NEW YORK (Reuters Health) - The prevalence of antibiotic resistance in pediatric urinary tract infection (UTI) has reached such high levels in many countries that existing empiric therapies may no longer be effective, researchers from UK report."
Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E. coli is high, and there was remarkable variability in E. coli resistance among countries in the study, particularly in countries outside the OECD (Organization for Economic Cooperation and Development), where one possible explanation is the availability of antibiotics over the counter," Ashley Bryce from the University of Bristol in the U.K. and Dr. C√©ire E. Costelloe from Imperial College London told Reuters Health in a joint email.
"This could render some antibiotics ineffective as first-line treatments for urinary tract infection," they said.
E. coli is responsible for more than 80% of all UTIs and is also the most common cause of bacteremia and foodborne infections and one cause of meningitis in neonates.
Bryce, Dr. Costelloe, and colleagues investigated the prevalence of resistance in community-acquired E. coli UTI to the most commonly prescribed antibiotics given to children in primary care in their systematic review of 58 published reports.
For all antibiotics tested, the prevalence of antibiotic resistance was higher in non-OECD countries than in OECD countries, the team reports in an article online March 15 in The BMJ.
The prevalence of resistance was highest for ampicillin, ranging from 41% in Switzerland to 100% in Ghana and Nigeria.
Resistance to co-trimoxazole and trimethoprim was 30% in OECD countries and 67% in Saudi Arabia, the only non-OECD country for which rates were available.
Pooled prevalences of resistance to ciprofloxacin and ceftazidime were around 2% in OECD countries but over 26% in non-OECD countries.
For all time periods analyzed, the odds of resistance were greater in children exposed to antibiotics than in those who were unexposed.
"The Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) recommend that an antibiotic should be selected for first line empirical treatment of urinary tract infection only if the local prevalence of resistance is less than 20%," the researchers note.
"According to these guidelines, our review suggests ampicillin, co-trimoxazole, and trimethoprim are no longer suitable first line treatment options for urinary tract infection in many OECD countries and that as a result many guidelines, such as those published by the National Institute for Health and Care Excellence (NICE), might need updating," they write. "In non-OECD countries, resistance to all first line antibiotics specified for urinary tract infections was in excess of 20%, suggesting that choices of first line treatment might need to be re-evaluated in less well developed countries."
"We are not able to advise clinicians on which antibiotic is best to prescribe as this often depends on the individual case," Bryce and Dr. Costelloe said. "Clinicians should, however, adhere to local or national guidelines wherever possible, which is why it is of great importance that such guidelines are kept up to date and reflect current resistance rates."
"Clinicians may also wish to consider the antibiotic history of the child when they present to primary care with symptoms of an infection, especially in light of the suggestion of our results that previous treatment with an antibiotic is associated with resistance to that same antibiotic, and that this association may be present up to 6 months post treatment," they added.
Dr. Grant Russell from Monash University in Melbourne, Australia, wrote an editorial accompanying the report. He told Reuters Health by email, "I found the extent of the resistance (and the fact that it covered all of the regularly used empiric antibiotics) both concerning and surprising. The fact that choices are diminishing is disturbing, and the fact that the situation is dire in the developing world is deeply troubling."
"We need to do what we can do to prevent bacterial infections, and when treating them to consider that effective antibiotics are a finite resource," he said. "We all have a responsibility in attempting to conserve that resource."
"No new classes of antibiotics have been developed in the last 30 years - this and the dire situation in both the developed and the developing world suggests that the 'global problem' of antibiotic resistance is going to become more and more of an issue in years and decades to come," Dr. Russell concluded.