Antimicrobial Resistance Trends in Urine Escherichia coli Isolates From Adult and Adolescent Females in the United States From 2011 to 2019: Rising ESBL Strains and Impact on Patient Management

Abstract

Background: Uncomplicated urinary tract infection (uUTI) is predominantly caused by Escherichia coli, which has increasing antimicrobial resistance (AMR) at the United States (US)-community level. As uUTI is often treated empirically, assessing AMR is challenging, and there are limited contemporary data characterizing period prevalence in the US.

Methods: This was a retrospective study of AMR using Becton, Dickinson and Company Insights Research Database (Franklin Lakes, New Jersey, US) data collected 2011-2019. Thirty-day, nonduplicate Escherichia coli urine isolates from US female outpatients (aged ≥12 years) were included. Isolates were evaluated for nonsusceptibility (intermediate/resistant) to trimethoprim-sulfamethoxazole, fluoroquinolones, or nitrofurantoin, and assessed for extended-spectrum β-lactamase production (ESBL+) and for ≥2 or ≥3 drug-resistance phenotypes. Generalized estimating equations were used to model AMR trends over time and by US census region.

Results: Among 1 513 882 E. coli isolates, the overall prevalence of isolates nonsusceptible to trimethoprim-sulfamethoxazole, fluoroquinolones, and nitrofurantoin was 25.4%, 21.1%, and 3.8%, respectively. Among the isolates, 6.4% were ESBL+, 14.4% had ≥2 drug-resistance phenotypes, and 3.8% had ≥3. Modeling demonstrated a relative average yearly increase of 7.7% (95% confidence interval [CI], 7.2-8.2%) for ESBL+ isolates and 2.7% (95% CI, 2.2-3.2%) for ≥3 drug-phenotypes (both P < .0001). Modeling also demonstrated significant variation in AMR prevalence between US census regions (P < .001).

Conclusions: Period prevalence of AMR among US outpatient urine-isolated E. coli was high, and for multidrug-resistance phenotypes increased during the study period with significant variation between census regions. Knowledge of regional AMR rates helps inform empiric treatment of community-onset uUTI and highlights the AMR burden to physicians.

Keywords: Escherichia coli; antimicrobial resistance; antimicrobial stewardship; uncomplicated urinary tract infection.

Figure 1.

Overall AMR results in non-duplicate urine E. coli isolates (N = 1 513 882) from US females, 2011–2019. Abbreviations: AMR, antimicrobial resistance; CI, confidence interval; E. coli, Escherichia coli; ESBL+, extended-spectrum β-lactamase-producing; FQ, fluoroquinolone; NFT, nitrofurantoin; NS, nonsusceptible; TMP-SMX, trimethoprim-sulfamethoxazole.

Figure 2.

Overall proportion of (A) AMR and (B) ≥2 and ≥3 nonsusceptible phenotype category E. coli isolates by census region. New England: CT, MA, ME, NH, RI, VT; Middle Atlantic: NJ, NY, PA; East North Central: IL, IN, MI, OH, WI; West North Central: IA, KS, MN, MO, ND, NE, SD; South Atlantic: DE, DC, FL, GA, MD, NC, SC, VA, WV; East South Central: AL, KY, MS, TN; West South Central: AR, LA, OK, TX; Mountain: AZ, CO, ID, MT, NM, NV, UT, WY; Pacific: AK, CA, OR, WA. Abbreviations: AMR, antimicrobial resistance; E. coli, Escherichia coli; ESBL+, extended-spectrum β-lactamase-producing; FQ, fluoroquinolone; NFT, nitrofurantoin; NS, nonsusceptible; TMP-SMX, trimethoprim-sulfamethoxazole.

Figure 3.

Regional distribution of E. coli AMR phenotypes in the US, 2019. (A) ESBL+; (B) FQ NS; (C) TMP-SMX NS; (D) NFT NS; (E) ≥2 nonsusceptible phenotypes; (F) ≥3 nonsusceptible phenotypes. For a county that did not have any isolates tested, the susceptibility results of the nearest county either within or across state lines were populated. Counties with insufficient isolates tested (<1% and <30 isolates tested) or states with no isolate results are marked in gray. Abbreviations: AMR, antimicrobial resistance; E. coli, Escherichia coli; ESBL+, extended-spectrum β-lactamase-producing; FQ, fluoroquinolone; NFT, nitrofurantoin; NS, nonsusceptible; TMP-SMX, trimethoprim-sulfamethoxazole.

Figure 4.

Trends in AMR among E. coli isolates, 2011–2019. Abbreviations: AMR, antimicrobial resistance; E. coli, Escherichia coli; ESBL+, extended-spectrum β-lactamase-producing; FQ, fluoroquinolone; NFT, nitrofurantoin; NS, nonsusceptible; TMP-SMX, trimethoprim-sulfamethoxazole.