The ARESC study: an international survey on the antimicrobial resistance of pathogens involved in uncomplicated urinary tract infections

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1 The ARESC study: n interntionl survey on the ntimicrobil resistnce of pthogens involved in uncomplicted urinry trct infections Gin Crlo Schito, Kurt G. Nber, Henry Botto, Jun Plou, Teresit Mzzei, Lur Gulco, Ann Mrchese To cite this version: Gin Crlo Schito, Kurt G. Nber, Henry Botto, Jun Plou, Teresit Mzzei, et l.. The ARESC study: n interntionl survey on the ntimicrobil resistnce of pthogens involved in uncomplicted urinry trct infections. Interntionl Journl of Antimicrobil Agents, Elsevier, 2009, 34 (5), pp.407. < /j.ijntimicg >. <hl > HAL Id: hl Submitted on 16 Jn 2011 HAL is multi-disciplinry open ccess rchive for the deposit nd dissemintion of scientific reserch documents, whether they re published or not. The documents my come from teching nd reserch institutions in Frnce or brod, or from public or privte reserch centers. L rchive ouverte pluridisciplinire HAL, est destinée u dépôt et à l diffusion de documents scientifiques de niveu recherche, publiés ou non, émnnt des étblissements d enseignement et de recherche frnçis ou étrngers, des lbortoires publics ou privés.

2 Title: The ARESC study: n interntionl survey on the ntimicrobil resistnce of pthogens involved in uncomplicted urinry trct infections Authors: Gin Crlo Schito, Kurt G. Nber, Henry Botto, Jun Plou, Teresit Mzzei, Lur Gulco, Ann Mrchese PII: S (09) DOI: doi: /j.ijntimicg Reference: ANTAGE 3040 To pper in: Interntionl Journl of Antimicrobil Agents Received dte: Revised dte: Accepted dte: Plese cite this rticle s: Schito GC, Nber KG, Botto H, Plou J, Mzzei T, Gulco L, Mrchese A, The ARESC study: n interntionl survey on the ntimicrobil resistnce of pthogens involved in uncomplicted urinry trct infections, Interntionl Journl of Antimicrobil Agents (2008), doi: /j.ijntimicg This is PDF file of n unedited mnuscript tht hs been ccepted for publiction. As service to our customers we re providing this erly version of the mnuscript. The mnuscript will undergo copyediting, typesetting, nd review of the resulting proof before it is published in its finl form. Plese note tht during the production process errors my be discovered which could ffect the content, nd ll legl disclimers tht pply to the journl pertin.

3 Edited mnuscript The ARESC study: n interntionl survey on the ntimicrobil resistnce of pthogens involved in uncomplicted urinry trct infections Gin Crlo Schito, *, Kurt G. Nber b, Henry Botto c, Jun Plou d, Teresit Mzzei e, Lur Gulco, Ann Mrchese Sezione di Microbiologi del DISCMIT, University of Geno, Geno, Itly b Technicl University of Munich, Munich, Germny c Deprtment of Urology, Hôpitl Foch, Suresnes, Frnce d Fundció Puigvert, Autonomous University of Brcelon, Brcelon, Spin e Deprtment of Preclinicl nd Clinicl Phrmcology, University of Florence, Florence, Itly ARTICLE INFO Article history: Received 26 Mrch 2009 Accepted 9 April 2009 Keywords: Escherichi coli Cystitis Fosfomycin Ciprofloxcin Amoxicillin/clvulnic cid Pge 1 of 30

4 * Corresponding uthor. Tel.: ; fx: E-mil ddress: (G.C. Schito). Pge 2 of 30

5 ABSTRACT The ARESC (Antimicrobil Resistnce Epidemiologicl Survey on Cystitis) study is n interntionl survey to investigte the prevlence nd susceptibility of pthogens cusing cystitis. Femle ptients (N = 4264) ged yers with symptoms of uncomplicted cystitis were consecutively enrolled in nine Europen countries s well s Brzil during Pthogens were identified nd their susceptibility to nine ntimicrobils ws determined. Escherichi coli ccounted for 76.7% of isoltes. Among E. coli, 10.3% of the isoltes were resistnt to t lst three different clsses of ntimicrobil gents. Resistnce ws most common to mpicillin (48.3%), trimethoprim/sulfmethoxzole (29.4%) nd nlidixic cid (18.6%). Fosfomycin, mecillinm nd nitrofurntoin were the most ctive drugs (98.1%, 95.8% nd 95.2% susceptible strins, respectively) followed by ciprofloxcin, moxicillin/clvulnic cid nd cefuroxime (91.7%, 82.5% nd 82.4%, respectively). Resistnce to ciprofloxcin ws >10% in Brzil, Spin, Itly nd Russi. Overll, Proteus mirbilis were more susceptible to -lctms nd less susceptible to non- -lctms thn E. coli, wheres Klebsiell pneumonie strins, which re intrinsiclly resistnt to mpicillin, were less susceptible to mecillinm (88.8%), fosfomycin (87.9%), cefuroxime (78.6%) nd nitrofurntoin (17.7%). Resistnce ws rre in Stphylococcus sprophyticus, with the exception of mpicillin (36.4%) nd trimethoprim/sulfmethoxzole (10.2%). In Itly, Spin, Brzil nd Russi, the countries most ffected by ntimicrobil resistnce, extended-spectrum -lctmse (ESBL) enzymes (minly CTX-M type) were detected in 48 strins (39 E. coli, 6 K. pneumonie nd 3 P. mirbilis). Despite wide intercountry vribility in bcteril susceptibility rtes to the other ntimicrobils tested, fosfomycin nd mecillinm hve preserved their in vitro ctivity in ll countries investigted ginst the most common uropthogens. Pge 3 of 30

6 1. Introduction Uncomplicted urinry trct infections (UTIs) re mong the most prevlent infectious diseses nd ffect minly women. Between one-qurter nd one-hlf of ll women experience UTI during their lifetime [1]. The overll etiology hs not chnged in recent yers nd Escherichi coli remins by fr the most common uropthogen, ccounting for >80% of ll positive cultures [2]. However, the mngement of these infections, generlly treted empiriclly, is becoming complicted due to the emergence of resistnce to severl first-line ntimicrobil gents in this primry pthogen [3]. Becuse there is close correltion between resistnce to ntibiotics nd the persistence of E. coli in UTIs s well s wide locl vritions in the susceptibility of uropthogens to these drugs, recommendtion of first-line tretment gents should be supported by updted epidemiologicl dt [4,5]. The ARESC (Antimicrobil Resistnce Epidemiologicl Survey on Cystitis) study ws conducted in nine countries in Europe s well s Brzil from September 2003 to June 2006 to determine the susceptibility of the mjor uropthogens circulting in the community of these geogrphic res. Prt of the ARESC dt focusing on E. coli, with emphsis on the clinicl implictions of the study for empiricl ntimicrobil therpy, hs recently been published [5]. In the present pper we report the complete set of microbiologicl results involving ll bcteril pthogens isolted from uncomplicted cystitis. Pge 4 of 30

7 2. Mterils nd methods 2.1. Collborting centres Seventy centres were enrolled over 3-yer period ( ) in nine Europen countries nd Brzil. Sixty-two centres (3 Austri, 6 Brzil, 10 Frnce, 7 Germny, 4 Hungry, 5 Itly, 6 Polnd, 10 Russi, 9 Spin nd 2 The Netherlnds) provided vluble strins. All prticipting lbortories dopted the sme protocol for clssifying urine smples s positive nd negtive in ccordnce with the Infectious Diseses Society of Americ (IDSA) guidelines [6]. Ech locl site forwrded the strins isolted to the centrl lbortory (DISCMIT, Microbiology Section, University of Geno, Itly) by courier, where the pthogens were reidentified nd stored t 70 C until susceptibility tests were performed Ptients This ws prospective, multicentre, multintionl, observtionl epidemiologicl survey. Written consent ws obtined from ll ptients. Helthy women between 18 yers nd 65 yers of ge with symptoms of uncomplicted lower UTI were eligible for inclusion. Detiled inclusion/exclusion criteri hve been reported previously [5]. Briefly, besides women with uncomplicted cystitis, ptients with recurrent UTI ( 3 episodes in the lst yer) s well s pregnnt nd dibetic women were included. Ptients with upper UTI, concomitnt or prophylctic ntimicrobil tretment Pge 5 of 30

8 within 15 dys before inclusion in the study, history of renl impirment, nd ntomicl nd functionl urinry trct bnormlities were excluded Bcteri All strins isolted (N = 3018) were identified by locl lbortories employing their routine methods nd were re-identified by the centrl lbortory using the API system (biomérieux, Miln, Itly) Susceptibility testing All bcteri were ssyed ginst the following ntimicrobil gents: mpicillin; moxicillin/clvulnic cid; cefuroxime; ciprofloxcin; trimethoprim/sulfmethoxzole; fosfomycin; mecillinm; nlidixic cid; nd nitrofurntoin. The compounds were obtined from their respective mnufcturers or from commercil sources. The miniml inhibitory concentrtions (MICs) of the ntimicrobils were ssessed by the broth microdilution method in ction-djusted Mueller Hinton broth s suggested by the Clinicl nd Lbortory Stndrds Institute (CLSI) [7]. The MICs of mecillinm nd fosfomycin were determined by the gr dilution method in Mueller Hinton gr, supplemented with glucose-6-phosphte t concentrtion of 25 mg/l when fosfomycin ws studied. Escherichi coli ATCC ws included in ech run s control. Strins were defined s susceptible, intermedite-resistnt or resistnt ccording to CLSI recommendtions [7]. To determine susceptibility/resistnce rtes for the whole spectrum of uropthogens isolted, E. coli brekpoints were used for ll orgnisms when specific figures were not vilble. Pge 6 of 30

9 Multiresistnce ws defined s simultneous lck of susceptibility to t lest three different clsses of ntimicrobil gents. Cross-resistnce ws defined s resistnce to two or more ntimicrobil gents within the sme clss of ntibiotics nd ws considered to be due to common genetic mechnism. Associted resistnce ws defined s resistnce to two or more ntimicrobil gents of different drug clsses nd ws considered to be due to unrelted mechnisms. The double-disk synergy test to detect extended-spectrum -lctmse (ESBL)-producing E. coli, Klebsiell pneumonie nd Proteus mirbilis strins ws performed s stndrd disk diffusion ssy on Mueller Hinton gr (Oxoid, Miln, Itly). Disks contining ztreonm, ceftzidime, cefepime, ceftrixone nd cefotxime (30 g ech) were plced t 30 mm distnce (centre-to-centre) round disk contining moxicillin (20 g) plus clvulnic cid (10 g). Enhncement of the inhibition zone towrds the moxicillin + clvulnic cid disk, indicting synergy between clvulnic cid nd ny one of the test ntibiotics, ws tken s presumptive evidence of ESBL production. The synergistic ctivity of clvulnic cid with both ceftzidime nd cefotxime ws confirmed by mens of Etest strips (AB BIODISK, Soln, Sweden) contining ceftzidime/ceftzidime plus clvulnic cid nd cefotxime/cefotxime plus clvulnic cid. Production of ESBL ws ssumed when clvulnic cid cused t lest three twofold decreses in the MICs of the bovementioned ntimicrobil gents. Pge 7 of 30

10 2.5. Moleculr chrcteristion of extended-spectrum -lctmse determinnts The 51 phenotypic puttive ESBL-producers nd their trnsconjugnts were screened for the presence of bl TEM, bl SHV nd bl CTX-M genes by polymerse chin rection (PCR) using primers nd conditions described previously [8] Sttisticl nlysis Sttisticl nlysis ws performed using Fisher s exct test nd 2 test. The threshold for sttisticl significnce ws P < Results Between September 2003 nd June 2006, 4264 eligible ptients ged yers with symptoms of cute uncomplicted UTI were enrolled in the survey. Uropthogens with colony counts of >10 4 /ml were cultured from 3181 ptients (74.6%). In 3060 ptients (96.2%) the infection ws monomicrobil nd mixed infection ws found in 121 ptients (3.8%). Of the 3181 ptients with bcteriuri, custive gents (n = 3018) from 2927 ptients were sent to the centrl lbortory for further evlution. Among the orgnisms cultured, E. coli ws the predominnt pthogen (2315/3018; 76.7%), rnging from 68.1% in Austri to 83.8% in Frnce (Tble 1), followed by Stphylococcus sprophyticus (108/3018; 3.6%), K. pneumonie (107/3018; 3.5%) nd P. mirbilis (104/3018; 3.4%). Other Enterobctericee (Enterobcter spp., Citrobcter spp., Serrti spp., Klebsiell spp., Pntoe spp., Slmonell spp., Morgnell morgnii nd Pge 8 of 30

11 Hfni lvei) were responsible for only 2.9% of infections. The number of non- Enterobctericee isolted ws very limited, nd in prticulr in this group only six strins of Pseudomons eruginos were found (0.2%). All other species represented <7% of the isoltes (Tble 1). Infections cused by K. pneumonie ppered to be most common in Brzil (6.1%), Austri nd Itly (both 5.5%), whilst S. sprophyticus ws more frequently responsible of UTIs in The Netherlnds nd Brzil (5.6% nd 4.9%, respectively). In contrst, infections due to K. pneumonie were seldom encountered in Frnce (1.0%), whilst in Hungry nd Itly no isolte of S. sprophyticus ws found. Proteus mirbilis ws significntly more common in the elderly (>50 yers) (P < 0.001), whilst S. sprophyticus ws mostly recovered from younger ptients (<30 yers) (P < 0.001) (dt not shown). Tble 2 shows the susceptibility ptterns of ll E. coli strins nlysed. Globlly, fosfomycin nd mecillinm emerged s the most ctive drugs tested (98.1% nd 95.8% susceptible strins, respectively) followed by nitrofurntoin (95.2%) nd ciprofloxcin (91.7%). Ampicillin nd trimethoprim/sulfmethoxzole were ctive ginst reduced number of isoltes (45.1% nd 70.6% susceptible strins, respectively). Almost 20% of ll E. coli hd reduced susceptibility to moxicillin/clvulnic cid, cefuroxime nd nlidixic cid. Not ll sites hd the sme susceptibility profile, with some countries being less ffected by resistnce problems thn others (Tble 3). For instnce, in Frnce only the ctivity of mpicillin ws drmticlly reduced (60.9% susceptible strins). Pge 9 of 30

12 In Germny, Hungry, Polnd nd The Netherlnds, >90% of the strins were susceptible to fosfomycin, mecillinm, nitrofurntoin nd ciprofloxcin. The susceptibility rtes vried widely between countries for mpicillin ( %), moxicillin/clvulnic cid ( %), cefuroxime ( %) nd trimethoprim/sulfmethoxzole ( %). For Itly, Spin nd Russi, only fosfomycin, mecillinm nd nitrofurntoin were chrcterised by percentges of susceptibility >90%. Resistnce rtes to ciprofloxcin exceeded 10%. In Itly nd Spin, mpicillin, trimethoprim/sulfmethoxzole, cefuroxime nd moxicillin/clvulnic cid were ll chrcterised by susceptibility rtes 80.9%. The MIC distributions of ll ntibiotics tested for ech country were lso nlysed. The highest MIC of fosfomycin ws 512 mg/l (one strin isolted in Spin), whilst the highest MIC vlue of nitrofurntoin ws 256 mg/l nd ws observed for strins isolted in Brzil, Germny, Russi nd Spin. Cefuroxime MIC vlues >128 mg/l were recorded in Brzil, Frnce, Itly, Russi nd Spin. Amoxicillin/clvulnic cid MICs reched 128 mg/l in Brzil, Frnce, Hungry, Itly, Polnd nd Spin. For the other drugs, the rnges of MIC vlues did not vry gretly mong different countries (dt not shown). Resistnce to ny gent ws ssocited with incresed resistnce to the other gents tested. The only exception ws the bsence of n ssocition between fosfomycin nd ciprofloxcin resistnce. The difference in the rte of ciprofloxcin resistnce between fosfomycin-resistnt nd -susceptible E. coli ws not sttisticlly significnt (P = 0.5). Of 2315 E. coli isoltes from 10 countries, less thn one-hlf were fully susceptible to the gents investigted (850/2315; 36.7%). Overll, 458 isoltes (19.8%) were resistnt only to one gent, which ws most commonly either mpicillin (13.6%) or Pge 10 of 30

13 trimethoprim/sulfmethoxzole (2.8%), nd 228 (9.8%) were resistnt to two ntimicrobils, generlly represented by mpicillin nd trimethoprim/sulfmethoxzole (7.3%). Multiresistnce (resistnce to t lest three different clsses of ntimicrobil gents) ws observed in 239 (10.3%) of 2315 isoltes (dt not shown). The resistnce pttern mpicillin/trimethoprim/sulfmethoxzole ws the most represented (333/2315; 14.4%), followed by the profile mpicillin/nlidixic cid/trimethoprim/sulfmethoxzole (6.8% of the totl isoltes) (dt not shown). Resistnce to cephlosporins, s mesured by cefuroxime testing, ws seen in 55 of the E. coli isoltes. Thirty-nine E. coli strins were ESBL-positive by the double-disk synergy test nd quntittive Etest. Moleculr chrcteristion by PCR showed tht of the 39 puttive ESBL-producers (nd their trnsconjugnts), 28 crried bl CTX-M gene, 7 bl SHV gene nd 4 bl TEM gene. The remining 16 cefuroxime-resistnt strins were found to be lso cefoxitin-resistnt (dt not shown). Although not sttisticlly significnt, with the exception of ciprofloxcin (P < 0.001), the percentges of ntimicrobil resistnce were generlly higher mong isoltes recovered from ptients suffering from recurrent UTIs (Tble 4). Despite the lrge number of ptients enrolled in this study, the number of isoltes of species other thn E. coli did not permit country-wise nlysis of the dt. Tble 5 shows the overll ntimicrobil resistnce in K. pneumonie, P. mirbilis nd S. sprophyticus. Aginst K. pneumonie, which is intrinsiclly resistnt to mpicillin, moxicillin/clvulnic cid nd ciprofloxcin showed susceptibility percentges >90%. For fosfomycin nd Pge 11 of 30

14 mecillinm c. 88% of the strins were susceptible, whilst nitrofurntoin ws chrcterised by the lowest percentge of susceptible strins (18%). Approximtely 80% of the K. pneumonie isoltes were susceptible to nlidixic cid nd trimethoprim/sulfmethoxzole. As expected, nitrofurntoin ws not ctive ginst P. mirbilis. Fosfomycin nd mecillinm inhibited >85% of these isoltes. Remrkble is the high trimethoprim/sulfmethoxzole, mpicillin nd nlidixic cid resistnce (>20%) in P. mirbilis. By the sme token, the first two drugs hd the lowest rtes of susceptibility in S. sprophyticus. Resistnce to cefuroxime ws seen in 6.5% nd 4.8% of K. pneumonie nd P. mirbilis isoltes, most of which produced ESBLs. Moleculr chrcteristion by PCR of these lst strins nd of their trnsconjugnts showed tht ll the P. mirbilis isoltes crried bl CTX-M gene whilst 7 K. pneumonie crried bl SHV (5), bl CTX-M (1) nd one bl TEM (1) genes. 4. Discussion Uncomplicted cystitis in femles is mong the most frequent infections in the community. The ARESC study hs ssessed the epidemiology nd susceptibility ptterns of common uropthogens to stndrd ntimicrobils used in the tretment of uncomplicted lower UTI (cystitis). The clinicl implictions for empiricl ntimicrobil therpy in nine Europen countries nd Brzil hve been published elsewhere [5]. Adoption of the sme strict criteri to enrol ptients nd to clssify microbiologicl infection in ll 62 centres s well s the uniformity of the method employed for identifiction to species level nd susceptibility testing in single lbortory gurntee homogeneity nd vlidity to the results. Pge 12 of 30

15 As fr s the etiology of UTIs is concerned, s expected E. coli ws the most prevlent pthogen (on verge 76.7%), rnging from 68.1% in Austri to 83.8% in Frnce. These dt gree with the rnge (70 95%) reported in the literture [4,9,10]. Among countries enrolling lrge number of ptients, non-e. coli infections ppered to be most common in Itly nd Russi (both 27.4%). For Russi, the high incidence of non- E. coli uropthogens could be scribed to the high percentge of ptients (33.7%) suffering from recurrent UTIs recruited in the study. Stphylococcus sprophyticus ws isolted more frequently mong young women (<30 yers) thn in older ones nd ws not found in Itly nd Hungry, confirming tht the occurrence of this pthogen is strongly influenced by the ge of the ptient, geogrphic loction nd sesonlity [11]. As expected, P. mirbilis, K. pneumonie nd other Enterobctericee species were recovered more frequently in ptients with recurrent UTI. Clssifiction of susceptibility/resistnce depends on the brekpoints dopted nd these my vry in different systems. Using the MIC vlues reported here, the results cn be djusted to ny interpretive locl system. In this study, CLSI methodologies nd brekpoints were employed for compring results from different countries. In ech single ntion, mpicillin nd trimethoprim/sulfmethoxzole were the lest ctive ntimicrobil gents ginst E. coli, whilst fosfomycin ws the most ctive drug in terms of susceptible strins, followed by mecillinm nd nitrofurntoin. This scenrio hs lredy been observed worldwide during recent yers. It is lrming tht ciprofloxcin-resistnt Pge 13 of 30

16 strins hve been isolted from ll countries prticipting into the study, reching >10% in Itly, Spin, Russi nd Brzil. In comprison with the ECO.SENS survey tht explored the period Jnury 1999 December 2000 in 17 Europen countries [10], the ARESC study shows for some countries incresed figures of resistnce to mpicillin, trimethoprim/sulfmethoxzole, nlidixic cid nd ciprofloxcin in E. coli nd the emergence of ciprofloxcin resistnce in Austri. Although two different methods nd interpretive criteri were used, this trend of incresing resistnce seems rel. For Itly, country tht did not prticipte into the ECO.SENS survey, previous locl dt re in greement with the results of the present study [12]. A significnt increse in ntibiotic resistnce in ll the countries prticipting in the ARESC study hs lso been recorded during the sme period ( ) by the Europen Antimicrobil Resistnce Surveillnce System (EARSS) network ( mong invsive isoltes of E. coli, with the exception of Russi nd Brzil (these countries were not included in the EARSS network). As expected, the rtes of ntibiotic resistnce observed mong nosocomil invsive isoltes were higher thn those observed in our study, but the rnking order of the countries is similr. Moreover, with Russi nd Brzil, comprison of the ARESC dt with those of two previous multicentre studies focused on uncomplicted community-cquired UTIs (UTIAP nd prt of the SENTRY Antimicrobil Surveillnce Progrm 2003, respectively) showed substntil increse in resistnce to -lctms, trimethoprim/sulfmethoxzole, nitrofurntoin nd quinolones [13,14]. Pge 14 of 30

17 A further thret is represented by the fct tht E. coli strins circulting in the community re often multiresistnt nd cn crry ESBL genes, feture tht hs been confirmed by our dt (of the tested microorgnisms, >10% were in fct multiresistnt nd 1.7% produced ESBLs). ESBL production ws lso observed in K. pneumonie (5.6%) nd P. mirbilis (2.9%) [15 17]. This negtive trend hs been directly linked to the different use of the ntimicrobil gents in diverse geogrphic res [18]. Antibiotics employed specificlly in UTIs (fosfomycin, mecillinm nd nitrofurntoin) exhibited low levels of resistnce in ll prticipting countries both in recurrent nd non-recurrent UTIs, whilst drugs brodly prescribed for severl types of infections seemingly select resistnt mutnts more esily. Associted resistnce involving -lctms, trimethoprim/sulfmethoxzole nd fluoroquinolones is common in our collection of strins. Similr ssocited resistnce ptterns were observed by Khlmeter nd Mendy [19] in the isoltes of the ECO.SENS study. This phenotype is selected for not only by the use of quinolones but lso by the use of mpicillin, moxicillin, trimethoprim/sulfmethoxzole nd sulfmethoxzole. However, it is ressuring tht fosfomycin is ctive ginst urinry E. coli irrespective of other resistnce trits [15,20,21], notion confirmed by our dt. The emergence nd dissemintion of ntibiotic-resistnt E. coli might be the result not only of the selection of different mutnt strins generted by locl ntimicrobil prescription hbits but lterntively or concomitntly by clonl spred. Some uthors hve in fct emphsised tht the introduction of drug-resistnt E. coli clonl strins into community plys greter role in chnging the prevlence of drug-resistnt UTIs thn the usge of drugs or the prescribing hbits in tht community [17,22]. Pge 15 of 30

18 It hs lso been shown tht certin clonl groups of trimethoprim/sulfmethoxzoleresistnt nd/or mpicillin-resistnt E. coli (i.e. clonl group A nd E. coli O15:K52:H1) s well s CTX-M ESBL-producers hve spred intercontinentlly [23 25]. We did not evlute clonl reltionship mong trimethoprim/sulfmethoxzole- nd/or mpicillin-resistnt strins but, in nother contribution from this lbortory, we hve demonstrted tht c. 50% of the ARESC ciprofloxcin-resistnt E. coli strins belong to two interntionl virulent clones (E. coli O15:K52:H1 nd O25:H4-ST131) [26]. Both the rtes nd qulity of ntimicrobil gent consumption nd clonl spred hve therefore contributed to the present scenrio, t lest in some Europen countries such Itly nd Spin. Conversely, fosfomycin-resistnt E. coli displyed heterogeneous biotypes nd ntibiotypes, suggesting no clonl expnsion for strins crrying this chrcter. In conclusion, the resistnce ptterns of E. coli strins cusing uncomplicted UTIs my vry considerbly mong different countries. As consequence, no generl recommendtions re pplicble in the bsence of lbortory guidnce in single ptients. Prticulrly for fluoroquinolones nd -lctms, the vilbility of locl epidemiologicl dt is mndtory for inititing correct empiricl therpy. Fluoroquinolone resistnce is n incresing problem in some countries nd my worsen becuse of clonl spred nd selection of resistnt mutnts tht cn occur redily given the high rte of circulting nlidixic cid-resistnt strins. These considertions strengthen the recommendtion to employ s first-line gents, when dignosis of uncomplicted UTI in femle ptient is firmly bsed, those ntibiotics tht, becuse of their use limited to the therpy of this Pge 16 of 30

19 condition, suffer very limited rtes of resistnce nd hve therefore superior chnce in microbiologicl terms to erdicte the infection. Acknowledgments: This study ws performed under the uspices of the Europen Society for Infection in Urology (ESIU) (Chirmn: Truls E. Bjerklund-Johnsen) ffilited to the Europen Assocition of Urology (EAU). The uthors re grteful to Antonio Colntoni for sttisticl evlution s well s the investigtors of the ARESC Study Group who contributed their findings to the study: Austri: Andres Sommerhuber (Linz), Dniel Ullisch (Wien), Andres Szly (Wien); Brzil: Sergio Cimermn (So Pulo), Juvencio Jose Dulibe Furtdo (So Pulo), Reginldo Guedes Coelho Lopes (So Pulo), Mozr De Cstro Neto (Belo Horizonte), Jose Mri Crdoso Slles (Belem), Helio Vsconcellos Lopes (So Pulo); Frnce: Dutilleul Ptrick (Le Cilr), Isbelle Cibois-Honnort (Mirbeu), Pierre Triot (Arrs), Jcques Allix (Rennes), Gilles Sorbe (L Rochelle), Michèle Pithon (Hyeres), Pierre Cusse (Sint Etienne), Nthn Abenhim (Strsbourg), Frncois Lcoin (Albens), Jen-Yves Vogel (Husseren-Wesserling); Germny: Thorsten Bruns (Hmburg), Florin M.E. Wgenlehner (Strubing), Andres Cld (Freiburg), Klus Buerger (Munich), Christoph Antwerpen (Eggenfelden), Klus Ruediger (Freiburg), Orlin Svov (Nuremberg); Hungry: Imre Romics (Budpest), Lszlo Pjor (Szeged), Istvn Csb (Gyul), Peter Tenke (Budpest); Itly: Ginfrnco Scrselli (Florence), Gin Luc Brcco (Florence), Aldo Tosto (Florence), Fulvio Zullo (Ctnzro), Slvtore Corsello (Pternò), Piero Bonifzi (Foligno), Cesrin Cecchini (Foligno), Roberto Equinozzi (Foligno); The Netherlnds: Alfred Schs (Utrecht), Ysbrnd Stoutenbeek (Utrecht); Polnd: Ireneusz Szymczyk (Ktowice), Elzbiet Mizgl (Zbrze), Dorot Frydryszczk (Wroclw), Krzysztof Buczkowski (Bydgoszcz), Bozen Bielk (Lublin), Slwomir Chlbicz (Bilystok); Russi: Oleg Apolikchin Oleg (Moscow), Oleg Lorn (Moscow), Andrey V. Zitsev (Moscow), Vldimir Rflski (Smolensk), Dimitry Bochkrev (Volgogrd), Mikchil Pge 17 of 30

20 Kogn (Rostov), Asy Ponomrev (Krsnodr), Vldimir Zurvlev (Ekterinburg), Sergey Gorelo (Sint Petersburg), Vlentin N. Krupin (Novgorod); Spin: Jun Plou Redort (Brcelon), Crles Pigru (Brcelon), Antoni Gelbert (Brcelon), Jvier Angulo Cuest (Mdrid), Ncho Alós Cortès (Mdrid), Remigio Vel Nvrrete (Mdrid), Mnolo de l Ros Frile (Grnd), Luis Rodriguez (Cbuenes de Gijón), Antonio Mrqués Queimdelos (Sntigo de Compostel). Funding: The study ws supported by reserch grnt from Zmbon S.p.A., Bresso (MI), Itly. Competing interests: GCS: Byer, investigtor, speker t scientific meetings; snofiventis, investigtor, speker t scientific meetings; Zmbon, investigtor, speker t scientific meetings; Wyeth, investigtor; nd Angelini, investigtor, speker t scientific meetings. KGN: Byer, investigtor, speker t scientific meetings; Bionoric, investigtor, consultnt; Eumedic Phrmceuticls, consultnt; MerLion Phrmceuticls, investigtor, consultnt; Diichi, speker t scientific meetings, scientific publiction; MUCOS Phrm, consultnt, speker t scientific meetings; NnoVibronix, consultnt; Ocen Spry Crnberries, investigtor; OM Phrm, investigtor, consultnt; Peninsul/Johnson & Johnson/Jnssen-Cilg, investigtor, speker t scientific meetings; Phrmtok, investigtor, consultnt; Polyphor, consultnt; Protez, consultnt; Rosen Phrm, consultnt; snofi-ventis, investigtor, speker t scientific meetings, scientific publiction; UroVision, investigtor; nd Zmbon, investigtor, speker t scientific meetings. HB: Phrmtok, consultnt, investigtor. JP: Snofi-Psteur, consultnt, speker t scientific meetings; Lilly, consultnt, investigtor; Amgen, consultnt; nd Zmbon, investigtor. TM: Angelini, speker t scientific meetings, scientific publiction; GlxoSmithKline, speker t scientific meetings; Jnssen-Cilg, consultnt; Merck Shrp Pge 18 of 30

21 & Dohme, speker t scientific meetings; Novrtis, speker t scientific meetings; Pfizer, speker t scientific meetings, scientific publiction; snofi-ventis, consultnt, speker t scientific meetings; Schrper, scientific publiction; Schering-Plough, speker t scientific meetings; Wyeth, speker t scientific meetings, scientific publiction; nd Zmbon, investigtor, consultnt, speker t scientific meetings. All other uthors hve no competing interests to declre. Ethicl pprovl: The protocol of the ARESC study ws first pproved by centrl ethicl committee (Byerische Lndesärztekmmer, Munich, Germny, No ) nd then by the respective locl ethicl committees. The study complies with the Declrtion of Helsinki. The study complies with the Declrtion of Helsinki (Edinburgh, Scotlnd, 2000), Good Clinicl Prctice (GCP) nd the pplicble regultory requirements. Pge 19 of 30

22 References [1] Grbe M, Bishop MC, Bjerklund-Johnsen TE, Botto H, Çek M, Lobel B, et l. EAU guidelines for the mngement of urinry nd mle genitl trct infections. Urinry Trct Infection (UTI) Working Group of the Helth Cre Office (HCO) of the Europen Assocition of Urology (EAU). Arnhem, The Netherlnds: EAU; [ccessed 10 December 2008]. [2] Khlmeter G. An interntionl survey of the ntimicrobil susceptibility of pthogens from uncomplicted urinry trct infections: the ECO.SENS Project. J Antimicrob Chemother 2003;51: [3] Hooton TM, Besser R, Foxmn B, Fritsche TR, Nicolle LE. Acute uncomplicted cystitis in n er of incresing ntibiotic resistnce: proposed pproch to empiricl therpy. Clin Infect Dis 2004;39: [4] Rz R, Chzn B, Kennes Y, Colodner R, Rottensterich E, Dn M, et l. Empiric use of trimethoprim sulfmethoxzole (TMP-SMX) in the tretment of women with uncomplicted urinry trct infections, in geogrphicl re with high prevlence of TMP-SMX-resistnt uropthogens. Clin Infect Dis 2002;34: [5] Nber KG, Schito G, Botto H, Plou J, Mzzei T. Surveillnce study in Europe nd Brzil on clinicl spects nd ntimicrobil resistnce epidemiology in femles with cystitis (ARESC): implictions for empiric therpy. Eur Urol 2008;54: [6] Rubin RH, Shpiro ED, Andriole VT, Dvis RJ, Stmm WE. Evlution of new ntiinfective drugs for the tretment of urinry trct infection. Infectious Diseses Society of Americ nd the Food nd Drug Administrtion. Clin Infect Dis 1992;15(Suppl 1):S Pge 20 of 30

23 [7] Clinicl nd Lbortory Stndrds Institute. Methods for dilution ntimicrobil susceptibility tests for bcteri tht grow erobiclly. 7th ed. Approved stndrd M7-A7. Wyne, PA: CLSI; [8] Mugnioli C, Luzzro F, De Luc F, Brignte G, Perilli M, Amicosnte G, et l. CTX-Mtype extended-spectrum -lctmses in Itly: moleculr epidemiology of n emerging countrywide problem. Antimicrob Agents Chemother 2006;50: [9] Nber KG, Bergmn B, Bishop MC, Bjerklund-Johnsen TE, Botto H, Lobel B, et l. EAU guidelines for the mngement of urinry nd mle genitl trct infections. Urinry Trct Infection (UTI) Working Group of the Helth Cre Office (HCO) of the Europen Assocition of Urology (EAU). Eur Urol 2001;40: [10] Khlmeter G. Prevlence nd ntimicrobil susceptibility of pthogens in uncomplicted cystitis in Europe. The ECO.SENS study. Int J Antimicrob Agents 2003;22(Suppl 2): [11] Rz R, Colodner R, Kunin CM. Who re you Stphylococcus sprophyticus? Clin Infect Dis 2005;40: [12] Fdd G, Nicoletti G, Schito GC, Temper G. Antimicrobil susceptibility ptterns of contemporry pthogens from uncomplicted urinry trct infections isolted in multicenter Itlin survey: possible impct on guidelines. J Chemother 2005;17: [13] Strtchounski LS, Rflski VV. Antimicrobil susceptibility of pthogens isolted from dult ptients with uncomplicted community-cquired urinry trct infections in the Russin Federtion: two multicentre studies, UTIAP-1 nd UTIAP-2. Int J Antimicrob Agents 2006;28(Suppl 1):S4 9. [14] Andrde SS, Sder HS, Jones RN, Pereir AS, Pigntri AC, Gles AC. Incresed resistnce to first-line gents mong bcteril pthogens isolted from urinry trct infections in Ltin Americ: time for locl guidelines? Mem Inst Oswldo Cruz 2006;101: Pge 21 of 30

24 [15] Krlowsky JA, Hobn DJ, Decorby MR, Ling NM, Zhnel GG. Fluoroquinoloneresistnt urinry isoltes of Escherichi coli from outptients re frequently multidrug resistnt: results from the North Americn Urinry Trct Infection Collbortive Allince Quinolone Resistnce study. Antimicrob Agents Chemother 2006;50: [16] Bonnet R. Growing group of extended-spectrum -lctmses: the CTX-M enzymes. Antimicrob Agents Chemother 2004;48:1 14. [17] Colodner R, Rock W, Chzn B, Keller N, Guy N, Skrn W, et l. Risk fctors for the development of extended-spectrum -lctmse-producing bcteri in nonhospitlized ptients. Eur J Clin Microbiol Infect Dis 2004;23: [18] Goossens H, Ferech M, Vnder Stichele R, Elseviers M; ESAC Project Group. Outptient ntibiotic use in Europe nd ssocition with resistnce: cross-ntionl dtbse study. Lncet 2005;365: [19] Khlmeter G, Mendy P. Cross-resistnce nd ssocited resistnce in 2478 Escherichi coli isoltes from the Pn-Europen ECO SENS Project surveying the ntimicrobil susceptibility of pthogens from uncomplicted urinry trct infections. J Antimicrob Chemother 2003;52: [20] Ho PL, Wong RC, Yip KS, Loke SL, Leung MS, Mk GC, et l. Antimicrobil resistnce in Escherichi coli outptient urinry isoltes from women: emerging multidrug resistnce phenotypes. Dign Microbiol Infect Dis 2007;59: [21] Ungheri D, Albini E, Belluco G. In vitro susceptibility of quinolone-resistnt clinicl isoltes of Escherichi coli to fosfomycin trometmol. J Chemother 2002;14: [22] Smith SP, Mnges AR, Riley LW. Temporl chnges in the prevlence of community-cquired ntimicrobil-resistnt urinry trct infection ffected by Escherichi coli clonl group composition. Clin Infect Dis 2008;46: Pge 22 of 30

25 [23] Mnges AR, Johnson JR, Foxmn B, O'Bryn TT, Fullerton KE, Riley LW. Widespred distribution of urinry trct infections cused by multidrug-resistnt Escherichi coli clonl group. N Engl J Med 2001;345: [24] Prts G, Nvrro F, Mirelis B, Dlmu D, Mrgll N, Coll P, et l. Escherichi coli serotype O15:K52:H1 s uropthogenic clone. J Clin Microbiol 2000;38: [25] Nicols-Chnoine MH, Blnco J, Leflon-Guibout V, Demrty R, Alonso MP, Cniç MM, et l. Intercontinentl emergence of Escherichi coli clone O25:H4-ST131 producing CTX-M-15. J Antimicrob Chemother 2008;61: [26] Cgncci S, Gulco L, Debbi E, Schito GC, Mrchese A. Europen emergence of ciprofloxcin-resistnt Escherichi coli clonl groups O25:H4-ST 131 nd O15:K52:H1 cusing community-cquired uncomplicted cystitis. J Clin Microbiol 2008;46: Pge 23 of 30

26 Edited Tble 1 Tble 1 Distribution of pthogens by country Country Pthogens [n (%)] Totl Escherichi coli Klebsiell Proteus Stphylococcus pneumonie mirbilis sprophyticus uropthogens Other Others Austri 91 (3.0) 62 (68.1) 5 (5.5) 3 (3.3) 2 (2.2) 12 (13.2) 7 (7.7) Brzil (73.9) 31 (6.1) 19 (3.8) 25 (4.9) 32 (6.3) 25 (4.9) (16.8) Frnce (83.8) 5 (1.0) 15 (3.1) 21 (4.3) 21 (4.3) 17 (3.5) (16.2) Germny (76.7) 8 (2.5) 15 (4.7) 9 (2.8) 19 (6.0) 23 (7.3) (10.5) Hungry 66 (2.2) 52 (78.8) 2 (3.0) 0 (0) 0 (0) 10 (15.2) 2 (3.0) Itly (72.6) 18 (5.5) 10 (3.0) 0 (0) 44 (13.4) 18 (5.5) (10.9) Polnd (75.6) 3 (2.5) 4 (3.4) 5 (4.2) 6 (5.0) 11 (9.2) (3.9) Russi (72.6) 19 (4.6) 10 (2.4) 15 (3.6) 46 (11.1) 24 (5.8) (13.8) Spin 650 (21.5) 515 (79.2) 15 (2.3) 28 (4.3) 29 (4.5) 38 (5.9) 25 (3.8) b Pge 24 of 30

27 The 36 (1.2) 29 (80.6) 1 (2.8) 0 (0) 2 (5.6) 2 (5.6) 2 (5.6) Netherlnds Totl (76.7) 107 (3.5) 104 (3.4) 108 (3.6) 230 (7.6) 154 (5.1) Other Enterobctericee (Enterobcter spp., Citrobcter spp., Serrti spp., Klebsiell spp., Pntoe spp., Slmonell spp., Morgnell morgnii nd Hfni lvei); non-enterobctericee (Pseudomons eruginos nd Burkholderi cepci); nd other Grm-positive bcteri (Enterococcus feclis, Enterococcus fecium nd Enterococcus spp.). b Stphylococcus ureus, cogulse-negtive stphylococci other thn S. sprophyticus nd Streptococcus spp. Pge 25 of 30

28 Edited Tble 2 Tble 2 Susceptibility pttern of 2315 Escherichi coli isolted from urinry trct infections Antimicrobil gent MIC (mg/l) Susceptibility [% (no. of strins)] Rnge MIC 50 MIC 90 S I R Ampicillin 0.25 to > > (1045) 6.6 (153) 48.3 (1117) AMC 0.25/0.12 to >128/64 8/4 16/ (1910) 13.7 (316) 3.8 (89) Mecillinm <0.12 to > (2215) 1.5 (34) 2.8 (64) Cefuroxime <0.12 to > (1907) 15.2 (353) 2.4 (55) Nlidixic cid <0.012 to >128 4 > (1885) d 18.6 (430) Ciprofloxcin b < < (2120) 0.2 (5) 8.1 (187) SXT c <0.015/0.30 to >16/ /4.75 >16/ (1633) d 29.4 (681) Nitrofurntoin < (2205) 3.1 (72) 1.6 (38) Fosfomycin < (2272) 1.3 (30) 0.6 (13) MIC, miniml inhibitory concentrtion; MIC 50/90, MIC for 50% nd 90% of the orgnisms, respectively; S, susceptible; I, intermedite; R, resistnt; AMC, moxicillin/clvulnic cid; SXT, trimethoprim/sulfmethoxzole strins ssyed. b 2312 strins ssyed. c 2314 strins ssyed. d MIC vlue for intermedite ctegory does not exist. Pge 26 of 30

29 Edited Tble 3 Tble 3 Susceptibility pttern of 2315 Escherichi coli isolted from different countries to vrious ntimicrobil gents Country Susceptibility (%) AMP AMC MEC CFX NAL CIP SXT NIT FOS S I R S I R S I R S I R S I R S I R S I R S I R S I R Austri Brzil Frnce Germny Hungry Itly Polnd Russi Spin The Netherln ds Pge 27 of 30

30 AMP, mpicillin; AMC, moxicillin/clvulnic cid; MEC, mecillinm; CFX, cefuroxime; NAL, nlidixic cid; CIP, ciprofloxcin; SXT, trimethoprim/sulfmethoxzole; NIT, nitrofurntoin; FOS, fosfomycin; S, susceptible; I, intermedite; R, resistnt. Miniml inhibitory concentrtion (MIC) vlue for intermedite ctegory does not exist. Pge 28 of 30

31 Edited Tble 4 Tble 4 Antimicrobil susceptibility of Escherichi coli isolted from recurrent nd not-recurrent urinry trct infection (UTI) Antimicrobil gent % (no. of isoltes) Not-recurrent UTI (n = 2062) Recurrent UTI (n = 253) S I R S I R Ampicillin 45.9 (947) 6.4 (131) 47.7 (984) 38.7 (98) 8.7 (22) 52.6 (133) AMC 82.6 (1703) 13.9 (286) 3.5 (73) 81.8 (207) 11.9 (30) 6.3 (16) Mecillinm 95.6 (1969) 1.6 (32) 2.9 (59) 97.2 (246) 0.8 (2) 2.0 (5) Cefuroxime 82.8 (1708) 15.2 (313) 2.0 (41) 78.7 (199) 15.8 (40) 5.5 (14) Nlidixic cid 82.5 (1701) 17.5 (361) 72.7 (184) (69) Ciprofloxcin 92.8 (1910) 0.2 (5) 7.0 (144) 83.0 (210) (43) SXT 71.2 (1468) 28.8 (593) 65.2 (165) 34.8 (88) Nitrofurntoin 95.3 (1965) 3.1 (64) 1.6 (33) 94.9 (240) 3.2 (8) 2.0 (5) Fosfomycin 98.0 (2021) 1.4 (29) 0.6 (12) 99.2 (251) 0.4 (1) 0.4 (1) S, susceptible; I, intermedite; R, resistnt; AMC, moxicillin/clvulnic cid; SXT, trimethoprim/sulfmethoxzole. Miniml inhibitory concentrtion (MIC) vlue for intermedite ctegory does not exist. Pge 29 of 30

32 Edited Tble 5 Tble 5 Susceptibility ptterns of the most common uropthogens other thn Escherichi coli Antimicrobil gent Susceptibility (%) Klebsiell pneumonie (n = 107) Proteus mirbilis (n = 104) Stphylococcus sprophyticus (n = 108) I R I R I R Ampicillin b 36.4 AMC Mecillinm c c Cefuroxime Nlidixic cid c c Ciprofloxcin SXT b 23.3 b 37.5 b 10.2 Nitrofurntoin Fosfomycin c c I, intermedite; R, resistnt; AMC, moxicillin/clvulnic cid; SXT, trimethoprim/sulfmethoxzole; MIC, miniml inhibitory concentrtion. Clinicl nd Lbortory Stndrds Institute brekpoints for E. coli hve lso been used for K. pneumonie nd P. mirbilis. b MIC vlue for intermedite ctegory does not exist. c MIC brekpoints for this ntimicrobil gent ginst this pthogen does not exist. Pge 30 of 30