Journal of Reconstructive Urology

.: ORIGINAL RESEARCH
Cinsiyet Farklılığının İdrar Kültürlerinden İzole Edilen Escherichia coli Suşlarındaki Antibiyotik Direncine Etkileri:Kesitsel Tanımlayıcı Araştırma
The Effects of Sex Differences on Antibiotic Resistance in Escherichia coli Strains Isolated from Urine Cultures: Cross-Sectional Descriptive Research
Gökhan ÇEKERa , Zeynep CİNGÖR BAYRAMb
aBaşakşehir Çam ve Sakura Şehir Hastanesi, Üroloji Kliniği, İstanbul, Türkiye
bSamsun Vezirköprü Devlet Hastanesi, Tıbbi Mikrobiyoloji Kliniği, Samsun, Türkiye
J Reconstr Urol. 2023;13(2):60-6
doi: 10.5336/urology.2023-98144
Article Language: TR
Full Text
ÖZET
 Amaç: Üriner enfeksiyonlar içerisindeki Escherichia coli (E. coli) yoğunluğunun tespit edilmesi, E. coli suşlarına karşı antibiyotik direncinin cinsiyet farklılığıyla ilişkisinin ve bölgesel antibiyotik direncinin öğrenilmesi. Gereç ve Yöntemler: Mart 2021-Aralık 2021 tarihleri arasında Samsun Vezirköprü Devlet Hastanesi poliklinikleri ve servislerinde alınan idrar kültürlerinde üreme saptanan 342 hasta değerlendirildi. E. coli suşlarına karşı gelişen antibiyotik direnci hastaların cinsiyet farklılığına göre değerlendirildi. Bulgular: Toplam 2.167 idrar kültürü alındı, 75 tanesi kontamine idi. 1.750 örnekte üreme saptanmadı, 342 örnekte bakteri ya da mantar üremesi saptandı. Pozitif idrar kültürü sonucu olanların yalnızca 10 tanesi yatan hastalardan, kalanların tamamı ayaktan hasta başvurusu sırasında polikliniklerden alındı. Polikliniklerden alınan örneklerden 252 tanesinde üreyen mikroorganizma E. coli idi. 80 örnekteki üreme Candida türleri ve diğer bakterilere aitti. Polikliniklerde E. coli üremesi olanların antibiyogram direnç profilinde en yüksek direnç %67,85 ile ampisiline karşı olmuştur. Siprofloksasin direnci kadınlarda %13,06 iken erkeklerde %30,26 tespit edilmiştir (p: 0,001). Sefazolin direnci kadınlarda %19,31 iken erkeklerde %51,31 tespit edilmiştir (p<0,001). Sonuç: Toplum kökenli üriner enfeksiyon etkenlerinin en sık sebebi E. coli'dir. Üriner enfeksiyondan şüphelenildiğinde ampirik antibiyoterapi başlanırken olası antibiyotik dirençleri de düşünülüp en uygun antibiyotik başlanmalıdır. Yüksek ampisilin direnci öngörülerek mümkünse ampirik tedavide bu antibiyotiğe yer verilmemelidir. Sefazolin ve siprofloksasin direnci erkeklerde kadınlara göre istatistiki anlamlı farklılık oluşturacak düzeyde daha fazladır. Ampirik antibiyoterapi başlanırken cinsiyet faktörünün göz önünde tutulması gerekmektedir.

Anahtar Kelimeler: Bakteri; ilaç direnci; cinsiyet; Escherichia coli
ABSTRACT
 Objective: To determine the frequency of Escherichia coli (E. coli) in urinary infections, to learn the relationship between antibiotic resistance against E. coli strains with sex differences and regional antibiotic resistance. Material and Methods: Between March 2021 and December 2021, 342 patients with urine cultures collected from Samsun Vezirköprü State Hospital outpatient clinics and services were evaluated. Antibiotic resistance to E. coli strains was evaluated according to the sex differences of the patients. Results: A total of 2,167 urine culture samples were collected, 75 of them were contaminated. No growth was detected in 1,750 samples, there were only 342 samples containing bacteria or fungus. Only 10 of the patients with a positive urine culture result were taken from hospitalized inpatients at the time of admission, and all of the remaining ones from the outpatient clinics. The microorganism that grew in 252 of the samples taken from the outpatient clinics was E. coli. Growth in 80 samples was Candida species and other bacteria. In the antibiogram resistance profile of those with E. coli growth in outpatient clinics, the highest resistance was against ampicillin with 67.85%. While ciprofloxacin resistance was 13.06% in women, it was 30.26% in men (p: 0.001). Cefazolin resistance was determined as 19.31% in women and 51.31% in men (p<0.001). Conclusion: The most common cause of community-acquired urinary infections is E. coli. When a urinary infection is suspected, possible antibiotic resistances should be considered while starting empirical antibiotic therapy, and the most appropriate antibiotic should be started. Considering high ampicillin resistance, this antibiotic should not be included in empirical treatment if possible. Cefazolin and ciprofloxacin resistance is higher in males than in females, at a level that creates a statistically significant difference. Sex factor should be taken into consideration when starting empirical antibiotic therapy.

Keywords: Bacteria; drug resistance; sex; Escherichia coli
REFERENCES:
  1. Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010;7(12):653-60. [Crossref]  [PubMed] 
  2. Ingersoll MA. Sex differences shape the response to infectious diseases. PLoS Pathog. 2017;13(12):e1006688. [Crossref]  [PubMed]  [PMC] 
  3. Lipsky BA. Urinary tract infections in men. Epidemiology, pathophysiology, diagnosis, and treatment. Ann Intern Med. 1989;110(2):138-50. [Crossref]  [PubMed] 
  4. Harrington RD, Hooton TM. Urinary tract infection risk factors and gender. J Gend Specif Med. 2000;3(8):27-34. [PubMed] 
  5. Stamm WE, Raz R. Factors contributing to susceptibility of postmenopausal women to recurrent urinary tract infections. Clin Infect Dis. 1999;28(4):723-5. [Crossref]  [PubMed] 
  6. Coker TJ, Dierfeldt DM. Acute bacterial prostatitis: diagnosis and management. Am Fam Physician. 2016;93(2):114-20. [PubMed] 
  7. Karigoudar RM, Karigoudar MH, Wavare SM, Mangalgi SS. Detection of biofilm among uropathogenic Escherichia coli and its correlation with antibiotic resistance pattern. J Lab Physicians. 2019;11(1):17-22. [Crossref]  [PubMed]  [PMC] 
  8. Kot B. Antibiotic resistance among uropathogenic Escherichia coli. Pol J Microbiol. 2019;68(4):403-15. [Crossref]  [PubMed]  [PMC] 
  9. Wayne PA. Clinical and Laboratory Standards Institute: Performance standards for antimicrobial susceptibility testing: 20th informational supplement. CLSI document M100-S20. Published online 2010. [Link] 
  10. Hulscher ME, Grol RP, van der Meer JW. Antibiotic prescribing in hospitals: a social and behavioural scientific approach. Lancet Infect Dis. 2010;10(3):167-75. [Crossref]  [PubMed] 
  11. Kahlmeter G, Poulsen HO. Antimicrobial susceptibility of Escherichia coli from community-acquired urinary tract infections in Europe: the ECO?SENS study revisited. Int J Antimicrob Agents. 2012;39(1):45-51. [Crossref]  [PubMed] 
  12. World Health Organization. Antimicrobial Resistance: Global Report on Surveillance. Geneva: World Health Organization; 2014. [Link] 
  13. Bell BG, Schellevis F, Stobberingh E, Goossens H, Pringle M. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect Dis. 2014;14:13. [Crossref]  [PubMed]  [PMC] 
  14. Lutay N, Ambite I, Grönberg Hernandez J, Rydström G, Ragnarsdóttir B, Puthia M, et al. Bacterial control of host gene expression through RNA polymerase II. J Clin Invest. 2013;123(6):2366-79. [Crossref]  [PubMed]  [PMC] 
  15. Hansson S, Jodal U, Lincoln K, Svanborg-Edén C. Untreated asymptomatic bacteriuria in girls: II--Effect of phenoxymethylpenicillin and erythromycin given for intercurrent infections. BMJ. 1989;298(6677):856-9. [Crossref]  [PubMed]  [PMC] 
  16. Cai T, Mazzoli S, Mondaini N, Meacci F, Nesi G, D'Elia C, et al. The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat? Clin Infect Dis. 2012;55(6):771-7. [Crossref]  [PubMed] 
  17. Bonkat G, Bartoletti R, Bruyère F, Cai T, Geerlings SE, Köves B, et al. Urological Infections. In: The European Association of Urology (EAU) Guidelines; 2023. Erişim tarihi: March 2023. [Link] 
  18. Aykan SB, Ciftci IH. Türkiye'de idrar kültürlerinden izole edilen escherichia coli suşlarının antibiyotiklere direnç durumu: bir meta-analiz [Antibiotic resistance patterns of Escherichia coli strains isolated from urine cultures in Turkey: a meta-analysis]. Mikrobiyol Bul. 2013;47(4):603-18. [Crossref]  [PubMed] 
  19. Guajardo-Lara CE, González-Martínez PM, Ayala-Gaytán JJ. Resistencia antimicrobiana en la infección urinaria por Escherichia coli adquirida en la comunidad. Cuál antibiótico voy a usar? [Antibiotic resistance of Escherichia coli from community-acquired urinary tract infections. What antimicrobial to use?]. Salud Publica Mex. 2009;51(2):155-9. Spanish. [Crossref]  [PubMed] 
  20. Neyrolles O, Quintana-Murci L. Sexual inequality in tuberculosis. PLoS Med. 2009;6(12):e1000199. [Crossref]  [PubMed]  [PMC] 
  21. Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol. 2016;16(10):626-38. [Crossref]  [PubMed] 
  22. Ortona E, Pierdominici M, Rider V. Editorial: sex hormones and gender differences in immune responses. Front Immunol. 2019;10:1076. [Crossref]  [PubMed]  [PMC] 
  23. Fink AL, Engle K, Ursin RL, Tang WY, Klein SL. Biological sex affects vaccine efficacy and protection against influenza in mice. Proc Natl Acad Sci U S A. 2018;115(49):12477-82. [Crossref]  [PubMed]  [PMC] 
  24. Furman D, Hejblum BP, Simon N, Jojic V, Dekker CL, Thiébaut R, et al. Systems analysis of sex differences reveals an immunosuppressive role for testosterone in the response to influenza vaccination. Proc Natl Acad Sci U S A. 2014;111(2):869-74. [Crossref]  [PubMed]  [PMC] 
  25. Jacobsen H, Klein SL. Sex differences in immunity to viral infections. Front Immunol. 2021;12:720952. [Crossref]  [PubMed]  [PMC] 
  26. Hewagama A, Patel D, Yarlagadda S, Strickland FM, Richardson BC. Stronger inflammatory/cytotoxic T-cell response in women identified by microarray analysis. Genes Immun. 2009;10(5):509-16. [Crossref]  [PubMed]  [PMC] 
  27. Zychlinsky Scharff A, Rousseau M, Lacerda Mariano L, Canton T, Consiglio CR, Albert ML, et al. Sex differences in IL-17 contribute to chronicity in male versus female urinary tract infection. JCI Insight. 2019;5(13):e122998. [Crossref]  [PubMed]  [PMC] 
  28. Zychlinsky Scharff A, Albert ML, Ingersoll MA. Urinary tract infection in a small animal model: transurethral catheterization of male and female mice. J Vis Exp. 2017;(130):54432. [Crossref]  [PubMed]  [PMC] 
  29. Olson PD, Hruska KA, Hunstad DA. Androgens enhance male urinary tract infection severity in a new model. J Am Soc Nephrol. 2016;27(6):1625-34. [Crossref]  [PubMed]  [PMC] 
  30. Yıldırım M, Şahin İ, Öksüz Ş, Özdemir D, Güçlü E, Acar S, et al. Üropatojen Escherichia Coli suşlarında bazı oral antibiyotiklere direnç ve dirençle ilişkili risk faktörleri [Resistance to some oral antibiotics and risk factors related to resistance in uropathogen escherichia coli strains]. ANKEM Derg. 2009;23(1):1-7. [Link] 
  31. Alós JI, Serrano MG, Gómez-Garcés JL, Perianes J. Antibiotic resistance of Escherichia coli from community-acquired urinary tract infections in relation to demographic and clinical data. Clin Microbiol Infect. 2005;11(3):199-203. [Crossref]  [PubMed] 
  32. Baerheim A, Digranes A, Hunskaar S. Are resistance patterns in uropathogens published by microbiological laboratories valid for general practice? APMIS. 1999;107(7):676-80. [Crossref]  [PubMed] 
  33. Richards J. Monitoring antibiotic resistance in urinary isolates from the community--a spotter practice model. Commun Dis Public Health. 2002;5(3):226-9. [PubMed] 
  34. Richards DA, Toop LJ, Chambers ST, Sutherland MG, Harris BH, Ikram RB, et al. Antibiotic resistance in uncomplicated urinary tract infection: problems with interpreting cumulative resistance rates from local community laboratories. N Z Med J. 2002;115(1146):12-4. [PubMed] 

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