Mapping antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli across low, middle and high-income countries highlights significant differences: insights for empiric treatment

Objectives: Rising antimicrobial resistance (AMR) in Escherichia coli urinary tract infections (UTI) poses a global challenge. Evidence-based treatment of cystitis requires local resistance data. The DASH to Protect Antibiotics (https://dashuti.com/), a multi-regional group, supports centers in generating and sharing focused antibiograms to guide stewardship in community UTIs. This multi-country study aimed to describe antimicrobial susceptibility patterns of community-acquired E. coli isolates in low, middle, and high-income countries (LMICs and HICs). Methods: The study was conducted in 37 representative centers across 13 countries in Asia (Middle East and Indian Subcontinent), Africa, Europe, and North America. A rigorous comparative analysis of the antimicrobial susceptibility of E. coli isolated from cases of simple cystitis presenting in outpatient or emergency departments was carried out. The impact of gross domestic product, climate, and population density per km² on E. coli susceptibility profile was analyzed using the Kruskal-Wallis test and two-way analysis of variance. Results: Antimicrobial susceptibility varied significantly between LMICs and HICs, with nitrofurantoin (89%) and fosfomycin (96%) emerging as empiric choices globally. Across most centers, susceptibility to other oral antimicrobials was low: co-trimoxazole <60%, amoxicillin-clavulanic acid <70%, first-generation cephalosporins <50%, fluoroquinolones <60%. Injectable antibiotics fared better: piperacillin-tazobactam >70%, amikacin and meropenem >80%. Higher susceptibilities were noted in countries with high gross domestic product (P < 0.001) and humidity (P = 0.002). Conclusion: Marked geographical differences in E. coli susceptibility patterns support the need for localized antibiograms and tailored empirical therapy. This study reinforces the utility of nitrofurantoin and fosfomycin as first-line agents and discourages the use of fluoroquinolones and third-generation cephalosporins.