Antibiotic resistance of coliform organisms from community-acquired urinary tract infections in Zenica-Doboj Canton, Bosnia and Herzegovina

Journal of Antimicrobial Chemotherapy Advance Access published June 14, 2006 Journal of Antimicrobial Chemotherapy doi:10.1093/jac/dkl243 Antibiotic resistance of coliform organisms from community-acquired urinary tract infections in Zenica-Doboj Canton, Bosnia and Herzegovina Selma Uzunovic-Kamberovic* Laboratory for Clinical and Sanitary Microbiology, Cantonal Public Health Institution Zenica, Fra Ivana Jukica 2/4, 72000 Zenica, Bosnia and Herzegovina Received 11 June 2005; returned 18 October 2005; revised 19 April 2006; accepted 18 May 2006 Objectives: To collect routine susceptibility data for coliforms isolated from patients with communityacquired urinary tract infections (UTIs) in Zenica-Doboj Canton, Bosnia and Herzegovina and to relate them to bacterial identification and patient demographics with a view to guiding empirical therapy. Methods: During, 54 638 consecutive urine samples were analysed by standard procedures. Antimicrobial susceptibility testing for 15 antimicrobials was performed by the disc diffusion method. Results: A total of 10 765 Escherichia coli and other coliforms were isolated, of which 5043 (46.8%) were duplicates. Resistance rates were significantly higher in duplicate isolates for almost all antibiotics tested (P < 0.05), except for ampicillin, cefazolin, aztreonam and co-trimoxazole. Inclusion of coliforms other than E. coli (25.8%) significantly increased resistance rates for all tested antibiotics (P < 0.001) except imipenem. Overall coliform resistance rates were significantly higher in males than in females (P < 0.001). Conclusions: Due to high ampicillin and trimethoprim/sulfamethoxazole resistance rates for all subsets analysed it is highly recommended to perform urinalysis and antibiotic susceptibility testing in all patients, except in the age group 0 6 years of male patients and in the age group 20 64 years of female patients, in which empirical therapy with these antibiotics can be applied. Nitrofurantoin should also be considered as the first-line therapy, especially in children. It is important for physicians to know susceptibility data for UTIs in order to optimize the use of empirical therapy. Keywords: Escherichia coli, susceptibility testing, surveillance Introduction Increasing resistance to ampicillin and trimethoprim/sulfamethoxazole in Escherichia coli, the main causative pathogen of urinary tract infections (UTIs), has been demonstrated in urinary tract isolates obtained from patients visiting their general practitioners. 1 6 Moreover, in the past few years, fluoroquinolones have been prescribed more frequently for the treatment of such infections. This has been followed by an increase in fluoroquinolone-resistant E. coli infections, which are difficult to treat. 1,2,7,8 Many studies do not distinguish between community-acquired urinary isolates that were recovered from adult females (most of whom have uncomplicated UTIs) and those that have been recovered from children or men. 2,9 11 In the present retrospective study, using the results of our routine diagnostic and susceptibility analyses, the aim was to investigate antimicrobial resistance and occurrence of the most common community-acquired UTI pathogens in Zenica-Doboj Canton during in relation to age, gender and identified microorganisms and to propose appropriate empirical therapy. Materials and methods The Laboratory for Clinical and Sanitary Microbiology of the Cantonal Public Health Institution in Zenica covers a population of 331 229 in Zenica-Doboj Canton (112 471 males and 218 758 females). In, 54 638 consecutive urine samples were analysed, of which 6309 (11.5%) were positive. All urinary specimens with significant bacteriuria ( 10 5 cfu/ml of urine) were further processed. E. coli and other coliform microorganisms were identified according to standard biochemical tests, which identified most... *Corresponding author. Tel: 00-387-32-443-580; Fax: 00-387-32-443-530; E-mail: selma_kamb@yahoo.com... Page 1 of 5 Ó The Author 2006. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Uzunovic-Kamberovic coliforms isolated to the genus level and many to the species level. 12 API 20 (biomérieux, France) tests were used for confirmation. The disc diffusion method using Mueller Hinton agar (Oxoid, Basingstoke, UK) was used to test 15 antimicrobials (Oxoid). The applied susceptibility criteria were in accordance with the NCCLS. 13 E. coli control strain ATCC 25922 was used. Name, surname, ID, address, date of birth and gender of the patient, date of isolation, specimen number, organism isolated and susceptibility results of positive UTI isolates were recorded as well as the number of urine specimens submitted during the study. The isolation of the same organism with the same susceptibility pattern from the same patient was considered as duplicate. Two sets of susceptibility rates were calculated: one including all coliform isolates and the other one excluding duplicate isolates. A few subsets in the group of non-duplicate coliform isolates were also calculated: E. coli/non-e. coli isolates, male/female and age groups (0 6, 7 14, 15 19, 20 64, >64 years). The significance of differences in resistance according to subsets analysed was determined by means of the c 2 test for independence. A statistically significant difference was defined as a P value of <0.05, and a 95% confidence interval was used. Results Susceptibility results were obtained for 10 765 coliform UTI isolates; among them there were 5043 (46.8%) duplicate isolates and 5722 (53.2%) non-duplicate isolates. E. coli was isolated in 4245 (74.2%) non-duplicate urine samples, and non-e. coli were isolated in 1477 (25.8%) non-duplicate urine samples. Non- E. coli isolates identified in non-duplicate urine samples were Klebsiella spp. in 936 (16.4%), Proteus spp. in 422 (7.4%), Citrobacter spp. in 114 (2.0%) and Enterobacter spp. in 5 (0.1%). Table 1 shows that resistance rates were higher in duplicate isolates compared with non-duplicate isolates for all antibiotics tested except for ampicillin and chloramphenicol, and differences in the prevalence varied from 0.9% to 6.6%. However, statistically significant differences in susceptibility rates calculated with or without duplicate isolates were found for almost all antibiotics tested (P < 0.05), except for ampicillin, cefalotin, aztreonam Table 1. Antimicrobial resistance of non-duplicate coliform UTI isolates in the period and trimethoprim/sulfamethoxazole (P > 0.05). During the study period we found a significant increase in the prevalence of resistance against cefotaxime (P < 0.05) and all tested quinolones (P < 0.001); however, a decreasing trend was noted for trimethoprim/sulfamethoxazole (P < 0.001). Male/female distribution of non-duplicate coliform UTI isolates was 16.0%/84.0%, respectively, resulting in incidence values of 1.6/5.2 per 1000 per year (mean values for ) (Table 2). Most isolates were obtained from patients over the age of 20 years, 81.9% for males and 72.9% for females. The lowest incidence of UTI coliform isolates of 1.1/1000/year was observed in the age group of 15 19 years, and the highest incidence of UTI coliform isolates was observed in the age group 0 6 years, 9.4/1000/year. Overall resistance rates for all antibiotics tested, except for imipenem, were significantly higher in the strains from the male population than from the female population (P < 0.001) (P > 0.05). Ampicillin and trimethoprim/ sulfamethoxazole displayed the highest resistance rates in both groups. E. coli/non-e. coli distributions were different in the strains from males versus females: 51.2%/48.8% and 78.6%/ 21.4%, respectively. E. coli was significantly (P < 0.001) more commonly isolated from female patients, and non-e. coli were isolated more commonly from male patients (P < 0.001). Further analyses of E. coli/non-e. coli distributions according to patient age have shown that E. coli was the most frequently isolated pathogen in all age groups of females: 83.1%, 88.3%, 74.2%, 75.2% and 79.9%, respectively (P < 0.05), compared with the frequency of isolation of non-e. coli isolates. However, the presence of non-e. coli isolates in male patients increased in proportion with increasing age: 28.6%, 48.9%, 40.0%, 48.7% and 65.2%, respectively. Therefore, E. coli was the more commonly isolated pathogen in the age group 0 6 years (P < 0.001) and non-e. coli were the more commonly isolated pathogens in the age group >64 years (P < 0.001) in male patients. Inclusion of non-e. coli isolates (25.8%) in the analysis significantly (P < 0.001) influenced the resistance rates against all antibiotics except imipenem, in all subsets analysed. Klebsiella spp. showed the highest resistance rates for ampicillin, co-amoxiclav, cefuroxime, cefotaxime and aztreonam (82.9%, 67.9%, 34.5%, Year/source of isolates No. of isolates Percentage of resistance to antimicrobial agents AMP AMC CEF CXM CTX IPM ATM GEN NAL NOR OFX CIP SXT CHL NIT 1998 1516 68.7 NT 34.7 NT 7.7 NT NT 9.1 9.8 4.3 7.7 2.7 55.6 18.7 NT 1999 1409 80.0 NT 20.6 12.3 7.4 NT NT 11.0 5.3 6.4 4.1 4.5 44.8 14.3 NT 2000 1512 79.0 NT 39.5 16.1 12.7 NT NT 23.5 15.5 11.4 10.1 8.3 49.8 20.2 NT 2001 1285 70.6 37.9 10.6 11.2 11.9 0.3 6.8 15.2 17.6 14.3 3.3 12.1 43.5 16.8 9.6 E. coli 4245 72.6 33.2 18.7 6.9 4.8 0.1 2.3 8.2 7.9 5.4 3.8 4.4 50.2 12.5 2.8 other coliforms 1477 82.1 54.7 60.2 40.1 29.4 0.8 21.5 34.1 30.1 21.4 16.7 16.3 47.6 36.6 33.5 total non-duplicate 5722 74.7 37.9 26.0 13.3 9.5 0.3 6.8 14.1 10.6 8.9 6.4 6.7 48.6 17.5 9.6 coliform isolates total duplicate coliform isolates 10 765 74.3 42.0 27.1 19.3 13.5 1.7 9.0 19.4 16.3 12.1 7.3 10.1 54.6 17.4 16.2 AMP, ampicillin; AMC, co-amoxiclav; CEF, cefalotin; CXM, cefuroxime; CTX, cefotaxime; IPM, imipenem; ATM, aztreonam; GEN, gentamicin; NAL, nalidixic acid; NOR, norfloxacin; OFX, ofloxacin; CIP, ciprofloxacin; SXT, trimethoprim/sulfamethoxazole; CHL, chloramphenicol; NIT, nitrofurantoin; NT, not tested. 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Antibiotic resistance of coliform organisms Table 2. Antimicrobial resistance of non-duplicate coliform UTI isolates in the period according to age and gender Percentage of resistance to antimicrobial agents AMP AMC CEF CXM CTX IPM ATM GEN NAL NOR OFX CIP SXT CHL NIT No. of isolates (male/ female) Age 0 6 40/219 76.7/71.9 21.7/41.4 17.1/15.5 18.2/4.6 12.8/6.1 0/1.2 3.8/1.2 22.2/6.3 31.3/3.7 6.1/4.1 2.3/0.6 4.1/2.8 17.9/37.2 11.5/7.9 2.2/1.8 7 14 4/98 100.0/76.6 33.3/35.6 50.0/12.0 25.0/4.3 33.3/5.4 0/0 0/1.4 0/2.4 50.0/5.1 25.0/2.0 0/0 25.0/1.0 75.0/44.9 0/6.5 50.0/0 15 19 2/50 100.0/82.1 50.0/32.4 0/10.6 0/0 0/2.5 0/0 0/2.5 0/7.3 0/8.0 0/6.0 0/0 0/2.0 0/30.2 0/8.6 0/4.3 20 64 85/499 85.7/52.3 34.6/37.5 48.7/13.6 47.1/8.4 43.3/6.0 0/0 11.1/0 48.7/10.1 54.9/13.9 49.4/11.6 15.2/1.6 42.4/9.8 65.4/18.1 42.1/16.6 40.3/8.2 >64 91/181 91.0/68.6 45.0/27.1 60.6/13.5 60.6/4.9 53.1/8.7 0/0 12.0/4.6 63.0/12.9 63.3/16.3 56.2/13.4 47.8/3.1 54.4/12.7 76.5/41.1 52.5/18.4 47.4/7.5 Total coliforms 916/4806 85.6/73.2 51.3/35.0 53.0/25.3 40.3/11.5 33.2/6.8 0.5/0.2 23.1/3.3 41.3/10.0 37.1/9.4 29.4/5.8 21.7/4.4 24.4/4.3 62.3/46.8 39.8/15.0 33.5/4.7 Total E. coli 469/3776 79.0/71.8 38.0/32.6 29.3/17.4 18.2/5.6 13.8/3.7 0/0.1 8.0/1.6 20.6/6.7 16.2/7.0 12.8/4.5 8.3/3.2 10.3/3.6 52.3/50.0 19.1/11.7 9.7/1.8 447/1030 91.7/77.5 65.3/47.8 74.2/53.4 60.4/30.2 53.2/18.6 1.2/0.7 39.0/11.3 60.2/21.6 60.6/17.9 45.0/10.6 36.1/8.3 37.6/6.6 72.1/35.6 58.3/26.2 62.4/17.8 Total other coliforms AMP, ampicillin; AMC, co-amoxiclav; CEF, cefalotin; CXM, cefuroxime; CTX, cefotaxime; IPM, imipenem; ATM, aztreonam; GEN, gentamicin; NAL, nalidixic acid; NOR, norfloxacin; OFX, ofloxacin; CIP, ciprofloxacin; SXT, trimethoprim/sulfamethoxazole; CHL, chloramphenicol; NIT, nitrofurantoin. 29.7% and 20.6%, respectively), whereas Proteus spp. showed the highest resistance rates for gentamicin (44.5%). The highest resistance rate for cefalotin was noted in Citrobacter spp. isolates (72.9%). Inclusion of these organisms did not affect the core finding of antimicrobial resistance rate in both groups (Table 1), but the values were much higher in males (Table 2). Overall coliform antibiotic resistance rates for all antibiotics tested, except for imipenem and aztreonam, did not show a significant difference in relation to the age groups of patients in both males and females (P > 0.05) (P < 0.05). Ampicillin displayed exceptionally high resistance rates in all age groups of both male and female patients (up to 100.0% and 82.1%, respectively). Alarmingly high proportions of resistance to extended-spectrum b-lactam antibiotics were found in male patients. The highest resistance rates were found in the age group >64 years, reaching 60.6% and 53.1% for cefuroxime and cefotaxime, respectively (P < 0.001). Trimethoprim/sulfamethoxazole resistance rates were the lowest in the age group 20 64 years of female patients and in the age group 0 6 years of male patients (18.1% and 17.9%, respectively) (P < 0.001). The proportion of isolates resistant to gentamicin, chloramphenicol, all quinolones tested and nitrofurantoin increased with increasing age, in both male and female patients, and it was the highest in the age group >64 years (P < 0.001). Discussion The present study provides information about the antimicrobial susceptibility of community-acquired UTIs in relation to aetiological agents (E. coli/non-e. coli coliforms), gender and age. It has to be estimated that no selection was carried out prior to sending urine samples in our region, due to a high number of duplicate urine samples, 53.2%, and a low frequency of positive samples, 11.5%. In some other reports the number of positive urine samples reached 53.6%, and the number of duplicate samples reached only 14.3%. 9 Therefore, the antibiotic susceptibility data presented here probably reflect actual antibiotic resistance in practice, and hence should exclude the bias caused by use of strains isolated in the microbiology laboratory, which comprise mainly complicated 1 or pre-selected urine samples. 9 Indeed, some authors observed that when potential sampling biases were evaluated, no evidence was found that practices with high resistance rates were more selective in submitting urine samples to the laboratory. 10 However, presented data still have certain limitations that are inherent to all laboratory-based surveys, thus urine samples in the present study were probably not representative of UTI in practice and might influence the susceptibility data obtained, as previously stated. 14,15 It is noteworthy that E. coli grew in 78.6% of the specimens from females, but in only 51.2.% of those from males. Corresponding rates for coliforms other than E. coli were 21.4% and 48.8%, respectively. Such a distribution of coliform communityacquired UTI pathogens was observed only in a few reports from the southern part of Europe, 2,16 Latin America 7 and Britain, 17 but not in other countries. 2 According to a postulate stated previously, 18 the distribution of community-acquired UTI pathogens in this region with a significant proportion of non-e. coli coliforms (25.8%), namely Klebsiella spp. (14.9%), comprising the secondary pathogenic species, corresponded to that in hospital settings or complicated community UTIs. 1,7,19 The findings in the Page 3 of 5

Uzunovic-Kamberovic present study did not match with the study from Wales and Finland, where duplicate isolates had little influence on community or non-catheter outpatient specimens, 20 but significantly affected estimates of resistance rates for inpatients. 21 Given the above mentioned facts, it is evident that the number of complicated UTIs in this report was large. Although this laboratory-based study did not provide the data about the presence and nature of symptoms and whether infection was complicated or not, the age, gender and microorganisms identified might provide necessary information needed for selection of empirical therapy. 14,20 The relations of resistance rates for all antibiotics tested between E. coli and other coliforms were similar for male and female patients, but the values were much higher in males. It is a usual finding due to the different nature of UTI in males compared with females, although some different findings were also reported. 5,7,16,20,22,23 These data illustrate several important points related to the drugs most frequently considered for empirical therapy for community-acquired UTIs. Despite the fact that no preselection of urine samples was made, ampicillin and co-trimoxazole resistance rates in the report were far higher in comparison with other reports. 5,6,17,20,23 As stated previously, the frequency of antimicrobial resistance in E. coli showed a geographical gradient, being greater in southern Europe, particularly in Spain and Portugal, than in northern Europe, 6,20,23,24 thus, the results from our region could be compared with those from the above mentioned countries. Empirical therapy with ampicillin in our region seems inadequate even for some usual population category, and should be avoided. In some regions co-trimoxazole also showed such high frequencies of resistance, 10 but in most European countries it is still useful. 2 Co-trimoxazole might be considered for empirical treatment of UTIs only in the age group 20 64 years of female patients and in the age group 0 6 years of male patients, in which resistance rates were low. Ciprofloxacin resistance in E. coli (4.4%) in our region still remained low 25 compared with some reports from Spain, where the resistance increased up to 20% and 36.0% in female and male patients, respectively. 1,2 But, our results suggest an alarmingly significant increase in the resistance to all quinolones (except to ofloxacin) in 2001 compared with 1998, an observation also reported by others. 5,6,23 Nitrofurantoin has shown a low overall coliform resistance rate in the age group 0 6 years of both male and female patients and should be considered as the first-line therapy. 26 Our results showed that it is highly recommended to perform urinalysis and antibiotic susceptibility testing in all patients, except in the age group 0 6 years of both male and female patients and in the age group 20 64 years of female patients, in which empirical therapy can be applied. Due to the crisis in Bosnia and Herzegovina during the war period, and the lack of other antibiotics, ampicillin and cotrimoxazole were widely used. It is likely that an intensive usage of ampicillin and co-trimoxazole during the war period might have contributed to their high resistance rates, although the reports about relationship of high usage and resistance are controversial. 9 11,16,17,27 31 A similar situation was reported in Serbia. 32 In poor and underdeveloped countries, where health organizations donate large amounts of antibiotics to treat many diseases, overall prevalence of antimicrobial resistance was notably high, reflecting irrational and inordinate use of antimicrobial agents. 4 In spite of the fact that the war finished by the end of 1995, a refugee camp still existed in Zenica-Doboj Canton until the end of 2001. This could also have influenced high ampicillin and co-trimoxazole resistance rates, because of increased prevalence of many diseases, person-to-person transmission of resistance plasmids or resistant strains in commensal faecal coliforms and crowding and poor sanitation. 10,20,28,33 36 The ease of procuring antibiotics without a prescription after the war in this region could have resulted in inordinate and irrational use of antibiotics. Consequently, ampicillin and co-trimoxazole were probably replaced by fluoroquinolones in the treatment of infectious diseases. As the decay in the prevalence of drug-resistant bacteria occurs slowly after reduction in consumption, 9 this could explain a decrease in ampicillin and cotrimoxazole resistance and an increase in fluoroquinolone resistance after the war period in the present study. Some authors have stated that quinolone resistance is higher in developing countries than in developed nations because of the use of less active quinolones, such as nalidixic acid, and/or the use of low dosages of more potent compounds such as ciprofloxacin resulting in selection of mutant isolates. 8 Although the current study addresses a local problem in Bosnia and Herzegovina, where a higher prevalence of antibiotic resistance compared with other countries appeared, many other poor and developing countries are faced with a similar situation. 4,32 The reason for high prevalence of resistance is not only limited to the level of prescribing and usage, 11,20,29 31 but is likely to be complex with respect to the age profile of the population, social deprivation, locality and the use of antibiotics in veterinary and agricultural practice. 4,26,37,38 To optimize the use of empirical antibacterial therapy for UTI, physicians should know the aetiology and susceptibility patterns of UTI pathogens in their population. Changes in rates of resistance have been observed to follow changes in prescribing of the drugs. Acknowledgements A part of this work was presented as a poster presentation at the Thirteenth European Congress of Clinical Microbiology and Infectious Diseases, Glasgow, UK, 2003 (Uzunovic-Kamberovic S. Epidemiology of community-acquired urinary tract infections in Zenica-Doboj Canton, Bosnia and Herzegovina. Clin Microbiol Infect 2003; 9 Suppl 1: 274). Transparency declarations None to declare. References 1. Oteo J, Aracil B, Hoyo JF et al. Do the quinolones still constitute valid empirical therapy for community-acquired urinary tract infections in Spain? Clin Microbiol Infect 1999; 5: 654 6. 2. Kahlmeter G. The ECO.SENS Project: a prospective, multinational, multicentre epidemiological survey of the prevalence and antimicrobial susceptibility of urinary tract pathogens interim report. J Antimicrob Chemother 2000; 46 Suppl 1: 15 22. 3. Zhanel GG, Karlowsky JA, Harding GKM et al. A Canadian national surveillance study of urinary tract isolates from outpatients: comparision of the activities of trimethoprim-sulfamethoxazole, ampicillin, mecillinam, nitrofurantoin, and ciprofloxacin. Antimicrob Agents Chemother 2000; 44: 1089 92. Page 4 of 5

Antibiotic resistance of coliform organisms 4. Ahmed AA, Osman H, Mansour AM et al. Antimicrobial agent resistance in bacterial isolates from patients with diarrhea and urinary tract infection in the Sudan. Am J Trop Med Hyg 2000; 63: 259 63. 5. Alós JI, Serrano M-G, Gómez-Garcés JL et al. Antibiotic resistance of Escherichia coli from community-acquired urinary tract infections in relation to demographic and clinical data. Clin Microbiol Infect 2005; 11: 199 203. 6. Junquera S, Loza E, Baquero F. Changes in the antimicrobial susceptibility of Escherichia coli isolates from nosocomial versus community-acquired urinary tract infections. Enferm Infecc Microbiol Clin 2005; 23: 197 201. 7. Gales AC, Jones RN, Gordon KA et al. Activity and spectrum of 22 antimicrobial agents tested against urinary tract infection pathogens in hospitalized patients in Latin America: report from second year of the SENTRY Antimicrobial Surveillance Program (1998). J Antimicrob Chemother 2000; 45: 295 303. 8. Acar JF, Goldsein FW. Trends in bacterial resistance to fluoroquinolones. Clin Infect Dis 1997; 24 Suppl 1: S67 73. 9. Grude N, Tveten Y, Kristiansen B-E. Urinary tract infections in Norway: bacterial etiology and susceptibility. A retrospective study of clinical isolates. Clin Microbiol Infect 2001; 7: 543 7. 10. Magee JT, Pritchard EL, Fitzgerald KA et al. Antibiotic prescribing and antibiotic resistance in community practice: retrospective study, 1996 98. Br Med J 1998; 319: 1239 40. 11. Batchelor BIF, Crook DWM, Jones T et al. Impact of guidelines for diagnosis of urinary tract infection on trimethoprim susceptibility of Escherichia coli. J Antimicrob Chemother 2002; 49: 223 4. 12. Kelly MT, Brenner DJ, Farmer JJ. Enterobacteriaceae. In: Balows A, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, Murray PR, eds. Manual of Clinical Microbiology. Washington, DC, USA: ASM Press, 1995; 263 77. 13. National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Susceptibility Testing: Twelfth Informational Supplement M100-S12. NCCLS, Wayne, PA, USA, 2002. 14. Gupta K, Sahm D, Mayfield D et al. Antimicrobial resistance among uropathogens that cause community/acquired urinary tract infections in women: a nationwide analysis. Clin Infect Dis 2001; 33: 89 94. 15. Ti TY, Kumarasinghe G, Taylor MB et al. What is true communityacquired infection? Comparision of pathogens identified in urine from routine outpatient specimens and from community clinics in a prospective study. Eur J Clin Microbiol Infect Dis 2003; 22: 242 5. 16. Prais D, Straussberg R, Avitzur Y et al. Bacterial susceptibility to oral antibiotics in community acquired urinary tract infections. Arch Dis Child 2003; 88: 215 8. 17. Barrett SP, Savage MA, Rebec MP et al. Antibiotic sensitivity of bacteria associated with community-acquired urinary tract infections in Britain. J Antimicrob Chemother 1999; 44: 359 65. 18. Aspevall O, Hallander H, Gant V et al. European guidelines for urinalysis: a collaborative document produced by European clinical microbiologists and clinical chemists under ECLM in collaboration with ESCMID. Clin Microbiol Infect 2001; 7: 173 8. 19. Hryniewicz K, Szczypa K, Sulikowska A et al. Antibiotic susceptibility of bacterial strains isolated from urinary tract infections in Poland. J Antimicrob Chemother 2001; 47: 773 80. 20. Howard AJ, Magee JT, Karen A et al. Factors associated with antibiotic resistance in coliform organisms from community urinary tract infections in Wales. J Antomicrob Chemother 2001; 47: 305 13. 21. Huovinen P. Recording of antimicrobial resistances of urinary tract isolates effect of repeat samples on resistance levels. J Antimicrob Chemother 1985; 16: 443 7. 22. Barnett BJ, Stephens DS. Urinary tract infections: an overview. Am J Med Sci 314: 245 9. 23. Goettisch W, van Pelt W, Nagelkerke N et al. Increasing resistance to fluoroquinolones in E. coli from urinary tract infections in The Netherlands. J Antimicrob Chemother 2000; 46: 223 8. 24. Kahlmeter G, Menday P. Cross-resistance and associated resistance in 2478 Escherichia coli isolates from the Pan-European ECO.SENS Project surveying the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections. J Antimicrob Chemother 2003; 52: 128 31. 25. Dimitrov TS, Udo EE, Emara M et al. Etiology and antibiotic susceptibility patterns of community-acquired urinary tract infections in a Kuwait hospital. Med Princ Pract 2004; 13: 334 9. 26. Gupta K, Scholes D, Stamm W. Increaing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women. JAMA 1999; 281: 736 8. 27. Livermoore DM, Stephens P, Weinberg J et al. Regional variation in ampicillin and trimethoprim resistance in Escherichia coli in England from 1990 to 1997, in relation to antimicrobial prescribing. J Antimicrob Chemother 2000; 46: 411 22. 28. Steinke DT, Seaton RA, Phillips G et al. Prior trimethoprim use and trimetoprim-resistant urinary tract infection: a nested case-control study with multivariate analysis for other risk factors. J Antimicrob Chemother 2001; 47: 781 7 29. Cizman M, Orazem A, Krizan-Hergout V et al. Correlation between increased consumption of fluoroquinolones in outpatients and resistance of Escherichia coli from urinary tract infections. J Antimicrob Chemother 2001; 47: 502. 30. Svetlansky I, Liskova A, Foltan V et al. Increased consumption of fluoroquinolones is not associated with resistance in Escherichia coli and Staphylococcus aureus in the community. J Antimicrob Chemother 2001; 48: 457 8. 31. Ishihara S, Yokoi S, Masue N et al. Urinary tract-derived Escherichia coli resistant to cotrimoxazole in Japan, where the drug is seldom used for treating acute urinary tract infections. J Antimicrob Chempther 2002; 49: 881 2. 32. Lazarevic G, Petreska D, Pavlovic S. Antibiotic sensitivity of bacteria isolated from the urine of children with urinary tract infections from 1985 to 1995. Srp Arh Celok Lek 1998; 126: 423 9. 33. Kunin CM, Lipton HL, Tupasi T et al. Social, behavioral, and practical factors affecting antibiotic use worldwide: report of Task Force 4. Rev Infect Dis 1987; 9 Suppl 3: S270 85. 34. Uzunovic-Kamberovic S. Some epidemiologic features of Campylobacter jejuni/coli infections in Bosnia and Herzegovina after the war. Clin Microbiol Infect 2003; 9: 458 60. 35. Stamm WE. An epidemic of urinary tract infections? N Engl J Med 2001; 345: 1055 7. 36. Sahm DF, Thornsberry C, Mayfield DC et al. Multidrug-resistant urinary tract isolates of Escherichia coli: prevalence and patient demographics in the United States in 2000. Antimicrob Agents Chemother 2001; 45: 1402 6. 37. Steinke D, Emslie-Smith A, Boyle P et al. A population study of first exposure to community antibacterials in children and the suitabilility of routine urine samples for study of the acquisition of drug resistance. J Antimicrob Chemother 2002; 50: 185 8. 38. Hillier SL, Magee JT, Howard AJ et al. How strong is the evidence that antibiotic use is a risk factor for antibiotic-resistant, communityacquired urinary tract infection? J Antimicrob Chemother 2002; 50: 241 7. Page 5 of 5