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Three risk factors associated with community-acquired ESBL UTIs

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January 9, 2019

Patients with indwelling urinary catheters, a history of recurrent urinary tract infections or recent antimicrobial use are at a higher risk for community-acquired extended-spectrum beta-lactamase–producing Enterobacteriaceae UTIs, according to researchers.

According to Dheeraj Goyal, MD, MPH, medical director of infection control and antibiotic stewardship at Mercy Health in Fairfield, Ohio, and colleagues, the prevalence of extended-spectrum beta-lactamase (ESBL) infections is increasing and previous studies in Spain and France have estimated a 4% to 38% prevalence of ESBL-producing Enterobacteriaceae in blood and urine cultures from hospitalized patients. In the United States, factors associated with community-acquired ESBL UTIs have not been extensively investigated, they said.

“This is one of the largest retrospective studies conducted to date in the U.S. to study potential risk factors for community-acquired ESBL UTIs,” Goyal told Infectious Disease News.

To identify predictive risk factors of ESBL UTIs, Goyal and colleagues conducted a case-control study of 251 adults admitted to an Intermountain Healthcare hospital with a UTI between 2001 and 2016. Exclusionary criteria included a history of ESBL infections or hospitalization within 3 months of index admission.

According to their analysis, a history of repeated UTIs, neurogenic bladder, urinary catheter presence at admission and exposure to outpatient third-generation cephalosporins or fluoroquinolones within 3 months were associated with a higher risk for ESBL UTIs, Goyal and colleagues reported. When they controlled for severity of illness and comorbid conditions, the researchers found that a history of repeated UTIs (adjusted OR = 6.4; 95% CI, 3.42-12.66), presence of urinary catheter at admission (aOR = 2.36; 95% CI, 1.15-4.98) and prior antibiotic exposure [aOR =7.98; 95% CI, 2.92-28.19) remained associated with a higher risk for ESBL infection.

They suggested that the study findings could potentially improve clinical outcomes, and that understanding the risk factors may help clinicians initiate effective antimicrobial therapy earlier.

“We found that patients with history of repeated UTIs, presence of a urinary catheter and prior antibiotic exposure within 3 months were associated with a higher risk of de-novo community-acquired ESBL UTIs,” Goyal said. “Clinicians should have a high index of suspicion for ESBL infections in these patients and should consider initiating carbapenems in such patients early on. This is especially true for sicker patients like those requiring ICU admission or those with preexisting immunocompromising conditions.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

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Perspective

Community-acquired infections caused by ESBL-producing bacteria, especially Enterobacteriaceae, are important. The recognition of who is at risk is an important additional detail or feature that a clinician should keep in mind when they are deciding empirically on how to treat these patients, or, when they are not doing well, to think why they are not doing well. The risk factors that this study demonstrated are quite expected, but at the same time, they confirm what infectious disease physicians understand to be a significant risk for more resistant organisms in the urine of people from the community. People who have had multiple prior infections have been treated usually with different antibiotics, applying significant antibiotic pressure impacting the patient’s gut flora. As it changes, it usually results in the presence of more resistant organisms which can then become the next urinary pathogen. Obviously, if you have a catheter in place, you are more likely to have prior episodes of infection and more likely to have resistant organisms. In general, being exposed to antibiotics, even if not prescribed for urinary tract infections, changes your gut flora and places one at a much higher risk of developing resistant organisms. Then, even though you have not been hospitalized, even though you have not been exposed in a hospital setting to resistant organisms, you may have developed “hospital like” resistance just from the community pressures described in this study.

Certainly, these results may make you consider a different empirical regimen to give this type of patient, especially if they are not doing well. For patients who have failed on initial therapy and for whom you do not have culture data — or for whom you are waiting on culture data — these study findings should make you think, Do I have to deal with something I was not expecting? A more highly resistant organism?

This was a solid study. Again, no shocking surprises, but it was a good study.

Aaron Glatt, MD, FACP, FIDSA, FSHEA

Spokesperson, Infectious Diseases Society of America
Chairman, medicine chief
South Nassau Communities Hospital
Oceanside, New York

Disclosure: Glatt reports no relevant financial disclosures.