Resistance to first-line antibiotic therapy among patients with uncomplicated acute cystitis in Melbourne, Australia: prevalence, predictors and clinical impact

Stephanie J Curtis; Jason C Kwong; Yee Lin Chaung; Danielle Mazza; Calum J Walsh; Kyra Y Chua; Andrew J Stewardson

doi:10.1093/jacamr/dlad145

Resistance to first-line antibiotic therapy among patients with uncomplicated acute cystitis in Melbourne, Australia: prevalence, predictors and clinical impact

JAC Antimicrob Resist. 2023 Dec 28;6(1):dlad145. doi: 10.1093/jacamr/dlad145. eCollection 2024 Feb.

Authors

Stephanie J Curtis¹, Jason C Kwong², Yee Lin Chaung³, Danielle Mazza⁴, Calum J Walsh⁵, Kyra Y Chua⁶, Andrew J Stewardson¹

Affiliations

¹ Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, 85 Commercial Road, Melbourne, VIC 3004, Australia.
² Department of Microbiology & Immunology, The University of Melbourne at the Peter Doherty Institute for Infection & Immunity, 792 Elizabeth Street, Melbourne, VIC 3000, Australia.
³ Heathmont General Practice, 220 Canterbury Road, Heathmont, VIC 3135, Australia.
⁴ Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, VIC 3168, Australia.
⁵ Doherty Applied Microbial Genomics, Department of Microbiology & Immunology, The University of Melbourne at the Peter Doherty Institute for Infection & Immunity, 792 Elizabeth Street, Melbourne VIC 3000, Australia.
⁶ Department of Microbiology, Dorevitch Pathology, 18 Banksia Street, Heidelberg, VIC 3084, Australia.

Abstract

Background: Australian guidelines recommend trimethoprim or nitrofurantoin as first-line agents for uncomplicated urinary tract infections (UTIs). Laboratory surveillance indicates high rates of trimethoprim resistance among urinary bacterial isolates, but there are scant local clinical data about risk factors and impact of trimethoprim resistance.

Objectives: To determine the prevalence, risk factors, mechanism and impact of resistance to first-line antibiotic therapy for uncomplicated UTIs in the community setting.

Methods: A prospective observational study from October 2019 to November 2021 in four general practices in Melbourne, Australia. Female adult patients prescribed an antibiotic for suspected or confirmed uncomplicated acute cystitis were eligible. Primary outcome was urine isolates with resistance to trimethoprim and/or nitrofurantoin.

Results: We recruited 87 participants across 102 UTI episodes with median (IQR) age of 63 (47-76) years. Escherichia coli was the most common uropathogen cultured (48/62; 77%); 27% (13/48) were resistant to trimethoprim (mediated by a dfrA gene) and none were resistant to nitrofurantoin. Isolates with resistance to a first-line therapy were more common among patients reporting a history of recurrent UTIs [risk ratio (RR): 2.08 (95% CI: 1.24-3.51)] and antibiotic use in the previous 6 months [RR: 1.89 (95% CI: 1.36-2.62)]. Uropathogen resistance to empirical therapy was not associated with worse clinical outcomes.

Conclusions: Resistance to trimethoprim is common in uncomplicated UTIs in Australia but may not impact clinical outcomes. Further research is warranted on the appropriateness of trimethoprim as empirical therapy, particularly for patients with antimicrobial resistance risk factors.