Editorial
Urinary tract infections and antimicrobial resistance
Infecciones del tracto urinario y resistencia antimicrobiana
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Sánchez-García, A. Sorlózano-Puerto, J.M. Navarro-Marí, J. Gutiérrez Fernández" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Sánchez-García" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Sorlózano-Puerto" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Navarro-Marí" ] 3 => array:2 [ "nombre" => "J." 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Morosini, R. del Campo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M.I." "apellidos" => "Morosini" "email" => array:1 [ 0 => "mariaisabel.morosini@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "del Campo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infecciones del tracto urinario y resistencia antimicrobiana" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the study by Sánchez-García et al. in this issue, the authors present data on the evolution of antibiotic resistance in the main causal microorganisms of urinary tract infections (UTIs). In this study, the authors present epidemiology data on this resistance over the course of 4 years in hospitalized patients. This study consisted of a retrospective analysis in which the authors assessed the results of cultures and antibiograms from urine samples from adult patients hospitalized in the Hospital Complex Virgen de la Nieves (Granada, Spain) with a microbiological confirmation of UTI between January 2013 and December 2016.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although UTIs are some of the most common infections in the adult hospitalized population, their incidence has decreased in recent years, according to the results of the EPINE program. The present study measured a rate of 20% for this type of process.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The increase in the number of elderly, immunosuppressed patients, with urinary catheterization, among other determinants, entails greater treatment complexity for these infections. In addition, there is the frequent involvement of multiresistant bacteria and, in some cases, a polymicrobial etiology,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> all of which greatly limit the success of empiric therapy. Having objective data is therefore indispensable for starting a targeted treatment as soon as possible.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the etiological agents reported in this study, the most common was <span class="elsevierStyleItalic">Escherichia coli</span>, followed (at a variable rate) by <span class="elsevierStyleItalic">Enterococcus</span> spp., <span class="elsevierStyleItalic">Klebsiella</span> spp., <span class="elsevierStyleItalic">Enterobacter</span> spp., <span class="elsevierStyleItalic">Proteus</span> spp., <span class="elsevierStyleItalic">Morganella morganii</span>, <span class="elsevierStyleItalic">Citrobacter</span> spp., <span class="elsevierStyleItalic">Serratia</span> spp., <span class="elsevierStyleItalic">Pseudomonas</span> spp., <span class="elsevierStyleItalic">Acinetobacter</span> spp., <span class="elsevierStyleItalic">Streptococcus</span> spp., <span class="elsevierStyleItalic">Staphylococcus</span> spp. and species of the <span class="elsevierStyleItalic">Candida</span> genus.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In terms of the most common resistance mechanisms and those that raise considerable concern due to the limited treatment options, we have those that affect beta-lactam antibiotics and fluoroquinolones. For the former, the presence of extended-spectrum beta-lactamase (ESBL)-producing and carbapenemase-producing bacteria (in both <span class="elsevierStyleItalic">Enterobacterales</span> and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>) completely restrict their use due to the frequent multiresistance observed in these types of isolates.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> The authors followed the standards of the Clinical, Laboratory Standards Institute for interpreting the clinical category, except for isolates against nitrofurantoin and isolates of <span class="elsevierStyleItalic">Streptococcus agalactiae</span> against cotrimoxazole, for which the authors followed the recommendations of the European Committee on Antimicrobial Susceptibility Testing.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The noteworthy aspects of the study's methodology include the use of chromogenic culture media, determining the identification and sensitivity using the automatic MicroScan system, confirming the identification by mass spectrometry (MALDI TOF), phenotypic confirmation using discs with specific inhibitors and the use of polymerase chain reaction for beta-lactam resistance mechanisms. The results were analyzed using statistical tests (SPSS method and Pearson's chi-squared test).</p><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 4347 microorganisms were identified as causal agents (3969 bacteria and 378 yeasts). <span class="elsevierStyleItalic">E. coli</span> was the most frequently isolated species, although 62.9% of the UTIs were caused by other microorganisms. <span class="elsevierStyleItalic">Enterococcus</span> spp. was the second most common causal agent, and <span class="elsevierStyleItalic">Klebsiella</span> spp. and <span class="elsevierStyleItalic">P. aeruginosa</span> were the third and fourth, respectively. It is worth mentioning that the species of the <span class="elsevierStyleItalic">Candida</span> genus represented 8.7% of the total of recovered isolates.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The presence of multiresistant microorganisms such as <span class="elsevierStyleItalic">Acinetobacter</span> spp. (1.2%), ESBL-producing enterobacteria (10.0%) and carbapenemase-producing enterobacteria (0.3%) were also relevant findings. The most active antimicrobial agents were imipenem, piperacillin-tazobactam and fosfomycin, which presented activity rates above 80%, considering all studied microorganisms. The rest of the antibiotics analyzed presented activity rates below 70%, with resistance rates greater than 40% for cefuroxime, ciprofloxacin and cotrimoxazole. Typically, the ESBL-producing strains presented a multiresistance profile that covered aminoglycosides, fluoroquinolones, fosfomycin and cotrimoxazole.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> For <span class="elsevierStyleItalic">K. pneumoniae</span> but not <span class="elsevierStyleItalic">E. coli</span>, the 86% resistance to nitrofurantoin was also significant. The observed carbapenemases (KPC, OXA-48 and VIM) were confirmed in 13 isolates, which were <span class="elsevierStyleItalic">K. pneumoniae</span> (11), <span class="elsevierStyleItalic">E. coli</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> and <span class="elsevierStyleItalic">E. cloacae</span>,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> respectively. For <span class="elsevierStyleItalic">P. aeruginosa</span>, the sensitivity to aminoglycosides (amikacin and tobramycin), piperacillin-tazobactam, ceftazidime and colistin was greater than 80%. In contrast, the <span class="elsevierStyleItalic">Acinetobacter</span> spp. isolates were highly resistant. The isolates maintained a significant sensitivity rate against only colistin (98%). For the Gram-positive cocci, <span class="elsevierStyleItalic">Enterococcus</span> spp. had a notable sensitivity (greater than 80%) against ampicillin, fosfomycin and nitrofurantoin. The same rate of sensitivity was found in the staphylococci against cotrimoxazole, aminoglycosides and nitrofurantoin.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The authors’ conclusions mentioned that although <span class="elsevierStyleItalic">E. coli</span> was the most common bacteria isolated in UTIs of hospitalized patients, other bacteria represented a high percentage of various etiological agents. Their resistance patterns should therefore be considered when starting an empiric antibiotic therapy. Furthermore, piperacillin-tazobactam, imipenem and fosfomycin were the most active antibiotics, which make them first-line antibiotics in the empiric treatment of UTIs in hospitalized patients. For imipenem, however, the need to restrict the use of carbapenems makes their de-escalation essential once the sensitivity of the etiological agent of the UTI is known. The use of fosfomycin-trometamol alone or in combination is recommended in the case of complicated UTIs. In contrast, the authors indicated that the use of amoxicillin-clavulanate, cefuroxime, cefotaxime, ceftazidime, cefepime, aminoglycosides, cotrimoxazole and fluoroquinolones should be limited to situations of demonstrated sensitivity but never as empiric treatment. As a result, the authors emphasize the need to determine the presence and type of the mechanisms responsible for the multiresistance due to the need for targeted treatment due to the limited treatment options established by these types of isolates.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morosini M, del Campo R. Infecciones del tracto urinario y resistencia antimicrobiana. 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