Which antibiotics should we prefer empirical treatment of urinary tract infections in elderly patients?

Year 2019, , 856 - 860, 03.12.2019

Nergis Asgin , Şerife Satılmış

https://doi.org/10.28982/josam.650249

Cited By: 1

Abstract

Aim: Urinary tract infection (UTI) is a major cause of mortality and morbidity in elderly patients. In this cross-sectional study, we aimed to determine the frequency and antibiotic resistance profile of the bacteria causing UTI and contribute to the empirical treatment options in elderly patients.

Methods: This study included urine culture results from 347 elderly outpatients who were referred to Karabuk Training and Research Hospital between January 2018 and June 2019. The identification and antibiotic susceptibilities of microorganisms were determined using the BD-Phoenix 100 fully automated system, and the extended-spectrum beta-lactamase (ESBL) positivity was analyzed using the combined disk diffusion method. The results were retrospectively analyzed. 

Results: The most common pathogens were Escherichia coli (58%), Enterococcus spp. (18%) and Klebsiella pneumoniae (11%). The rate of resistance to ampicillin, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole (TMP-SMX), cefixime, and ciprofloxacin, which are oral antibiotics used in the treatment of UTI, was between 30% and 70%. The rate of resistance to nitrofurantoin was 3%. The gentamicin and piperacillin-tazobactam resistance were 12% and 9%, respectively. The ESBL positivity for E. coli and K. pneumoniae were 29% and 49%, respectively (P=0.03).

Conclusion: The rates of resistance to oral antibiotics such as ampicillin, amoxicillin-clavulanic acid, TMP-SMX, cefixime, and ciprofloxacin, which are used treatment of UTI, were more than 20%. Therefore, these antibiotics should not be used in the empirical treatment of UTI. Instead, nitrofurantoin may be preferred in the empirical treatment of uncomplicated UTI, or gentamicin and piperacillin-tazobactam, which are parenteral antibiotics that may be used depending on the patient’s clinical condition.

Keywords

Antibiotics, Enterococcus species, Escherichia coli, Nitrofurantoin, Ciprofloxacin, Urinary tract infection

Yaşlı hastalarda üriner sistem infeksiyonlarının ampirik tedavisinde hangi antibiyotikleri tercih etmeliyiz?

Abstract

Amaç: Üriner sistem infeksiyonları (ÜSİ) yaşlı hastalarda önemli bir mortalite ve morbidite nedenidir. Bu kesitsel çalışmada yaşlı hastalarda toplum kaynaklı ÜSİ etkenlerinin sıklığını ve antibiyotik direnç profilini belirleyerek ampirik tedavi seçimine katkıda bulunmayı amaçladık.

Yöntemler: Ocak 2018 - Haziran 2019 tarihleri arasında Karabük Eğitim ve Araştırma Hastanesi’ne ayaktan başvuran 347 yaşlı hastanın idrar kültür sonuçları çalışmaya dahil edilmiştir. Mikroorganizmaların identifikasyonu ve antibiyotik duyarlılıkları BD-Phoenix (Becton-Dickinson, MD,USA) tam otomatize sistem ile, genişlemiş spektrumlu beta-laktamaz varlığı (GSBL) ise kombine disk difüzyon yöntemi ile araştırılmıştır. Sonuçlar retrospektif olarak incelenmiştir. 

Bulgular: En sık izole edilen patojenler Escherichia coli (%58), Enterococcus spp (%18) ve Klebsiella pneumoniae (%11) idi. Üriner infeksiyon tedavisinde kullanılan oral antibiyotiklerden ampisilin, amoksisilin-klavulanik asit, trimethoprim-sulfametoksazol (TMP-SMX), sefiksim ve siprofloksasine direnç %30-70 arasında idi. Nitrofurantoin direnci ise %3 idi. Gentamisine %12 ve piperasilin-tazobaktama ise %9 oranında direnç saptandı. GSBL pozitifliği ise E.coli‘de % 29 iken, K. pneumoniae suşlarında %49 idi (P=0.03).

Sonuç: Üriner sistem infeksiyonlarının tedavisinde kullanılan oral antibiyotiklerden ampisilin, amoksisilin-klavulanik asit, TMP-SMX, sefiksim ve siprofloksasine %20’nin üzerinde direnç saptanmıştır. Bu nedenle ÜSİ’ nın ampirik tedavisinde bu antibiyotikler kullanılmamalıdır. Onun yerine komplike olmayan ÜSİ’ da nitrofurantoin, parenteral antibiyotiklerden ise gentamisin ve piperasilin-tazobaktam hastanın klinik durumuna göre tercih edilebilir.

Keywords

Antibiyotik, Enteroccus türleri, Escherichia coli, Nitrofurantoin, Siprofloksasin, Üriner sistem infeksiyonları

References

• 1. Gbinigie OA, Ordonez-Mena JM, Fanshawe TR, Pluddemann A, Heneghan C. Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: systematic review and meta-analysis. J Infection. 2018;77(5):379-90.
• 2. Turkey General Directorate of Public Health. https://hsgm.saglik.gov.tr/depo/birimler/kronik-hastaliklar-engelli-db/hastaliklar/Yasli_Sagligi/raporlar_istatistikler/TUIK_Yasli_Istatistik_2018.pdf Accessed 15 Oct 2019.
• 3. Cortes-Penfield NW, Trautner BW, Jump RL. Urinary tract infection and asymptomatic bacteriuria in older adults. Infect Dis. Clin. North Am. 2017;31(4):673-88.
• 4. Nicolle LE. Urinary tract infections in the older adult. Clin Geriatr Med. 2016;32(3):523-38.
• 5. Marques LPJ, Flores JT, Junior ODOB, Rodrigues GB, de Medeiros Mourao C, Moreira RMP. Epidemiological and clinical aspects of urinary tract infection in community-dwelling elderly women. Braz J Infect Dis. 2012;16(5):436-41.
• 6. Ulug M, Gul I. Investigation of the Results of Urine Cultures and Approaches to Empirical Antibiotic Treatment of Community-Acquired Urinary Tract Infections in Elderly Patients. Klimik Derg. 2012; 25:71-6.
• 7. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. International clinical practice guidelines or the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):103-20.
• 8. The Guide to Analysis and Presentation of Antibiotic Susceptibility Data. Available at: https://www.klimud.org/public/uploads/content/files/Antibiyotik%20Duyarl%C4%B1l%C4%B1k%20Verilerinin%20Analizi%20ve%20Sunumu%20RRehberi.pdf Accessed 11 Oct 2019.
• 9. European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 8.1, (2018). Available athttp://www.eucast.org/ast_of_bacteria/previous_versions_of_documents/ Accessed 14 Oct 2019.
• 10. Asgin N, Cakmakliogullari EK. In-vitro antibiotic resistance profile of E. coli strains isolated from community- acquired pediatric urinary tract infections in Karabuk province. J Contemp Med. 2017;7(3):241-5.
• 11. Sundvall PD, Ulleryd P, Gunnarsson RK. Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes. BMC Fam Pract.2011;12(1):36.
• 12. Ginde AA, Rhee SH, Katz ED. Predictors of outcome in geriatric patients with urinary tract infections. J Emerg Med. 2014;27(2):101-8.
• 13. Das R, Perrelli E, Towle V, Van Ness PH, Juthani-Mehta M. Antimicrobial susceptibility of bacteria isolated from urine samples obtained from nursing home residents. Infect Control Hosp Epidemiol. 2009;30(11):1116-9.
• 14. Coskun USS, Coskun G. Determination of the Prevalence and Antibiotic Susceptibilities of Extended Spectrum Beta-Lactamase Positive Escherichia coli Strains Isolated from Urine of Outpatient Patients of a State Hospital. Kocatepe Tıp Derg. 2015;16(1):25-30.
• 15. Caliskan E, Dede A, Aytar AA, Biten G, Kas E. The Evaluation of Resistance Rates to Various Antibiotics and Extended Spectrum Beta-lactamase Positivity of Esherichia coli and Klebsiella spp. Strains Isolated from Outpatients with Urinary Tract Infection. ANKEM Derg. 2015;29(2):47-53.
• 16. Duman Y, Gucluer N, Serindag A, Tekerekoglu MS. Antimicrobial Susceptibility of E. coli Strains and Presence of Extended-Spectrum Beta Lactamase. Fırat Tıp Derg. 2010;15(4):197-200.
• 17. Fagan M, Lindbaek M, Grude N, Reiso H, Romoren M, Skaare D, et al. Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living in nursing homes versus the elderly living at home: an observational study. BMC Geriatrics. 2015;15:98.
• 18. Sanchez GV, Adams SJ, Baird AM, Master RN, Clark RB, Bordon JM. Escherichia coli antimicrobial resistance increased faster among geriatric outpatients compared with adult outpatients in the USA, 2000–10. J Antimicrob Chemother. 2013;68(8):1838-41.
• 19. Tasbakan MI, Pullukcu H, Sipahi OR, Yamazhan T, Arda B, Ulusoy S. A pooled analysis of the resistance patterns of Escherichia coli strains isolated from urine cultures in Turkey: a comparison of the periods 1997-2001 and 2002-2007. Turkish J Med Sci. 2011;41(3):557-64.
• 20. Asgin N, Eroglu S, Cakmakliogullari EK. Which Antibiotics Should be First Line Options for Empirical Treatment of Urinary Tract Infections During Pregnancy? ANKEM Derg. 2018;32(3):94-102.
• 21. Caktır DA. The Distribution of the Factors Causing Childhood Urinary Tract Infections and Investigation of Antibiotic Susceptibility (dissertation) Istanbul; 2008.
• 22. Yasar KK, Pehlivanoglu F, Sengoz G. Distribution of gram-negative microorganisms and their antibiotic resistance in urinary tract infections of children. Medical Bulletin of Zeynep Kamil. 2010;41(3):137-41.
• 23. Coban B, Ulkü N, Kaplan H, Topal B, Erdogan H, Baskın E. Five-year assessment of causative agents and antibiotic resistances in urinary tract infections. Turk Pediatr Ars. 2014;49(2):124-9.
• 24. Kacmaz B, Aksoy A, Sultan N. The Investigation of Resistance to Oral Antibiotics in Escherichia coli Isolates Obtained from Urine. Turk Hij Den Biyol Derg. 2007;64(1):11-5.
• 25. Lob SH, Nicolle LE, Hoban DJ, Kazmierczak KM, Badal RE, Sahm DF. Susceptibility patterns and ESBL rates of Escherichia coli from urinary tract infections in Canada and the United States, SMART 2010–2014. Diagn Microbiol Infect Dis. 2016;85(4):459-65.
• 26. Smithson A, Chico C, Ramos J, Netto C, Sanchez M, Ruiz J, et al. Prevalence and risk factors for quinolone resistance among Escherichia coli strains isolated from males with community febrile urinary tract infection. Eur J Clin Microbiol Infect Dis. 2012;31:423–30.
• 27. Gulcan A, Aslanturk A, Gulcan E. The Microorganisms Isolated from Urine Culture and Their in Vitro Antibiotic Susceptibility. Abant Med J. 2012;1(3):129-35.
• 28. Uyanık MH, Hancı H, Yazgı H. In-vitro Activity of Fosfomycin Trometamol and some other Antibiotics to Escherichia coli Strains Isolated from Community-acquired Urinary Tract Infections. ANKEM Derg. 2009;23(4):172-6.
• 29. Rodríguez-Bano J, Navarro MD, Romero L, Martínez-Martínez L, Muniain MA, Perea EJ et al. Epidemiology and clinical features of infections caused by extended-spectrum beta-lactamase-producing Escherichia coli in nonhospitalized patients. J Clin Microbiol. 2004;42(3):1089-94.
• 30. Bayram Y, Eren H, Berktas M. Distribution of Bacterial Pathogens in Urine Samples and Resistance Patterns of ESBL positive and negative Escherichia coli Isolates against Fosfomycin and other Antimicrobials. ANKEM Derg. 2011;25(4):232-6.
• 31. Kutlu O, Arabacı Ç. Antibiotic susceptibility pattern of Enterococcus isolates in a five-year period at a tertiary care hospital. J Surg Med. 2019;3(9):644-7.