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. 2025 Jul 17:16:100706.
doi: 10.1016/j.ijregi.2025.100706. eCollection 2025 Sep.

Mapping antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli across low, middle and high-income countries highlights significant differences: insights for empiric treatment

Meher Rizvi  1 , Maria Khan  2 , Amina Al-Jardani  3 , Seif Salem Al-Abri  4 , Ujjala Ghoshal  5 , Zaaima Al Jabri  1 , Mohammad Ahanjan  6 , Azza Al Mamari  7 , Nawal Al Shizawi  8 , Hiba Sami  9 , Abdullah Balkhair  10 , Adila Shaukat  11 , Alwarith Nasser Salem Alkharusi  12 , Abdulrahman Almahrouqi  13 , Afreenish Hassan  14 , Ajay Kumar  15 , Amal Saki Malehi  16 , Amina Gul  17 , Ashima Singh  18 , Asma Said Hamed Al Shidhani  19 , Areena Hoda Siddiqui  20 , Aruna Poojary  21 , Azza Al Rashdi  22 , Bradley Langford  23 , Dmytro Stepanskyi  24 , Abbas Dolatabadi  25 , Amal Al Maani  26 , Aisha Al Mufarji  1 , Elham Said Ahmed AlRisi  27 , Garima Kapoor  28 , Isabella Princess  29 , Hawra J Al Lawati  30 , Hatim Ali Eltahir  31 , Hilal Al Sidairi  4 , Katia Iskandar  32 , Ken Masters  33 , Ibrahim Khalaf Hamdan Al-Busaidi  10 , Laila Al Yazidi  34 , Mahfuza Nasrin  35 , Mahmood Salim Al Subhi  36 , Mallika Sengupta  5 , Manisha Khandait  37 , Nada Khalfan Al Tamtami  38 , Nada Khafan Al Siyabi  39 , Nawal Al Kindi  40 , Nazla Musthafa Luthfee  41 , Neha Shreshtha  42 , Nihal Mohamed Amur Al Riyami  43 , Noora Hilal Ali Al Busaidi  44 , Nupur Goel  45 , Oksana Ishchenko  24 , Omnia Mohamed Elnabawy Ahmed Taher  46 , Pragnya Paramita Jena  47 , Rajni Ekadashi  48 , Razan Al Zadjali  49 , Reba Kanungo  50 , Sara Abolghasemi  25 , Salima Al Maqbali  51 , Sayantan Banerjee  5 , Shadma Yaqoob  52 , Shahnaz Sali  25 , Shafqat Husnain Khan  53 , Shalini Malhotra  54 , Stephen Hughes  45 , Sundas Shaukat  55 , Syed Mohammed Atif  56 , Vrushali Vishwas Patwardhan  57 , Victorien Dougnon  58 , Wahid Khan  56 , Walid Wali  11 , Zakariya Al Muharrmi  59 , Zeeshana Basit  60 , Jasashree Choudhury  61 , Rachita Pravalina  62 , Keith H St John  63 , Sanjeev Singh  64 , Sarman Singh  65 , Neelam Taneja  66 , Raman Sardana  67   68   69 , Abdul Ghafur  70 , Pawan Kapoor  71 , Rajeev Soman  72 , Rashid Al Abri  16
Affiliations

Mapping antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli across low, middle and high-income countries highlights significant differences: insights for empiric treatment

Meher Rizvi et al. IJID Reg. .

Abstract

Objectives: Rising antimicrobial resistance (AMR) in Escherichia coli urinary tract infections (UTI) poses a global challenge. Evidence-based treatment of cystitis requires local resistance data. The DASH to Protect Antibiotics (https://dashuti.com/), a multi-regional group, supports centers in generating and sharing focused antibiograms to guide stewardship in community UTIs. This multi-country study aimed to describe antimicrobial susceptibility patterns of community-acquired E. coli isolates in low, middle, and high-income countries (LMICs and HICs).

Methods: The study was conducted in 37 representative centers across 13 countries in Asia (Middle East and Indian Subcontinent), Africa, Europe, and North America. A rigorous comparative analysis of the antimicrobial susceptibility of E. coli isolated from cases of simple cystitis presenting in outpatient or emergency departments was carried out. The impact of gross domestic product, climate, and population density per km2 on E. coli susceptibility profile was analyzed using the Kruskal-Wallis test and two-way analysis of variance.

Results: Antimicrobial susceptibility varied significantly between LMICs and HICs, with nitrofurantoin (89%) and fosfomycin (96%) emerging as empiric choices globally. Across most centers, susceptibility to other oral antimicrobials was low: co-trimoxazole <60%, amoxicillin-clavulanic acid <70%, first-generation cephalosporins <50%, fluoroquinolones <60%. Injectable antibiotics fared better: piperacillin-tazobactam >70%, amikacin and meropenem >80%. Higher susceptibilities were noted in countries with high gross domestic product (P < 0.001) and humidity (P = 0.002).

Conclusion: Marked geographical differences in E. coli susceptibility patterns support the need for localized antibiograms and tailored empirical therapy. This study reinforces the utility of nitrofurantoin and fosfomycin as first-line agents and discourages the use of fluoroquinolones and third-generation cephalosporins.

Keywords: Antimicrobial susceptibility; Escherichia coli; GDP; Humidity; Multi-regional; UTI.

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Conflict of interest statement

The authors have no competing interests to declare.

Figures

Figure 1
Figure 1
a and b. Geographic location of participating centers and susceptibility profile of Escherichia coli to commonly prescribed antimicrobials.
Figure 2
Figure 2
Susceptibility rates of Escherichia coli to common antibiotics across the participating countries.
Figure 3
Figure 3
Association of GDP and Escherichia coli susceptibility in simple urine tract infections. GDP, gross domestic product.
See this image and copyright information in PMC

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