Original Article SMJ
Antimicrobial Resistance Patterns Amid
Community-Acquired Uropathogens in Outpatient
Settings of a Tertiary Care Hospital in Thailand
Tarntip Sangsuwan, M.D., Khongkrit Jariyasoonthornkit, M.D., Silom Jamulitrat, M.D.
Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Tailand.
ABSTRACT
Objective: To document the distribution of antimicrobial resistance patterns of community-acquired uropathogens.
Materials and Methods: Outpatient microbiology data of urine culture results in Songklanagarind Hospital between
January to December 2019 were reviewed.
Results: Tis study included 649 episodes of positive urine cultures in 598 patients, in which 80.7% were symptomatic
cases. Te elderly (median 63 ± IQR 26 years) showed high prevalence of urinary tract infections in this study, for
which nearly 80% of all samples were female. Te three most common uropathogens identified were: Escherichia
coli (E. coli) (69.6%), Klebsiella pneumoniae (9.5%) and Staphylococcus saprophyticus (4.9%). E. coli were highly
resistant to ciprofloxacin (49.0 %), cotrimoxazole (41.2%) and cefriaxone (20.6%), but had a low level of resistance
to fosfomycin (0%), and amikacin (0.4%).
Conclusion: Te antimicrobial resistance pattern of E. coli was high for commonly antimicrobial agents used in
outpatients; especially quinolone, cotrimoxazole and cephalosporin. However, due to low resistance levels, fosfomycin
and amikacin could be considered as effective treatment options for community acquired UTIs in our study.
Keywords: Community; urinary tract infection; antibiotic resistance (Siriraj Med J 2021; 73: 501-509)
INTRODUCTION
In a previous study in Songklanagarind Hospital,
Urinary tract infections (UTIs) are amongst one of
20084, Escherichia coli (E. coli) isolated from outpatients
the common infectious conditions in a primary setting.1
with UTIs were resistant to norfloxacin (41.2%), cefriaxone
Te main cause of an UTI is bacterial infection, for
(16.4%), and cotrimoxazole (49.3%).4 However, resistance
which 95% of UTI cases, in primary settings, prescribe
patterns are ever changing over time, and vary in different
antibiotics.2 Frequently, the therapy for an UTI are
regions. Terefore, it is necessary to periodically review
initiated empirically before the results of urine culture
these changes, for enabling better decision making in
and antibiotic susceptibilities are received. Consequently,
antimicrobial selection.
drug-resistance may increase, because of frequent and
inappropriate use of antibiotics.
MATERIALS AND METHODS
Te Trend of antibiotic resistance is increasing
Setting
around the world, with misuse or overuse of antibiotics
We conducted a retrospective cohort study in
seemingly being the primary driver of this problem.3
Songklanagarind Hospital, which is an 860-bed tertiary
Corresponding author: Tarntip Sangsuwan
E-mail: be_med29@hotmail.com
Received 30 June 2021 Revised 15 July 2021 Accepted 16 July 2021
Volume 73, No.8: 2021 Siriraj Medical Journal
501
Sangsuwan et al.
care facility, serving as a medical school with residency
susceptibility. Te data was collected via Google form
training and as a referral center for the South of Tailand.
and entered into Microsof Excel for analysis.
Inclusion criteria
Microbiological studies
-
Patients above the age of 15 years who visited the
Urine collection and processing
Outpatient Department (OPD) and Emergency Department
Clean-catch midstream urine specimens were processed
(ED) from 1 January 2019 to 31 December 2019.
within 2 hours afer collection. In the laboratory, the
-
Single bacterial species with significant bacteriuria
sample is plated on Mac Conkey medium and Blood
(≥105 cfu/ml).
agar, by using a standard loop (0.001-millimeter diameter
-
A clean catch mid-stream urine sample.
loop). Te cultures plated were incubated at 35 ± 2 C, for
18-24 hours. For this study, significant bacteriuria was
Exclusion criteria
identified as a culture of a single bacterial species with
-
Patients with suspected healthcare issues associated
colony count ≥ 105 cfu/ml. Te uropathogens isolated
with UTIs; following the adapted Friedman criteria5,
were identified by standard biomedical methods, and
were excluded.
susceptibility tests were interpreted corresponding to
(a) An indwelling urinary catheter in place at the
the Clinical and Laboratory Standard Institute 2019
time or within 48 hours before urine collection.
(CLSI).8
(b) Prior hospital admissions within 90 days.
(c) Regular dialysis or received intravenous
Susceptibility testing
chemotherapy within 30 days.
Te antibiotic discs used were for amikacin, cefotaxime,
(d) Receiving intravenous therapy, wound care, or
ceftazidime, cefuroxime, cotrimoxazole, imipenem,
nursing care at home within 30 days.
tazocin, ampicillin, cefoxtin, cefriaxone, cephalothin,
(e) Receiving any urinary procedure within 30
gentamicin, norfloxacin and meropenem. Extended-
days.
spectrum β-lactamases (ESBLs) were interpreted by
-
Patients with follow up clinical symptoms afer
using zone diameter breakpoints. Te CLSI interpretation
treatment, and repeat urine cultures.
breakpoint for fosfomycin sensitivity is at least 16 mm,
intermediate is between 13-15 mm and resistant is at
All positive aerobic urine cultures were identified by
most 14 mm. Disc diffusion is required for fosfomycin
the Hospital Information System (HIS). In total there were
Antimicrobial Susceptibility Testing (AST), and was
1,013 samples from patients presenting with significantly
performed according to the CLSI recommendations.8
positive urine cultures at the OPD and ED. From this
295 samples were excluded, due to suspected healthcare
Data analysis:
associated UTI, and 69 samples were excluded due to
Descriptive statistical analysis was performed using
repeat or follow up urine cultures in the same conditions.
Microsof Excel 2010. Discrete variables were expressed as
Finally, there were 649 samples analyzed in this study.
percentages and proportions. Te 95% confidence interval
was derived from exact binomial statistic calculation.
Definitions
Uncomplicated UTI is identified as a UTI with no
RESULTS
relevant functional or anatomical anomalies in the urinary
All positive aerobic urine cultures were identified by
tract or comorbiditie.6 Complicated UTI is identified
HIS, with 1,013 samples from patients presenting with a
as a UTI with one of the following characteristics: male
significantly positive urine. From this 295 samples were
gender, pregnancy, diabetes mellitus, abnormal urological
excluded due to suspected healthcare associated UTIs;
structure, and immunosuppression.6
additionally, 69 samples were excluded due to repeat or
Extended spectrum beta-lactamases (ESBLs) are
follow up urine cultures. Finally, there were 649 samples
defined as enzymes produced by certain bacteria that
analyzed in this study.
are able to hydrolyze extended spectrum cephalosporin.7
Sample characteristics
Data collection:
Tis included; 125 (19.3%) asymptomatic bacteriuria
Clinical information was extracted from medical
and 524 (80.7%) symptomatic UTIs. Among the symptomatic
databases; including: patient age, gender, medical condition,
cases, which were classified to be complicated UTI (57.4%)
clinical symptoms of urinary tract infection, risk factors of
and uncomplicated UTI (42.6%). (Table 1)
complicated UTIs, the uropathogens isolate and antibiotic
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TABLE 1. Demographic data of patients presenting with culture-positive urine in the study.
Variable
N (%)
Total
Asymptomatic
Symptomatic UTI
N = 649
bacteriuria
N = 524
N = 125
Sex
Female
512 (79%)
91 (72.8%)
421 (80.3%)
Male
137 (21%)
34 (27.2%)
103 (19.7%)
Age
Overall Age, Years
63 ± 26
68 ± 22
62 ± 25
(Median ± IQR)
15- 30
64 (9.9%)
7 (5.6%)
64 (12.2%)
31 - 45
59 (9.1%)
10 (8%)
59 (11.3%)
46 -60
125 (19.3%)
26 (20.8%)
125 (23.9%)
>60
401 (61.8%)
82 (65.6%)
276 (52.7%)
Medical conditions
Diabetes mellitus
183 (28%)
48 (38.4%)
135 (25.8%)
Hypertension
222 (34%)
48 (38.4%)
174 (33.5%)
Asthma
18 (3%)
2 (1.6%)
16 (3.1%)
COPD
9 (1%)
0 (0%)
9 (1.7%)
Ischemic heart disease
37 (6%)
6 (4.8%)
31 (5.9)
Thyroid disease
28 (4%)
7 (5.6%)
21 (4%)
Gout
19 (3%)
6 (4.8%)
13 (2.5%)
Cerebrovascular disease
28 (4%)
5 (4%)
23 (4.4%)
Chronic kidney disease
80 (12%)
32 (25.6%)
48 (9.2)
Abbreviations: N: number, UTI: urinary tract infection, IQR: interquartile range
Clinical symptoms are shown in Table 2. More than
(73.2%), ciprofloxacin (49.0%) and norfloxacin (49.3 %).
half of the patients rated dysuria as the most frequent
Te resistance pattern of E. coli, classified and analyzed
symptom, in both uncomplicated and complicated UTIs.
by type of UTI, are shown in Table 5. (uncomplicated
UTI and complicated UTI) and Table 6. (asymptomatic
Distribution of uropathogens and antibiotic resistance
bacteriuria).
patterns
Table 3 shows the frequency and distribution of
Asymptomatic bacteriuria
uropathogens in related types of UTIs, in which E. coli
Among E. coli in asymptomatic bacteriuria (N= 87),
was the main causative uropathogens in each group of
high proportions of isolates were resistant to ampicillin
UTI.
(75.9%), norfloxacin (70.1%). However, the study found
Table 4 shows that the resistance to antibiotic of
low resistance of E. coli to amikacin (1.1%), carbapenem
E. coli urinary isolates that were highly resistant to ampicillin
groups (0%) and fosfomycin (0%).
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Sangsuwan et al.
TABLE 2. Clinical symptoms of patients with uncomplicated and complicated urinary tract infection.
Symptoms of UTIs
N (%)
Uncomplicated UTI
Complicated UTI
Common in lower
part UTI
Dysuria
140 (62.78%)
154 (51.16%)
Urgency
32 (14.32%)
49 (16.28%)
Increase frequency
53 (23.77%)
67 (22.26%)
Hematuria
38 (17.04%)
36 (11.96%)
Cloudy urine
32 (14.35%)
33 (10.96%)
Abdominal pain
111 (49.78%)
22 (7.31%)
Common in upper
part UTI
Fever
69 (30.94%)
138 (45.85%)
(documented >38 or subjective)
Flank pain
29 (13%)
25 (8.31%)
Abbreviations: N: number, UTI: urinary tract infection, IQR: interquartile range
TABLE 3. Frequency and distribution of uropathogens in related type of urinary tract infections.
No Uropathogens
Asymptomatic
Uncomplicated UTI
Complicated UTI
Total
bacteriuria
N= 223
N= 301
N= 649
N= 125
N (%)
95% CI
N (%)
95% CI
N (%)
95% CI
N (%)
95% CI
1
Escherichia coli
Non- ESBLs
66 (52.8%)
44.0
- 61.6
141 (63.2%)
57.0
- 69.5
152 (50.5%)
44.9
- 56.1
359 (55.3%)
51.5
- 59.2
ESBLs
21 (16.8%)
10.4
- 23.2
22 (9.9%)
6.3
- 13.9
50 (16.6%)
12.6
- 20.9
93 (14.3%)
11.7
- 17.1
2
Klebsiella
pneumoniae
Non- ESBLs
12 (9.6%)
4.8
- 15.2
16 (7.2%)
4.0
- 10.8
22 (7.3%)
4.7
- 10.3
50 (7.7%)
5.7
- 9.9
ESBLs
2 (1.6%)
0.0
- 4.0
2 (0.9%)
0.0
- 2.2
8 (2.7%)
1.0
- 4.7
12 (1.8%)
0.9
- 2.9
3
Staphylococcus
0 (0%)
NA
30 (13.5%)
9.0
- 17.9
2 (0.7%)
0.0
- 1.7
32 (4.9%)
3.4
- 6.6
saprophyticus
4
Enterococcus spp.
9 (7.2%)
3.2
- 12.0
2 (0.9%)
0.0
- 2.2
16 (5.3%)
3.0
- 8.0
27 (4.2%)
2.6
- 5.7
5
Proteus mirabilis
3 (2.4%)
0.0
- 5.6
3 (1.3%)
0.0
- 3.1
12 (4.0%)
2.0
- 6.3
18 (2.8%)
1.5
- 4.2
6
Streptococcus spp.
4 (3.2%)
0.8
- 6.4
3 (1.3%)
0.0
- 3.1
10 (3.3%)
1.3
- 5.3
17 (2.6%)
1.5
- 3.9
7
Staphylococcus
2 (1.6%)
0.0
- 4.0
1 (0.4%)
0.0
- 1.3
7 (2.3%)
0.7
- 4.3
10 (1.5%)
0.6
- 2.6
aureus
8
Citrobacter spp.
1 (0.8%)
0.0
- 2.4
2 (0.9%)
0.0
- 2.2
7 (2.3%)
0.7
- 4.3
10 (1.5%)
0.6
- 2.6
9.
Pseudomonas
3 (2.4%)
0.0
- 5.6
0 (0%)
NA
3 (1%)
0.0
- 2.3
6 (0.9%)
0.3
- 1.7
aeruginosa
10. Others
2 (1.6%)
0.0
- 4.0
1 (0.4%)
0.0
- 1.3
12 (4%)
2.0
- 6.3
15 (2.3%)
1.2
- 3.5
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TABLE 4. Te in vitro resistance pattern among E. coli urinary isolates from outpatient.
Antibiotic agent
Test (N)
Resistance N (%)
95% CI
Aminoglycoside
Gentamicin
452
119 (26.3%)
22.3
- 30.5
Amikacin
452
2 (0.4%)
0.0
- 1.1
Carbapenems
Imipenem
452
1 (0.2%)
0.0
- 0.7
Ertapenem
452
1 (0.2%)
0.0
- 0.7
Meropenem
421
0 (0%)
NA
Cephalosporin
Cefuroxime
452
128 (28.3%)
24.1
- 32.5
Cefotaxime
452
93 (20.6%)
16.8
- 24.3
Ceftriaxone
452
93 (20.6%)
16.8
- 24.3
Ceftazidime
451
93 (20.6%)
16.9
- 24.4
Cephamycin
Cefoxitin
448
15 (3.3%)
1.8
- 5.1
Fluoroquinolones
Ciprofloxacin
447
219 (49.0%)
44.3
- 53.7
Norfloxacin
450
222 (49.3%)
44.7
- 54.0
Folate pathway inhibitors
Cotrimoxazole
452
186 (41.2%)
36.7
- 45.8
Penicillin
Ampicillin
452
331 (73.2%)
69.0
- 77.2
Antipseudomonal penicillin+ beta lactamase inhibitor
Tazocin
449
2 (0.4%)
0.0
- 1.1
Phosphonic acids
Fosfomycin
403
0 (0%)
NA
Polymyxins
Colistin
451
0 (0%)
NA
DISCUSSION
10,11
Out of the 649 significantly positive bacteriuria
community acquired UTIs.
Tis is probably because
samples that were reviewed in this study, a large number
of the difference of characteristics in our geography; in
of organisms were isolated from female patients in both
that tertiary hospitals might have more elderly patients
groups. Older adults represented as a high proportion in
with complex medical problems. In addition to the
this study (median of all age 63 years old, IQR 26 years).
fact that young, adult females were frequently in the
Tese findings were similar to a prior study conducted
uncomplicated UTI group, which ofen leads to self-
by Ho, in Singapore.9 On the other hand, they were
limiting and said group may prefer self-medication, or
inconsistent with some studies conducted in rural areas
over the counter drug use. Tis could explain our low
in India, and a multicenter in Russia; wherein, younger
prevalence in young adult community acquired UTIs
to middle aged adults had the highest prevalence rate in
in our study.
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TABLE 5. E. coli resistance to antibiotic among Uncomplicated and Complicated UTI.
Antibiotics
Uncomplicated UTI
Complicated UTI
Tests
Resistance
95% CI
Tests
Resistance
95% CI
(N)
N (%)
(N)
N (%)
Aminoglycoside
Gentamicin
163
48 (29.4%)
22.7-36.8
202
50 (24.8%)
18.8-30.7
Amikacin
163
0 (0%)
NA
202
1 (0.5%)
0.0-1.5
Carbapenems
Imipenem
163
0 (0%)
NA
202
1 (0.5%)
0.0-1.5
Ertapenem
163
0 (0%)
NA
202
1 (0.5%)
0.0-1.5
Meropenem
149
0 (0%)
NA
191
0 (0%)
0.0-1.5
Cephalosporin
Cefuroxime
163
35 (21.5%)
15.3-28.2
202
64 (31.7%)
25.2-38.1
Cefotaxime
163
22 (13.5%)
8.6-19.0
202
49 (24.3%)
18.3-30.2
Ceftriaxone
163
22 (13.5%)
8.6-19.0
202
49 (24.3%)
18.3-30.2
Ceftazidime
162
22 (13.6%)
8.6-19.1
202
49 (24.3%)
18.3-30.2
Cephamycin
Cefoxitin
162
5 (3.1%)
0.6-6.2
200
8 (4%)
1.5-7.0
Fluoroquinolone
Ciprofloxacin
162
58 (35.8%)
28.4-43.2
201
103 (51.2%)
44.3-58.2
Norfloxacin
163
59 (36.2%)
28.8-43.6
200
102 (51%)
44.0-58.0
Folate pathway inhibitors
Cotrimoxazole
163
69 (42.3%)
35.0-49.7
202
87 (43.1%)
36.1-50.0
Penicillin
Ampicillin
163
123 (75.5%)
68.7-82.2
202
142 (70.3%)
63.9-76.7
Antipseudomonal penicillin+ beta lactamase inhibitor
Tazocin
163
0 (0%)
NA
201
2 (1%)
0.0-2.5
Phosphonic acids
Fosfomycin
147
0 (0%)
NA
179
0 (0%)
NA
Polymyxins
Colistin
163
0 (0%)
NA
201
0 (0%)
NA
Abbreviations: N: number, UTI: urinary tract infection, 95%CI: 95% confidence interval, NA: not applicable
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TABLE 6. E. coli resistance to antibiotic among asymptomatic bacteriuria.
Antibiotic agent
Test (N)
Resistance N (%)
95% CI
Aminoglycoside
Gentamicin
87
21 (26.3%)
14.9-33.3
Amikacin
87
1 (1.1%)
0.0-3.4
Carbapenems
Imipenem
87
0 (0%)
NA
Ertapenem
87
0 (0%)
NA
Meropenem
81
0 (0%)
NA
Cephalosporin
Cefuroxime
87
29 (33.3%)
24.1-43.7
Cefotaxime
87
22 (25.3%)
16.1-34.5
Ceftriaxone
87
22 (25.3%)
16.1-34.5
Ceftazidime
87
22 (25.3%)
16.1-34.5
Cephamycin
Cefoxitin
86
2 (2.3%)
0.0-5.8
Fluoroquinolones
Ciprofloxacin
84
58 (69.0%)
59.5-78.6
Norfloxacin
87
61 (70.1%)
59.8-79.3
Folate pathway inhibitors
Cotrimoxazole
87
30 (34.5%)
24.1-44.8
Penicillin
Ampicillin
87
66 (75.9%)
66.7-85.1
Antipseudomonal penicillin + beta lactamase inhibitor
Tazocin
85
0 (0%)
NA
Phosphonic acids
Fosfomycin
77
0 (0%)
NA
Polymyxins
Colistin
87
0 (0%)
NA
Abbreviations: N: number, UTI: urinary tract infection, 95%CI: 95% confidence interval, NA: not applicable
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Sangsuwan et al.
E. coli (69.9 %) was the main causative organism
results. Tese were higher when compared with a previous
of community acquired UTIs in our study. Tis is in
study conducted by Arslan in Turkey15 and Klingenberg
concordance to previous studies from other locations
in Germany16 (23.3% - 42% in cotrimoxazole,15.6% -
around the world 4,9-10,12-16, which also showed E. coli as
38% in ciprofloxacin). In addition, the resistance rate of
the commonest uropathogens isolated in community
complicated UTIs seems to be higher when compared
acquired UTI patients. Furthermore, the extend-spectrum
with uncomplicated groups; especially in quinolone and
beta-lactamase (ESBL) producing among E. coli was
cephalosporin. So, the selection of empirical antibiotics
reported as 14.3% in this study, which was similar to the
in complicated UTI should be of more concern, due to
research in Lob et al. done in the USA and Canada 2014
probability of treatment failure from antibiotic resistance.
(15%)12, and was lower than the prior study in Young
Low resistance levels were detected to antibiotics;
Jun et al. conducted in Korea 2017. (23.3%).13
such as, fosfomycin, carbapenem groups, and amikacin in
In 2019, the National Antimicrobial Resistant
both complicated and uncomplicated UTI in this study.
Surveillance in Tailand (NARST) 201917 reported that
Te carbapenem groups were high board spectrum drugs
E. coli urinary isolates from outpatients were susceptible
that are not commonly used within the community, so
to ciprofloxacin 30.1%, cotrimoxazole 42.2%, cefriaxone
fosfomycin and amikacin may be an effective treatment
59.7%, fosfomycin 98.8% and amikacin 98.8%, which
option for community acquired UTIs in our study. Te
meant that the resistance level to quinolone, cotrimoxazole
major issue of aminoglycoside use concerns its toxicity
and cephalosporin were higher when compared with our
such as decrease in renal function, ototoxicty. Te rate
study. Te interpretation of these information must be
of amiglycoside-related nephrotoxicity is 8% to 14%19,
done with precaution because of difference in inclusion
which increases at higher doses, with prolonged therapy
and exclusion criteria.
of 10 days or more, and with the co-administration of
However, the in vitro resistance rates among
nephrotoxic agents.20
E. coli urinary isolates in our study had changed when
Strengths of our research include; an update to the
compared with a previous study in 20084. Te percentage
distribution and antibiogram of community-acquired
of resistance was higher in norfloxacin (41.2% in 2008
uropathogens in 2019. In addition, we classified and
and 49.3% in 2019) and cefriaxone (16.4% in 2008 and
analyzed patients according to clinical presentation, and
20.6% in 2019). On the other hand, the percentage of
host risk factors (uncomplicated, complicated UTI and
resistance was greatly declined in cotrimoxazole (56.7%
asymptomatic bacteriuria), for the aim of minimizing
in 2008 and 41.2% in 2019). Tis is attributable to a
risk of bias between groups.
decrease in the popularity of prescribed cotrimoxazole
Tere were some limitations in our study, which
and the fact that physicians have been prescribing new
warrant caution in interpreting the results. First, only
antibiotics instead. Tis result implies that antibiotic
tertiary-care hospital patients participated in the study.
resistance can change over time, and the resistance of
Consequently, our results, theoretically, may not be
antibiotics commonly used in primary care is still high.
fully concluded to other populations receiving care
For uncomplicated UTIs, the prevalence of E. coli
in different facilities. Second, we did not perform the
resistance to cotrimoxazole (42.3%) and ciprofloxacin
minimum inhibitory concentration (MIC) of potent
(35.8%) was higher when compared with the study
antibiotics, for which we did not receive information of
in Hongkong 201214 and Singapore 20159 (29-31.8%
the lowest concentration of an antibiotic that inhibits
in cotrimoxazole and 23.4-29% in ciprofloxacin). Te
visible growth.
Infectious Diseases Society of America (IDSA) guidelines
Nevertheless, our findings demonstrate purely in-
of 201018 suggest avoiding empirical specific antibiotics
vitro antibiotic resistance, for which the efficacy may
when local resistance among E. coli isolated is more than
be quite different from those obtained in vivo. Tus, in
20% in cotrimoxazole and 10% for quinolone. However,
addition to considering resistance patterns, the selection
low resistance levels were detected to antibiotics; such
of empirical antibiotics should depend on other factors;
as, fosfomycin 0%, carbapenem groups 0% and amikacin
such as, drug absorption and clearance, cost, and adverse
0%, which were not easily obtained as over-the counter
events. Future prospective studies are needed to evaluate
drugs, and are relatively expensive in cost compared to
the in vivo outcomes and other risk factors of antibiotic
others.
resistance, in order to determine the most appropriate
For complicated UTI, E. coli reported resistance to
treatment for community UTIs.
ciprofloxacin at 51.2 %, and cotrimoxazole at 43.1% in our
508
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Original Article SMJ
CONCLUSION
Care. J Clin Microbiol [Internet]. 2019 [cited 2020 Feb 7];57(9).
Te antimicrobial resistance patterns of uropathogens
10.
Dash M, Padhi S, Mohanty I, Panda P, Parida B. Antimicrobial
has changed overtime when compared to the previous
resistance in pathogens causing urinary tract infections in a
study of 2008, with an increased resistance in commonly
rural community of Odisha, India. J Family Community Med
antimicrobial agent use; especially quinoline and
2013; 20(1): 20-6.
cephalosporin. However, due to low resistance levels,
11.
Rafalskiy V, Pushkar D, Yakovlev S, Epstein O, Putilovskiy
fosfomycin and amikacin could be considered as an
M, Tarasov S, et al. Distribution and antibiotic resistance profile
of key Gram-negative bacteria that cause community-onset
effective treatment option for community acquired UTIs
urinary tract infections in the Russian Federation: RESOURCE
in our study.
multicentre surveillance 2017 study. J Glob Antimicrob Resist
2020; 21: 188-94.
ACKNOWLEDGEMENTS
12.
Lob SH, Nicolle LE, Hoban DJ, Kazmierczak KM, Badal RE,
We would like to thank Mr. Andrew Tait, from the
Sahm DF. Susceptibility patterns and ESBL rates of Escherichia
International Affairs Department, who assisted in the
coli from urinary tract infections in Canada and the United
States, SMART 2010-2014. Diagn Microbiol Infect Dis 2016;0
editing of the English language for this manuscript.
85(4): 459-65.
13.
Kim YJ, Lee J-M, Cho J, Lee J. Change in the Annual Antibiotic
Conflicts of interest: None to declare
Susceptibility of Escherichia coli in Community-Onset Urinary
Tract Infection between 2008 and 2017 in a Tertiary Care
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