Risk stratification for trimethoprim-sulfamethoxazole resistance in community-acquired, uncomplicated urinary tract infections

Mentler, Philippe A.; Kuhn, Bryan R.; Gandhi, Guneet

doi:10.2146/ajhp060177

Cited by 3 publications

(2 citation statements)

References 3 publications

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“…However, given the observed 15% prevalence of TMP-SMX resistance, our sample size was sufficient to provide an 80% power to detect a six-to eightfold between-group difference in TMP-SMX exposure proportions at an alpha level of 0.05. Although these risk estimates are in the range of the results from some previous retrospective studies, they are higher than the risk estimates of 2 to 5 that others have found (1,16,27). Thus, it is certainly possible that the association between TMP-SMX use and resistance lies in a range that is below the power of our study to detect or occurs in a time frame outside the 3-month period that we assessed.…”

Section: Discussioncontrasting

confidence: 70%

“…Although several studies have attempted to elucidate such individual risk factors, most of those studies have been limited by being retrospective or including mixed gender and age groups that do not fulfill the traditional criteria for acute uncomplicated cystitis (1,2,16,17,24,27). In this study, we evaluated specific risk factors as independent predictors of TMP-SMX resistance among prospectively enrolled women presenting with uncomplicated cystitis.…”

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confidence: 99%

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Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis

Colgan

Johnson

Kuskowski

et al. 2008

Antimicrob Agents Chemother

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Emerging antimicrobial resistance among uropathogens makes the management of acute uncomplicated cystitis increasingly challenging. Few prospective data are available on the risk factors for resistance to trimethoprim-sulfamethoxazole (TMP-SMX), the drug of choice in most settings. In order to evaluate this, we prospectively enrolled women 18 to 50 years of age presenting to an urban primary care practice with symptoms of cystitis. Potentially eligible women provided a urine sample for culture and completed a questionnaire regarding putative risk factors for TMP-SMX resistance. Escherichia coli isolates were tested for clonal group A (CGA) membership by a fumC-specific PCR. Of 165 women with cystitis symptoms, 103 had a positive urine culture and were eligible for participation. E. coli was the predominant uropathogen (86%). Fifteen (14.6%) women had a TMP-SMX-resistant (TMP-SMX r ) organism (all of which were E. coli). Urinary tract infection (UTI) is one of the most common indications for antimicrobial therapy. Recent studies have demonstrated that fluoroquinolones are increasingly being used instead of trimethoprim-sulfamethoxazole (TMP-SMX) to treat UTIs in ambulatory women, the majority of whom likely have acute uncomplicated cystitis (9, 14, 25). Concurrently, and perhaps consequently, fluoroquinolone resistance among uropathogens is increasing in prevalence (5, 10). Clearly, strategies that can be used to decrease the rate of fluoroquinolone use, particularly for uncomplicated cystitis, are needed.One such strategy is to facilitate the appropriate prescription of TMP-SMX as the preferred agent for the treatment of UTIs in women. The use of TMP-SMX for uncomplicated cystitis is declining (14). The reasons for this are not entirely clear, but a contributing factor may be concerns over the rising rates of TMP-SMX resistance among uropathogens (23). Guidelines for the treatment of acute uncomplicated cystitis recommend the use of alternative agents in settings where TMP-SMX is problematic due to anticipated resistance, intolerance, or other factors (8,26). Unfortunately, local susceptibility data often come from hospital-based microbiology laboratories and may not accurately reflect the prevalence of TMP-SMX resistance among otherwise healthy outpatient women with UTIs, many of whom do not have urine cultures and susceptibilities performed (7). Thus, the actual prevalence of resistance in any given locale is usually unknown or may be overestimated on the basis of hospital-derived data, leading to the unnecessary avoidance of TMP-SMX as a first-line agent.Knowledge of the individual host factors that predict TMP-SMX resistance would allow clinicians to make an informed prescribing decision on a case-by-case basis, eliminating the need to know population-specific resistance rates. Although several studies have attempted to elucidate such individual risk factors, most of those studies have been limited by being retrospective or including mixed gender and age groups that do not fulfill the traditional criteria fo...

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Section: Discussioncontrasting

confidence: 70%

mentioning

confidence: 99%

Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis

Colgan

Johnson

Kuskowski

et al. 2008

Antimicrob Agents Chemother

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Antimicrobial resistance in Escherichia coli outpatient urinary isolates from women: emerging multidrug resistance phenotypes

Wong

Yip

et al. 2007

Diagnostic Microbiology and Infectious Disease

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Contemporary Management of Uncomplicated Urinary Tract Infections

Guay

2008

Drugs

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Uncomplicated urinary tract infections (uUTIs) are common in adult women across the entire age spectrum, with mean annual incidences of approximately 15% and 10% in those aged 15-39 and 40-79 years, respectively. By definition, UTIs in males or pregnant females and those associated with risk factors known to increase the risk of infection or treatment failure (e.g. acquisition in a hospital setting, presence of an indwelling urinary catheter, urinary tract instrumentation/interventions, diabetes mellitus or immunosuppression) are not considered herein. The majority of uUTIs are caused by Escherichia coli (70-95%), with Proteus mirabilis, Klebsiella spp. and Staphylococcus saprophyticus accounting for 1-2%, 1-2% and 5-10% of infections, respectively. If clinical signs and symptoms consistent with uUTI are present (e.g. dysuria, frequency, back pain or costovertebral angle tenderness) and there is no vaginal discharge or irritation present, the likelihood of uUTI is >90-95%. Laboratory testing (i.e. urinary nitrites, leukocyte esterase, culture) is not necessary in this circumstance and empirical treatment can be initiated. The ever-increasing incidence of antimicrobial resistance of the common uropathogens in uUTI has been and is a continuing focus of intensive study. Resistance to cotrimoxazole (trimethoprim/sulfamethoxazole) has made the empirical use of this drug problematic in many geographical areas. If local uropathogen resistance rates to cotrimoxazole exceed 10-25%, empirical cotrimoxazole therapy should not be utilized (fluoroquinolones become the new first-line agents). In a few countries, uropathogen resistance rates to the fluoroquinolones now exceed 10-25%, rendering empirical use of fluoroquinolones problematic. With the exception of fosfomycin (a second-line therapy), single-dose therapy is not recommended because of suboptimal cure rates and high relapse rates. Cotrimoxazole and the fluoroquinolones can be administered in 3-day regimens. Nitrofurantoin, a second-line therapy, should be given for 7 days. beta-Lactams are not recommended because of suboptimal clinical and bacteriological results compared with those of non-beta-lactams. If a beta-lactam is chosen, it should be given for 7 days. Management of uUTIs can frequently be triaged to non-physician healthcare personnel without adverse clinical consequences, resulting in substantial cost savings. It can be anticipated that the optimal approach to the management of uUTIs will change substantially in the future as a consequence of antimicrobial resistance.

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Risk stratification for trimethoprim-sulfamethoxazole resistance in community-acquired, uncomplicated urinary tract infections

Cited by 3 publications

References 3 publications

Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis

Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis

Antimicrobial resistance in Escherichia coli outpatient urinary isolates from women: emerging multidrug resistance phenotypes

Contemporary Management of Uncomplicated Urinary Tract Infections

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