The role of extended-spectrum cephalosporin-resistance in recurrent community-onset Enterobacteriaceae urinary tract infections: a retrospective cohort study

BMC Infect Dis. 2019 Feb 14;19(1):163. doi: 10.1186/s12879-019-3804-y.


Background: Bacterial resistance to first line antibiotics used to treat community-onset urinary tract infections (UTIs) continues to emerge. We sought to determine the association between extended-spectrum cephalosporin resistance (ESC-R) and recurrence among Enterobacteriaceae (EB) UTIs.

Methods: A retrospective cohort study was performed. All patients presenting to the Emergency Departments (EDs) or outpatient practices in a large health system with EB UTIs between 2010 and 2013 were included. Exposed patients had ESC-R EB UTIs. Unexposed patients had ESC-susceptible EB UTIs and were matched to exposed patients 1:1 on study year. Multivariable Cox proportional hazards regression analyses were performed to evaluate the association between ESC-R EB UTI and time to recurrent UTI within 12 months.

Results: A total of 302 patients with an index community-onset EB UTI were included, with 151 exposed and 151 unexposed. Overall, 163 (54%) patients experienced a recurrent UTI with a median time to recurrence of 69 days (interquartile range 25-183). On multivariable analyses, ESC-resistance was associated with an increased hazard of recurrent UTI (hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.01-1.91, P = 0.04). Other variables that were independently associated with recurrence included a history of UTI prior to the index UTI and presence of a urinary catheter at the time of the index UTI. Secondarily, we found that when the treatment for the index UTI was adjusted for, there was no longer a significant association between ESC-R status and time to recurrent UTI (aHR 1.26, 95% CI 0.91-1.76, P = 0.17).

Conclusions: Community-onset UTI due to EB demonstrating ESC-resistance is associated with a significantly increased hazard of recurrent UTI within 12 months compared to ESC-susceptible EB, even after adjusting for baseline factors that predispose patients to UTI recurrence. This association appears to be driven primarily by delayed or inappropriate treatment for the index ESC-R EB UTI.

Keywords: Community-onset; Enterobacteriaceae; Extended-spectrum beta-lactamase (ESBL); Extended-spectrum cephalosporin-resistant; Urinary tract infection.

MeSH terms

  • Adult
  • Aged
  • Anti-Bacterial Agents / therapeutic use
  • Cephalosporin Resistance* / drug effects
  • Cephalosporin Resistance* / genetics
  • Cephalosporins / therapeutic use*
  • Cohort Studies
  • Community-Acquired Infections* / drug therapy
  • Community-Acquired Infections* / epidemiology
  • Community-Acquired Infections* / microbiology
  • Enterobacteriaceae / drug effects
  • Enterobacteriaceae / genetics
  • Enterobacteriaceae Infections / drug therapy
  • Enterobacteriaceae Infections / epidemiology*
  • Enterobacteriaceae Infections / microbiology*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Recurrence
  • Retrospective Studies
  • Urinary Tract Infections / drug therapy
  • Urinary Tract Infections / epidemiology*
  • Urinary Tract Infections / microbiology*
  • beta-Lactamases / genetics


  • Anti-Bacterial Agents
  • Cephalosporins
  • beta-Lactamases