Time trends of antimicrobial resistance in urinary pathogens in India: A study based on big data analytics

Clinicians and microbiologists have a common observation regarding increasing antimicrobial resistance among pathogens and also their increasing susceptibility to older and obsolete antimicrobial agents. The reason of changing trends of antimicrobial resistance over time is multi-factorial. Regulatory norms, availability, human movement, burden of infections, genetic changes in microorganism are few important factors. It is important to have an eye on these time trends as this is important to understand associated factors in detail and take necessary initiatives to curb down menace of antimicrobial resistance.

Urinary infections are common infections with high occurrence rate among women, elderly and diabetics. There is growing evidence in relation to excessive use of parenteral antibiotics and inpatient stay among subjects with urinary tract infections because of antimicrobial resistance.

We conducted an analysis on big data from our repository of diagnostic lab data to assess changing patterns of antimicrobial resistance among urinary pathogens between 2007-2018. Sample included 84506 subjects, tested for urine culture and sensitivity from 2007-2018 in various diagnostic laboratories in Indian states. Share of females in the sample was 69.6%. Six microorganisms constituted >90% of total isolates, namely E.coli, Klebsiella, Pseudomonas, Proteus, Enterococcus and staphylococcus aureus. Other important pathogens were Citrobacter, Enterobacter, Acinetobacter baumanii and methicillin resistant staphylococcus aureus (MRSA). Sensitivity of commonly used antibiotics for UTIs was calculated for all isolates together. Time periods were divided into four divisions as 2007-2012, 2013-2014, 2015-2016, 2017-2018 to compare sensitivities.

Antimicrobial agents included in the study are as follows. 1. Carbapenems (Imipenem, Meropenem, Ertapenem, Doripenem) 2. Fluoroquinolones (Ciprofloxacin, Levofloxacin, Norfloxacin, Ofloxacin) 3. Cephalosporins (Cefepime, Ceftriaxone, Cefuroxime, Cefpodoxime) 4. Nitrofurantoin 5. Penicillins (Amoxicillin, Amoxicillin-clavulanic acid) 6. Cotrimoxazole 7. Fosfomycin 8. Trimethoprim 9. Colistin

Decreasing trends of sensitivity : Carbapenems showed significant decline in sensitivity between 2007-2012 to 2017-2018 ranging from 2.7% (Meropenem) to 15.6% for Ertapenem. Among cephalosporins, cefuroxime, cefpodoxime, ceftriaxone showed significant decline ranging from 24.5 to 41.1%. Among fluoroquinolones, all except Ofloxacin showed significant decline in sensitivity. Nitrofurantoin had a decrease of 13%. Sensitivity to Fosfomycin was also reduced by 6.2% though it was not statistically significant (p: 0.78).

Many older and less used drugs showed increasing trends of sensitivity. Trimethoprim and cotrimoxazole both have significantly increasing trend of sensitivity. Among others Ofloxacin, amoxicillin, amoxicillin-clavulanic acid, Cefepime and Colistin also showed increasing trends (Ranging from 103% for Amoxicillin to 7% for Ofloxacin, and 10% for Colistin)

Our analysis highlighted, that how obsolete choices are re-emerging as future options, while high end, last resort drugs like carbapenems, showing declining coverage. It is important to ensure judicious use of latest antibiotics as well careful consideration of older and obsolete drugs in future.