Community-onset symptomatic urinary tract infections (SUTI) caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales: independent predictors and comparative effectiveness of oral agents.

Background: The incidence of community-onset (CO) symptomatic urinary tract infection (SUTI) caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales is increasing worldwide. Our study aims were to explore the independent predictors for CO-ESBL SUTI and to compare the effectiveness of several oral therapeutics, which are used for this indication in community health settings. Methods: Retrospective matched case-case-control and case-case studies, among insurers of Maccabi health maintenance organization, Shfella district, Israel (10-11/2019). Patients with CO-ESBL (Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis) SUTI were matched to patients with CO-non-ESBL SUTI and to uninfected controls (1:1:1). Matched analyses (logistic regressions) were used to model predictors for CO-ESBL SUTI. A composite parameter for worse SUTI outcomes was compared among patients who were managed with a single, supposedly effective (ie, in vitro), oral agent. Results: The study consisted of 1,455 patients (ie, three matched groups of 485 patients). The independent predictors for CO-ESBL SUTI were certain recent exposures: (1) hospitalization (3 months), (2) past carriage of multidrug-resistant organisms (2 years), (3) exposure to any antimicrobial (3 months), and (4) prior SUTI (6 months). Among 331 patients with CO-ESBL SUTI, resistance rates were lowest for fosfomycin (4.9%), while outcomes were worst for patients managed with oral amoxicillin-clavulanate. Conclusions: CO-ESBL SUTI independent predictors in this community region were recent hospitalization, known MDRO carriage, exposure to antimicrobials and prior SUTI. Amoxicillin-clavulanate should be avoided, even for ESBL susceptible isolates.