Suscetibilidade a antibióticos em infecções de trato
                        urinário em um hospital secundário, 2005-2006 e 2010-2011, em
                        São Paulo, Brasil: dados de 11.943 uroculturas

Miranda, Érique José Peixoto De; Oliveira, Gerson Sobrinho Salvador De; Roque, Felício Lopes; Santos, Sílvia Regina Dos; Olmos, Rodrigo Diaz; Lotufo, Paulo Andrade

doi:10.1590/S0036-46652014000400009

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Microbiology • Rev. Inst. Med. Trop. São Paulo 56 (4) • Jul-Aug 2014 • https://doi.org/10.1590/S0036-46652014000400009 copiar

Suscetibilidade a antibióticos em infecções de trato urinário em um hospital secundário, 2005-2006 e 2010-2011, em São Paulo, Brasil: dados de 11.943 uroculturas

Autoria SCIMAGO INSTITUTIONS RANKINGS

Introdução: A infecção do trato urinário (ITU) tem alta incidência e recorrência, e o tratamento é empírico na maioria dos casos.

Objetivos: O objetivo deste estudo foi analisar as culturas de urina realizadas em um hospital secundário, durante dois períodos: 2005-2006 e 2010-2011, para estimar a resistência microbiana.

Pacientes e métodos: Foram analisadas 11.943 culturas aeróbicas de urina de acordo com um conjunto de dados demográficos básicos e susceptibilidade aos antibióticos, obedecendo às normas do Clinical and Laboratory Standards Institute (CLSI) para Vitek 1 e 2.

Resultados: A maioria dos participantes era adulta e jovem atendida no Serviço de Emergência. E. coli foi a mais freqüente (70,2%) entre as 75 espécies isoladas. Resistência de todos os isolados foi ≥ 20% para sulfametoxazol/trimetoprim (SMX/TMP), norfloxacina, nitrofurantoína, cefazolina e ácido nalidíxico, apesar de E. coli ter sido mais suscetível (resistência ≥ 20% apenas para SMX/TMP e ácido nalidíxico) entre todos os isolados, levando em conta a porcentagem de resistência e o número de antibióticos testados. Resistência às fluoroquinolonas foi de 12%. Fatores de risco para E. coli: sexo feminino e idade < 65 anos. Homens e pacientes com mais de 65 anos apresentaram isolados mais resistentes. Beta-lactamases de espectro estendido (ESBL) foram identificadas em 173 de 5.722 isolados Gram-negativos (3,0%), 2010-2011.

Conclusões:E. coli foi o isolado mais sensível a antibióticos. Houve uma evolução significativa da resistência antimicrobiana entre os dois períodos. Foi preocupante o aumento da resistência às fluoroquinolonas.

Order	Bacteria isolated in urine culture	Frequency (n)	Percentage (%)
1°	Escherichia coli	8,376	70.2%
2°	Proteus mirabilis	795	6.8%
3°	Klebsiella pneumoniae	692	5.9%
4°	Enterococcus faecalis	322	2.8%
5°	Enterobacter aerogenes	187	1.7%
6°	Staphylococcus saprophyticus	148	1.2%
7°	Pseudomonas aeruginosa	132	1.1%
8°	Enterobacter cloacae	126	1.1%
9°	Citrobacter freundii	122	1.0%
10°	Morganella morganii	104	0.9%
11°	Staphylococcus aureus	98	0.8%
12°	Staphylococcus epidermidis	85	0.7%
13°	Citrobacter koseri	82	0.7%
14°	Staphylococcus sp. DNAse negative	65	0.5%
15°	Staphylococcus warneri	62	0.5%
16°	Serratia marcescens	62	0.5%
17°	Klebsiella oxytoca	58	0.5%
18°	Streptococcus agalactiae	43	0.4%
19°	Staphylococcus hominis	38	0.3%
20°	Acinetobacter baumannii	36	0.3%
21°	Others	310	2.1%
	Total	11,943	100.0%

Notes: 1: neg.: negative, or Staphylococcus spp., neither classified as S. aureus (DNAse positive) nor had a specie discrimination, due to lack of discriminatory power by automated method (Vitek 1 or 2).
Appendix: Another isolates, in order of frequency, from the twenty-first: Staphylococcus haemolyticus, Enterococcus faecium, Streptococcus viridans, Streptococcus mitis, Proteus vulgaris, Staphylococcus simulans, Providencia stuartii, Providencia rettgeri, Staphylococcus sciuri, Salmonella spp., Stenotrophomonas maltophilia, Staphylococcus auricularis, Staphylococcus capitis, Citrobacter amalonaticus, Proteus penneri, Raoultella ornithinolytica, Raoultella planticola, Staphylococcus xylosus, Enterobacter asburiae, Enterococcus spp., Serratia fonticola, Serratia liquefaciens, Streptococcus anginosus, Streptococcus sanguinis, Aeromonas spp., Gram-negative (not discriminated), Burkholderia cepacia, Citrobacter braakii, Citrobacter spp., Enterobacter gergoviae, Enterobacter spp., Pseudomonas spp., coagulase-negative Staphylococcus spp., Staphylococcus intermedius, Staphylococcus lentus, Staphylococcus lugdunensis, Streptococcus bovis, Streptococcus spp. gallolyticus var. gallolyticus, Acinetobacter haemolyticus, Acinetobacter lwoffii, Acinetobacter spp., nonfermenting Gram-negative bacteria, Enterobacter sakazaki, Enterococcus hirae, Klebsiella ornithinolytica, Pantoea spp., Proteus spp., Providencia spp., Pseudomonas fluorescens, Pseudomonas putida, Staphylococcus cohnii spp. cohnii, Streptococcus gordonii, Streptococcus parasanguinis, Streptococcus pyogenes, beta-hemolytic group G Streptococcus spp.

Order	Male, n = 2,673	Female, n = 9,270	Odds ratio^* * (F): female, reference is male; (M): male, reference is female (reference is the counterpart of the gender indicated in parentheses). Morganella morganni: OR = 10.15 (95% CI: 6.53-15.76), p < 0.0001 (male); Pseudomonas aeruginosa: OR = 4.81 (95% CI: 3.40-6.82), p < 0.0001 (male); Staphylococcus saprophyticus: OR = 10.37 (95% CI: 3.84-28.0), p < 0.0001 (female); Enterobacter aerogenes: OR = 1.48 (95% CI: 1.08-2.02), p = 0.012 (male).	CI 95%	p
1°	Escherichia coli, 1,271 (47.5%)	Escherichia coli, 7,103 (76.6%)	3.60 (F)	3.30-3.90	<0.0001
2°	Proteus mirabilis, 302 (11.3%).	Proteus mirabilis, 493 (5.31%)	2.27 (M)	1.94-2.64	<0.0001
3°	Klebsiella pneumoniae, 215 (8.04%)	Klebsiella pneumoniae, 477 (5.1%)	1.61 (M)	1.36-1.91	<0.0001
4°	Enterococcus faecalis, 151 (5.65%)	Enterococcus faecalis, 171 (1.8%)	3.19 (M)	2.53-4.01	<0.0001
5°	Morganella morganni, 77 (2.88%)	Staphylococcus saprophyticus, 144 (1.5%)	–	–	–
6°	Pseudomonas aeruginosa, 76 (2.84%)	Enterobacter aerogenes, 131 (1.4%)	–	–	–
7°	Enterobacter cloacae, 59 (2.20%)	Enterobacter cloacae, 67 (0.72%)	3.09 (M)	2.17-4.41	<0.0001
8°	Citrobacter freundii, 56 (2.10%)	Citrobacter freundii, 66 (0.71%)	2.98 (M)	2.08-4.27	<0.0001
9°	Enterobacter aerogenes, 56 (2.10%)	Staphylococcus warneri, 59 (0.63%)	–	–	–
10°	Staphylococcus aureus, 52 (1.94%)	Pseudomonas aeruginosa, 56 (0.60%)	–	–	–

Antibiotic	*Escherichia coli*			*Proteus mirabilis*			*Klebsiella pneumoniae*			*Enterococcus faecalis*			*Enterobacter aerogenes*			*S. saprophyticus*			*Pseudomonas aeruginosa*
Antibiotic	2005-2006	2010-2011	p	2005-2006	2010-2011	p	2005-2006	2010-2011	p	2005-2006	2010-2011	p	2005-2006	2010-2011	p	2005-2006	2010-2011	P	2005–2006	2010–2011	P
Nalidixic acid	90.1%	78.1%	<0.0001	91.6%	85.9%	0.011	87.1%	74.9%	<0.0001			86.2%	90%	0.422				42.9%
Amikacin	99.8%	99.8%	0.783	98.8%	99.7%	0.316	96.7%	99.7%	0.006				95.3%	96.9%	0.932				78.6%	95.5%	0.004
Amoxicillin/clavulanate	83.5%	86.8%	<0.0001	91.9%	78.6%	<0.0001	90.4%	84.9%	0.034				5.7%	1%	0.155				28.6%
Ampicillin										100%	90.2%	0.004
Cefazolin	95.2%	91.9%	0.040	95.6%	76.2%	0.023	95.3%	79.2%	0.054				17.4%	0%	0.888
Cefepime	99.6%	97.2%	<0.0001	98.2%	95.4%	0.035	94.8%	84.2%	<0.0001				95.3%	97.9%	0.643			80.3%	92.4%	0.076
Ceftazidime				100%	95.4%	1.000	50%	85.5%	0.073					95%					75.8%	92.4%	0.017
Ceftriaxone	99.6%	97.8%	<0.0001	98.5%	81%	<0.0001	95.9%	91.7%	0.328			93%	100%	1.000
Cefuroxime axetil	96.8%	92.3%	<0.0001	96.9%	81%	0.003	88.6%	87.5%	1.000
Ciprofloxacin	92.9%	84.9%	<0.0001	95.1%	87.9%	<0.0001	89.9%	78.1%	<0.0001	73.9%	74.8%	0.859	92%	92%	0.991	100%	100%	1.000	68.2%	89.4%	0.003
Clindamycin																99.3%
Colistin		100%			0%			66.7%
Erythromycin																79.5%
Ertapenem		100%			99.5%			98.5%						100%
Streptomycin										68.8%
Streptomycin (high level resistance)									78.8%
Gentamicin	96.6%	94.3%	<0.0001	95.8%	91.5%	0.013	94.9%	90.1%	0.021	100%			96.6%	97%	1.000				61.5%	89.4%	<0.0001
Gentamicin (high level resistance)										78.8%	79.8%	0.206
Imipenem	100%	100%	1.000	100%	100%	1.000	100%	100%	1.000				100%						89.4%	91.2%	0.762
Levofloxacin		100%						100%
Linezolid										97.5%	98.9%	1.000
Meropenem	100%	100%	1.000	100%	100%	1.000		100%						100%					85%	92.4%
Minocycline
Nitrofurantoin	98.4%	92.3%	<0.0001	1%	0%	0.147	63%	32.7%	<0.0001	100%	97.3%	0.478	47.1%	5%	<0.0001	99.3%			28.6%
Norfloxacin	92.7%	85.7%	<0.0001	94.8%	100%	0.695	89.7%	82.6%	0.479				92%	100%	1.000				67.9%	86.7%	0.037
Oxacillin																	100%
Penicillin G										89.8%	85.9%	0.294
Piperacillin/tazobactam	100%	96.9%	1.000	100%	96.2%	1.000	16.7%	88.7%	<0.0001					87.5%					89.4%	94%	0.588
Rifampin																99.3%	100%	1.000
Tetracycline										26.8%	18.9%	0.326				81.5%
Trimethoprim/sulfamethoxazole	65%	62.9%	0.023	77.8%	74.5%	0.268	82.7%	77.9%	<0.0001				92%	94%	0.583	95.2%			3.1%
Vancomycin										98.6%	97.3%	0.699				100%	100%	1.000

Antibiotic, susceptible, n(%)	Male gender			Female gender
Antibiotic, susceptible, n(%)	0-14 years	15-64 years	≥65 years	0-14 years	15-64 years	≥65 years
Nalidixic acid	603 (97.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	532 (74.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	506 (59.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.198 (94.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	4.794 (88.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.220 (69.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Amikacin	528 (100)	635 (96.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	794 (95.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.107 (100)	4.740 (99.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.569 (99.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Amoxicillin/clavulanate	454 (73.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	490 (68.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	530 (62.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.050 (82.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	4.637 (85.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.395 (79.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Ampicillin	253 (38.8)	304 (37.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	318 (31.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	539 (41.2)	2.802 (48.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	880 (46.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Ampicillin/sulbactam	3 (16.7)	17 (29.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	40 (44.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	2 (11.1)	39 (17.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	14 (23.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Aztreonam	9 (100)	25 (49.0)	31 (41.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	18 (85.7)	11 (45.8)	27 (64.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Cephalothin	457 (73.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	448 (60.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	443 (49.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	964 (75.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	4.154 (76.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.185 (66.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Cefazolin	87 (77.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	102 (68.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	106 (70.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	178 (87.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	741 (73.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	217 (83.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Cefepime	527 (99.8)	604 (91.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	725 (86.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.095 (98.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	4.692 (98.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.499 (94.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Cefotaxime	230 (95.0)	296 (81.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	374 (73.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	549 (95.8)	2.717 (97.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	854 (88.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Cefoxitin	0	4 (14.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	3 (6.8)	5 (45.5)	17 (65.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	4 (16.0)
Ceftazidime	254 (98.8)	349 (87.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	444 (81.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	609 (97.9)	2.902 (97.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.383 (87.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Ceftriaxone	383 (98.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	374 (91.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	382 (91.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	705 (100)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	2.677 (99.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	807 (97.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Cefuroxime axetil	272 (93.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	243 (77.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	227 (70.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	528 (97.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.954 (96.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	557 (88.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Ciprofloxacin	657 (98.8)	641 (76.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	692 (63.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.308 (98.2)	5.519 (92.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.446 (74.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Clindamycin	12 (100)	21 (63.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	41 (75.9)	14 (100)	263 (98.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	25 (58.1)
Chloramphenicol	–	–	1 (100)	–	2 (100)	–
Carbenicillin	32 (37.6)	52 (61.9)	32 (45.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	59 (39.6)	306 (55.8)	97 (60.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Colistin	–	3 (75.0)	2 (100)	1 (100)	4 (80.0)	4 (100)
Erythromycin	9 (75.0)	16 (48.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	31 (57.4)	13 (86.7)	216 (81.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	23 (53.5)
Ertapenem	231 (100)	318 (99.4)	446 (98.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	563 (100)	2778 (99.9)	933 (99.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Streptomycin	7 (58.3)	10 (62.5)	38 (73.1)	5 (55.6)	14 (63.6)	30 (62.5)
Streptomycin (high level resistance)	10 (83.3)	15 (57.7)	39 (76.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	8 (100)	35 (72.9)	18 (34.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Gentamicin	623 (97.0)	702 (86.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	855 (84.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.271 (96.6)	5.617 (96.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.680 (91.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Gentamicin (high level resistance)	21 (87.5)	27 (64.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	80 (77.7)	17 (100)	64 (91.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	70 (70.0)
Imipenem	296 (100)	338 (98.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	383 (98.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	545 (100)	1.975 (100)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	646 (99.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Levofloxacin	–	–	–	–	7 (100)	3 (100)
Linezolid	24 (100)	55 (100)	117 (99.2)	22 (100)	205 (98.6)	96 (99.0)
Meropenem	241 (100)	362 (98.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	509 (97.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	582 (100)	2.800 (100)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	968 (99.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Minocycline	50 (58.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	58 (69.0)	47 (67.1)	115 (77.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	393 (71.7)	115 (71.4)
Nitrofurantoin	389 (60.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	584 (74.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	660 (67.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.119 (86.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	5.010 (86.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.515 (81.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Norfloxacin	400 (98.0)	363 (80.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	338 (65.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	733 (98.4)	2.664 (94.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	712 (79.3)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Oxacillin	5 (29.4)	16 (39.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	43 (51.8)	7 (31.8)	67 (18.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	21 (37.5)
Penicillin G	23 (54.8)	38 (44.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	89 (47.1)	19 (49.6)	112 (23.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	95 (57.6)
Piperacillin/tazobactam	131 (97.8)	184 (84.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	258 (81.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	306 (96.5)	1.326 (96.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	503 (93.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Polymyxin B	2 (100)	15 (100)	23 (100)	13 (100)	4 (100)	11 (100)
Quinupristin/dalfopristin	3 (50.0)	11 (68.8)	17 (56.7)	1 (33.3)	28 (93.3)	10 (45.5)
Rifampin	17 (100)	35 (85.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	78 (94.0)	22 (100)	361 (99.7)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	51 (89.5)
Teicoplanin	16 (100)	27 (100)	59 (89.4)	17 (100)	135 (99.3)	61 (98.4)
Tetracycline	20 (47.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	50 (54.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	81 (54.4)	45 (71.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	350 (66.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	78 (48.4)
Ticarcillin	73 (81.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	86 (78.9)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	82 (73.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	141 (91.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	520 (93.4)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	162 (89.5)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Tigecycline	–	3 (75.0)	2 (100)	1 (100)	4 (80.0)	3 (100)
Tobramycin	85 (100)	83 (98.8)	71 (98.6)	147 (98.7)	547 (99.5)	159 (98.8)
Trimethoprim/sulfamethoxazole	415 (65.5)	485 (63.0)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	564 (59.2)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	807 (62.4)	4.007 (70.6)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	1.176 (65.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).
Vancomycin	43 (100)	93 (98.9)	190 (94.1)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).	43 (100)	496 (100)	170 (98.8)^* * p < 0.05 compared between gender within each stratum of age indicated (Pearson uncorrected chi-square test or Fisher's exact test when values ≤ 5).

	Rocha JL et al.²⁵25. Rocha JL, Tuon FF, Johnson JR. Sex, drugs, bugs, and age: rational selection of empirical therapy for outpatient urinary tract infection in an era of extensive antimicrobial resistance. Braz J Infect Dis. 2012;16:115-21.	Costa LC et al.⁹9. Costa LC, Belém LF, Freitas e Silva PM, Pereira HS, Silva Júnior ED, Leite TR, et al. Infecções urinárias em pacientes ambulatoriais: prevalência e perfil de resistência aos antimicrobianos. Rev Bras Anal Clin. 2010;42:175-80.	Braoios A et al.⁴4. Braoios A, Turatti TF, Meredija LCS, Campos TRS, Denadai FHM. Infecções do trato urinário em pacientes não hospitalizados: etiologia e padrão de resistência aos antimicrobianos. J Bras Patol Med Lab. 2009;45:449-56.	Koch CR et al.²⁰20. Koch CR, Ribeiro JC, Schnor OH, Zimmermann BS, Müller FM, D' Agostin J, et al. Antimicrobial resistance of uropathogens among outpatients, 2000-2004. Rev Soc Bras Med Trop. 2008;41:277-81.	Kiffer CR et al.¹⁹19. Kiffer CR, Mendes C, Oplustil CP, Sampaio JL. Antibiotic resistance and trend of urinary pathogens in general patients from a major urban city. Int Braz J Urol. 2007;33:42-9.	Santo E et al.²⁶26. Santo E, Salvador MM, Marin JM. Antimicrobial resistance among urinary tract Escherichia coli isolates from inpatients and outpatients in a tertiary care center in São Paulo, Brazil. Int J Infect Dis. 2007;11:558-9.	Dias RC et al.¹⁰10. Dias RC, Marangoni DV, Smith SP, Alves EM, Pellegrino FL, Riley LW, et al. Clonal composition of Escherichia coli causing community-acquired urinary tract infections in the State of Rio de Janeiro, Brazil. Microb Drug Resist. 2009;15:303-8.	Ba il L et al.²2. Bail L, Ito CAS, Esmerino LA. Infecção do trato urinário: comparação entre o perfil de susceptibilidade e a terapia empírica com antimicrobianos. Rev Bras Anal Clin. 2006;38:51-6.	Dias VC et al.¹¹11. Dias VC, da Silva VL, Firmo Ede O, Bastos LQ, Bastos AN, Bastos RV, et al. Distribution of ESBL-producing enterobacteria associated to community-acquired monomicrobial urinary tract infections and antimicrobial susceptibility trends over a 9-year period. J Chemother. 2012;24:178-81.	Andrade SS et al.¹1. Andrade SS, Sader HS, Jones RN, Pereira AS, Pignatari AC, Gales AC. Increased resistance to first-line agents among bacterial pathogens isolated from urinary tract infections in Latin America: time for local guidelines? Mem Inst Oswaldo Cruz. 2006;101:741-8.
Positive urine cultures (n)	9,798	566	1,252	957	37,261	78	186; 118 E. coli	106	78,964	611
Setting of study	Curitiba, Southern of Brazil	Campina Grande, Northeastern of Brazil	Presidente Prudente, Southeastern of Brazil	Porto Alegre, Southern of Brazil	São Paulo, Southeastern of Brazil	Ribeirão Preto, Southeastern of Brazil	Rio de Janeiro, So utheastern of Brazil	Ponta Grossa, Southern of Brazil	Juiz de Fora, Southeastern of Brazil	Brasília, Florianópolis, Porto Alegre, São Paulo, Brazil
Period of study	May to Dec 2009	Jan 2006 to Jun 2008	Jan 2006 to Dec 2007	Jan 2000 to Dec 2004	Jan 2000 to Dec 2003	Jul 2000 and Jul 2003.	Mar 2005 to Nov 2006	Jan to Dec 2001	2001 to 2009	Jan to Dec 2013
Year of publication	2012	2010	2009	2008	2007	2007	2009	2006	2012	2006
Antibiogram method	Vitek 2	disk diffusion	disk diffusion	disk diffusion	disk diffusion, Vitek 1	disk diffusion	disk diffusion and E-test	disk diffusion	disk diffusion	microdilution
Standardization	CLSI	CLSI	CLSI	CLSI	CLSI	CLSI	CLSI	CLSI	CLSI	CLSI
Females (%)	88%	85.2%	69.01%	81.3%	88.8%	not available	100%	70%	69.8%	75.6%
Most frequent age strata	21-40 years (36.9%)	> 60 years (36.9%)	20-49 years (52.95%)	not available	13-60 years (60.0%)	not available	not available	not available	not available	not available
Gram-negatives (%)	not available	not available	84.42%	not available	87.3%	100%	100%	92.5%	100%	not available
E. coli (%)	66.1%	48.2%	65.97%	66.2%	71.6%	100%	100%	58.6%	72.4%	66%
Other frequent agents (%)	Enterococcus spp (8.1), Klebsiella spp. (5.9), S.saprophyticus 381 (3.9), Proteus mirabilis (3.9), Enterobacter spp. (2.7), Pseudomonas aeruginosa (1.2)	P.mirabilis (11), K. pneumoniae (9.9), S.saprophyticus (5.5), Enteroba cter sp. (5.3), S. epidermidis (5.1), S.aureus (3.5), K.oxytoca (3.5). P.aeruginosa (2.5)	Klebsiella pneumoniae (6.07), Proteus mirabilis (5.51), Enterobacter sp (2.88), Pantoea agglomerans (1.92), Citrobacter sp (1.36).	Proteus mirabillis (8.4), Klebsiella sp (5.6)	K. pneumoniae (6.4), P. mirabilis (6.1), E. faecalis (4.8), P. aeruginosa (1.8), S. saprophyticus (1.6), E. aerogenes (1.6), E. cloacae (1.1).	No	No	Enterobacter sp. (11.8), Proteus sp.(4.4), Serratia sp (2.9), Klebsiella sp.(2.9).	Klebsiella pneumoniae (17.4%), Morganella morganii (2.5%), Proteus mirabilis (1.9%), Klebsiella oxytoca (1.3%), Klebsiella ozaenae (1.1%).	Klebsiella spp. (7%), P. mirabilis (6.4%), Enterococcus spp. (5.6%), P. aeruginosa (4.6%).
Clinical variables present	no	no	no	no	no	no	yes	no	no	no
E. coli susceptibility	Ampicillin (55.9), nitrofurantoin (96.0), TMP-SMX (65.8), fluoroquinolones¹ (82.2), extended-spectrum cepholosporins² (96.8), Gentamicin (93.1).	Ciprofloxacin (78.8), norfloxacin (77), nitrofuratoin (93), TMP/SMX (54.3)	Amoxicillin/clavulanate (94), ampicillin (48), cephalotin (59), cefuroxime (86), ceftriaxone (90), ceftazidime (97), cefepime (97), ciprofloxacin (86), gentamicin (96), nitrofurantoin (96), TMP/SMX (62)	Gentamicin (88), cephalotin (55), nitrofurantoin (86), ceftriaxone (98), ciprofloxacin (87), TMP/SMX (54).	Ampicillin (57), cephalotin (86), ceftriaxone (99), ciprofloxacin (88), gentamicin (97), nitrofurantoin (97), norfloxacin (88), TMP/SMX (66), tetracycline (69)	Ampicillin (63), cephalotin (92), cefuroxime (99), ceftriaxone (99), gentamicin (100), nitrofurantoin (97), norfloxacin (88), TMP/SMX (71), tetracycline (69)	Ampicillin (29), TMP/SMX (52), amoxicilline/clavulanate (81), floroquinolones³ (94), cefuroxime (96), fosfomycin (97), nitrofurantoin (97), gentamicin (97), cefotaxime (98)	Ampicillin (49), cephalotin (74), TMP/SMX (56), nitrofurantoin (95), norfloxacin (88), gentamicin (88)	2009: Amikacin (94), ciprofloxacin (24), gentamicin (69), nitrofurantoin (88), TMP/SMX (24), imipenem (100)	Ampicillin (50), amoxicillin/clavulanate (89), cefuroxime (99), ciprofloxacin (90), levofloxacin (91), nitrofurantoin (98), TMP/SMX (58).
Proteus sp. susceptibility	–	Ciprofloxacin (91.2), norfloxacin (91.2), nitrofurantoin (58.1), TMP/SMX (58.1)	Amoxicillin/clavulanate (96), ampicillin (5), cephalotin (92), cefuroxime (85), ceftriaxone (82), ceftazidime (93), cefepime (95), ciprof loxacin (83), gentamicin (93), nitrofurantoin (83), TMP/SMX (82)	Gentamicin (91), cephalotin (44), nitrofurantoin (40), ceftriaxone (91), ciprofloxacin (91), TMP/SMX (47).	Ampicillin (81), cephalotin (97), ceftriaxone (99), ciprofloxacin (96), gentamicin (98), nitrofurantoin (0), norfloxacin (96), TMP/SMX (78), tetracycline (0)	–	–	–	2009: Amikacin (100), ciprofloxacin (100), gentamicin (0), nitrofurantoin (0), TMP/SMX (50), imipenem (100)	–
Klebsiella sp. susceptibility	–	Ciprofloxacin (82.1), norfloxacin (78.6), nitrofurantoin (76.8), TMP/SMX (71.4)	Amoxicillin/clavulanate (90), ampicillin (42), cephalotin (80), cefuroxime (84), ceftriaxone (88), ceftazidime (94), cefepime (97), ci profloxacin (94), gentamicin (94), nitrofurantoin (12), TMP/SMX (96)	Gentamicin (85), cephalotin (43), nitrofurantoin (42), ceftriaxone (94), ciprofloxacin (79), TMP/SMX (53).	Ampicillin (0), cephalotin (92), ceftriaxone (98), ciprofloxacin (94), gentamici n (97), nitrofurantoin (79), norfloxacin (91), TMP/SMX (82), tetracycline (80)	–	–	–	2009: Amikacin (94), ciprofloxacin (13), gentamicin (63), nitrofurantoin (44), TMP/SMX (24), imipenem (100)	–
E. faecalis susceptibility	–	–	–	–	Ampicillin (99), ciprofloxacin (84), nitrofurantoin (99), tetracycline (40)	–	–	Nitrofurantoin (100), norfloxacin (100), gentamicin (100)	–	–
E. aerogenes susceptibility	–	Ciprofloxacin (85.7), norfloxacin (81), nitrofurantoin (66.7), TMP/SMX (47.6)	–	–	Ampicillin (0), cephalotin (0), ceftriaxone (98), ciprofloxacin (95), gentamicin (98), nitrofurantoin (79), norfloxacin (95), TMP/SMX (92), tetracycline (93)	–	–	–	2009: Amikacin (76), ciprofloxacin (50), gentamicin (75), nitrofurantoin (0), TMP/SMX (50), imipenem (100)	–
S. saprophyticus susceptibility	–	Ciprofloxacin (73.3), norfloxacin (72.4), nitrofurantoin (86.7), TMP/SMX (39.3)	Amoxicillin/clavulanate (94), cephalotin (86), clindamicin (94), oxacillin (91), ciprofloxacin (94), gentamicin (97), nitrofurantoin (97), norfloxacin (97), TMP/SMX (94), vancomycin (100).	–	Ciprofloxacin (99), nitrofurantoin (99), tetracycline (84).	–	–	–	–	–
P. aeruginosa susceptibility	–	–	–	–	Ceftriaxone (11), ciprofloxacin (37), gentamicin (52), norfloxacin (38).	–	–	Norfloxacin (33), gentamicin (33)	–	–
Temporal trend of resistance	–	–	–	Ciprofloxacin (p=0.07), nalidixic acid (P=0.02)	Ciprofloxacin, norfloxacin, tetracycline, nalidixic acid (all: p< 0.0001).	–	–	–	–	–

Instituto de Medicina Tropical de São Paulo Av. Dr. Enéas de Carvalho Aguiar, 470, 05403-000 - São Paulo - SP - Brazil, Tel. +55 11 3061-7005 - São Paulo - SP - Brazil
E-mail: revimtsp@usp.br

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[1] Correspondence to: Érique José Peixoto de Miranda, Hospital Universitário (HU-USP), Universidade de São Paulo, Av. Prof. Lineu Prestes 2565, Butantã, 05508-000 São Paulo, SP, Brasil. Tel.: +55 11 3091-9275. E-mail: eriquemiranda@gmail.com.