e Antibiotic selection pressure and genetic associations may lead to the cooccurrence of resistance and virulence in individual pathogens. However, there is a lack of rigorous epidemiological evidence that demonstrates the cooccurrence of resistance and virulence at the population level. Using samples from a population-based case-control study in 25 villages in rural Ecuador, we characterized resistance to 12 antibiotics among pathogenic (n ؍ 86) and commensal (n ؍ 761) Escherichia coli isolates, classified by the presence or absence of known diarrheagenic virulence factor genes. The prevalences of resistance to single and multiple antibiotics were significantly higher for pathogenic isolates than for commensal isolates. Using a generalized estimating equation, antibiotic resistance was independently associated with virulence factor carriage, case status, and antibiotic use (for these respective factors: odds ratio [OR] ؍ 3.0, with a 95% confidence interval [CI] of 1.7 to 5.1; OR ؍ 2.0, with a 95% CI of 1.3 to 3.0; and OR ؍ 1.5, with a 95% CI of 0.9 to 2.5). Virulence factor carriage was more strongly related to antibiotic resistance than antibiotic use for all antibiotics examined, with the exception of fluoroquinolones, gentamicin, and cefotaxime. This study provides epidemiological evidence that antibiotic resistance and virulence factor carriage are linked in E. coli populations in a community setting. Further, these data suggest that while the cooccurrence of resistance and virulence in E. coli is partially due to antibiotic selection pressure, it is also genetically determined. These findings should be considered in developing strategies for treating infections and controlling for antibiotic resistance.A ntimicrobial resistance is a major public health problem, identified by the World Health Organization (WHO) as one of the most pressing issues in global health (1). In the United States, more than 2 million people per year acquire bacterial infections that are resistant to antibiotics, resulting in at least 23,000 deaths and expenditures of 20 to 35 billion dollars annually (2). Elsewhere, losses to the gross domestic product (GDP) from antibiotic resistance are estimated to be 0.4% to 1.6% (3). Antibiotic resistance can occur in any bacteria but is of direct concern among pathogens, because of the resulting increased duration of care, cost of treatment, morbidity, and mortality (4, 5). Although selection due to antibiotic use is considered a major factor associated with increased antibiotic resistance among pathogens, studies on the molecular mechanisms of resistance and virulence suggest a genetic association. For example, genes for both resistance and virulence can be colocalized in the genome, indicating coselection (6). While these mostly laboratory-based studies suggest a plausible ecological and biological link, there is a lack of rigorous epidemiological evidence demonstrating this link between antibiotic resistance and virulence in human populations.Pathogenic Escherichia coli and shigel...