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Perfis de sensibilidade e resistência aos antibióticos na infeção urinária da comunidade no distrito de Lisboa
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A resistência crescente aos antibióticos é um grave problema de saúde pública, que ameaça o tratamento eficaz de infeções. As ITU são muito prevalentes na comunidade e o tratamento indicado é a antibioterapia, na maioria das vezes empírica. O objetivo deste estudo é traçar os perfis de sensibilidade e resistência dos microrganismos mais frequentes nas ITU da comunidade, no Distrito de Lisboa.
Neste estudo retrospetivo, observacional e transversal analisaram-se 10813 uroculturas colhidas em 2018 no distrito de Lisboa. Estimou-se a frequência de uroculturas positivas por sexo e grupo etário, determinou-se a prevalência das estirpes bacterianas no total das uroculturas, em cada sexo e em cada grupo etário, analisaram-se os perfis de sensibilidade e resistência dos seis microrganismos mais frequentes da amostra e realizou-se uma subanálise das resistências de E. coli, K. pneumoniae e PSAE, para avaliar quais eram simultaneamente resistentes a dois antibióticos de relevo no seu tratamento. Utilizou-se o teste T de Student para determinar diferenças significativas de médias e o teste Qui-Quadrado para averiguar diferenças significativas de distribuição entre os sexos e grupos etários.
Das 10813 uroculturas, aproximadamente 25% das uroculturas na Grande Lisboa em 2018, 84,3% pertencia a indivíduos do sexo feminino e 61,4% à população acima dos 59 anos. A estirpe bacteriana mais prevalente foi E. coli (68,6%), seguida por K. pneumoniae (12,4%), P. mirabilis (6,1%), E. faecalis (2,3%), S. saprophyticus (1,9%) e PSAE (1,8%). Encontrou-se uma maior dispersão de agentes etiológicos nos homens e nos idosos (p<0,001). E. coli apresentou sensibilidade >90% à fosfomicina, nitrofurantoína e cefalosporinas de 3ª Geração e resistência > 20% à AAC, CTX e ciprofloxacina. K. pneumoniae apresentou taxas de sensibilidade > 80% apenas para a fosfomicina e cefixima. As resistências foram superiores nos homens e idosos (p<0,001). Dos isolados de E. coli resistentes à cefotaxima (n=460), 83,7% eram também resistentes à ciprofloxacina (5.1% de E.coli); dos isolados de K. Pneumoniae resistentes à ciprofloxacina (n=398), 62,0% eram resistentes à cefotaxima (18.5% de K.pneumoniae); e dos isolados de PSAE resistentes à ceftazidima (n=33), 75% eram resistentes à ciprofloxacina (12.9% de PSAE). As resistências concomitantes foram superiores na população idosa (p<0,02).
A distribuição das uroculturas pelos sexos e grupos etários e os microrganismos isolados com maior frequência foram de encontro ao esperado. Os resultados deste estudo apoiam a Norma da DGS, que aconselha fosfomicina e a nitrofurantoína como primeira linha na terapêutica de uma cistite aguda não complicada. A maior dispersão de agentes etiológicos e a maior taxa de resistências encontradas nos homens e idosos exigem maior ponderação na escolha da opção terapêutica nestes grupos. Verificou-se uma diminuição da sensibilidade à AAC em comparação com estudos portugueses prévios. O perfil de resistência obtido neste estudo foi inferior ao perfil obtido no Surveillance of antimicrobial resistance in Europe de 2018, que é relativo a dados hospitalares. Resistência a dois antibióticos em simultâneo é encontrada em >5% das amostras, tendo maior preponderância em faixa etárias avançadas.
A constante mudança e a variação entre regiões dos perfis de sensibilidade e resistência justificam uma monitorização periódica destes perfis, para promover uma otimização da prescrição na prática clínica.
The growing resistance to antibiotics is a severe public health issue that threatens the effective treatment of infections. UTIs are very common infections in the community setting and empirical antibiotics is the recommended treatment in the majority of cases. The aim of this study is to determine the antimicrobial susceptibility and resistance patterns for the most frequent microorganisms in community-acquired UTIs, in the district of Lisbon, Portugal. In this retrospective, observational and cross-sectional study 10813 positive urine cultures, from 2018 obtained from an outpatient laboratory in the district of Lisbon, were analyzed. The frequency of positive urine cultures and the prevalence of bacteria were estimated by sex and by age group. The antimicrobial susceptibility and resistance patterns were analysed for the six most frequent bacteria. Concomitant resistance to two antibiotics was analysed for E. coli, K. pneumoniae and PSAE. T-Student Test was applied to detect significant differences between distributions and mean and a Chi-Square Test was used to ascertain significant differences associated with sex and age. From the 10813 urine cultures, about 25% of all urine cultures in the district of Lisbon in 2018, 84,3% belonged to females and 61,4% to people over 59 years old. E. coli was the most frequent bacteria (68,6%), followed by K. pneumoniae (12,4%), P. mirabilis (6,1%), E. faecalis (2,3%), S. saprophyticus (1,9%) and PSAE (1,8%). In the elderly and in men the etiological agents differed significantly more (p<0,001). E. coli’s susceptibility to fosfomycin, nitrofurantoin and 3rd generation cephalosporins was above 90% and its resistance rate to amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole and ciprofloxacin was above 20% . K. pneumoniae susceptibility rate was above 80% for fosfomycin and e cefixime only. Resistances were higher in men and in the elderly (p<0,001). From the E. coli resistant to cefotaxime (n=460), 83,7% were also resistant to ciprofloxacin (5.1% of E.coli); from the K. Pneumoniae resistant to ciprofloxacin (n=398), 62,0% were also resistant to cefotaxime (18.5% of K. pneumoniae); and from the PSAE resistant to ceftazidime (n=33), 75% were also resistant to ciprofloxacin (12.9% of PSAE). Concomitant resistance to two antibiotics was higher in the elderly population (p<0,02). The urine cultures’ distribution among genders and age groups and the most frequent microorganisms were similar to what was expected according to the literature. The results support portuguese guidelines recommendation that fosfomycin and nitrofurantoin as the first line antibiotics in the treatment of non complicated cystitis. Caution should is warranted when dealing with UTIs in men or older people due to the variation in etiological agents and higher resistance rates. In comparison with previous portuguese studies an increase in the resistance rates to amoxicillin/clavulanic acid was detected. As expected, our study shows lower resistance rates when compared to the rates from the Surveillance of antimicrobial resistance in Europe 2018, corresponding to hospital associated infections. Simultaneous resistance against two antibiotics is found in >5% , especially in the elderly population. The constant change and variation between regions of the antimicrobial susceptibility and resistance patterns implies the necessity of a periodic surveillance so as to improve prescription and clinical results.
The growing resistance to antibiotics is a severe public health issue that threatens the effective treatment of infections. UTIs are very common infections in the community setting and empirical antibiotics is the recommended treatment in the majority of cases. The aim of this study is to determine the antimicrobial susceptibility and resistance patterns for the most frequent microorganisms in community-acquired UTIs, in the district of Lisbon, Portugal. In this retrospective, observational and cross-sectional study 10813 positive urine cultures, from 2018 obtained from an outpatient laboratory in the district of Lisbon, were analyzed. The frequency of positive urine cultures and the prevalence of bacteria were estimated by sex and by age group. The antimicrobial susceptibility and resistance patterns were analysed for the six most frequent bacteria. Concomitant resistance to two antibiotics was analysed for E. coli, K. pneumoniae and PSAE. T-Student Test was applied to detect significant differences between distributions and mean and a Chi-Square Test was used to ascertain significant differences associated with sex and age. From the 10813 urine cultures, about 25% of all urine cultures in the district of Lisbon in 2018, 84,3% belonged to females and 61,4% to people over 59 years old. E. coli was the most frequent bacteria (68,6%), followed by K. pneumoniae (12,4%), P. mirabilis (6,1%), E. faecalis (2,3%), S. saprophyticus (1,9%) and PSAE (1,8%). In the elderly and in men the etiological agents differed significantly more (p<0,001). E. coli’s susceptibility to fosfomycin, nitrofurantoin and 3rd generation cephalosporins was above 90% and its resistance rate to amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole and ciprofloxacin was above 20% . K. pneumoniae susceptibility rate was above 80% for fosfomycin and e cefixime only. Resistances were higher in men and in the elderly (p<0,001). From the E. coli resistant to cefotaxime (n=460), 83,7% were also resistant to ciprofloxacin (5.1% of E.coli); from the K. Pneumoniae resistant to ciprofloxacin (n=398), 62,0% were also resistant to cefotaxime (18.5% of K. pneumoniae); and from the PSAE resistant to ceftazidime (n=33), 75% were also resistant to ciprofloxacin (12.9% of PSAE). Concomitant resistance to two antibiotics was higher in the elderly population (p<0,02). The urine cultures’ distribution among genders and age groups and the most frequent microorganisms were similar to what was expected according to the literature. The results support portuguese guidelines recommendation that fosfomycin and nitrofurantoin as the first line antibiotics in the treatment of non complicated cystitis. Caution should is warranted when dealing with UTIs in men or older people due to the variation in etiological agents and higher resistance rates. In comparison with previous portuguese studies an increase in the resistance rates to amoxicillin/clavulanic acid was detected. As expected, our study shows lower resistance rates when compared to the rates from the Surveillance of antimicrobial resistance in Europe 2018, corresponding to hospital associated infections. Simultaneous resistance against two antibiotics is found in >5% , especially in the elderly population. The constant change and variation between regions of the antimicrobial susceptibility and resistance patterns implies the necessity of a periodic surveillance so as to improve prescription and clinical results.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Palavras-chave
Resistências microbianas Antibioterapia Infeções do trato urinário Lisboa