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Rate of ESBL-producing bacteria on the rise
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Community-acquired and health care-associated infections caused by extended-spectrum beta-lactamase–producing bacteria are increasing, according to new data published in Antimicrobial Resistance and Infection Control.
“Over the last several years, we’ve seen an increase in the number of bacteria — many of which are forms of E. coli — that are resistant to commonly administered antibiotics,” Leonard Mermel, DO, medical director of the department of epidemiology and infection control at Rhode Island Hospital, said in a press release. “However, we also found that many of these bacteria causing urinary tract infections were susceptible to an older, inexpensive antibiotic, nitrofurantoin.”
Mermel and colleagues tracked the epidemiology of all clinical infections due to extended-spectrum beta-lactamase–producing bacteria (ESBL) in adult patients hospitalized at a tertiary care center in Providence, R.I., between 2006 and 2011.
The researchers identified 321 infections due to ESBL-producing bacteria; 18% were community-acquired, 53% were health care-associated and 29% were hospital-acquired. Urinary tract infections were the most common (80%), followed by bloodstream infections (10%), skin and soft tissue infections (5%), pneumonia (3%) and intra-abdominal infections (1%). During the study period, the predominant pathogen causing the infections changed from Klebsiella pneumoniae to E. coli, which accounted for most of all three acquisition types.
Ninety-five percent of ESBL-producing E. coli isolates were resistant to ciprofloxacin, and 65% were resistant to trimethoprim-sulfamethoxazole. However, the researchers found that 94% of the E. coli isolates were susceptible to nitrofurantoin.
The number of ESBL infections increased from 23 infections in 2006 to 81 in 2011. The incidence of ESBL infections per 10,000 discharges increased significantly from 2006 to 2011 for health care-associated infections (1.9 per year; 95% CI, 1-2.8) and for community-acquired infections (0.85 per year; 95% CI, 0.3-1.4). The rate of hospital-acquired infections remained unchanged, the researchers said.
Steven Kassakian
“We found an increase in the number of patients admitted with ESBL infections in each of the five years of our study, and equally concerning was that more and more of those patients are coming from the community,” Steven Kassakian, MD, of the Warren Alpert Medical School of Brown University, told Infectious Disease News. “ESBLs have traditionally been a problem only in the hospital, but they now need to be on the mind of those practicing in the community, as well. In someone with a history of ESBL-related UTIs or risk factors for the infection, just treating empirically with ciprofloxacin is a risky move based on our findings. One encouraging finding was that most of the ESBLs in our study cohort remained susceptible to the old drug nitrofurantoin, and another reason to use this underutilized drug is for cystitis.” – John Schoen
Kassakian, MD, can be reached at 593 Eddy Street, Providence, RI 02903; email: skassakian@lifespan.org.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Jason Newland, MD, MEd
The study by Kassakian and Mermel further demonstrates the impact of our excess use of antibiotics on pathogens causing common community-acquired infections. Kassakian and Mermel report a significant increase in ESBL-producing bacteria. Importantly, they found that a large increase occurred in community-acquired strains that were also resistant to common antibiotics used to treat urinary tract infections (UTI): trimethoprim/sulfamethoxazole and ciprofloxacin. In some areas of the United States, a normal healthy individual has a significant chance of having a resistant infection without any previous exposure to a health care institution. More patients will subsequently receive antibiotics that now aren’t effective against common bacteria causing UTIs and subsequently will result in worse outcomes. Our society must stress and advocate for the appropriate use of antibiotics in all settings: hospitals, ambulatory clinics, urgent cares, retail-based clinics, emergency departments and the agriculture industry. Without a societal effort, we will continue to see the development of bacterial resistance at a rate in which we might learn what it was like to practice medicine prior to the use of antibiotics.
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