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International Journal of Antimicrobial Agents xxx (2014) xxx–xxx
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International Journal of Antimicrobial Agents journal homepage: http://www.elsevier.com/locate/ijantimicag
Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin
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Michael Kresken a,b,∗ , Yvonne Pfeifer c , Dieter Hafner d , Rebecca Wresch a , Barbara Körber-Irrgang a , Working Party ‘Antimicrobial Resistance’ of the Paul-Ehrlich-Society of Chemotherapy1 a
Antiinfectives Intelligence GmbH, Rheinbach, Germany Rhine University of Applied Sciences, Cologne, Germany Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistance, Wernigerode, Germany d Institute of Pharmacology and Clinical Pharmacology, Heinrich-Heine-University, Düsseldorf, Germany b c
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Article history: Received 14 February 2014 Accepted 6 May 2014
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Keywords: CTX-M-15 ST131 Uropathogen Outpatients Community-acquired
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1. Introduction
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The in vitro activities of fosfomycin and seven other antibiotics commonly used for oral treatment of urinary tract infections (UTIs) were evaluated for 499 Escherichia coli isolated from urine samples during a nationwide laboratory-based surveillance study in 2010. Overall, the highest resistance rates were found for amoxicillin (42.9%), followed by amoxicillin/clavulanic acid (32.7%), trimethoprim/sulfamethoxazole (SXT) (30.9%), ciprofloxacin (19.8%), cefuroxime (10.0%), cefpodoxime (8.6%) and cefixime (8.2%). Onehalf of the isolates (n = 252; 50.5%) were fully susceptible to the eight drugs, whilst only 6 strains (1.2%) were resistant to fosfomycin. Combined resistance to amoxicillin, cefuroxime, ciprofloxacin and SXT was detected in 29 isolates (5.8%). Moreover, 40 isolates (8.0%) produced an extended-spectrum -lactamase (ESBL), including CTX-M-type ESBLs detected in 39/40 isolates (97.5%) and a TEM-52 ESBL in 1 strain (2.5%). The predominant CTX-M-type ESBL was CTX-M-15 (27/39; 69.2%). Of the 27 CTX-M-15 producers, 19 (70.4%) belonged to the clonal lineage E. coli O25b-ST131. All but one ESBL-producing strains were fosfomycin-susceptible. In view of the emergence of multidrug resistance to standard oral antibiotics, these data support that oral fosfomycin (trometamol salt) may represent a valuable option in the treatment of uncomplicated UTIs. © 2014 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
Yearly, more than 150 million urinary tract infections (UTIs) occur throughout the world [1], with Escherichia coli being involved in 70–80% of uncomplicated UTIs [2]. Increased acquired resistance to a variety of orally administered antibiotics in E. coli has complicated the management of UTIs in the outpatient setting [3]. The spread of extended-spectrum -lactamase (ESBL)-producing E. coli
∗ Corresponding author at: Present address: Antiinfectives Intelligence GmbH, Campus of the University of Applied Sciences, Von-Liebig-Straße 20, 53359 Rheinbach, Germany. Tel.: +49 2226 908 912; fax: +49 2226 908 918. E-mail address: [email protected] (M. Kresken). 1 See Appendix A for list of participants.
strains, which are usually cross-resistant to many other classes of antibiotics, has been recognised worldwide as a significant cause of community-acquired infections [4]. In particular, the CTX-M-15 ESBL has been shown to be linked to the widespread clonal group of E. coli serotype O25b-sequence type 131 (O25b-ST131) isolates causing different community-onset infections [5]. Use of fosfomycin in the form of a single oral dose of its trometamol salt has attracted increasing attention as first-line therapy of uncomplicated UTIs. Fosfomycin exhibits bactericidal activity against a broad spectrum of aerobic bacteria, including E. coli, and does not exhibit cross-resistance to other classes of antibiotics, including those associated with high or increasing rates of resistance [6,7]. Studies from many countries detected low rates of fosfomycin resistance (usually 32 mg/L) was detected in 53 isolates (10.6%). Six E. coli isolates (1.2%) were resistant to fosfomycin, and 19 fosfomycin-susceptible isolates showed increased MICs of fosfomycin (16–32 mg/L). Of the 499 isolates, 252 (50.5%) were fully susceptible to amoxicillin, AMC, cefixime, cefpodoxime, cefuroxime, ciprofloxacin, SXT and fosfomycin. In total, 40 isolates (8.0%) were resistant to one agent, 64 (12.8%) to two agents and 143 isolates (28.7%) met the criterion of multidrug resistance. Among these MDR E. coli, 18 isolates (3.6%) from 10 laboratories were detected that were resistant to all antibiotics except fosfomycin, and 1 strain (0.2%) was resistant to all eight drugs. Resistance patterns were evaluated considering the four ‘key antibiotics’ amoxicillin, cefuroxime, ciprofloxacin and SXT. The results showed that 245 isolates (49.1%) were resistant to at least one of the four drugs, whilst quadruple resistance was noted in 29 isolates (5.8%) (Table 2). An ESBL phenotype was confirmed for 40 isolates (8.0%). Resistance rates in the subgroups of ESBL-positive and ESBL-negative isolates were, respectively, 80.0% vs. 28.5% for AMC (difference 51.5%, 95% CI 36.1–61.7%), 77.5% vs. 26.8% for SXT (difference 50.7%, 95% CI 35.1–61.6%) and 75.0% vs. 15.0% for ciprofloxacin (difference 60.0%, 95% CI 44.4–71.2%). Resistance to fosfomycin was observed
Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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1 (100) 1 (99.8) 4 (99.6) 152 (100) 5 (98.8) 83 (100) 2 (69.5) 14 (97.8)
2 (0.4) 213 (63.5) 113 (86.2) 242 (56.9) 144 (85.8) 25 (77.6) 9 (79.4) 328 (65 .7) 8 (67.3) 27 (5 .4) 77 (20.8) 6 (1 .2) 36 (8.4) 353 (70 .7) 9 (72.5)
Amoxicillin AMCa Cefuroxime Cefixime Cefpodoxime Ciprofloxacin SXTb Fosfomycin
MIC, minimum inhibitory concentration; MIC50/90 , MIC required to inhibit 50% and 90% of the isolates, respectively; %S, percent susceptible; %I, percent intermediate; %R, percent resistant; AMC, amoxicillin/clavulanic acid; SXT, trimethoprim/sulfamethoxazole. Numbers in bold include isolates with an MIC less than the value shown; numbers in italic include isolates with an MIC greater than the highest concentration tested. a The concentration of clavulanic acid was fixed at 2 mg/L; MICs are expressed as the amoxicillin concentration. b Trimethoprim/sulfamethoxazole in a ratio of 1:19; MICs are expressed as the trimethoprim concentration.
42.9 32.7 10.0 8.2 8.6 19.8 30.9 1.2 57.1 67.3 90.0 91.8 91.4 79.4 68.7 98.8 ≥64 64 8 1 1 ≥16 ≥32 4 4 4 4 0.25 0.25 ≤0.063 ≤0.25 ≤1 16 (100) 11 (96.8) 5 (58.1) 77 (82.8) 13 (92.6)
114 (26.9) 171 (40.1) 80 (18.4) 5 (92.8) 3 (92.0) 1 (80.4) 3 (68.7) 129 (84.6) 2 (0.4)
18 (4.0) 29 (5 .8) 10 (2.4) 28 (91.8) 28 (91.4) 4 (80.2) 4 (68.1) 293 (58.7)
144 (55.7) 90 (58.1) 262 (70.9) 3 (93.4) 3 (92.6) 6 (81.6) 2 (69.1) 39 (92.4)
7 (57.1) 46 (67.3) 95 (90.0) 33 (100) 37 (100) 9 (83.4) 0 (69.1) 13 (95.0)
5 (59.1) 33 (89.4) 37 (100)
204 (100) 26 (94.6)
– – – – – 0.8 0.4 –
%S MIC90 MIC50 ≥256 128 16 8 4 2 1 0.5 0.25 0.12 ≤0.06
No. (cumulative %) of isolates with an MIC (mg/L) of Antibacterial agent
Table 1 In vitro activity of fosfomycin in comparison with seven commonly used antibiotics against 499 Escherichia coli urinary isolates.
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Susceptibility MIC (mg/L)
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Table 2 Resistance patterns of 245 Escherichia coli isolates resistant to at least one of the four ‘key antibiotics’.a Antibiotic
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AMX CIP SXT AMX, SXT AMX, CIP SXT, CIP AMX, CXM AMX, SXT, CIP AMX, CXM, CIP AMX, CXM, SXT CXM, SXT, CIP AMX, CXM, SXT, CIP
53 14 10 71 12 6 4 29 8 8 1 29
10.6 2.8 2.0 14.2 2.4 1.2 0.8 5.8 1.6 1.6 0.2 5.8
a Four antibiotics were considered: amoxicillin (AMX), cefuroxime (CXM), trimethoprim/sulfamethoxazole (SXT) and ciprofloxacin (CIP).
in 5 (1.1%) of 459 ESBL-negative isolates and in 1 (2.5%) of 40 ESBLpositive isolates. 3.2. Extended-spectrum ˇ-lactamase types and E. coli clonal group O25b-ST131 CTX-M ESBLs were present in 39 (97.5%) of the 40 ESBL-positive isolates. The remaining isolate harboured a TEM-52 ESBL. The predominant CTX-M ESBL was CTX-M-15 (27/39; 69.2%) followed by CTX-M-1 (4/39; 10.3%), CTX-M-14 (4/39; 10.3%), CTX-M-3 (2/39; 5.1%) and CTX-M-27 (2/39; 5.1%). Resistance to ciprofloxacin was more frequently distributed among CTX-M-15-producers than isolates harbouring other types of ESBL (92.6% vs. 38.5%; difference 54.1%, 95% CI 23.6–75.6%). In contrast, there was no significant difference in the resistance rates for AMC and SXT between both groups. However, MIC50/90 values of AMC were ≥4-fold higher for CTX-M-15-producers (64/≥256 mg/L) compared with isolates producing other types of ESBL (16/64 mg/L). The rfbO25b gene was detected in 19 (70.4%) of the 27 CTX-M15-positive isolates. The majority of these 19 isolates were also resistant to ciprofloxacin (18/19; 94.7%), AMC (16/19; 84.2%) and SXT (16/19; 84.2%). A single CTX-M-15-producing E. coli O25bST131 isolate (1/19; 5.3%) was fosfomycin-resistant. 3.3. Prevalence of resistance among isolates from different patient subgroups In general, antibiotic resistance was most common in isolates from men and elderly women and was least common in isolates from young women. However, resistance to amoxicillin and AMC was least frequently detected in isolates of females aged 18–65 years (Table 3). The prevalence of resistance to ciprofloxacin was >30% in isolates from men (32.4%) and gradually increased in isolates from females by age group (from 25% in elderly women), whilst resistance to second-generation (cefuroxime) and third-generation (cefixime, cefpodoxime) cephalosporins as well as ESBL production was fairly similar between the four patient groups (Table 3). The rate of sevenfold-resistant isolates was 32 mg/L) were identified in five laboratories and the 19 isolates with fosfomycin MICs of 16–32 mg/L were collected in fourteen laboratories. Of these 25
Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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Table 3 Prevalence (%) of drug resistance among 499 Escherichia coli isolates in different subgroups of patients. Antibacterial agent
Amoxicillin AMC Cefuroxime Cefixime Cefpodoxime Ciprofloxacin SXT Fosfomycin Sevenfold-susceptiblea Quadruple-resistantb Sevenfold-resistantc ESBL-positive isolates E. coli O25b-ST131 CTX-M-15
Patient group Men (n = 71)
Women 65 years (n = 175)
Women total (n = 428)
45.1 36.6 12.7 9.9 8.5 32.4 35.2 1.4 45.1 7.0 4.2 8.5 5.6
43.7 35.6 6.9 5.7 5.7 9.2 25.3 0 55.2 2.3 1.1 5.7 2.3
34.9 24.7 9.6 9.6 10.2 13.9 25.9 0.6 58.4 6.0 4.8 9.6 3.6
49.1 37.1 10.9 7.4 8.6 25.7 36.6 2.3 43.4 6.9 4.0 7.4 4.0
42.5 32.0 9.6 7.9 8.6 17.8 30.1 1.2 51.6 5.6 3.7 7.9 3.5
AMC, amoxicillin/clavulanic acid; SXT, trimethoprim/sulfamethoxazole; ESBL, extended-spectrum -lactamase. a Susceptible to amoxicillin, AMC, cefuroxime, cefixime, cefpodoxime, ciprofloxacin and SXT. b Resistant to amoxicillin, cefuroxime, ciprofloxacin and SXT. c Resistant to amoxicillin, AMC, cefuroxime, cefixime, cefpodoxime, ciprofloxacin and SXT.
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isolates, 17 (68%), 14 (56%), 10 (40%), 7 (28%) and 4 (16%) were resistant to amoxicillin, AMC, SXT, ciprofloxacin and cefuroxime, respectively. One fosfomycin-resistant strain and two strains with a fosfomycin MIC of 16 mg/L were additionally resistant to the other seven antibacterial agents. These three isolates harboured the blaCTX-M-15 gene and were collected at three different sites. Two of the three isolates belonged to E. coli clonal group O25b-ST131. The remaining 22 isolates were ESBL-negative. Co-resistance to amoxicillin and AMC occurred more frequently among isolates with fosfomycin MICs of ≥16 mg/L than among isolates with fosfomycin MICs of ≤8 mg/L (amoxicillin, 68.0% vs. 41.6%; difference 26.4%, 95% CI 6.3–41.9%; AMC, 56.0% vs. 31.4%, difference 24.6%, 95% CI 5.1–42.4%).
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4. Discussion
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The present surveillance study involving 25 clinical microbiological laboratories across Germany has investigated the occurrence of resistance to eight oral antibiotics among 499 E. coli isolated from urine samples of outpatients. As expected, the vast majority of isolates (>85%) were obtained from women. The finding that ca. 40% of the isolates were resistant to amoxicillin, 30% to SXT and 20% to ciprofloxacin is consistent with that of E. coli isolates from uncomplicated cystitis in women collected at 20 centres in Spain over a 1-year period (November 2003–October 2004) [8]. In contrast, an international survey on the antimicrobial resistance of pathogens involved in uncomplicated UTI (ARESC) reported lower rates of resistance to ciprofloxacin for E. coli isolates obtained from patients in Germany (4%) and Spain (11%) [2]. In the current study, resistance rates to AMC and cefuroxime were ca. 30% and 10%, respectively. In contrast, the nationwide study performed in Spain in 2003/2004 reported only 2% resistance for both drugs [8]. The differences in resistance rates might be explained by the continuous increase in E. coli isolates with resistance to third-generation cephalosporins in both countries since 2003 [17]. Moreover, detection of resistance to AMC is strongly influenced by the amount of clavulanic acid applied to the test system. The ISO has suggested adding a fixed concentration of 2 mg/L to serial dilutions of amoxicillin [12], whereas the CLSI has proposed a concentration ratio of 2:1 for amoxicillin to clavulanic acid [14]. EUCAST has recently set a breakpoint of >32 mg/L for resistance to AMC in Enterobacteriaceae isolates obtained from patients with uncomplicated UTI [13]. If this breakpoint was applied in the current study, 10.6% of the isolates would be considered resistant to AMC.
Similar to other studies, the incidence of antimicrobial resistance in E. coli tended to be higher in men than in women [18,19] and varied with age, affecting most commonly elderly female patients [8,19]. Large differences between resistance rates in this study were particularly evident for fluoroquinolones (ciprofloxacin), varying from 25% in elderly women and men. Previous use of fluoroquinolones has been shown to be a risk factor for community-acquired UTI due to quinolone-resistant E. coli [18]. Fluoroquinolones are rarely administered to children and adolescents, but they are frequently prescribed for treatment of infections (predominately respiratory infections) in elderly patients. German data on antibiotic prescribing for outpatients from 2011 showed that fluoroquinolones are the fourth and second most common drugs consumed by patients aged >60 years and >80 years, respectively [20]. In Germany, fluoroquinolones are no longer recommended for the treatment of simple self-limiting conditions such as uncomplicated cystitis but they are still considered first-line drugs for therapy of acute pyelonephritis and complicated UTI [21]. Inconsistent results regarding the impact of fluoroquinolone resistance on the clinical outcome in patients with uncomplicated acute pyelonephritis were reported from studies in South Korea. One study did not find a statistically significant difference between the clinical cure rates of the ciprofloxacin-susceptible group and the ciprofloxacin-resistant group (although the microbiological cure rate was lower in the ciprofloxacin-resistant group than in the ciprofloxacin-susceptible group) [22], whilst the other study found a statistically significant lower clinical response rate and a longer hospital stay for patients in the fluoroquinolone-resistant group [23]. Unlike resistance to fluoroquinolones, in this study we observed that the presence of ESBL-producing E. coli (overall ESBL rate, 8.0%) was nearly equally distributed between various patient groups. Similar results were shown in a study on ESBL-producing E. coli in the German community with an ESBL carriage rate of 6.3%, without significant differences among various patient age groups [24]. In that study, the majority (95.2%) of ESBL-positive isolates harboured a CTX-M-type ESBL, with CTX-M-15 (46%) as the most common type. In the current study the prevalence of strains harbouring a CTX-M ESBL was similar but CTX-M-15 occurred more frequently (69.2%). Furthermore, in the current study E. coli O25b:H4-ST131 producing CTX-M-15 was identified as the predominant ESBLproducing clone. Escherichia coli O25b:H4-ST131 was also found to be the most prevalent clone among CTX-M-15-producing isolates
Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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obtained from hospitalised patients and nursing home patients in Germany [25,26] and it has been reported as the dominant extraintestinal pathogenic E. coli clone worldwide [5]. A recent study analysing the molecular epidemiology of a large collection of E. coli isolates, including a considerable number of strains from Germany, indicated that most CTX-M-15-producing ST131 strains belong to a single highly pathogenic subclone called H30-Rx [27]. Fosfomycin (as trometamol salt) has been considered a drug of first choice for empirical treatment of uncomplicated cystitis in Germany [21]. Data from the current study show that fosfomycin was highly active in vitro against the isolates tested. No more than six strains (1.2%) were fosfomycin-resistant (MIC > 32 mg/L). Thus, these findings confirm the high rate of fosfomycin susceptibility (98%) found for German isolates in the ARESC study [2]. Notably, only 1 (2.5%) of the 40 ESBL-producing strains seen in the present study was fosfomycin-resistant. Interestingly, in a study performed in Spain with isolates collected between 2005 and 2009, Oteo et al. [10] observed a strong correlation between fosfomycin resistance in ESBL-producing E. coli from UTIs (from 4.4% in 2005 to 11.4% in 2009) and the use of fosfomycin in outpatients, but the overall rate of fosfomycin resistance remained low (2.9% in 2009). In Spain, community use of fosfomycin had increased from 0.05 defined daily doses (DDD) per 1000 inhabitants per day (DID) in 1997 to 0.22 DID in 2008 [10], whilst in Germany outpatient use of fosfomycin was comparatively low, with 0.5 million DDD (corresponding to 45 years old, isolates from routine samples showed lower susceptibility to the three -lactams and norfloxacin compared with those from solicited samples [30]. The approved method for in vitro susceptibility testing of fosfomycin is agar dilution [14]. In the present study, the broth microdilution method was used. In preceding experiments we found comparable MICs of fosfomycin for E. coli ATCC 25922 with both methods of susceptibility testing (unpublished data). Moreover, MICs of fosfomycin determined for the quality control strain E. coli ATCC 25922 in the present study (≤1–2 mg/L) were always within the concentration range published in the documents ISO 20776-1 and CLSI M100-S21 [12,14]. In conclusion, resistance to -lactams (e.g. amoxicillin and AMC), fluoroquinolones and SXT appears to be widespread amongst E. coli isolated from urine samples of outpatients in Germany. This fact must be considered for empirical treatment of UTI. In contrast,
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The technical assistance of G. Anlauf, A. Frank, J. Fritz, E. Luhmer, N. Scheliga and N. Schmandt is gratefully acknowledged. Appendix A. Members of the Working Party ‘Antimicrobial Resistance’ of the Paul-Ehrlich-Society of Chemotherapy In addition to the authors, the following members of the study group (in alphabetical order) contributed to the study: L. Artz (Ingolstadt), T. Becker (Munich), S. Burak (Düsseldorf), J. Cremer (Kempten), A. Eberhard (Dortmund), U. Eigner (Heidelberg), R. Englert (Freiburg), J. Enzenauer (Osnabrück), J. Esser (Osnabrück), I. Fenner (Hamburg), P. Finzer (Moers, now Cologne), G. Funke (Ravensburg), A. Gehrt (Düsseldorf), R.R.E. Gyenes (Essen), T. Hermann (Würzburg), R. Hillert (Görlitz), W. Hönerlage (Hamburg), M. Holfelder (Heidelberg), R. Huber (Cologne), F. Hugo (Berlin), M. Jacobs (Dillingen/Saar), U. Knipp (Trier), S. Krämer (Essen), R. Krajewski (Würzburg), E. Kühnen (Trier), C. Lensing (Hamburg), J. Lerner (Augsburg), A. Pranada (Dortmund), F. Pranada (Dortmund), A. Reinecke (Rostock), H. Sahly (Hamburg), S. Schmitt (Kaiserslautern), M. Schröter (Jena), R. Schwarz (Mönchengladbach), A. Siedlaczek (Freiburg), R. Tauchnitz-Hiemisch (Leipzig), U. Thalmaier (Augsburg), F. Wisplinghoff (Cologne) and H. Wisplinghoff (Cologne). Funding This study was funded by grants from Abbott GmbH & Co. KG, ACTAVIS Deutschland GmbH & Co. KG, Apogepha Arzneimittel GmbH, Bayer Vital GmbH, betapharm Arzneimittel GmbH, Q2 Daiichi-Sankyo Deutschland GmbH, DOLORGIET GmbH & Co. KG, Dr. R. Pfleger Chemische Fabrik GmbH, GlaxoSmithKline GmbH & Co. KG, InfectoPharm Arzneimittel und Consilium GmbH, Kohne Pharma GmbH, KSK-Pharma AG, Rottapharm/Madaus GmbH, MEDA Pharma GmbH & Co. KG, mibe GmbH Arzneimittel, Pfizer Pharma GmbH, Sanofi-Aventis Deutschland GmbH, STADA Arzneimittel AG and Wörwag Pharma GmbH & Co. KG to the PaulEhrlich-Society of Chemotherapy. The present work was funded by a grant from Zambon S.p.A. to the Antiinfectives Intelligence GmbH. Q3 Competing interests MK is a partner and CEO of Antiinfectives Intelligence GmbH, a research organisation providing services to pharmaceutical companies; BK-I and RW are employees of Antiinfectives Intelligence GmbH. All other authors declare no competing interests. Ethical approval Not required. References [1] Stamm WE, Norrby SR. Urinary tract infections: disease panorama and challenges. J Infect Dis 2001;183(Suppl. 1):S1–4. [2] Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol 2008;54:1164–75. [3] Kahlmeter G, Poulsen HO. Antimicrobial susceptibility of Escherichia coli from community-acquired urinary tract infections in Europe: the ECO·SENS study revisited. Int J Antimicrob Agents 2012;39:45–51.
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Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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Contents lists available at ScienceDirect
International Journal of Antimicrobial Agents journal homepage: http://www.elsevier.com/locate/ijantimicag
Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin
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Michael Kresken a,b,∗ , Yvonne Pfeifer c , Dieter Hafner d , Rebecca Wresch a , Barbara Körber-Irrgang a , Working Party ‘Antimicrobial Resistance’ of the Paul-Ehrlich-Society of Chemotherapy1 a
Antiinfectives Intelligence GmbH, Rheinbach, Germany Rhine University of Applied Sciences, Cologne, Germany Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistance, Wernigerode, Germany d Institute of Pharmacology and Clinical Pharmacology, Heinrich-Heine-University, Düsseldorf, Germany b c
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Article history: Received 14 February 2014 Accepted 6 May 2014
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Keywords: CTX-M-15 ST131 Uropathogen Outpatients Community-acquired
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1. Introduction
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The in vitro activities of fosfomycin and seven other antibiotics commonly used for oral treatment of urinary tract infections (UTIs) were evaluated for 499 Escherichia coli isolated from urine samples during a nationwide laboratory-based surveillance study in 2010. Overall, the highest resistance rates were found for amoxicillin (42.9%), followed by amoxicillin/clavulanic acid (32.7%), trimethoprim/sulfamethoxazole (SXT) (30.9%), ciprofloxacin (19.8%), cefuroxime (10.0%), cefpodoxime (8.6%) and cefixime (8.2%). Onehalf of the isolates (n = 252; 50.5%) were fully susceptible to the eight drugs, whilst only 6 strains (1.2%) were resistant to fosfomycin. Combined resistance to amoxicillin, cefuroxime, ciprofloxacin and SXT was detected in 29 isolates (5.8%). Moreover, 40 isolates (8.0%) produced an extended-spectrum -lactamase (ESBL), including CTX-M-type ESBLs detected in 39/40 isolates (97.5%) and a TEM-52 ESBL in 1 strain (2.5%). The predominant CTX-M-type ESBL was CTX-M-15 (27/39; 69.2%). Of the 27 CTX-M-15 producers, 19 (70.4%) belonged to the clonal lineage E. coli O25b-ST131. All but one ESBL-producing strains were fosfomycin-susceptible. In view of the emergence of multidrug resistance to standard oral antibiotics, these data support that oral fosfomycin (trometamol salt) may represent a valuable option in the treatment of uncomplicated UTIs. © 2014 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
Yearly, more than 150 million urinary tract infections (UTIs) occur throughout the world [1], with Escherichia coli being involved in 70–80% of uncomplicated UTIs [2]. Increased acquired resistance to a variety of orally administered antibiotics in E. coli has complicated the management of UTIs in the outpatient setting [3]. The spread of extended-spectrum -lactamase (ESBL)-producing E. coli
∗ Corresponding author at: Present address: Antiinfectives Intelligence GmbH, Campus of the University of Applied Sciences, Von-Liebig-Straße 20, 53359 Rheinbach, Germany. Tel.: +49 2226 908 912; fax: +49 2226 908 918. E-mail address: [email protected] (M. Kresken). 1 See Appendix A for list of participants.
strains, which are usually cross-resistant to many other classes of antibiotics, has been recognised worldwide as a significant cause of community-acquired infections [4]. In particular, the CTX-M-15 ESBL has been shown to be linked to the widespread clonal group of E. coli serotype O25b-sequence type 131 (O25b-ST131) isolates causing different community-onset infections [5]. Use of fosfomycin in the form of a single oral dose of its trometamol salt has attracted increasing attention as first-line therapy of uncomplicated UTIs. Fosfomycin exhibits bactericidal activity against a broad spectrum of aerobic bacteria, including E. coli, and does not exhibit cross-resistance to other classes of antibiotics, including those associated with high or increasing rates of resistance [6,7]. Studies from many countries detected low rates of fosfomycin resistance (usually 32 mg/L) was detected in 53 isolates (10.6%). Six E. coli isolates (1.2%) were resistant to fosfomycin, and 19 fosfomycin-susceptible isolates showed increased MICs of fosfomycin (16–32 mg/L). Of the 499 isolates, 252 (50.5%) were fully susceptible to amoxicillin, AMC, cefixime, cefpodoxime, cefuroxime, ciprofloxacin, SXT and fosfomycin. In total, 40 isolates (8.0%) were resistant to one agent, 64 (12.8%) to two agents and 143 isolates (28.7%) met the criterion of multidrug resistance. Among these MDR E. coli, 18 isolates (3.6%) from 10 laboratories were detected that were resistant to all antibiotics except fosfomycin, and 1 strain (0.2%) was resistant to all eight drugs. Resistance patterns were evaluated considering the four ‘key antibiotics’ amoxicillin, cefuroxime, ciprofloxacin and SXT. The results showed that 245 isolates (49.1%) were resistant to at least one of the four drugs, whilst quadruple resistance was noted in 29 isolates (5.8%) (Table 2). An ESBL phenotype was confirmed for 40 isolates (8.0%). Resistance rates in the subgroups of ESBL-positive and ESBL-negative isolates were, respectively, 80.0% vs. 28.5% for AMC (difference 51.5%, 95% CI 36.1–61.7%), 77.5% vs. 26.8% for SXT (difference 50.7%, 95% CI 35.1–61.6%) and 75.0% vs. 15.0% for ciprofloxacin (difference 60.0%, 95% CI 44.4–71.2%). Resistance to fosfomycin was observed
Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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1 (100) 1 (99.8) 4 (99.6) 152 (100) 5 (98.8) 83 (100) 2 (69.5) 14 (97.8)
2 (0.4) 213 (63.5) 113 (86.2) 242 (56.9) 144 (85.8) 25 (77.6) 9 (79.4) 328 (65 .7) 8 (67.3) 27 (5 .4) 77 (20.8) 6 (1 .2) 36 (8.4) 353 (70 .7) 9 (72.5)
Amoxicillin AMCa Cefuroxime Cefixime Cefpodoxime Ciprofloxacin SXTb Fosfomycin
MIC, minimum inhibitory concentration; MIC50/90 , MIC required to inhibit 50% and 90% of the isolates, respectively; %S, percent susceptible; %I, percent intermediate; %R, percent resistant; AMC, amoxicillin/clavulanic acid; SXT, trimethoprim/sulfamethoxazole. Numbers in bold include isolates with an MIC less than the value shown; numbers in italic include isolates with an MIC greater than the highest concentration tested. a The concentration of clavulanic acid was fixed at 2 mg/L; MICs are expressed as the amoxicillin concentration. b Trimethoprim/sulfamethoxazole in a ratio of 1:19; MICs are expressed as the trimethoprim concentration.
42.9 32.7 10.0 8.2 8.6 19.8 30.9 1.2 57.1 67.3 90.0 91.8 91.4 79.4 68.7 98.8 ≥64 64 8 1 1 ≥16 ≥32 4 4 4 4 0.25 0.25 ≤0.063 ≤0.25 ≤1 16 (100) 11 (96.8) 5 (58.1) 77 (82.8) 13 (92.6)
114 (26.9) 171 (40.1) 80 (18.4) 5 (92.8) 3 (92.0) 1 (80.4) 3 (68.7) 129 (84.6) 2 (0.4)
18 (4.0) 29 (5 .8) 10 (2.4) 28 (91.8) 28 (91.4) 4 (80.2) 4 (68.1) 293 (58.7)
144 (55.7) 90 (58.1) 262 (70.9) 3 (93.4) 3 (92.6) 6 (81.6) 2 (69.1) 39 (92.4)
7 (57.1) 46 (67.3) 95 (90.0) 33 (100) 37 (100) 9 (83.4) 0 (69.1) 13 (95.0)
5 (59.1) 33 (89.4) 37 (100)
204 (100) 26 (94.6)
– – – – – 0.8 0.4 –
%S MIC90 MIC50 ≥256 128 16 8 4 2 1 0.5 0.25 0.12 ≤0.06
No. (cumulative %) of isolates with an MIC (mg/L) of Antibacterial agent
Table 1 In vitro activity of fosfomycin in comparison with seven commonly used antibiotics against 499 Escherichia coli urinary isolates.
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%I
Susceptibility MIC (mg/L)
%R
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Table 2 Resistance patterns of 245 Escherichia coli isolates resistant to at least one of the four ‘key antibiotics’.a Antibiotic
n
% of total (N = 499)
AMX CIP SXT AMX, SXT AMX, CIP SXT, CIP AMX, CXM AMX, SXT, CIP AMX, CXM, CIP AMX, CXM, SXT CXM, SXT, CIP AMX, CXM, SXT, CIP
53 14 10 71 12 6 4 29 8 8 1 29
10.6 2.8 2.0 14.2 2.4 1.2 0.8 5.8 1.6 1.6 0.2 5.8
a Four antibiotics were considered: amoxicillin (AMX), cefuroxime (CXM), trimethoprim/sulfamethoxazole (SXT) and ciprofloxacin (CIP).
in 5 (1.1%) of 459 ESBL-negative isolates and in 1 (2.5%) of 40 ESBLpositive isolates. 3.2. Extended-spectrum ˇ-lactamase types and E. coli clonal group O25b-ST131 CTX-M ESBLs were present in 39 (97.5%) of the 40 ESBL-positive isolates. The remaining isolate harboured a TEM-52 ESBL. The predominant CTX-M ESBL was CTX-M-15 (27/39; 69.2%) followed by CTX-M-1 (4/39; 10.3%), CTX-M-14 (4/39; 10.3%), CTX-M-3 (2/39; 5.1%) and CTX-M-27 (2/39; 5.1%). Resistance to ciprofloxacin was more frequently distributed among CTX-M-15-producers than isolates harbouring other types of ESBL (92.6% vs. 38.5%; difference 54.1%, 95% CI 23.6–75.6%). In contrast, there was no significant difference in the resistance rates for AMC and SXT between both groups. However, MIC50/90 values of AMC were ≥4-fold higher for CTX-M-15-producers (64/≥256 mg/L) compared with isolates producing other types of ESBL (16/64 mg/L). The rfbO25b gene was detected in 19 (70.4%) of the 27 CTX-M15-positive isolates. The majority of these 19 isolates were also resistant to ciprofloxacin (18/19; 94.7%), AMC (16/19; 84.2%) and SXT (16/19; 84.2%). A single CTX-M-15-producing E. coli O25bST131 isolate (1/19; 5.3%) was fosfomycin-resistant. 3.3. Prevalence of resistance among isolates from different patient subgroups In general, antibiotic resistance was most common in isolates from men and elderly women and was least common in isolates from young women. However, resistance to amoxicillin and AMC was least frequently detected in isolates of females aged 18–65 years (Table 3). The prevalence of resistance to ciprofloxacin was >30% in isolates from men (32.4%) and gradually increased in isolates from females by age group (from 25% in elderly women), whilst resistance to second-generation (cefuroxime) and third-generation (cefixime, cefpodoxime) cephalosporins as well as ESBL production was fairly similar between the four patient groups (Table 3). The rate of sevenfold-resistant isolates was 32 mg/L) were identified in five laboratories and the 19 isolates with fosfomycin MICs of 16–32 mg/L were collected in fourteen laboratories. Of these 25
Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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Table 3 Prevalence (%) of drug resistance among 499 Escherichia coli isolates in different subgroups of patients. Antibacterial agent
Amoxicillin AMC Cefuroxime Cefixime Cefpodoxime Ciprofloxacin SXT Fosfomycin Sevenfold-susceptiblea Quadruple-resistantb Sevenfold-resistantc ESBL-positive isolates E. coli O25b-ST131 CTX-M-15
Patient group Men (n = 71)
Women 65 years (n = 175)
Women total (n = 428)
45.1 36.6 12.7 9.9 8.5 32.4 35.2 1.4 45.1 7.0 4.2 8.5 5.6
43.7 35.6 6.9 5.7 5.7 9.2 25.3 0 55.2 2.3 1.1 5.7 2.3
34.9 24.7 9.6 9.6 10.2 13.9 25.9 0.6 58.4 6.0 4.8 9.6 3.6
49.1 37.1 10.9 7.4 8.6 25.7 36.6 2.3 43.4 6.9 4.0 7.4 4.0
42.5 32.0 9.6 7.9 8.6 17.8 30.1 1.2 51.6 5.6 3.7 7.9 3.5
AMC, amoxicillin/clavulanic acid; SXT, trimethoprim/sulfamethoxazole; ESBL, extended-spectrum -lactamase. a Susceptible to amoxicillin, AMC, cefuroxime, cefixime, cefpodoxime, ciprofloxacin and SXT. b Resistant to amoxicillin, cefuroxime, ciprofloxacin and SXT. c Resistant to amoxicillin, AMC, cefuroxime, cefixime, cefpodoxime, ciprofloxacin and SXT.
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isolates, 17 (68%), 14 (56%), 10 (40%), 7 (28%) and 4 (16%) were resistant to amoxicillin, AMC, SXT, ciprofloxacin and cefuroxime, respectively. One fosfomycin-resistant strain and two strains with a fosfomycin MIC of 16 mg/L were additionally resistant to the other seven antibacterial agents. These three isolates harboured the blaCTX-M-15 gene and were collected at three different sites. Two of the three isolates belonged to E. coli clonal group O25b-ST131. The remaining 22 isolates were ESBL-negative. Co-resistance to amoxicillin and AMC occurred more frequently among isolates with fosfomycin MICs of ≥16 mg/L than among isolates with fosfomycin MICs of ≤8 mg/L (amoxicillin, 68.0% vs. 41.6%; difference 26.4%, 95% CI 6.3–41.9%; AMC, 56.0% vs. 31.4%, difference 24.6%, 95% CI 5.1–42.4%).
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4. Discussion
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The present surveillance study involving 25 clinical microbiological laboratories across Germany has investigated the occurrence of resistance to eight oral antibiotics among 499 E. coli isolated from urine samples of outpatients. As expected, the vast majority of isolates (>85%) were obtained from women. The finding that ca. 40% of the isolates were resistant to amoxicillin, 30% to SXT and 20% to ciprofloxacin is consistent with that of E. coli isolates from uncomplicated cystitis in women collected at 20 centres in Spain over a 1-year period (November 2003–October 2004) [8]. In contrast, an international survey on the antimicrobial resistance of pathogens involved in uncomplicated UTI (ARESC) reported lower rates of resistance to ciprofloxacin for E. coli isolates obtained from patients in Germany (4%) and Spain (11%) [2]. In the current study, resistance rates to AMC and cefuroxime were ca. 30% and 10%, respectively. In contrast, the nationwide study performed in Spain in 2003/2004 reported only 2% resistance for both drugs [8]. The differences in resistance rates might be explained by the continuous increase in E. coli isolates with resistance to third-generation cephalosporins in both countries since 2003 [17]. Moreover, detection of resistance to AMC is strongly influenced by the amount of clavulanic acid applied to the test system. The ISO has suggested adding a fixed concentration of 2 mg/L to serial dilutions of amoxicillin [12], whereas the CLSI has proposed a concentration ratio of 2:1 for amoxicillin to clavulanic acid [14]. EUCAST has recently set a breakpoint of >32 mg/L for resistance to AMC in Enterobacteriaceae isolates obtained from patients with uncomplicated UTI [13]. If this breakpoint was applied in the current study, 10.6% of the isolates would be considered resistant to AMC.
Similar to other studies, the incidence of antimicrobial resistance in E. coli tended to be higher in men than in women [18,19] and varied with age, affecting most commonly elderly female patients [8,19]. Large differences between resistance rates in this study were particularly evident for fluoroquinolones (ciprofloxacin), varying from 25% in elderly women and men. Previous use of fluoroquinolones has been shown to be a risk factor for community-acquired UTI due to quinolone-resistant E. coli [18]. Fluoroquinolones are rarely administered to children and adolescents, but they are frequently prescribed for treatment of infections (predominately respiratory infections) in elderly patients. German data on antibiotic prescribing for outpatients from 2011 showed that fluoroquinolones are the fourth and second most common drugs consumed by patients aged >60 years and >80 years, respectively [20]. In Germany, fluoroquinolones are no longer recommended for the treatment of simple self-limiting conditions such as uncomplicated cystitis but they are still considered first-line drugs for therapy of acute pyelonephritis and complicated UTI [21]. Inconsistent results regarding the impact of fluoroquinolone resistance on the clinical outcome in patients with uncomplicated acute pyelonephritis were reported from studies in South Korea. One study did not find a statistically significant difference between the clinical cure rates of the ciprofloxacin-susceptible group and the ciprofloxacin-resistant group (although the microbiological cure rate was lower in the ciprofloxacin-resistant group than in the ciprofloxacin-susceptible group) [22], whilst the other study found a statistically significant lower clinical response rate and a longer hospital stay for patients in the fluoroquinolone-resistant group [23]. Unlike resistance to fluoroquinolones, in this study we observed that the presence of ESBL-producing E. coli (overall ESBL rate, 8.0%) was nearly equally distributed between various patient groups. Similar results were shown in a study on ESBL-producing E. coli in the German community with an ESBL carriage rate of 6.3%, without significant differences among various patient age groups [24]. In that study, the majority (95.2%) of ESBL-positive isolates harboured a CTX-M-type ESBL, with CTX-M-15 (46%) as the most common type. In the current study the prevalence of strains harbouring a CTX-M ESBL was similar but CTX-M-15 occurred more frequently (69.2%). Furthermore, in the current study E. coli O25b:H4-ST131 producing CTX-M-15 was identified as the predominant ESBLproducing clone. Escherichia coli O25b:H4-ST131 was also found to be the most prevalent clone among CTX-M-15-producing isolates
Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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obtained from hospitalised patients and nursing home patients in Germany [25,26] and it has been reported as the dominant extraintestinal pathogenic E. coli clone worldwide [5]. A recent study analysing the molecular epidemiology of a large collection of E. coli isolates, including a considerable number of strains from Germany, indicated that most CTX-M-15-producing ST131 strains belong to a single highly pathogenic subclone called H30-Rx [27]. Fosfomycin (as trometamol salt) has been considered a drug of first choice for empirical treatment of uncomplicated cystitis in Germany [21]. Data from the current study show that fosfomycin was highly active in vitro against the isolates tested. No more than six strains (1.2%) were fosfomycin-resistant (MIC > 32 mg/L). Thus, these findings confirm the high rate of fosfomycin susceptibility (98%) found for German isolates in the ARESC study [2]. Notably, only 1 (2.5%) of the 40 ESBL-producing strains seen in the present study was fosfomycin-resistant. Interestingly, in a study performed in Spain with isolates collected between 2005 and 2009, Oteo et al. [10] observed a strong correlation between fosfomycin resistance in ESBL-producing E. coli from UTIs (from 4.4% in 2005 to 11.4% in 2009) and the use of fosfomycin in outpatients, but the overall rate of fosfomycin resistance remained low (2.9% in 2009). In Spain, community use of fosfomycin had increased from 0.05 defined daily doses (DDD) per 1000 inhabitants per day (DID) in 1997 to 0.22 DID in 2008 [10], whilst in Germany outpatient use of fosfomycin was comparatively low, with 0.5 million DDD (corresponding to 45 years old, isolates from routine samples showed lower susceptibility to the three -lactams and norfloxacin compared with those from solicited samples [30]. The approved method for in vitro susceptibility testing of fosfomycin is agar dilution [14]. In the present study, the broth microdilution method was used. In preceding experiments we found comparable MICs of fosfomycin for E. coli ATCC 25922 with both methods of susceptibility testing (unpublished data). Moreover, MICs of fosfomycin determined for the quality control strain E. coli ATCC 25922 in the present study (≤1–2 mg/L) were always within the concentration range published in the documents ISO 20776-1 and CLSI M100-S21 [12,14]. In conclusion, resistance to -lactams (e.g. amoxicillin and AMC), fluoroquinolones and SXT appears to be widespread amongst E. coli isolated from urine samples of outpatients in Germany. This fact must be considered for empirical treatment of UTI. In contrast,
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the prevalence of fosfomycin resistance was low (1.2%). Thus, oral fosfomycin (trometamol salt) may represent a valuable option in the treatment of uncomplicated UTIs. Acknowledgment
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The technical assistance of G. Anlauf, A. Frank, J. Fritz, E. Luhmer, N. Scheliga and N. Schmandt is gratefully acknowledged. Appendix A. Members of the Working Party ‘Antimicrobial Resistance’ of the Paul-Ehrlich-Society of Chemotherapy In addition to the authors, the following members of the study group (in alphabetical order) contributed to the study: L. Artz (Ingolstadt), T. Becker (Munich), S. Burak (Düsseldorf), J. Cremer (Kempten), A. Eberhard (Dortmund), U. Eigner (Heidelberg), R. Englert (Freiburg), J. Enzenauer (Osnabrück), J. Esser (Osnabrück), I. Fenner (Hamburg), P. Finzer (Moers, now Cologne), G. Funke (Ravensburg), A. Gehrt (Düsseldorf), R.R.E. Gyenes (Essen), T. Hermann (Würzburg), R. Hillert (Görlitz), W. Hönerlage (Hamburg), M. Holfelder (Heidelberg), R. Huber (Cologne), F. Hugo (Berlin), M. Jacobs (Dillingen/Saar), U. Knipp (Trier), S. Krämer (Essen), R. Krajewski (Würzburg), E. Kühnen (Trier), C. Lensing (Hamburg), J. Lerner (Augsburg), A. Pranada (Dortmund), F. Pranada (Dortmund), A. Reinecke (Rostock), H. Sahly (Hamburg), S. Schmitt (Kaiserslautern), M. Schröter (Jena), R. Schwarz (Mönchengladbach), A. Siedlaczek (Freiburg), R. Tauchnitz-Hiemisch (Leipzig), U. Thalmaier (Augsburg), F. Wisplinghoff (Cologne) and H. Wisplinghoff (Cologne). Funding This study was funded by grants from Abbott GmbH & Co. KG, ACTAVIS Deutschland GmbH & Co. KG, Apogepha Arzneimittel GmbH, Bayer Vital GmbH, betapharm Arzneimittel GmbH, Q2 Daiichi-Sankyo Deutschland GmbH, DOLORGIET GmbH & Co. KG, Dr. R. Pfleger Chemische Fabrik GmbH, GlaxoSmithKline GmbH & Co. KG, InfectoPharm Arzneimittel und Consilium GmbH, Kohne Pharma GmbH, KSK-Pharma AG, Rottapharm/Madaus GmbH, MEDA Pharma GmbH & Co. KG, mibe GmbH Arzneimittel, Pfizer Pharma GmbH, Sanofi-Aventis Deutschland GmbH, STADA Arzneimittel AG and Wörwag Pharma GmbH & Co. KG to the PaulEhrlich-Society of Chemotherapy. The present work was funded by a grant from Zambon S.p.A. to the Antiinfectives Intelligence GmbH. Q3 Competing interests MK is a partner and CEO of Antiinfectives Intelligence GmbH, a research organisation providing services to pharmaceutical companies; BK-I and RW are employees of Antiinfectives Intelligence GmbH. All other authors declare no competing interests. Ethical approval Not required. References [1] Stamm WE, Norrby SR. Urinary tract infections: disease panorama and challenges. J Infect Dis 2001;183(Suppl. 1):S1–4. [2] Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol 2008;54:1164–75. [3] Kahlmeter G, Poulsen HO. Antimicrobial susceptibility of Escherichia coli from community-acquired urinary tract infections in Europe: the ECO·SENS study revisited. Int J Antimicrob Agents 2012;39:45–51.
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Please cite this article in press as: Kresken M, et al. Occurrence of multidrug resistance to oral antibiotics among Escherichia coli urine isolates from outpatient departments in Germany: Extended-spectrum -lactamases and the role of fosfomycin. Int J Antimicrob Agents (2014), http://dx.doi.org/10.1016/j.ijantimicag.2014.05.020
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