Correspondence
Urinary Tract Infections and a Multidrug-Resistant Escherichia coli Clonal Group
N Engl J Med 2002; 346:535-536February 14, 2002
- Article
To the Editor:
The report by Manges et al. (Oct. 4 issue)1 regarding the widespread distribution of multidrug-resistant Escherichia coli is both important and timely. We have found even higher rates of resistance to trimethoprim–sulfamethoxazole (TMP-SMX) among E. coli and other organisms at Elmhurst Hospital in Queens, New York. This hospital serves an incredibly diverse immigrant population that includes large numbers of people from Asia and Latin America. As part of a quality-improvement project, we reviewed more than 900 positive urine cultures that had been obtained since October 1998; approximately 40 percent were resistant to TMP-SMX. The majority of our urine cultures grew E. coli with patterns of resistance that were similar to those reported by Manges et al.
Our data also show that about 15 percent of the cultures with minimal resistance to ciprofloxacin were resistant to cephalexin. Ciprofloxacin would seem to be a good choice, but since the World Trade Center tragedy and the anthrax scare, there has been a shortage of ciprofloxacin. Even if the supply of ciprofloxacin were not in question, the cost of treatment with this drug is often prohibitive for indigent, uninsured patients.
Are the authors aware of high levels of resistance in other urban or immigrant populations? What alternatives do they suggest for effective empirical treatment of urinary tract infections at a reasonable cost?
1 ReferencesDarrell C. Sandel, M.D.
Cheng-Teng Wang, M.D.
Stuart Kessler, M.D.
Mt. Sinai School of Medicine, New York, NY 10029
dsandel@erols.com 1
Manges AR ,Johnson JR ,Foxman B ,O'Bryan TT ,Fullerton KE ,Riley LW . Widespread distribution of urinary tract infections caused by a multidrug-resistant Escherichia coli clonal group. N Engl J Med 2001;345:1007-1013
Full Text | Web of Science | Medline
To the Editor:
Manges et al. reported finding a clonal strain of E. coli that was responsible for urinary tract infections in women in three states between 1996 and 2000. Is this strain responsible for cases of outpatient urinary tract infections in other geographic areas?1
We examined 213 isolates of E. coli from urine cultures obtained in 1998 from patients — 85 percent of whom were outpatients and 84 percent of whom were women — to investigate the incidence of antibiotic-resistant strains at Cook County Hospital in Chicago.2 Our findings were similar to those of Manges et al.; 24 percent of isolates were resistant to TMP-SMX. However, using the same method of pulsed-field gel electrophoresis3 used by Manges et al., we found that our TMP-SMX–resistant isolates were distinct, unrelated strains. Hence, epidemic spread of a single E. coli clone could not explain the high prevalence of resistance to TMP-SMX in urinary isolates in Chicago, although the spread of a common resistance element is conceivable.
Our chart review suggested an alternative hypothesis: 68 percent of the patients had Hispanic surnames. In contrast, only 20 to 30 percent of our outpatient population is Hispanic. Recent travel to or acquisition of TMP-SMX from Mexico or other Latin American countries, where the use of antibiotics is unrestricted, may have contributed to the incidence of TMP-SMX–resistant isolates at our facility. International travel and Hispanic ethnic background were predictors of infection with TMP-SMX–resistant strains in another study of urinary tract infections with E. coli.4 Although Manges et al. do not report their patients' race or ethnic group, their infections and any antecedent antibiotic treatments may have been more likely than those in our patients to have been acquired locally.
4 ReferencesElaine O. Petrof, M.D.
University of Chicago, Chicago, IL 60637David N. Schwartz, M.D.
Cook County Hospital, Chicago, IL 60612
schwartz@hektoen.org John P. Quinn, M.D.
University of Illinois, Chicago, Chicago, IL 606121
Stamm WE . An epidemic of urinary tract infections? N Engl J Med 2001;345:1055-1057
Full Text | Web of Science | Medline2
Petrof EO, Goldfarb M, Kelkar S, et al. Incidence and clinical correlates of resistance to trimethoprim sulfamethoxazole (TMP-SMX) among urinary isolates of E. coli. In: Final program and abstracts of the 37th Annual Meeting of the Infectious Diseases Society of America, November 18–21, 1999. Alexandria, Va.: Infectious Diseases Society of America, 2000:59. abstract.
3
Tenover FC ,Arbeit RD ,Goering RV , et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol 1995;33:2233-2239
Web of Science | Medline4
Burman W ,Breese P ,Batal H ,MacKenzie T ,Mehler PS . Increasing prevalence of trimethoprim-sulfamethoxazole resistant Escherichia coli. J Gen Intern Med 2000;15:Suppl 1:56-56 abstract.
CrossRef | Web of Science | Medline
To the Editor:
Manges et al. describe an epidemic of antibiotic-resistant E. coli urinary tract infections in women, stating that contaminated food may have been the culprit. Much of the antibiotics used in this country are given to food animals.
To date, the concern about infections with antibiotic-resistant food-borne pathogens has focused on salmonella1,2 and campylobacter.3 However, food-borne strains of resistant E. coli also infect people, either through direct colonization with resistant strains from animals or through the transfer of drug-resistance plasmids from salmonella or E. coli in animals to E. coli in people.4 The next logical step in understanding the findings of Manges et al. would be to screen E. coli isolates from food animals to determine whether a related strain is present. The finding of a similar strain would be compelling evidence that antibiotic use in animals poses a widespread threat to the nearly 8 million women who have urinary tract infections each year. It would also provide additional scientific data to support actions by the Food and Drug Administration or Congress to phase out the use of medically important antibiotics in livestock and poultry.
4 ReferencesTamar Barlam, M.D.
Center for Science in the Public Interest, Washington, DC 20009
tbarlam@cspinet.org Robert Moellering, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 022151
Fey PD ,Safranek TJ ,Rupp ME , et al. Ceftriaxone-resistant salmonella infection acquired by a child from cattle. N Engl J Med 2000;342:1242-1249
Full Text | Web of Science | Medline2
Molbak K ,Baggesen DL ,Aarestrup FM , et al. An outbreak of multidrug-resistant, quinolone-resistant Salmonella enterica serotype typhimurium DT104. N Engl J Med 1999;341:1420-1425
Full Text | Web of Science | Medline3
Smith KE ,Besser JM ,Hedberg CW , et al. Quinolone-resistant Campylobacter jejuni infections in Minnesota, 1992-1998. N Engl J Med 1999;340:1525-1532
Full Text | Web of Science | Medline4
Winokur PL ,Vonstein DL ,Hoffman LJ ,Uhlenhopp EK ,Doern GV . Evidence for transfer of CMY-2 AmpC beta-lactamase plasmids between Escherichia coli and Salmonella isolates from food animals and humans. Antimicrob Agents Chemother 2001;45:2716-2722
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: The prevalence of antibiotic resistance among E. coli causing urinary tract infections varies geographically for reasons that are poorly understood.1 Ethnic background has received little attention to date as a predictor of antibiotic resistance in uropathogenic E. coli, so the findings described by Dr. Sandel and colleagues and by Dr. Petrof and colleagues suggest a need for further research. It is probable that some resistant strains are imported into the United States, as indicated by the emergence of TMP-SMX–resistant fecal E. coli among tourists who have taken this agent prophylactically while visiting Mexico.2
Multidrug-resistant salmonella infections in the United States were found to be associated with Hispanic surnames.3 In the case of enteric pathogens, such an association could have several possible explanations: resistant organisms may be imported from areas with a high prevalence of resistance, differences in antibiotic use among different populations in the United States may predispose users to acquire multidrug-resistant strains,3 and cultural or ethnic differences in diet may contribute to an increased risk of exposures to some types of foods contaminated with resistant organisms.4 In any case, we strongly agree with Drs. Barlam and Moellering that the use of antibiotics as growth promoters in animal feed is a major contributor to the emergence of multidrug-resistant food-borne pathogens and that there is no reason to believe that this situation applies only to traditional enteric organisms, such as salmonella and campylobacter.
Finally, to address the important questions posed by Sandel and colleagues, oral alternatives to TMP-SMX for the treatment of urinary tract infections with TMP-SMX–resistant E. coli include ciprofloxacin and other fluoroquinolones, nitrofurantoin, fosfomycin tromethamine, amoxicillin–clavulanate, and extended-spectrum cephalosporins.1,5 Of these, the fluoroquinolones would probably be the most effective, whereas nitrofurantoin would be the least expensive.5 However, nitrofurantoin must be given for more than three days, even in cases of cystitis,5 and is not useful for the treatment of pyelonephritis.
5 ReferencesJames R. Johnson, M.D.
University of Minnesota, Minneapolis, MN 55417Amee R. Manges, M.P.H.
Lee W. Riley, M.D.
University of California at Berkeley, Berkeley, CA 94720
lwriley@uclinic4.berkeley. edu 1
Gupta K ,Hooton TM ,Stamm WE . Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections. Ann Intern Med 2001;135:41-50
Web of Science | Medline2
Murray BE ,Rensimer ER ,DuPont HL . Emergence of high-level trimethoprim resistance in fecal Escherichia coli during oral administration of trimethoprim or trimethoprim-sulfamethoxazole. N Engl J Med 1982;306:130-135
Full Text | Web of Science | Medline3
Riley LW ,Cohen ML ,Seals JE , et al. Importance of host factors in human salmonellosis caused by multiresistant strains of Salmonella. J Infect Dis 1984;149:878-883
CrossRef | Web of Science | Medline4
Cody SH ,Abbott SL ,Marfin AA , et al. Two outbreaks of multidrug-resistant Salmonella serotype typhimurium DT104 infections linked to raw-milk cheese in Northern California. JAMA 1999;281:1805-1810
CrossRef | Web of Science | Medline5
Warren JW ,Abrutyn E ,Hebel JR ,Johnson JR ,Schaeffer AJ ,Stamm WE . Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999;29:745-758
CrossRef | Web of Science | Medline
- Citing Articles (9)
Citing Articles
1
S. Ghanem. (2011) Cloning of the nptII gene of Escherichia coli and construction of a recombinant strain harboring functional recA and nptII antibiotic resistance. Genetics and Molecular Research 10:3, 1445-1454
CrossRef2
Rubens C.S. Dias, Denise V. Marangoni, Sherry P. Smith, Elizabeth M. Alves, Flavia L.P.C. Pellegrino, Lee W. Riley, Beatriz M. Moreira. (2009) Clonal Composition of Escherichia coli Causing Community-Acquired Urinary Tract Infections in the State of Rio de Janeiro, Brazil. Microbial Drug Resistance 15:4, 303-308
CrossRef3
L. Blaettler, D. Mertz, R. Frei, L. Elzi, A. F. Widmer, M. Battegay, U. Flückiger. (2009) Secular Trend and Risk Factors for Antimicrobial Resistance in Escherichia coli Isolates in Switzerland 1997–2007. Infection 37:6, 534-539
CrossRef4
Mark R. Sannes, Edward A. Belongia, Burney Kieke, Kirk Smith, Amy Kieke, Mary Vandermause, Jeff Bender, Connie Clabots, Patricia Winokur, James R. Johnson. (2008) Predictors of Antimicrobial‐Resistant Escherichia coli in the Feces of Vegetarians and Newly Hospitalized Adults in Minnesota and Wisconsin. The Journal of Infectious Diseases 197:3, 430-434
CrossRef5
James A. Karlowsky, Sam Kasloff, Kim A. Nichol, Daryl J. Hoban, George G. Zhanel. (2007) Genetic relatedness of multidrug-resistant Escherichia coli cultured from geographically diverse outpatient, midstream urine specimens. Diagnostic Microbiology and Infectious Disease 58:3, 283-287
CrossRef6
Dearbhaile Morris, Martina Ni Chulain, Martin Cormican. (2007) Dissemination of clonal groups of uropathogenic Escherichia coli is not a significant contributor to trimethoprim and sulfamethoxazole resistance in Galway, Ireland. International Journal of Antimicrobial Agents 30:1, 97-98
CrossRef7
Anne Marie France, Kiersten M. Kugeler, Alison Freeman, Christy Ann Zalewski, Matthew Blahna, Lixin Zhang, Carl F. Marrs, Betsy Foxman. (2005) Clonal Groups and the Spread of Resistance to Trimethoprim‐Sulfamethoxazole in Uropathogenic Escherichia coli. Clinical Infectious Diseases 40:8, 1101-1107
CrossRef8
Kalpana Gupta. (2003) Emerging antibiotic resistance in urinary tract pathogens. Infectious Disease Clinics of North America 17:2, 243-259
CrossRef9
Gregor Reid, Duane Charbonneau, Julie Erb, Barbara Kochanowski, Dee Beuerman, Russ Poehner, Andrew W. Bruce. (2003) Oral use of Lactobacillus rhamnosus GR-1 and L. fermentum RC-14 significantly alters vaginal flora: randomized, placebo-controlled trial in 64 healthy women. FEMS Immunology & Medical Microbiology 35:2, 131-134
CrossRef
