a Department of Internal Medicine, Warsaw University Medical School, Lindleya 1,Warsaw; b The National Reference Centre for Antibiotics, Sera and Vaccines Central Research Laboratory, Chelmska 30/34, 00-725 Warsaw, Poland
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Abstract |
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Introduction |
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The aim of this study was to obtain data on susceptibility patterns of major pathogens from both community and hospital UTIs in Poland to antimicrobial agents currently used in the treatment of UTI.
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Materials and methods |
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Twenty centres participated in the study. They were selected to cover all administrative regions in Poland. The bacterial strains were isolated from urine specimens from 601 patients (2535 per centre) who either consulted general practitioners (n = 460) in different regions or were hospitalized (n = 141) in University Clinics in Warsaw, Cracow, Wrocaw, Szczecin and Bia
ystok with symptoms suggestive of UTI. The study was carried out between July 1998 and May 1999. Only patients who had pyuria and significant bacteriuria2 obtained from a clean-catch midstream urine sample were included in the microbiological analysis. Only one specimen per patient was accepted. No mixed infections were encountered. Local laboratories performed identification to species level and antibiotic susceptibility testing by disc diffusion. Subsequently all strains were sent to the National Reference Centre for Antibiotics in the Sera and Vaccines Central Research Laboratory (co-ordinating centre) along with completed questionnaires containing demographic, clinical and microbiological data. They were re-identified to the species level by ID32E, ID32GN, ID32STAPH or rapid ID32STREP (bioMérieux, Charbonnieres-les-Bains, France).
Antimicrobial agents
The antibiotics tested were ampicillin, gentamicin (Polfa, Tarchomin, Poland), co-amoxiclav (SmithKline Beecham, Worthing, West Sussex, UK), piperacillin (Lederle, Piperacillin Inc., Carolina, Puerto Rico), tazobactam (Lederle Laboratories, Pearl River, NY, USA), ceftazidime (Glaxo Wellcome, Stevenage, UK), ceftriaxone, trimethoprim/ sulphamethoxazole (Roche, Basel, Switzerland), trimethoprim (Sigma Chemical Co., St Louis, MO, USA), cephalexin (Polfa), meropenem (Zeneca, Macclesfield, UK), amikacin, cefepime, aztreonam (Bristol-Myers Squibb, New Brunswick, NJ, USA), doxycycline (Pfizer, Groton, CT, USA), netilmicin (Abbott Laboratories, Chicago, IL, USA), norfloxacin (Krka d.d., Nove Mesto, Slovenia), ciprofloxacin (Bayer, Wuppertal, Germany), nitrofurantoin (Unitex/Fis Fabrica Italiana Sintetici SpA, Milano, Italy), fosfomycin trometamol (Zambon Group S.p.A., Lonigo, Italy). For community isolates recovered from uncomplicated infections, 18 antimicrobial agents were tested. For complicated community and all hospital cases, cefepime was also included. For hospital isolates fosfomycin trometamol and cephalexin were excluded since they are used by GPs only.
Antibiotic susceptibility testing
The MICs of antibiotics were determined by the agar dilution method, as described in the National Committee for Clinical Laboratory Standards (NCCLS) guidelines, on MuellerHinton agar (bioMérieux).4 An inoculum of 104 cfu/spot was applied to antibiotic-containing plates with a multipoint inoculator (West Sussex Instruments Ltd, Denley, UK). Amoxycillin was combined with clavulanic acid in a 2:1 ratio and the concentration of tazobactam in combinations with piperacillin was 4 mg/L. The conventional double-disc test with co-amoxiclav, ceftriaxone and ceftazidime was used to detect extended-spectrum ß-lactamase (ESBL) production in Enterobacteriaceae strains.5 MICs of aztreonam were determined only for ESBLproducing strains. High-level resistance to gentamicin and streptomycin (Polfa) of all Enterococcus strains was determined on brainheart infusion agar (Becton Dickinson Microbiology Systems, Cockeysville, MD, USA) supplemented with streptomycin (2000 mg/L) and gentamicin (500 mg/L). Methicillin resistance in staphylococci was detected using an oxacillin 1 µg disc (Becton Dickinson Microbiology Systems).4 For the quality control of susceptibility tests Escherichia coli ATCC 25922, E. coli ATCC 35218, Staphylococcus aureus ATCC 29213, Enterococcus faecalis ATCC 29212, E. faecalis ATCC 51299 and Pseudomonas aeruginosa ATCC 27853 strains were used.
Statistical method
P value was measured by the 2 test with Yates' correction.
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Results |
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Discussion |
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Our studies indicate that E. coli is still the most common cause of community-acquired UTI in Poland. This corresponds with the data obtained by other investigators.1,79 Some have shown, however, that the percentage of E. coli is slowly declining, being replaced by other members of the Enterobacteriaceae and enterococci.10 Our patients with complicated community UTI had fewer E. coli and more Proteus spp. The low percentage of E. coli amongst hospital isolates in our study corresponded to that obtained by other investigators.1114 In general, as in other studies, more of our hospital isolates were resistant to antibiotics than were the pathogens causing UTI in the community.10,15
Most E. coli from community infections investigated in this study were susceptible to oral drugs commonly used in general practice such as trimethoprim/sulphamethoxazole, norfloxacin, ciprofloxacin, nitrofurantoin, cephalexin and fosfomycin trometamol. The resistance pattern of hospital E. coli was similar to that of community isolates except for those found to produce ESBL. These data are similar to those obtained in other countries indicating that E. coli is still susceptible to many antimicrobial agents.12,13,16 Other species of the Enterobacteriaceae were more resistant when isolated from the hospital setting.13,17 Multi-resistance was usually related to production of ESBL, in both community and hospital isolates. ESBL producers, however, were recovered only from complicated community UTIs. The percentage of ESBL production by Polish isolates of Enterobacteriaceae was 6.9% and was high as compared with other recently published data.16,18,19 It reflects the overall epidemiological situation in Poland with respect to ESBL production20 and several hospital outbreaks have been described.21 Isolates of P. aeruginosa, in our study found exclusively in nosocomial infections, presented a worrying pattern of resistance. Only meropenem had good activity. A high percentage of ciprofloxacin-resistant strains (53.3%) was found as compared with recent publications on nosocomial isolates recovered from various clinical specimens.11,16,2123 Surprisingly, the new fourth-generation cephalosporin, cefepime, which has just been introduced into the Polish market, exhibited poorer activity toward P. aeruginosa than ceftazidime and piperacillin. The data are different from those reported by Blondeau et al.24 As can be seen from our data, cefepime was inactive (in vitro) against 44.7% of ESBL-producing Enterobacteriaceae. Similar results have been obtained by other workers.25,26
Data presented in this study indicate that antibiotics commonly used in UTIs are still effective, particularly in community infections, but species distribution and their susceptibility to antibiotics are changing in general all around the world. It requires regular monitoring in order to make reliable information available for optimal empirical therapy for patients with UTIs.
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Acknowledgments |
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Notes |
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References |
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Received 10 October 2000; returned 29 December 2000; revised 19 February 2001; accepted 13 March 2001