Antibiotic Resistance in Treatment of UTIs

Antibiotic Resistance in Treatment of UTIs
Antibiotic Resistance in Treatment of UTIs

Antibiotic Resistance in Treatment of UTIs

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Antibiotic Resistance in Treatment of UTIs


Infections of the urinary tract are among the most prevalent infectious diseases that are also accompanied by a substantial financial burden on the patient and the entire healthcare system (Grabe et al., 2008). Urinary Tract Infections (UTIs) range from these affecting the urinary bladder to those affecting the kidneys. The infections are classified according to the site of infection. These include urethritis (urethra), vaginitis (vagina), pyelonephritis (upper urinary tract), and cystitis (urinary bladder) (Mazulli, 2012). Different pathogenic microbes can be attributed to the condition. These include bacteria from the staphylococcus species such as Staphylococcus saprophyticus, the Klebsiella species, Pseudomonas aeruginosa, enterococci bacteria and also from the yeast fungi which is common among women (Mazulli, 2012). However, the main causative agent in the community and hospitals is the bacterium Escherichia coli (E.coli) that is a normal flora in the bowel and accounts for approximately 75 – 95% of UTI cases (A.D.A.M Inc, 1997-2008). Antibiotics are commonly used in the prevention and treatment of UTIs. However, this frequent use of antibiotics has resulted into the development of antibiotic resistance and vaginal and intestinal dysbiosis. This has become problematic in the treatment of UTIs and this paper, therefore, provides evidence of the spread of antibiotic resistance in UTI treatment.

Problem Statement

The treatment and prevention of UTIs has most of the time involved the use of antibiotics as the first-line treatment. This often follows the isolation and culture of the etiological agent to select the appropriate antibiotic for use. However, today there is increasing resistance to most of the antimicrobial agents prescribed for the treatment of UTIs in both community and hospitals settings. This is spreading to even the most potent antimicrobial agents hence the need to establish alternative approaches for treatment.

For example, a study was conducted in India and was aimed at reporting the resistance pattern among the most common uropathogens that were isolated in a tertiary care hospital setting. The focus of this study was on resistance to ciprofloxacin (Mandal, Acharya, Buddhapriya, & Parija, 2010). Nineteen thousand and fifty samples were collected, cultured and the pathogenic microbes isolated. The susceptibility to antibiotic tests were done using the Kirby-Bauer disk diffusion method after noting the clinical and demographic characteristics of each patient. E.coli was isolated and out of the total samples selected 62% were sterile while 26.01% had significant growth (Mandal, Acharya, Buddhapriya, & Parija, 2010).

In addition, 2.3% had insignificant growth, and 9.6% of the samples were contaminated. The ciprofloxacin-resistant E.coli had a strong association with gynecological surgery among the female participants, UTI in adulthood, prior antibiotic use, and uropathy among men and complicated UTI among women (Mandal, Acharya, Buddhapriya, & Parija, 2010). The continuous of ciprofloxacin was, therefore, linked to the development of resistance in males, females, and in-patients. This indicates the need to rationalize the use of antibiotic treatment or most importantly develop alternative approaches.

Trimethoprim and Sulfamethoxazole are often used as a first-line treatment for UTIs. However, there is increasing resistance towards the drug that is resulting to a significant decrease in its use. This antibiotic is an inhibitor of the bacterial folate synthesis that is needed for the synthesis of thymidine hence the synthesis of DNA (Hilbert, 2011). These drugs are administered in a combined ratio of 1:5 (SXT) and the guidelines indicate that it should be avoided where the resistance reaches between 15% – 20% (Gupta et al., 2011).

The North American Urinary Tract Infection Collaborative Alliance (NAUTICA) conducted a study to analyze the development of resistance towards SXT. They used 1,142 Uropathogenic Escherichia coli UPEC isolates from 40 medical centers. The results revealed that 21% of the participants had resistant isolates (Hilbert, 2011). In another study conducted by the Arkansas River Education Service Cooperative (ARESC), a similar result was found and in this case the resistance was higher at 29%. Trimethoprim and Sulfamethoxazole inhibit the enzymes dihydrate folate reductase and dihydropteroate synthetase respectively. The resistance to the drug is mediated by gene transfer of the genes that are responsible for encoding the resistant enzymes (Hilbert, 2011). In a study conducted using 305 UPEC isolates revealed that 66% had encoded a dfr allele that encoded a trimethoprim-resistant dihydtrate folate reductase and 96% had a sul gene encoding for the sulfamethoxazole-resistant dihydropteroate synthetase (Hilbert, 2011). These genes appeared due to the continuous use of SXT, and their presence facilitate the spread of resistance elements among the bacterial population hence the increased resistance.

Finally, there is also the development of resistance to other aetiological agents for UTIs. For example, the Klebsiella species (K. pneumoniae) accounts for approximately 1-6% of the uncomplicated cases of UTIs (Schito et al., 2009). The bacterium is resistant to penicillin and nitrofurantion intrinsically and shows resistance to other common antibiotics used for the treatment of UTIs. Per Schito et al. (2009), a study conducted to establish the resistance of K.pneumoniae indicated 23% resistance to SXT, 21% to cefuroxime, 12% fosfomycin and 6% ciprofloxacin (Schito et al., 2009).

An earlier study by Kahlmeter in 2003 revealed similar results. In the two studies mentioned, the 94-99% of the isolates showed susceptibility to ciprofloxacin and 91-96% were susceptible to amoxicillin-clavulanic acid. However, due to the continuous use of the drugs today, there is increasing resistance (Hilbert, 2011). Moreover, K. pneumoniae accounts for 8-11% 0f catheter-associated UTIs (CAUTIs) within the hospital setting (nosocomial infections). In the above studies, 17-21% of isolates from individuals with CAUTIs were resistant to an extended spectrum of cephalosporins while 10% were resistant to carbapenems (Hilbert, 2011). This indicates the growing resistance of UTIs etiological agents to antibiotics and the need for new treatment approaches.


UTIs are among the most common forms infections today. Moreover, their prevalence is also on the rise including among men. Antibiotics have been for a long time the first line of treatment for infectious diseases. Treatment involves the isolation and culturing of isolates to identify the main causative agent. The common cause of UTIs is the bacteria E.coli; however, there are other species of bacteria that can also cause the disease. In the past, antibiotics were effective for UTI treatment, but due to the continuous use of the antibacterial drugs the bacteria are increasingly developing resistance. The resistance is developing as a result of mutations and other processes. The resistance is continuously increasing from the “weaker” forms of antibiotics to even those that were initially thought to be the most efficacious including the development of multiple resistance. Due to the increasing prevalence of UTIs and the resultant rise in resistance to antibiotics, it is imperative that alternative approaches of treatment should be employed.


A.D.A.M Inc. (1997-2008). Urinary Tract Infection. 1-4.

Grabe, M., Bishop, M. C., Bjerklund-Johansen, T. E., Botto, H., Çek, M., Lobel, B., et al. (2008). Guidelines on the management of urinary and male genital tract infections. European Association of Urology.

Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., et al. (2011).            International clinical practice guidelines for the treatment of acute uncomplicated  cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases  Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis, 52, e103-120.

Hilbert, D. W. (2011). Antibiotic resistance in urinary tract infections: Current issues and  future solutions. In P. Tenke (Ed.), Urinary tract infections (pp. 194-206). InTech.

Mandal, J., Acharya, N. S., Buddhapriya, D., & Parija, S. C. (2010). Antibiotic resistance pattern among common bacterial uropathogens with a special reference to ciprofloxacin resistant Escherichia coli. Indian J Med Res, 136, 842-849.

Mazulli, T. (2012). Diagnosis and Management of Simple and Complicated Urinary Tract Infections (UTIs). Can J Urol., 19 (Suppl 1), 42-48.

Schito, G. C., Naber, K. G., Botto, H., Palou, J., Mazzei, T., Gualco, L., et al. (2009). The ARESC study: an international survey on the antimicrobial resistance of pathogens  involved in uncomplicated urinary tract infections. Int J Antimicrob Agents, 32, 407   -413.

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