UTI study finds high rates of resistance to common antibiotics
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A study of nearly 150,000 patients who presented to the ED with complicated UTIs found many were resistant to commonly used oral antibiotics, according findings published in Open Forum Infectious Disease.
“There has been considerable research on antibiotic resistance among hospitalized complicated urinary tract infection (cUTI) patients in the U.S. in recent years, but less is known about resistance among common uropathogens among adult patients presenting with a cUTI to the ED,” Thomas P. Lodise, PharmD, PhD, professor of pharmacy practice at Albany College of Pharmacy and Health Sciences, told Healio.
“More importantly, scant data are available on co-resistance rates among common oral cUTI agents across the U.S. regions, and few have studied the likelihood of resistance to one or more oral agents among adult patients presenting to the hospital with cUTIs,” Lodise said.
Lodise and colleagues conducted a retrospective multicenter analysis using data from the Premier Healthcare Database from 2013 to 2018. They classified patients who met all study criteria — aged 18 years or older, diagnosed with cUTI, positive blood or urine culture for an Enterobacterales, not transferred from another acute care facility — as “ED only” if they were discharged from the ED without a hospital admission or as “inpatient” if they were admitted to the hospital.
The ED-only cohort included 60,006 patients and the inpatient cohort included 86,743. Lodise and colleagues reported that the ED-only cohort were younger, less likely to be male, had less baseline comorbid conditions and were less likely to be transferred from a non-acute-care long-term care facility than the inpatient cohort.
Across both cohorts, Escherichia coli was the predominant pathogen (n = 48,357), but a more diverse group of Enterobacterales was observed in the inpatient cohort, the study showed.
Lodise noted that resistance rates were more pronounced among patients in the inpatient cohort — the study calls this unsurprising “given the baseline difference between patients.” Specifically, in the ED-only cohort, 40% to 50% of cUTIs in each region displayed resistance to at least one antibiotic 10% to 18% in each region had resistance to two or more. These rates were 55% to 65% and 25% to 35% in the inpatient cohort.
In the ED-only cohort, resistance to fluoroquinolones and nitrofurantoin exceeded 15% and resistance exceeded 25% for trimethoprim sulfamethoxazole (TMP-SMX). The rate of resistance to third-generation cephalosporin resistance was approximately 6% in the ED-only cohort.
Lodise said that these findings have important implications for clinical practice because the results of urine culture and antimicrobial susceptibility testing are usually not available for up to 2 or 3 days after an ED visit. Treatment decisions thus are largely empiric and based on symptoms, physical findings and underlying perceived risk of resistance, he said.
“Given the high observed rates of resistance and co-resistance observed in this study, adult patients who present to the ED with a cUTI are at an elevated risk for receiving an inappropriate empiric agent if prescribed a fluoroquinolone, TMP-SMX, nitrofurantoin or an oral third-generation cephalosporin,” Lodise said. “This is concerning as the deleterious outcomes associated with delayed appropriate therapy are well documented for adult patients with community-onset UTIs.”
Because of the current lack of rapid diagnostics for urine culture, Lodise said clinicians should ideally use institution-specific antibiotic resistance risk stratification tools to guide empiric antibiotic decisions among patients presenting to the ED with a cUTI, regardless of their disease acuity.
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