Post on 24-Jun-2020
Drugs 2008; 68 (9): Supplementary Material
0012-6667/08/0009-0001/$53.45/0REVIEW ARTICLE © 2008 Adis Data Information BV. All rights reserved.
Contemporary Management of Uncomplicated Urinary Tract Infections David R.P. Guay Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
Supplementary Material This supplementary material contains the table referred to in the full version of this article, which can be found at http://drugs.adisonline.com.
Epi
dem
iolo
gy o
f an
tim
icro
bial
s re
sist
ance
in u
ncom
plic
ated
uri
nary
trac
t inf
ecti
on (
uUT
I)
St
udy
Loc
atio
n #
(T
imef
ram
e)
isol
ates
D
etai
ls
G
upta
et a
l.[21]
U
SA
43
42
Res
ista
nce
rate
s:
(1
999)
(1
992-
6)
(all
18-5
0 y.
o.
Am
p 26
%-3
4%a (
E. c
oli,
N =
373
4),
29%
-38%
a (ov
eral
l, N
= 4
342)
fe
mal
e C
ipro
0-0
.2%
0.
2%-1
%
sour
ces)
N
itro
0.2%
-2%
6%
-9%
TM
P-S
MX
9%
-18%
a 8%
-16%
a
TM
P 9
%-1
8%a
9%-1
6%a
Kar
low
sky
et a
l.[22]
U
SA
51
3 R
esis
tanc
e ra
tes
for
E. c
oli:
(2
000)
(1
/00-
5/00
) (u
rina
ry is
olat
es
Am
p 39
.4/4
6.8%
(F/
M),
40
.1/3
7.4%
(18
-65/
>65
),
40.8
/40.
1%(i
npt./
outp
t.)
of E
. col
i fro
m
TM
P-S
MX
22.
5/31
.6%
24
.8/2
3.5%
22
.5/4
.3%
TR
UST
C
ipro
3.2
/12.
7%
3.7/
7%
7.1/
3.6%
surv
eilla
nce.
L
evo
3.2/
12.7
%
3.7/
7%
7.1/
3.6%
ty
pes
of U
TIs
w
ere
unkn
own)
G
upta
et a
l.[23]
U
SA
10
3223
R
esis
tanc
e ra
tes
wer
e si
gn. h
ighe
r in
> 5
0 ye
ar o
lds
vs. 1
5-50
yea
r ol
ds f
or
(200
1)
(199
8)
(out
patie
nt
Kle
bsie
lla
spp.
, Pro
teus
spp
., P
. aer
ugin
osa,
oth
er g
ram
-neg
ativ
e ro
ds,
fem
ales
≥
ente
roco
cci,
othe
r ba
cter
ia (
all p
< 0
.001
). R
esis
tanc
e ra
tes
wer
e si
gn. l
ower
15
yea
rs o
ld
in >
50
year
old
s vs
. 15-
50 y
ear
olds
for
E. c
oli a
nd S
. sap
roph
ytic
us
from
the
TSN
(b
oth
p <
0.0
01).
da
taba
se)
Res
ista
nce
rate
s fo
r E
. col
i (N
= 6
3196
):
A
mp
40/3
3% (
15-5
0/ >
50)
Nitr
o 1/
2%
C
ipro
1/2
%
Lev
o 1/
3%
T
MX
-SM
X 1
8/16
%
R
esis
tanc
e ra
tes
for
non-
E. c
oli (
N =
316
02):
Am
p 49
/49%
(15
-50/
> 5
0)
N
itro
40/3
9%
C
ipro
10/
22%
L
evo
5/21
%
T
MX
-SM
X 6
/11%
Res
ista
nce
rate
s ov
eral
l (N
= 9
4798
):
A
mp
42/3
9% (
15-5
0/ >
50)
Nitr
o 9/
16%
Cip
ro 2
/10%
L
evo
12/1
1%
T
MX
-SM
X 1
6/14
%
In
term
s of
E. c
oli s
usce
ptib
ilit
y by
reg
ion,
ther
e w
as n
o si
gn. a
ge-r
elat
ed
va
riat
ion
in r
esis
tanc
e ra
tes
wit
hin
regi
ons
for
Am
p or
TM
P-S
MX
. How
ever
,
ther
e w
as s
ign.
inte
r-re
gion
var
iatio
n in
res
ista
nce
rate
s fo
r bo
th a
gent
s w
ithi
n
bo
th a
ge s
trat
a (p
< 0
.001
). I
n ge
nera
l, re
sist
ance
rat
es w
ere
high
est i
n th
e
W
est a
nd S
outh
Cen
tral
reg
ions
, int
erm
edia
te in
the
Mid
wes
t and
Sou
thea
st
re
gion
s, a
nd lo
wes
t in
the
Nor
thea
st r
egio
n. T
he E
. col
i res
ista
nce
rate
s fo
r
N
itro
and
the
quin
olon
es d
id n
ot v
ary
by r
egio
n.
N
otab
le r
esis
tanc
e pa
ttern
s (1
5-50
/ > 5
0):
A
mp
vs. S
. sap
roph
ytic
us
71/7
3%
A
mp
vs. S
. aur
eus
84/9
3%
C
ipro
vs.
ent
eroc
occi
33
/56%
Lev
o vs
. ent
eroc
occi
17
/44%
Am
p vs
. Ent
erob
acte
r sp
p.
97
/95%
Nitr
o vs
. Ent
erob
acte
r sp
p.
49
/45%
Am
p vs
. Kle
bsie
lla
spp.
99
/98%
Nitr
o vs
. Kle
bsie
lla
spp.
43
/42%
Cip
ro v
s. P
. aer
ugin
osa
26/2
9%
L
evo
vs. P
. aer
ugin
osa
28/2
9%
C
ipro
vs.
S. a
ureu
s 10
/62%
Lev
o vs
. S. a
ureu
s 5/
50%
Cli
nica
lly-
sign
. age
-rel
ated
var
iatio
ns in
res
ista
nce
rate
s ex
iste
d fo
r th
e
qu
inol
ones
vs.
S. a
ureu
s an
d th
e en
tero
cocc
i. T
MP
/SM
X p
erfo
rmed
bet
ter
agai
nst n
on-E
. col
i iso
late
s (6
-11%
res
ista
nt)
vs. E
. col
i iso
late
s (1
6-18
%
re
sist
ant)
. Am
ong
the
non-
E. c
oli i
sola
tes,
thos
e fr
om p
atie
nts
over
50
year
s
old
exhi
bite
d a
12-1
6% in
crea
se in
res
ista
nce
rate
s to
the
quin
olon
es c
ompa
red
wit
h th
ose
patie
nts
15-5
0 ye
ars
old.
In
the
over
all i
sola
te p
opul
atio
n, th
ose
from
pat
ient
s ov
er 5
0 ye
ars
old
exhi
bite
d an
8-9
% in
crea
se in
res
ista
nce
rate
s
to th
e qu
inol
ones
and
Nitr
o co
mpa
red
wit
h th
ose
from
pat
ient
s 15
-50
year
s
ol
d.
Lau
plan
d et
al.[7
] C
alga
ry, C
anad
a 31
270
Res
ista
nce
rate
s:
(200
7)
(200
4-20
05)
(am
bula
tory
T
MP
-SM
X
14%
su
bjec
ts o
f bo
th
Cip
ro
5%
gend
ers)
N
itro
6%
T
MP
-SM
X r
esis
tanc
e ra
te m
odes
tly
decl
ined
wit
h ad
vanc
ing
age
(15
→
12
.5%
) w
hile
Cip
ro a
nd N
itro
resi
stan
ce r
ates
ros
e (2
.5 →
10%
and
4 →
12.5
%, r
espe
ctiv
ely)
. In
nurs
ing
hom
e re
side
nts
(N =
390
7), T
MP
-SM
X,
C
ipro
, and
Nitr
o re
sist
ance
rat
es w
ere
15, 1
8, a
nd 2
1%, r
espe
ctiv
ely
(lat
ter
two,
p <
0.0
01 v
s. a
mbu
lato
ry p
atie
nts)
. K
arlo
wsk
y et
al.[2
4]
US
A +
Can
ada
1858
R
esis
tanc
e ra
tes
for
Cip
ro-r
esis
tant
E. c
oli:
(200
6)
(1/0
4-6/
05)
(Cip
ro-r
esis
tant
A
mp
79.8
%
E. c
oli f
rom
uri
ne
TM
P-S
MX
66
.5%
sp
ecim
ens
Nitr
o 4%
ob
tain
ed f
rom
N
itro
and
Am
p M
ICs
incr
ease
d as
Cip
ro M
ICs
incr
ease
d (b
oth
p <
0.0
1).
outp
atie
nts)
T
MP
-SM
X M
ICs
stay
ed th
e sa
me
as C
ipro
MIC
s in
crea
sed.
Qui
nolo
ne-r
esis
tant
uri
nary
E. c
oli i
sola
tes
wer
e fr
eque
ntly
mul
tires
ista
nt
(o
nly
11%
wer
e re
sist
ant t
o C
ipro
alo
ne).
K
iffe
r et
al.[2
5]
Sao
Pau
lo, B
razi
l 37
,261
R
esis
tanc
e ra
tes:
(2
007)
(2
000-
2003
)
(out
patie
nt
E
. col
i K
. pne
umon
iae
P. m
irab
ilis
is
olat
es f
rom
(N =
22,
679)
(N
= 2
059)
(N
= 1
944)
bo
th g
ende
rs;
Am
p 43
%
100%
19
%
GN
R, 3
2,53
0;
Cip
ro
12%
6%
4%
GP
C, 2
,570
) N
itro
3%
21%
10
0%
Nor
flox
12
%
9%
4%
T
MP
-SM
X
34%
18
%
22%
Res
ista
nce
rate
s si
gn. f
ell w
ith
incr
easi
ng a
ge f
or A
mp
and
TM
P-S
MX
(bo
th p
< 0
.000
1) a
nd r
ose
wit
h in
crea
sing
age
for
Cip
ro, N
itro,
and
Nor
flox
(al
l p <
0.00
01).
Wit
h re
spec
t to
resi
stan
ce r
ates
for
E. c
oli o
ver
tim
e, o
nly
cipr
o an
d
no
rflo
x ex
hibi
ted
a si
gn. c
hang
e (i
.e. i
ncre
ase)
ove
r ti
me
(bot
h p
< 0
.000
1).
Ric
hard
s et
al.[1
] N
ew Z
eala
nd
94
Res
ista
nce
rate
s:
(200
2)
(12
wk.
(a
ll 16
-50
y.o.
A
mox
29
% o
vera
ll (N
= 9
4),
34%
E. c
oli (
N =
59)
pe
riod
dur
ing
fe
mal
e so
urce
s)
Am
ox-C
lav
8%
10%
late
200
0 or
TM
P 9%
12
%
20
01)
T
MP
-SM
X
11%
15
%
N
itro
2%
0
Cip
ro
0 0
N
orfl
ox
0 0
T
he o
nly
resi
stan
ce n
oted
wit
h S.
sap
roph
ytic
us (
N =
19)
was
that
to A
mox
(21%
). T
MP
res
ista
nce
rate
was
hig
her
in 3
1-40
yea
r ol
ds (
22%
) co
mpa
red
to
th
ose
in th
e 16
-21,
22-
30, a
nd 4
1-50
yea
r ol
d ag
e gr
oups
. G
olds
tein
[26]
Fr
ance
11
60
Res
ista
nce
rate
s (i
n pa
tien
ts w
ith
neit
her
rece
nt p
rior
hos
pita
liza
tion
nor
(2
000)
(1
2/96
-3/9
7)
(adu
lt o
utpa
tien
ts
rece
ipt o
f an
tim
icro
bial
s):
wit
h U
TIs
[no
E. c
oli
Kle
bsie
lla
spp.
P
. mir
abil
is
nurs
ing
hom
e
(N =
588
) (N
= 2
5)
(N =
39)
re
side
nts]
) A
mox
31
%
8%
18%
Nor
flox
3%
0
5%
Ofl
ox
3%
0 8%
C
ipro
1%
0
5%
T
MP
-SM
X
16%
8%
13
%
Fo
sfo
1%
32%
13
%
T
here
wer
e no
sig
n. d
iffe
renc
es in
res
ista
nce
rate
s by
age
(≥
65 y
ear
olds
vs.
< 6
5 ye
ar o
lds)
or
by g
ende
r.
Hum
mer
s-P
radi
er
Ger
man
y 28
1 27
% h
ad c
ompl
icat
ing
fact
ors
and
33%
had
rec
urre
nt U
TIs
so
not a
pur
e uU
TI
et
al.[2
7] (2
006)
(1
1/00
-2/0
1)
(all
fem
ales
>
stud
y po
pula
tion
12
yea
rs o
ld
Res
ista
nce
rate
s:
wit
h sy
mpt
oms
E
. col
i P
rote
us s
pp.
c/w
UT
I)
(N
= 1
91)
(N =
27)
A
mox
39
%
33%
A
mox
-Cla
v 33
%
22%
Cip
ro
9%
11%
TM
P-S
MX
29
%
41%
T
MP
29%
48
%
Nitr
o 2%
−
Log
istic
Reg
ress
ion
Mod
elin
g of
Res
ista
nce
Ris
k Fa
ctor
s: E
. col
i res
ista
nce
rate
s in
crea
sed
wit
h in
crea
sing
age
for
Cip
ro (
OR
3.2
1), T
MP
(O
R 1
.73)
, and
TM
P-S
MX
(O
R 1
.82)
. E. c
oli r
esis
tanc
e ra
tes
wer
e re
duce
d in
pat
ient
s w
ith
com
plic
ated
vs.
uU
TIs
for
Am
ox-C
lav
(OR
2.2
0), C
efaz
(O
R
2.
12),
TM
P (O
R 2
.92)
, and
TM
P-S
MX
(O
R 3
.00)
. E. c
oli r
esis
tanc
e ra
tes
wer
e
incr
ease
d in
old
er (
> 7
0 ye
ars
old)
vs.
you
nger
(<
50
year
s ol
d) p
atie
nts
for
C
efaz
(O
R 2
.36)
, Cip
ro (
OR
6.5
2), T
MP
(O
R 4
.03)
, and
TM
P-S
MX
(O
R
4.
48).
All
of
thes
e as
soci
atio
ns w
ere
stat
isti
call
y-si
gnif
ican
t. U
nghe
ri e
t al.[2
8]
Ital
y 79
R
esis
tanc
e ra
tes
for
quin
olon
e-re
sist
ant E
. col
i: (2
002)
(N
A)
(sou
rce
NA
) Fo
sfo
0%
A
mox
63
%
T
MP
-SM
X
48%
Nitr
o 13
%
T
etra
84
%
C
hlor
o 58
%
Mar
ches
e et
al.[2
9]
Ital
y 42
6 R
esis
tanc
e ra
tes:
(2
003)
(N
A)
(sub
ject
s w
ith
E
. col
i P
. mir
abil
is
K. p
neum
onia
e
uU
TIs
)
(N =
387
) (N
= 2
4)
(N =
15)
Fo
sfo
1%
13%
47
%
A
mox
-Cla
v 11
%
0 7%
T
MP
-SM
X
24%
33
%
11%
C
ipro
12
%
4%
7%
N
orfl
ox
15%
8%
7%
Nitr
o 3%
−
21%
T
empe
ra e
t al.[3
0]
Ital
y 58
2 R
esis
tanc
e ra
tes:
(2
004)
(1
1/01
-2/0
2)
(sub
ject
s w
ith
Fosf
o 6.
2% o
vera
ll, (
N =
582
),
1.6%
E.c
oli (
N =
430
)
uU
TIs
) C
ipro
10
.7%
10
.0%
N
orfl
ox
10.8
%
10.5
%
Nitr
o 11
.7%
1.
6%
T
MP
-SM
X
18.9
%
15.4
%
A
mox
-Cla
v 12
.7%
5.
8%
Ges
u an
d M
arch
etti[3
1] It
aly
2486
55
.3%
of
isol
ates
wer
e E
. col
i.
(200
7)
(6 w
k. p
erio
d (a
dult
subj
ects
R
esis
tanc
e ra
tes
for
E. c
oli (
N =
137
5):
be
twee
n M
ay
atte
ndin
g A
mox
37
%
an
d O
ctob
er
non-
hosp
ital
TM
P-S
MX
19
.2%
2004
) la
bora
tori
es)
Fosf
o 5.
9%
N
itro
8.9%
Cip
ro
14.4
%
L
evo
14.6
%
N
alA
c 23
.2%
Alt
houg
h E
. col
i res
ista
nce
incr
ease
d in
inci
denc
e w
ith
incr
easi
ng a
ge a
nd
w
ith
mal
e as
com
pare
d to
fem
ale
gend
er, t
he d
ata
pres
enta
tion
was
prob
lem
atic
. SE
MIC
[32]
B
resc
ia, I
taly
56
3 (2
002)
R
esis
tanc
e ra
tes:
(2
007)
(2
002-
5)
936
(200
3)
E
. col
i K
. pne
umon
iae
Pro
teus
spp
.
11
14 (
2004
)
(N =
241
8)
(N =
217
) (N
= 1
01)
12
05 (
2005
) A
mp
49%
−
40%
Am
ox-C
lav
8%
2%
10%
T
MP
-SM
X
27%
8%
37
%
Cip
ro
19%
3%
19
%
N
itro
9%
− −
R
esis
tanc
e ra
tes
did
not c
hang
e si
gnif
ican
tly
for
any
gram
-neg
ativ
e or
-pos
itiv
e
ur
opat
hoge
n ov
er th
e st
udy
peri
od.
In
358
isol
ates
of
E. f
aeca
lis,
res
ista
nce
rate
s fo
r A
mp,
Cip
ro, N
orfl
ox, a
nd
N
itro
wer
e 1%
, 20%
, 39%
, and
6%
, res
pect
ivel
y.
Hry
niew
icz
et a
l.[33]
P
olan
d 37
7 R
esis
tanc
e ra
tes:
(2
001)
(7
/98-
5/99
) (s
ubje
cts
wit
h
E. c
oli (
N =
330
) O
ther
Ent
erob
acte
riac
eae
(N =
40)
uU
TIs
) A
mp
45%
58
%
Am
ox-C
lav
4%
15%
Cip
ro
4%
5%
N
orfl
ox
14%
0
N
itro
9%
90%
TM
P 26
%
43%
TM
P-S
MX
17
%
25%
Fo
sfo
3%
10%
Z
emko
va e
t al.[3
4]
Hra
dec
Kra
love
, 11
,856
E. c
oli
Fluo
roqu
inol
one
resi
stan
ce r
ates
am
ong
E. c
oli i
ncre
ased
fro
m 2
% →
10%
(2
007)
C
zech
oslo
vaki
a is
olat
es
(hos
pita
l iso
late
s) a
nd 1
% →
11%
(ou
tpat
ient
isol
ates
) fr
om 2
001
to 2
006
(2
001-
2006
) (i
npat
ient
s an
d (b
oth
p <
0.0
1). O
ver
the
sam
e ti
me
peri
od, f
luor
oqui
nolo
ne u
tili
zati
on
outp
atie
nts)
in
crea
sed
in th
e in
patie
nt s
etti
ng (
2.73
→ 4
.89
DB
D, p
< 0
.01)
and
in th
e
outp
atie
nt s
etti
ng (
0.29
→ 1
.15
DID
, p <
0.0
1). T
he d
evel
opm
ent o
f re
sist
ance
of E
. col
i to
fluo
roqu
inol
ones
cor
rela
ted
sign
. wit
h ut
iliza
tion
in b
oth
the
hosp
ital
(r
= 0
.996
, p =
0.0
05)
and
outp
atie
nt (
r =
0.8
78, p
= 0
.029
) se
ttin
gs.
Gob
erna
do e
t al.[3
5,36
] Spa
in
2230
R
esis
tanc
e ra
tes:
(2
007)
(1
1/03
-10/
04)
(E. c
oli i
sola
tes
Am
p 52
%
from
fem
ales
T
MP
-SM
X
26%
w
ith
Am
ox-C
lav
< 3
%
uUT
Is)
Fosf
o <
3%
Qui
nolo
nes
18%
Res
ista
nce
rate
s w
ere
sign
. hig
her
in th
e el
derl
y vs
. you
ng f
or C
ipro
(29
vs.
13%
, p <
0.0
01),
TM
P-S
MX
(32
vs.
23%
, p <
0.0
01),
and
Am
p (5
6 vs
. 50%
,
p =
0.0
2). S
ign.
cor
rela
tion
was
fou
nd b
etw
een
quin
olon
e co
nsum
ptio
n an
d
E
. col
i res
ista
nce
to C
ipro
(r
= 0.
5, p
= 0
.025
). T
here
wer
e al
so s
ign.
reg
iona
l
diff
eren
ces
in q
uino
lone
res
ista
nce
of E
. col
i (8%
in n
orth
vs.
17%
in s
outh
and
east
).
Gar
cia
et a
l.[37]
Sp
ain
2724
(20
02)
Res
ista
nce
rate
s:
(200
7)
(200
2, 2
004)
30
13 (
2004
)
E
. col
i
P
. mir
abil
is
(∼
80%
fro
m
20
02
2004
20
02
2004
w
omen
)
(N =
198
9)
(N =
210
8)
(N =
196
) (N
= 1
97)
A
mox
59
58
38
36
Am
ox-C
lav
9 8
6 2
T
MP
-SM
X
34
31
38
36
C
ipro
23
24
17
13
Nitr
o 6
4 96
98
Fosf
o 2
3 24
20
2.7%
of
gram
-neg
ativ
e or
gani
sms
in 2
004
wer
e E
SBL
pro
duce
rs.
D
rug-
resi
stan
t E. c
oli w
ere
sign
. mor
e fr
eque
nt in
men
(in
200
2, 3
3 vs
. 21%
,
p <
0.0
001)
and
in th
e el
derl
y (o
vera
ll an
d fo
r A
mox
, TM
P-S
MX
). T
here
wer
e
hi
gh c
o-re
sist
ance
rat
es b
etw
een
Am
ox, C
ipro
, and
TM
P-S
MX
. The
re w
ere
sign
. reg
iona
l dif
fere
nces
in r
esis
tanc
e ra
tes
in th
e 9
regi
ons.
St
orby
et a
l.[38]
S
wed
en
4671
D
ata
wer
e no
t str
atif
ied
for
isol
ates
fro
m u
ncom
plic
ated
vs.
com
plic
ated
(2
004)
(1
990-
2001
) (1
990-
1993
) U
TIs
. E. c
oli c
onst
itut
ed 6
5.5%
and
73.
7% o
f 19
90-1
993
and
1998
-200
1
4110
is
olat
es, r
espe
ctiv
ely.
Sig
n. li
near
tren
ds f
or in
crea
sing
res
ista
nce
over
tim
e
(1
998-
2001
) w
ere
seen
for
Am
p (p
= 0
.005
), T
MP
(p
= 0
.004
), a
nd th
e qu
inol
ones
(p
<
0.
001)
. No.
sig
n. c
hang
e ov
er ti
me
was
not
ed f
or P
ivm
ec (
rang
e 0-
3%)
and
N
itro
(≤ 1
%).
Res
ista
nce
fell
over
tim
e vs
. Cef
adro
x (p
< 0
.007
).
Ars
lan
et a
l.[39]
T
urke
y 32
1 E
. col
i con
stitu
ted
90%
of
isol
ates
. 5%
of
thes
e is
olat
es p
rodu
ced
ESB
L.
(200
5)
(1/0
4-6/
04)
(gra
m-n
egat
ive
Res
ista
nce
rate
s vs
. Cip
ro w
ere
17%
in u
UT
Is a
nd 3
8% in
pa
thog
ens
in
com
plic
ated
UT
Is.
uUT
I)
Res
ista
nce
rate
s fo
r E
. col
i:
A
mp
51%
A
mox
-Cla
v 26
%
Cef
az
22%
O
flox
17
%
N
alA
c 20
%
T
MP
-SM
X
36%
Nitr
o 4%
Fosf
o 0.
3%
R
isk
fact
ors
for
Cip
ro-r
esis
tant
E. c
oli (
univ
aria
te a
naly
ses)
: age
> 5
0 ye
ars
old
(p =
0.0
004)
, iso
late
s fr
om a
rur
al a
rea
(p =
0.0
39),
pre
senc
e of
com
plic
ated
UT
I (p
< 0
.001
), E
SBL
-pro
duci
ng s
trai
n (p
< 0
.001
), a
nd C
ipro
use
> o
nce
in p
revi
ous
year
(p
= 0
.001
).
R
isk
fact
ors
for
Cip
ro-r
esis
tant
E. c
oli (
mul
tiva
riat
e an
alys
es):
age
> 5
0 ye
ars
old
(OR
1.6
, p =
0.0
2), c
ipro
use
> o
nce
in p
revi
ous
year
(O
R 2
.8, p
= 0
.004
),
an
d pr
esen
ce o
f co
mpl
icat
ed U
TI
(OR
2.4
, p <
0.0
01).
ESB
L-p
rodu
cing
isol
ates
wer
e tw
ice
as c
omm
on in
Cip
ro r
ecip
ient
s (1
5%)
vs. n
on-C
ipro
reci
pien
ts (
7.4%
) R
ock
et a
l.[40]
N
orth
ern
Isra
el
6212
(19
95)
Res
ista
nce
rate
s fo
r E
. col
i (19
95/1
999/
2002
/200
5):
(200
7)
(199
5, 1
999,
200
2,
6519
(19
99)
Am
p 55
/56/
54/5
4%
20
05)
6272
(20
02)
Am
ox-C
lav
11/1
0/5/
4% (
p <
0.0
01 f
or tr
end)
63
68 (
2005
) C
ipro
6/
6/7/
11%
(p
< 0
.001
for
tren
d)
(out
patie
nt
TM
P-S
MX
29
/27/
25/2
8% (
p =
0.0
1 fo
r tr
end)
gr
am-n
egat
ive
Nitr
o 6/
5/3/
3% (
p <
0.00
1 fo
r tr
end)
is
olat
es)
Res
ista
nce
rate
s fo
r ot
her
GN
Rs
(199
5/19
99/2
002/
2005
):
A
mp
76/8
5/86
/81%
(p
< 0
.001
for
tren
d)
A
mox
-Cla
v 32
/25/
20/2
6% (
p <
0.0
01 f
or tr
end)
Cip
ro
8/4/
9/11
% (
p =
0.0
04 f
or tr
end)
TM
P-S
MX
19
/19/
14/2
0%
N
itro
56/6
2/49
/56%
Fro
m 2
000-
2006
, the
re w
ere
sign
. dec
reas
es in
the
util
izat
ion
of T
MP
-SM
X
an
d N
itro
(bot
h p
< 0
.001
) an
d a
sign
. inc
reas
e in
the
util
izat
ion
of A
mp
(p <
0.00
1) in
the
com
mun
ity
(bas
ed o
n D
DD
). T
hese
ant
imic
robi
al u
tili
zati
on
pa
tter
ns c
ould
not
exp
lain
the
chan
ges
seen
in a
ntim
icro
bial
res
ista
nce
pa
ttern
s.
Him
a-L
erib
le
Cen
tral
Afr
ican
31
3 R
esis
tanc
e ra
tes:
et
al.[4
1]
(200
3)
Rep
ublic
(o
utpa
tient
s E
. col
i (N
= 1
74)
Oth
er E
nter
obac
teri
acea
e (N
= 9
2)
(1
/00-
4/02
) w
ith
susp
ecte
d A
mox
80
%
96%
uUT
Is)
TM
P-S
MX
80
%
70%
C
ipro
8%
5%
Fosf
o 2%
10
%
N
alA
c 9%
9%
Am
ox-C
lav
28%
36
%
R
andr
iani
rain
a M
adag
asca
r 90
3 E
. col
i con
stitu
ted
67.2
% o
f is
olat
es.
et
al.[4
2] (
2007
) (1
/04-
4/06
) (o
utpa
tient
s R
esis
tanc
e ra
tes:
w
ith
susp
ecte
d
E. c
oli (
N =
607
) A
ll G
NR
(N
= 7
94)
uUT
Is)
Am
ox
74%
77
%
TM
P-S
MX
70
%
66%
C
ipro
16
%
16%
Nal
Ac
25%
26
%
Fo
sfo
0.2%
4.
6%
C
ipro
res
ista
nce
rate
s w
ere
sign
. inc
reas
ed in
isol
ates
fro
m o
lder
(≥
65 y
ears
old)
vs.
you
nger
pat
ient
s (<
65
year
s ol
d) (
p <
0.0
1).
Issa
ck e
t al.[4
3]
Mau
riti
us
260
Res
ista
nce
rate
s:
(2
007)
(1
/05-
4/05
) (o
utpa
tien
ts
E
nter
obac
teri
acea
e E
. col
i K
lebs
iell
a sp
p.
> 1
5 ye
ars
old
(N =
212
) (N
= 1
21)
(N =
36)
requ
irin
g U
C
Am
p 80
%
73%
10
0%
for
clin
ical
car
e)
TM
P-S
MX
50
%
54%
44
%
Nal
Ac
34%
31
%
47%
Cip
ro
26%
23
%
42%
M
ec
2%
3%
3%
Fo
sfo
0 0
0 N
abet
h et
al.[4
4]
Sene
gal
102
Res
ista
nce
rate
s:
(200
5)
(6/0
1-6/
03)
(qui
nolo
ne-
Am
p 93
%
resi
stan
t GN
R)
Am
ox-C
lav
78%
T
etra
78
%
SMX
78
%
Gen
t 31
%
M
ec
47%
Nitr
o 32
%
Fo
sfo
2%
Dro
mig
ny e
t al.[4
5]
Sene
gal
398
73%
of
isol
ates
wer
e fr
om u
UT
Is. O
nly
11%
of
isol
ates
wer
e (2
005)
(6
/01-
6/03
) (E
. col
i onl
y)
susc
eptib
le to
all
test
ed a
gent
s.
R
esis
tanc
e ra
tes:
Am
p 74
%
A
mox
-Cla
v 58
%
Nal
Ac
23%
Qui
nolo
nes
19%
TM
P-S
MX
68
%
R
esis
tanc
e ra
tes
rose
ove
r ti
me
wit
h A
mox
-Cla
v (5
0.4%
→64
%)
and
TM
P-S
MX
(64
.6%
→71
.1%
).
R
esis
tanc
e ph
enot
ype
rate
s w
ith
“top
5”
agen
ts:
A
mp
+ T
MP
-SM
X
60
%
A
mp
+ A
mox
-Cla
v +
TM
P-S
MX
47
%
A
mp
+ A
mox
-Cla
v +
TM
P-S
MX
+ N
alA
c 15
%
A
mp
+ A
mox
-Cla
v +
TM
P-S
MX
+ N
alA
c +
Qui
nolo
nes
12%
Ris
k fa
ctor
s fo
r re
sist
ance
:
Am
p:
gend
er (
men
> w
omen
, OR
2.1
), e
xpos
ure
duri
ng
prev
ious
6 m
o. (
OR
3.7
)
Am
ox-C
lav:
ex
posu
re d
urin
g pr
evio
us 6
mo.
(O
R 2
.5)
N
alA
c:
age
grea
ter
than
45
year
s ol
d (O
R 3
.1),
UT
I in
pre
viou
s
ye
ar (
OR
3.0
), e
xpos
ure
in p
revi
ous
6 m
o. (
OR
1.8
)
Qui
nolo
nes:
ag
e gr
eate
r th
an 4
5 ye
ars
old
(OR
3.5
), U
TI
in p
revi
ous
year
(O
R 4
.1)
T
MP
-SM
X:
expo
sure
in p
revi
ous
6 m
o. (
OR
2.4
) A
hmed
et a
l.[46]
Su
dan
362
Res
ista
nce
rate
s:
(200
0)
(NA
) (≥
5 y
ear
old
E
. col
i K
. pne
umon
iae
P. m
irab
ilis
in
patie
nts
and
(N
= 1
65)
(N =
60)
(N
= 2
7)
ou
tpat
ient
s)
TM
P-S
MX
67
%
68%
81
%
T
MP
74%
73
%
83%
N
alA
c 6%
18
%
7%
C
ipro
0
0 0
A
mox
72
%
85%
78
%
N
itro
10%
46
%
59%
For
E. c
oli,
58%
of
isol
ates
wer
e re
sist
ant t
o at
leas
t 4 o
f 10
age
nts
and
26%
wer
e re
sist
ant t
o 5
or m
ore
of 1
0 ag
ents
. For
K. p
neum
onia
e, th
e
co
rres
pond
ing
freq
uenc
ies
wer
e 70
% a
nd 5
2% w
hile
for
P. m
irab
ilis
, the
y
w
ere
82%
and
60%
(an
d, f
or th
e la
tter,
33%
wer
e re
sist
ant t
o 6
or m
ore
of
10
age
nts)
.
A
kram
et a
l.[47]
In
dia
100
36.5
% a
nd 1
6.7%
of
isol
ates
wer
e ob
tain
ed f
rom
ped
iatr
ic a
nd e
lder
ly
(200
7)
(08/
04-0
7/05
) (p
atie
nts
of a
ll
(≥ 5
0 ye
ars
old)
sub
ject
s, r
espe
ctiv
ely.
ag
es a
tten
ding
R
esis
tanc
e ra
tes:
th
e ho
spita
l
E. c
oli (
N =
61)
K
. pne
umon
iae
(N =
22)
ou
tpat
ient
T
MP
-SM
X
76%
53
%
cl
inic
) N
itro
80%
76
%
Cip
ro
69%
47
%
N
orfl
ox
69%
47
%
E
SBL
was
pro
duce
d by
34.
4% o
f E
. col
i and
27.
3% o
f K
. pne
umon
iae
isol
ates
. A
rya
and
Aga
rwal
[48]
Del
hi, I
ndia
22
76 (
inpa
tient
, A
ll bu
t 6 is
olat
es (
E. f
aeca
lis)
wer
e G
NR
s. R
esis
tanc
e ra
tes
for
outp
atie
nt/
(200
7)
(200
4-20
06)
474;
out
patie
nt,
inpa
tient
isol
ates
:
18
02)
Am
ox-C
lav
12/9
%
N
itro
2/1%
Am
ikac
in
7/8%
Net
ilm
icin
12
/11%
Res
ista
nce
rate
s ro
se s
ign.
fro
m 2
004
to 2
006
for
ceft
azid
ime
(11
→ 2
6%, p
=
0.
0007
) an
d fe
ll si
gn. f
or g
enta
mic
in (
36 →
27%
, p =
0.0
20).
K
ahlm
eter
[49]
17
cou
ntri
es
3278
E
. col
i rep
rese
nted
77%
of
isol
ates
. 42%
of
stra
ins
wer
e re
sist
ant t
o ≥
1 of
12
(200
3)
(EC
O-S
EN
S)
(out
patie
nt
test
ed a
gent
s. F
or E
. col
i, re
sist
ance
was
mos
t com
mon
ly n
oted
wit
h A
mp
(1/9
9-12
/00)
fe
mal
es ≤
65
(30%
), S
MX
(29
%),
TM
P (
15%
), T
MP
-SM
X (
14%
), a
nd N
alA
c (5
.4%
). I
n
year
s ol
d w
ith
cont
rast
, rat
es f
or A
mox
-Cla
v, M
ec, N
itro,
Fos
fo, G
ent,
and
Cip
ro w
ere
all
sym
ptom
s c/
w
< 3
%. R
ates
var
ied
as a
fun
ctio
n of
geo
grap
hy:
uUT
Is)
eg. E
. col
i vs.
A
mox
-Cla
v in
P
ortu
gal (
9% r
esis
tanc
e ra
te)
Nal
Ac
Por
tuga
l (12
%)
Cip
ro
Por
tuga
l (6%
)
N
alA
c Sp
ain
(27%
)
Cip
ro
Spai
n (1
5%)
P
. mir
abil
is (
4.4%
of
isol
ates
) ha
d a
low
er r
esis
tanc
e ra
te v
s. A
mp
(16.
1%)
but
hi
gher
rat
e vs
. TM
P (2
5.5%
) th
an E
. col
i. K
lebs
iell
a sp
p. (
2.2%
of
isol
ates
)
ha
d hi
gher
res
ista
nce
rate
s th
an E
. col
i vs.
Am
p (8
3.5%
) an
d Fo
sfo
(56.
7%).
Oth
er E
nter
obac
teri
acea
e (2
.7%
of
isol
ates
) ha
d hi
gher
rat
es, c
ompa
red
to
E
. col
i, vs
. Am
p (4
5.9%
), A
mox
-Cla
v (2
1.3%
), N
itro
(40.
2%)
and
Fosf
o
(1
5.6%
).
R
esis
tanc
e w
as r
are
for
S. s
apro
phyt
icus
(hi
ghes
t wit
h G
ent a
t 4.3
%-e
xpec
ted)
.
In g
ener
al, a
ntim
icro
bial
res
ista
nce
rate
s w
ere
low
est i
n th
e N
ordi
c co
untr
ies
and
high
est i
n S
pain
/Por
tuga
l. T
he e
mpi
ric
use
of T
MP
-SM
X m
ay n
o lo
nger
be a
ppro
pria
te in
Ger
man
y, I
rela
nd, S
pain
, and
Por
tuga
l (E
. col
i res
ista
nce
rate
s >
20%
for
all)
.
A
bbre
viat
ions
: A
mp
= a
mpi
cill
in, C
ipro
= c
ipro
flox
acin
, Nit
ro =
nitr
ofur
anto
in, T
MP
-SM
X =
trim
etho
prim
-sul
fam
etho
xazo
le, L
evo
= le
vofl
oxac
in, F
= f
emal
e, M
= m
ale,
MIC
= m
inim
um in
hibi
tory
co
ncen
trat
ion,
Am
ox =
am
oxic
illin
, Am
ox-C
lav
= a
mox
icill
in-c
lavu
lana
te, N
orfl
ox =
nor
flox
acin
, Ofl
ox =
ofl
oxac
in, F
osfo
= f
osfo
myc
in, O
R =
odd
s ra
tio, C
efaz
= c
efaz
olin
, Tet
ra =
te
trac
ycli
ne, C
hlor
o =
chl
oram
phen
icol
, Nal
Ac
= n
alid
ixic
aci
d, P
ivm
ec =
piv
mec
illi
nam
, ESB
L =
ext
ende
d-sp
ectr
um b
eta-
lact
amas
e, G
NR
= g
ram
-neg
ativ
e ro
ds, M
ec =
mec
illi
nam
, Gen
t =
gent
amic
in, C
efad
rox
= c
efad
roxi
l, T
RU
ST =
Tra
ckin
g R
esis
tanc
e in
the
Uni
ted
Stat
es T
oday
sur
veill
ance
stu
dy, N
A =
not
ava
ilabl
e, U
C =
uri
ne c
ultu
re, T
SN =
The
Sur
veil
lanc
e N
etw
ork,
D
BD
= d
efin
ed d
aily
dos
es p
er 1
00 b
eds-
days
, DID
= d
efin
ed d
aily
dos
es p
er 1
000
clie
nts
per
day,
GP
C =
gra
m-p
ositi
ve c
occi
. a si
gn. l
inea
r tr
end
(upw
ard)
ove
r ti
me
(all
p ≤
0.00
2).
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