE PATTERNS OF URINARY TRACT INFECTIONS IN A NORTHEASTERN BRAZILIAN CAPITAL

Urinary tract infection is a common problem worldwide. Its clinical characteristics and susceptibility rates of bacteria are important in determining the treatment of choice and its duration. This study assessed the frequency and susceptibility to antimicrobials of uropathogens isolated from community-acquired urinary tract infections in the city of Natal, Rio Grande do Norte State capital, northeastern Brazil, from 2007 to 2010. A total of 1,082 positive samples were evaluated; E. coli was the most prevalent pathogen (60.4%). With respect to the uropathogens susceptibility rates, the resistance of enterobacteria to ciprofloxacin and sulfamethoxazole-trimethoprim was 24.4% and 50.6%, respectively. Susceptibility was over 90% for nitrofurantoin, aminoglycosides and third-generation cephalosporins. High resistance rates of uropathogens to quinolones and sulfamethoxazole-trimethoprim draws attention to the choice of these drugs on empirical treatments, especially in patients with pyelonephritis. Given the increased resistance of community bacteria to antimicrobials, local knowledge of susceptibility rates of uropathogens is essential for therapeutic decision making regarding patients with urinary tract infections.

[Prevalence and risk factors for extended-spectrum β-lactamase-producing Escherichia coli causing community-onset urinary tract infections in Colombia]

INTRODUCTION

Urinary tract infections (UTI) are common in the community. However, information of resistant isolates in this context is limited in Latin America. This study aims to determine the prevalence and risk factors associated with community-onset UTI (CO-UTI) caused by extended-spectrum β-lactamase (ESBL)-Producing Escherichia coli in Colombia.

MATERIALS AND METHODS

A case-control study was conducted between August and December of 2011 in three Colombian tertiary-care institutions. All patients who were admitted to the Emergency Department with a probable diagnosis of CO-UTI were invited to participate. All participating patients were asked for a urine sample. ESBL confirmatory test, antibiotic susceptibility, and molecular epidemiology were performed in these E.coli isolates (Real Time-PCR for bla genes, repetitive element palindromic PCR [rep-PCR], multilocus sequence typing [MLST] and virulence factors by PCR). Clinical and epidemiological information was recorded, and a statistical analysis was performed.

RESULTS

Of the 2124 recruited patients, 629 had a positive urine culture, 431 of which grew E.coli; 54 were positive for ESBL, of which 29 were CTX-M-15. The majority of ESBL isolates were susceptible to ertapenem, phosphomycin and amikacin. Complicated UTI was strongly associated with ESBL-producing E.coli infections (OR=3.89; 95%CI: 1.10-13.89; P=.03). CTX-M-15-producing E.coli showed 10 different pulsotypes, 65% were PT1 or PT4, and corresponded to ST131. Most of these isolates had 8 out of the 9 analysed virulence factors.

DISCUSSION

E.coli harbouring bla_CTX-M-15 associated with ST131 is still frequent in Colombia. The presence of complicated CO-UTI increases the risk of ESBL-producing E.coli, and must be taken into account in order to provide an adequate empirical therapy.

Virulence factors of Candida species isolated from patients with urinary tract infection and obstructive uropathy

OBJECTIVE

Fungal urinary tract infections due to Candida have increased significantly in recent years. Our research objective was to study Candida species in urine samples of patients with urinary tract infections (UTIs) associated with obstructive uropathy and to investigate the virulence factors of the isolated Candida.

METHODS

Patients were divided into two groups: Group I (cases): 50 patients with UTIs and obstructive uropathy. Group II (control): 50 patients with UTIs but with no functional or anatomical obstruction of their urinary tract. Clinical histories and physical examinations, together with laboratory investigations of urine samples were carried out in all patients in this study. Mid stream urine samples were examined microscopically and by fungal cell culture. The isolated Candida species were identified by analytical profile index (API). Candida Virulence factors were determined for the isolated Candida. The susceptibility to fluconazole was evaluated.

RESULTS

This study revealed an overall isolation rate of 27% of Candida species among all patient groups. The rate was 36% in cases, and 18% in controls, a difference found to be statistically significant (P<0.05). By API, C.albicans was detected in 44% of Candida species in cases, and in 33% in controls. While C.glabrata was detected in 28% of Candida species in cases, and in 22% in controls. C.tropicalis was detected in 17% of Candida species in cases, and in 22% in controls. Both C.krusei and C.kyfr were detected in 5.5% of Candida species in cases, and in 11% in controls. In terms of virulence factors the study showed that 11 out of 27 (40.5%) of Candida isolates were biofilm positive by tube adherence. Phospholipase activity was demonstrated in 12 out of 27 (44.5%) of Candida isolates. Secretory aspartic proteinase activity was demonstrated in 13 out of 27 (48%) of the Candida isolates.

CONCLUSION

Candida is an important cause of UTIs and obstructive uropathy is a major predisposing factor.

Molecular epidemiological survey of the quinolone- and carbapenem-resistant genotype and its association with the type III secretion system in Pseudomonas aeruginosa

This study evaluated the predictors of mortality and the impact of inappropriate therapy on the outcomes of patients with bacteraemia and ventilator-associated pneumonia (VAP). Additionally, we evaluated the correlation of the type III secretion system (TTSS) effector genotype with resistance to carbapenems and fluoroquinolones, mutations in the quinolone resistance-determining regions (QRDRs), metallo-β-lactamase and virulence factors. A retrospective cohort was conducted at a tertiary hospital in patients with multidrug-resistant (MDR) P. aeruginosa bacteraemia (157 patients) and VAP (60 patients). The genes for blaIMP, blaVIM, blaSIM, blaGIM and blaSPM and virulence genes (exoT, exoS, exoY, exoU, lasB, algD and toxA) were detected; sequencing was conducted for QRDR genes on fluoroquinolone-resistant strains. The multivariate analyses showed that the predictors independently associated with death in patients with bacteraemia were cancer and inappropriate therapy. Carbapenem resistance was more frequent among strains causing VAP (53.3 %), and in blood we observed the blaSPM genotype (66.6 %) and blaVIM genotype (33.3 %). The exoS gene was found in all isolates, whilst the frequency was low for exoU (9.4 %). Substitution of threonine to isoleucine at position 83 in gyrA was the most frequent mutation among fluoroquinolone-resistant strains. Our study showed a mutation at position 91 in the parC gene (Glu91Lys) associated with a mutation in gyrA (Thre83Ile) in a strain of extensively drug-resistant P. aeruginosa, with the exoT(+)exoS(+)exoU(+) genotype, that has not yet been described in Brazil to the best of our knowledge. This comprehensive analysis of resistance mechanisms to carbapenem and fluoroquinolones and their association with TTSS virulence genes, covering MDR P. aeruginosa in Brazil, is the largest reported to date.

Phylogenetic groups of Escherichia coli strains from patients with urinary tract infection in Iran based on the new Clermont phylotyping method

OBJECTIVES

In 2013, Clermont classified E. coli strains into eight phylogenetic groups using a new quadruplex PCR method. The aims of this study were to identify the phylogenetic groups of E. coli based on this method and to assess their antibiotic resistance patterns in Bushehr, Iran.

METHODS

In this cross-sectional study, 140 E. coli isolates were subjected to phylogenetic typing by a quadruplex PCR method. Antimicrobial susceptibility testing was performed by disk diffusion method.

RESULTS

Phylogenetic group B2 was most predominant (39.3%), followed by unknown (27.1%), E (9.3%), C and clade I (each 6.4%), B1 (5%), F and D (each 2.9%), and A (0.7%). The most common antibiotic resistance was related to amoxicillin (82.1%) and the least to meropenem (0.7%). 82.14% of isolates were multiple drug resistant (MDR). Antibiotic resistance was mainly detected in group B2 (50%).

CONCLUSIONS

Our findings showed the high prevalence of MDR E. coli isolates with dominance of group B2. About 25% of E. coli isolates belong to the newly described phylogroups C, E, F, and clade I. Such studies need to be done also in other regions to provide greater understanding of the antibiotic resistance pattern and the prevalences of different phylogenetic groups.

Resistant plasmid profile analysis of multidrug resistant Escherichia coli isolated from urinary tract infections in Abeokuta, Nigeria

BACKGROUND

Multi-drug resistant Escherichia coli has become a major threat and cause of many urinary tract infections (UTIs) in Abeokuta, Nigeria.

OBJECTIVES

This study was carried out to determine the resistant plasmids of multidrug resistant Escherichia coli isolated from (Urinary tract infections)UTIs in Abeokuta.

METHODS

A total of 120 Escherichia coli isolates were obtained from urine samples collected from patients attending inpatient and outpatient clinics presenting UTI; with their biodata. Antibiotics susceptibility was performed and multi-drug resistant isolates were selected for plasmid profiling. Plasmids were extracted by the alkaline lysis method, electrophoresed on 0.8% agarose gel and profiled using a gel-photo documentation system gel.

RESULTS

Escherichia coli isolates obtained shows high resistance to cloxacillin (92.5%), amoxicillin (90.8%), ampicillin (90.8%), erythromycin (75.8%), cotrimoxazole (70.0%), streptomycin (70.0%) and tetracycline (68.3%) while 85.8% and 84.2% were susceptible to gentamycin and ceftazidime respectively. Sixteen Escherichia coli strains were observed to be resistant to more than two classes of antibiotics. The resistant plasmid DNA was detectable in 6(37.5%) of the 16 multidrug resistant Escherichia coli having single sized plasmids of the same weight 854bp and were all resistant to erythromycin, cefuroxime, cloxacillin, amoxicillin, ampicillin and cotrimoxazole.

CONCLUSION

This study has highlighted the emergence of multidrug resistant R-plasmids among Escherichia coli causing urinary tract infections in Abeokuta, Nigeria. There is a high level of resistance to many antimicrobials that are frequently used in Abeokuta, Nigeria.

Susceptibility to antibiotics in urinary tract infections in a secondary care setting from 2005-2006 and 2010-2011, in São Paulo, Brazil: data from 11,943 urine cultures

INTRODUCTION

Urinary tract infection (UTI) has a high incidence and recurrence, therefore, treatment is empirical in the majority of cases.

OBJECTIVES

The aim of this study was to analyze the urine cultures performed at a secondary hospital, during two periods, 2005-2006 and 2010-2011, and to estimate the microbial resistance.

PATIENTS AND METHODS

We analyzed 11,943 aerobic urine cultures according to basic demographic data and susceptibility to antibiotics in accordance with the Clinical and Laboratory Standards Institute (CLSI) for Vitek 1 and 2.

RESULTS

Most of our cohort consisted of young adult females that were seen at the Emergency Department. E. coli was the most frequent (70.2%) among the 75 species isolated. Resistance of all isolates was ≥ 20% for trimethoprim/sulfamethoxazole (TMP/SMX), norfloxacin, nitrofurantoin, cefazolin and nalidixic acid. Although E. coli was more susceptible (resistance ≥ 20% for TMP/SMX and nalidixic acid) among all of the isolates, when classified by the number and percentage of antibiotic resistance. Global resistance to fluoroquinolones was approximately 12%. Risk factors for E. coli were female gender and an age less than 65 years. Men and patients older than 65 years of age, presented more resistant isolates. Extended spectrum beta-lactamases (ESBL) were identified in 173 out of 5,722 Gram-negative isolates (3.0%) between 2010 and 2011.

CONCLUSION

E. coli was the most frequent microbe isolated in the urine cultures analyzed in this study. There was a significant evolution of bacterial resistance between the two periods studied. In particular, the rise of bacterial resistance to fluoroquinolones was concerning.

Extended spectrum β-lactamase producers among nosocomial Enterobacteriaceae in Latin America

To review the epidemiology of nosocomial extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America, a systematic search of the biomedical literature (PubMed) was performed for articles published since 2005. Rates of nosocomial infections caused by extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America have increased since 2005. Up to 32% of Escherichia coli and up to 58% of Klebsiella pneumoniae isolates are extended spectrum β-lactamase-positive, rates that are higher than in other world regions. From a region-wide perspective, 11–25% of E. coli isolates and 45–53% of K. pneumoniae isolates were nonsusceptible to third-generation cephalosporins. At the country level, there was a wide range in Enterobacteriaceae resistance rates to third-generation cephalosporins, with especially high rates of resistance to E. coli in Guatemala, Honduras, and Mexico, and high resistance rates to Klebsiella spp. in Argentina, Brazil, Chile, Guatemala, Honduras, and Paraguay. Susceptibility of extended spectrum β-lactamase-producing Enterobacteriaceae to cefepime, fluoroquinolones, ampicillin/sulbactam, aminoglycosides, and piperacillin/tazobactam has also been compromised, leaving the carbapenems, tigecycline, and colistin as the only antibiotics with >90% susceptibility rates. There is a steady increase in the prevalence and types of extended spectrum β-lactamases produced by Enterobacteriaceae isolates in Latin American hospitals (particularly CTX-Ms), suggesting endemic conditions overlaid by clonal outbreaks. Appropriate treatment decisions and infection control strategies informed by surveillance of regional and local susceptibilities and mechanisms of resistance are required to mitigate this major public health concern.

Pharmacodynamic profiling of commonly prescribed antimicrobial drugs against Escherichia coli isolates from urinary tract

Since antimicrobial resistance among uropathogens against current first line agents has affected the management of severe urinary tract infection, we determined the likelihood that antibiotic regimens achieve bactericidal pharmacodynamic exposures using Monte Carlo simulation for five antimicrobials (ciprofloxacin, ceftriaxone, piperacillin/tazobactam, ertapenem, and meropenem) commonly prescribed as initial empirical treatment of inpatients with severe community acquired urinary tract infections. Minimum inhibitory concentration determination by Etest was performed for 205 Brazilian community urinary tract infection Escherichia coli strains from 2008 to 2012 and 74 E. coli bloodstream strains recovered from a surveillance study. Pharmacodynamic exposure was modeled via a 5000 subject Monte Carlo simulation. All isolates were susceptible to ertapenem and meropenem. Piperacillin/tazobactam, ceftriaxone and ciprofloxacin showed 100%, 97.5% and 83.3% susceptibility among outpatient isolates and 98.6%, 75.7% and 64.3% among inpatient isolates, respectively. Against outpatient isolates, all drugs except ciprofloxacin (82.7% in aggressive and 77.6% in conservative scenarios) achieved high cumulative fraction of response: carbapenems and piperacillin/tazobactam cumulative fraction of responses were close to 100%, and ceftriaxone cumulative fraction of response was 97.5%. Similar results were observed against inpatients isolates for carbapenems (100%) and piperacillin/tazobactam (98.4%), whereas ceftriaxone achieved only 76.9% bactericidal cumulative fraction of response and ciprofloxacin 61.9% (aggressive scenario) and 56.7% (conservative scenario) respectively. Based on this model, standard doses of beta-lactams were predicted to deliver sufficient pharmacodynamic exposure for outpatients. However, ceftriaxone should be avoided for inpatients and ciprofloxacin empirical prescription should be avoided in both inpatients and outpatients with complicated urinary tract infection.

The problem of Helicobacter pylori resistance to antibiotics: a systematic review in Latin America

OBJECTIVES

Latin America has a high prevalence of Helicobacter pylori infection and associated diseases, including gastric cancer. Antibiotic therapy can eradicate the bacterial infection and decrease associated morbidity and mortality. To tailor recommendations for optimal treatments, we summarized published literature and calculated region- and country-specific prevalences of antibiotic resistance.

METHODS

Searches of PubMed and regional databases for observational studies evaluating H. pylori antibiotic resistance yielded a total of 59 independent studies (56 in adults, 2 in children, and 1 in both groups) published up to October 2013 regarding H. pylori isolates collected between 1988 and 2011. Study-specific prevalences of primary resistance to commonly prescribed antibiotics were summarized using random-effects models. Between-study heterogeneity was assessed by meta-regression. As a sensitivity analysis, we extended our research to studies of patients with prior H. pylori-eradication therapy.

RESULTS

Summary prevalences of antimicrobial primary resistance among adults varied by antibiotic, including 12% for clarithromycin (n=35 studies), 53% for metronidazole (n=34), 4% for amoxicillin (n=28), 6% for tetracycline (n=20), 3% for furazolidone (n=6), 15% for fluoroquinolones (n=5), and 8% for dual clarithromycin and metronidazole (n=10). Resistance prevalence varied significantly by country, but not by year of sample collection. Analyses including studies of patients with prior therapy yielded similar estimates. Pediatric reports were too few to be summarized by meta-analysis.

CONCLUSIONS

Resistance to first-line anti-H. pylori antibiotics is high in Latin American populations. In some countries, the empirical use of clarithromycin without susceptibility testing may not be appropriate. These findings stress the need for appropriate surveillance programs, improved antimicrobial regulations, and increased public awareness.

Spectrum and patterns of antimicrobial resistance of uropathogens isolated from a sample of hospitalised Lebanese patients with urinary tract infections

A retrospective study was carried out to assess the current distribution and antimicrobial susceptibility patterns of uropathogens isolated from patients with community-acquired (CA) or hospital-acquired (HA) urinary tract infections (UTIs) who were admitted to the largest governmental hospital in Beirut City (Lebanon) in 2009-2012. Overall, 292 uropathogens were isolated. Enterobacteriaceae constituted 81% of the isolated uropathogens, with Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis being the most reported species. Moreover, 37% of the isolated uropathogens produced extended-spectrum β-lactamases (ESBLs). ESBL-producing strains were more prevalent in CA-UTIs than in HA-UTIs. In the CA-UTI group, ESBL-producing strains were more prevalent in older patients (age >60 years), male patients and patients with diabetes mellitus, urinary catheterisation and benign prostatic hyperplasia. Uropathogens isolated from CA-UTI and HA-UTI had similar resistance patterns. The highest resistance rates were found for ampicillin, amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole and ciprofloxacin. Imipenem, nitrofurantoin and piperacillin/tazobactam showed good overall activity against the isolated uropathogens. Of the isolated non-ESBL-producing E. coli, 29% were found to be multidrug-resistant. These data suggest that there is an urgent need to implement a national policy regulating the use of antibiotics, notably in the community, in order to limit the widespread increase in antimicrobial resistance.

Resistance patterns of nosocomial urinary tract infections in urology departments: 8-year results of the global prevalence of infections in urology study

OBJECTIVE

To present the worldwide antibiotic resistance rates of uropathogens reported in nosocomial urinary tract infections (NAUTI) during the period of 2003-2010.

MATERIALS AND METHODS

Data from the Global Prevalence Study of Infections in Urology from the period of 2003-2010 were analyzed to evaluate the resistance rates of pathogens causing NAUTI. The web-based application was used to record data of investigators from urology departments participating in the study every year during the days allocated in November. Each center was allowed to enter data on a single day of the study. The point prevalence data was used to find differences among geographic regions and years by utilizing multiple logistic regression analysis.

RESULTS

A total of 19,756 patients were hospitalized during the study period, and in 1,866 of them, NAUTI was reported. Proof of infection was reported in 1,395 patients. Resistance rates of all antibiotics tested other than imipenem against the total bacterial spectrum were higher than 10 % in all regions. Resistance to almost all pathogens was lowest in North Europe, and there is no single year where an outbreak of resistance has been detected.

CONCLUSION

The resistance rates of most of the uropathogens against the antibiotics tested did not show significant trends of increase or decrease with Asia exhibiting the highest rates in general. The only antibiotic tested with an overall resistance rate below 10 % was imipenem. Knowledge of regional and local resistance data and prudent use of antibiotics are necessary to optimize antibiotic therapy in urological patients with NAUTI.

Resistant gram-negative infections in the outpatient setting in Latin America

Latin America has a high rate of community-associated infections caused by multidrug-resistant Enterobacteriaceae relative to other world regions. A review of the literature over the last 10 years indicates that urinary tract infections (UTIs) by Escherichia coli, and intra-abdominal infections (IAIs) by E. coli and Klebsiella pneumoniae, were characterized by high rates of resistance to trimethoprim/sulfamethoxazole, quinolones, and second-generation cephalosporins, and by low levels of resistance to aminoglycosides, nitrofurantoin, and fosfomycin. In addition, preliminary data indicate an increase in IAIs by Enterobacteriaceae producing extended-spectrum β-lactamases, with reduced susceptibilities to third- and fourth-generation cephalosporins. Primary-care physicians in Latin America should recognize the public health threat associated with UTIs and IAIs by resistant Gram-negative bacteria. As the number of therapeutic options become limited, we recommend that antimicrobial prescribing be guided by infection severity, established patient risk factors for multidrug-resistant infections, acquaintance with local antimicrobial susceptibility data, and culture collection.

Antibiograms from community-acquired uropathogens in Gulu, northern Uganda--a cross-sectional study

Background

Urinary tract infections (UTI) are common in clinical practice and empirical treatment is largely employed due to predictability of pathogens. However, variations in antibiotic sensitivity patterns do occur, and documentation is needed to inform local empirical therapy. The current edition of the Uganda Clinical Guidelines recommends amoxicillin or cotrimoxazole as choice drugs for empirical treatment of community-acquired UTI. From our clinical observations, we suspected that this recommendation was not effective in our setting. In order to examine validity, we sought to identify bacteria from community-acquired infections and determine their susceptibility against these antibiotics plus a range of potentially useful alternatives for treatment of UTI.

Methods

A cross-sectional study of mid-stream urine collected from 339 symptomatic patients over a three-month period at Gulu regional referral hospital. Qualitative culture and identification of bacteria and antibiotic sensitivity testing using the modified Kirby-Bauer disk diffusion method was done. Participants’ demographic and clinical characteristics were collected using a standard form. Results were analyzed by simple proportions among related variables and confidence intervals computed using binomial exact distribution.

Results

Eighty two cultures were positive for UTI. Staphylococcus spp (46.3%) and Escherichia coli (39%) were the most common pathogens. There was high resistance to cotrimoxazole (73.2%), nalidixic acid (52.4%) and amoxicillin (51.2%). The most favorable antibiograms were obtained with gentamicin, amoxicillin-clavulanate and levofloxacin where 85.4%, 72.0%, 67.1% of isolates respectively, were either sensitive or intermediate. Only 51% of isolates were sensitive to ciprofloxacin.

Conclusion

There was high resistance to most antibiotics tested in this study. The recommendations contained in the current edition of the Uganda Clinical Guidelines are not in tandem with antibiotic sensitivity pattern of uropathogens seen in our setting. Amoxicillin-clavulanate or gentamicin should be considered for replacement of amoxicillin and cotrimoxazole for empirical treatment of UTI in our setting.

Antibiotic susceptibility patterns of urinary pathogens in female outpatients

Background:

Urinary tract Infection (UTI) is among the most common infections described in outpatient setting and hospital patients. In almost all cases empirical antimicrobial treatment initiates before the laboratory results of urine culture are available; thus antibiotic resistance may increase in uropathogens due to frequent use of antibiotics.

Aims:

The study was designed to find the prevalence of UTI in females with urinary tract symptoms, to determine the causative organism (s) of UTI, and to determine the antibiotic susceptibility pattern of microbial agents isolated from urine culture (antibiogram).

Materials and Methods:

The prospective, observational study involved 139 females, aged 15 years and above clinically suspected for UTI attending outpatient Departments of Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow. A structured questionnaire was used to interview the study subjects. A chi-square test and Fisher Exact test were used to analyze data.

Results:

The overall prevalence of UTI was found to be 45.32% (63/139). Escherichia coli (33.1%) and Klebsiella pneumoniae (7.9%) were the most common organisms isolated. The most effective antibiotic for both was Nitrofurantoin.

Conclusions:

Regular monitoring is required to establish reliable information about susceptibility pattern of urinary pathogens for optimal empirical therapy of patients with UTI.

[Differences between species involved and fluoroquinolone resistance patterns of strains isolated from bacteriuria according to nosocomial, health-related or community-acquired onset]

PURPOSE

To describe and to compare species and antibiotics resistance patterns of bacteria involved among bacteriuria from hospital and city laboratories and among health-related and community-acquired bacteriuria.

METHODS

Epidemiologic transversal study conducted among Bacteriology laboratories of University Hospital (UH) and the whole city of Reims, during the week 21 to 26 June 2010. A standardized investigation form was completed after telephonical interview with the prescriber.

RESULTS

One hundred and eighty-nine strains have been isolated among 179 urocultures. One hundred and seven strains were isolated in city laboratories and 82 in UH laboratory. Strains were community-acquired, health-related and nosocomial in 136, 22 and 31 cases, respectively. More Gram positive bacteria and ofloxacin resistant strains were isolated among UH strains (P=0.001 and P=0.015, respectively) and among health-related strains (P=0.01 and P=0.003, respectively). When analysis was restricted only to Enterobacteriaceae or to Escherichia coli, the ofloxacin resistance rate was no more elevated among health-related or UH strains. Ofloxacin resistant Enterobacteriaceae were more frequently resistant to all other classes of antibiotics except nitrofurans.

DISCUSSION

Strains isolated in health-related bacteriuria are more frequently ofloxacin resistant principally because of the greater proportion of Gram positive bacteria and because of a non-significant higher ofloxacin resistance rate among Enterobacteriaceae. Numerous studies only focus on Enterobacteriaceae, and the data from our study need to be confirmed on larger samples, in order to validate the predictive value of health-related bacteriuria for ofloxacin resistance.

Increase resistant rates and ESBL production between E. coli isolates causing urinary tract infection in young patients from Iran

Emerging antimicrobial resistance rates and Extended-spectrum beta-lactamase producing Escherichia coli recovered from urinary tract infections (UTI) is an increasing problem in specific regions, limiting therapeutic options. One hundred E. coli isolates causing UTI in patients with age from 2 months to 12 years admitted at CMC in the period of April 2009 to March 2010 were tested for antibiotic susceptibility using the disk diffusion method. Surprisingly high resistance rates were recorded for E. coli against TMP/SMX (84%), cefalotin (66%), cefuroxime (50%), cefixime (50%) and ceftriaxone (45%). Antimicrobial susceptibility of E. coli isolates was followed by meropenem (98%), amikacin (95%), nitrofurantoin (91%) and gentamicin (68%). Extended spectrum beta-lactamase production, was observed in 32% of community and 42% of nosocomial isolates. The results of this study and numerous observations regarding the increasing resistance to these antibiotics, in several countries, emphasize the need for local population-specific surveillance for guiding empirical therapy for UTI in children.

Decreased susceptibility to commonly used antimicrobial agents in bacterial pathogens isolated from urinary tract infections in Rwanda: need for new antimicrobial guidelines

The aim of this study was to obtain data on susceptibility patterns of pathogens responsible for both community and hospital urinary tract infections (UTIs); and analyzed risk factors for infection caused by ciprofloxacin-resistant Escherichia coli and extended-spectrum β-lactamase (ESBL)-producing strains in Rwanda. Of 1,012 urine cultures prospectively studied, a total of 196 (19.3%) yielded significant growth of a single organism. The most common isolate (60.7%) was Escherichia coli. The antibiotics commonly used in UTIs are less effective except Fosfomycin-trometamol and imipinem. The use of ciprofloxacin in the previous 6 months (odds ratio [OR] = 7.59 [1.75-32.74]), use of other antibiotics in the previous 6 months (OR = 1.02 [1.02-2.34]), and production of ESBL (OR = 19.32 [2.62-142.16]) were found to be associated with ciprofloxacin resistance among the E. coli isolates. Risk factors for ESBL positivity were the use of ciprofloxacin and third-generation cephalosporin in the preceding 6 months (OR = 3.05 [1.42-6.58] and OR = 9.78 [2.71-35.25], respectively); and being an inpatient (OR = 2.27 [1.79-2.89]). Fosfomycin-trometamol could be included as a reasonable alternative for the therapy of uncomplicated UTI in Rwanda.

Health conditions and health-policy innovations in Brazil: the way forward

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change. In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Increasing resistance in community-acquired urinary tract infections in Latin America, five years after the implementation of national therapeutic guidelines

BACKGROUND

The worldwide increasing resistance to antibiotics has complicated antimicrobial treatment of urinary tract infections (UTIs), especially in Latin America. This study aimed to report the present etiology and antimicrobial susceptibility of UTIs, and the effects of the national guidelines for UTIs introduced in 2003.

METHODS

Urine samples were collected from 304 patients with a clinical suspicion of UTI at the university hospital and primary health centers of León, Nicaragua. When bacterial growth was reported, antimicrobial susceptibility tests for nine frequently used antibiotics were performed.

RESULTS

Ninety-one (29.9%) patients had a positive urine culture. The most frequently isolated microorganisms were Escherichia coli (n=44), Serratia spp (n=11), and Escherichia fergusonii (n=10). High resistance rates were observed in E. coli to ampicillin (61.4%), cefalothin (45.5%), trimethoprim-sulfamethoxazole (38.6%), ciprofloxacin (31.8%), and ceftriaxone (20.5%). Amikacin and nitrofurantoin were the only drugs to which >90% of E. coli were susceptible. E. fergusonii and Serratia spp showed comparable high resistance patterns. Thirteen strains (29.5%) of E. coli were suspected to produce extended-spectrum beta-lactamase (ESBL).

CONCLUSIONS

Resistance rates in community-acquired UTIs in Nicaragua are increasing. The introduction of therapeutic guidelines with ceftriaxone recommended for upper UTIs and nitrofurantoin for lower UTIs, has led to increasing resistance against both antibiotics. The emergence of ESBL-producing E. coli is worrisome, along with the appearance of Serratia spp in the population.

Surveillance programs for detection and characterization of emergent pathogens and antimicrobial resistance: results from the Division of Infectious Diseases, UNIFESP

Several epidemiological changes have occurred in the pattern of nosocomial and community acquired infectious diseases during the past 25 years. Social and demographic changes possibly related to this phenomenon include a rapid population growth, the increase in urban migration and movement across international borders by tourists and immigrants, alterations in the habitats of animals and arthropods that transmit disease, as well as the raise of patients with impaired host defense abilities. Continuous surveillance programs of emergent pathogens and antimicrobial resistance are warranted for detecting in real time new pathogens, as well as to characterize molecular mechanisms of resistance. In order to become more effective, surveillance programs of emergent pathogens should be organized as a multicenter laboratory network connected to the main public and private infection control centers. Microbiological data should be integrated to guide therapy, adapting therapy to local ecology and resistance patterns. This paper presents an overview of data generated by the Division of Infectious Diseases, Federal University of São Paulo, along with its participation in different surveillance programs of nosocomial and community acquired infectious diseases.

Clonal composition of Escherichia coli causing community-acquired urinary tract infections in the State of Rio de Janeiro, Brazil

Recent studies from North America and Europe have demonstrated community-wide clonal spread of uropathogenic Escherichia coli (UPEC). To investigate if a similar pattern of spread occurs in Brazil, we characterized UPEC from women with community-acquired urinary tract infection (UTI) in Rio de Janeiro. E. coli isolates from women with UTI in one public outpatient clinic were evaluated for antibiotic susceptibility, E. coli phylogenetic grouping, enterobacterial repetitive intergenic consensus (ERIC) 2 PCR and pulsed-field gel electrophoresis fingerprinting, and multilocus sequence typing. From March 2005 to November 2006, 344 patients were studied. Of these, 186 (54%) had confirmed UTI, 118 (63.4%) of which were caused by E. coli. More than 50% of these isolates were resistant to ampicillin and trimethoprim/sulfamethoxazole. Of these, 96 (81%) belonged to 19 ERIC2 clonal groups. The largest group included 15 isolates, all belonging to multilocus sequence typing group ST69 and phylogenetic group D; they had pulsed-field gel electrophoresis patterns sharing at least 89% similarity compared with the CgA reference strain ATCC BAA-457. CgA strains have been found to be widespread in the United States in the early 2000s. Clonal group E. coli strains accounted for a large proportion (52%) of all UTIs and 82% of the trimethoprim/sulfamethoxazole-resistant E. coli UTIs. Thus, as in North America and Europe, UPECs that cause UTI in Rio de Janeiro also show clonal distribution, and a substantial proportion of drug-resistant UTI is caused by a small set of genetically related E. coli strains.

Antimicrobial activity, inhibition of urogenital pathogens, and synergistic interactions between lactobacillus strains

Lactobacillus fermentum strain L23 and L. rhamnosus strain L60 were selected as an alternative treatment to prevent or treat urogenital infections based on their probiotic properties and production of bacteriocins. The objectives of the present work were to study the inhibitory activities of these two bacteriocin-producing strains, and to analyze the interactions between pairs of bacteriocins that inhibit urogenital pathogens. Antimicrobial activity tests of L23 and L60 were performed by a diffusion method with 207 bacterial strains, isolated from female patients presenting a urogenital infection. Inhibitory substances interaction tests were carried out by using a streak-diffusion method on agar plates. One hundred percent of the clinical isolates showed sensitivity to the antimicrobial substances produced by L23 and L60. The selected lactobacilli produced larger inhibition halos when compared to several antibiotics commonly used for treating these infections. Synergistic interactions and indifferent interactions were recorded in 68.6% and 31.4% of the cases, respectively. No antagonistic interactions were observed. In conclusion, the bacteriocin-producing strains L23 and L60 are potential candidates for probiotic prophylaxis and treatment of urogenital disorders in women.

The ARESC study: an international survey on the antimicrobial resistance of pathogens involved in uncomplicated urinary tract infections

The ARESC (Antimicrobial Resistance Epidemiological Survey on Cystitis) study is an international survey to investigate the prevalence and susceptibility of pathogens causing cystitis. Female patients (n=4264) aged 18-65 years with symptoms of uncomplicated cystitis were consecutively enrolled in nine European countries as well as Brazil during 2003-2006. Pathogens were identified and their susceptibility to nine antimicrobials was determined. Escherichia coli accounted for 76.7% of isolates. Among E. coli, 10.3% of the isolates were resistant to at last three different classes of antimicrobial agents. Resistance was most common to ampicillin (48.3%), trimethoprim/sulfamethoxazole (29.4%) and nalidixic acid (18.6%). Fosfomycin, mecillinam and nitrofurantoin were the most active drugs (98.1%, 95.8% and 95.2% susceptible strains, respectively) followed by ciprofloxacin, amoxicillin/clavulanic acid and cefuroxime (91.7%, 82.5% and 82.4%, respectively). Resistance to ciprofloxacin was >10% in Brazil, Spain, Italy and Russia. Overall, Proteus mirabilis were more susceptible to beta-lactams and less susceptible to non-beta-lactams than E. coli, whereas Klebsiella pneumoniae strains, which are intrinsically resistant to ampicillin, were less susceptible to mecillinam (88.8%), fosfomycin (87.9%), cefuroxime (78.6%) and nitrofurantoin (17.7%). Resistance was rare in Staphylococcus saprophyticus, with the exception of ampicillin (36.4%) and trimethoprim/sulfamethoxazole (10.2%). In Italy, Spain, Brazil and Russia, the countries most affected by antimicrobial resistance, extended-spectrum beta-lactamase (ESBL) enzymes (mainly CTX-M type) were detected in 48 strains (39 E. coli, 6 K. pneumoniae and 3 P. mirabilis). Despite wide intercountry variability in bacterial susceptibility rates to the other antimicrobials tested, fosfomycin and mecillinam have preserved their in vitro activity in all countries investigated against the most common uropathogens.

Distribution and Resistance Trends of Community Associated Urinary Tract Pathogens in Sharjah, UAE

Objective

To describe the spectrum of etiologic agents causing community associated UTI and their antimicrobial resistance trends in a large teaching hospital in Sharjah, United Arab Emirates.

Methods

A retrospective review of the microbiology laboratory records of four hundred ninety two cases of community associated UTI between April 2006 and March 2007 was carried out. Etiologic agents and their antimicrobial susceptibility pattern were analyzed.

Results

A wide spectrum of uropathogens was isolated of which the leading etiologic agents of community associated UTI were Escherichia coli (207 strains) and Klebsiella species (90 strains). Sixty-six per cent of Gram-negative bacilli were resistant to amoxicillin, 58.5% were resistant to trimethoprim-sulfamethoxazole and more than 50% were resistant to cephalexin. However, resistance rate to antimicrobials like ciprofloxacin and ceftriaxone remain relatively low 9.7% and 7.6% respectively.

Conclusions

Escherichia coli remains the leading cause of community associated UTI. In-vitro antimicrobial resistance pattern of the isolates revealed that trimethoprim-sulfamethoxazole, cephalexin and amoxycillin the commonly used first-line antimicrobials were becoming less and less effective in their treatment. This information can help in changing preferences of suitable antimicrobial agent in treatment of community associated UTI.

Resistência antimicrobiana dos uropatógenos em pacientes ambulatoriais, 2000-2004

Foi realizado um estudo retrospectivo, baseado no banco de dados eletrônico de um hospital universitário, com objetivo de investigar a prevalência dos germes causadores e suas suscetibilidades aos antibióticos em adultos (idade >18 anos), com infecção do trato urinário atendidos ambulatorialmente. Foram identificados 957 exames de urocultura positiva no período entre janeiro de 2000 e dezembro de 2004. Escherichia coli, Proteus mirabillis e Klebsiella sp foram três principais bactérias causadoras. Sulfametoxazol-trimetropim apresentou a maior (46,9%) prevalência de resistência bacteriana seguida por cefalotina (46,7%), ácido nalidíxico (27,6%) e nitrofurantoína (22,3%). Durante o período estudado, o ácido nalidíxico apresentou um aumento anual de 5,9% na taxa de resistência bacteriana (p= 0,02). Ciprofloxacina mostrou também a tendência de aumento, com um crescimento anual de 3,3% (p= 0,07). Este estudo demonstrou que os antibióticos amplamente recomendados no tratamento empírico da infecção do trato urinário em adultos apresentaram altas taxas de resistência bacteriana na população estudada.

Antimicrobial resistance profiles of enterococci isolated from poultry meat and pasteurized milk in Rio de Janeiro, Brazil

The enterococci are important nosocomial pathogens with a remarkable capacity of expressing resistance to several antimicrobial agents. Their ubiquitous nature and resistance to adverse environmental conditions take account for their ability to colonize different habitats and for their potential for easy spreading through the food chain. In the present study we evaluated the distribution of species and antimicrobial susceptibility among enterococcal isolates recovered from food obtained in retail stores in Rio de Janeiro, Brazil. The following species were identified among 167 isolates obtained from poultry meat and 127 from pasteurized milk: Enterococcus faecalis (62.6%), E. casseliflavus (17.3%), E. durans (6.5%), E. gallinarum (3.0%), E. gilvus (2.4%), E. faecium (2.0%), E. hirae (1.4%), and E. sulfureus (1.0%). The overall percentages of antimicrobial resistant isolates were: 31.2 % to tetracycline, 23.8% to erythromycin, 11.3% to streptomycin, 4.3% to chloramphenicol, 3.9% to gentamicin, 1.4% to norfloxacin, 1.1% to imipenem, 0.7% to ciprofloxacin, nitrofurantoin, and penicillin, and 0.4% to ampicillin. Intermediate resistance was detected in frequencies varying from 0.5% for linezolid to 58.2% for erythromycin. None of the isolates showed resistance to glycopeptides. High-level resistance to aminoglycosides was observed in 13.1% of the isolates. Multiresistance was observed in E. faecalis, E. casseliflavus, E. faecium, E. gallinarum, E. durans and E. gilvus.

Role of prophylaxis in vesicoureteral reflux

PURPOSE OF REVIEW

Traditional management of vesicoureteral reflux focuses on preventing renal complications associated with ascending urinary tract infection by either providing continuous antibiotic prophylaxis to sterilize the urine and thus prevent recurrent infection, or abolishing reflux via surgical intervention. This review will consider the rationale for antibiotic prophylaxis in light of contemporary data regarding the natural history of vesicoureteral reflux, urinary tract infection and renal scarring, as well as the efficacy of various treatment strategies.

RECENT FINDINGS

Recent studies have shown that in grades I-IV vesicoureteral reflux, open surgical intervention compared with antibiotic prophylaxis is no better at preventing renal complications. Endoscopic subureteral injection of biomaterials has been proposed as a cost-effective, minimally invasive alternative to surgical or medical intervention; however, given the variety of materials and techniques, the literature has yet to achieve consensus on its efficacy. The first study to compare antibiotic prophylaxis with increased surveillance and prompt treatment of urinary tract infection shows no difference between the two approaches in low-grade (grades I-II) vesicoureteral reflux.

SUMMARY

Recent studies have challenged the traditional paradigm of aggressive vesicoureteral reflux management with surgery or antibiotic prophylaxis. In light of these findings, pediatric urologists will need to reexamine treatment modalities for vesicoureteral reflux.