Volume 14, Number 2—February 2008
Increasing Resistance in Commensal Escherichia coli, Bolivia and Peru
To the Editor: The global increase of antimicrobial-drug resistance, including resistance to the new and most potent antimicrobial agents, is a major public health concern. In low-resource countries, where bacterial infections are still among the major causes of death, especially for children, it is of particular concern (1).
ANTRES (Towards Controlling Antimicrobial Use and Resistance in Low-income Countries—An Intervention Study in Latin America) is a research project on antimicrobial-drug use and resistance in low-resource countries of Latin America (see www.unifi.it/infdis/antres/default.htm). In 2002, the baseline ANTRES study showed a high rate of fecal carriage of Escherichia coli with acquired resistance to several antimicrobial drugs, especially older drugs (e.g., ampicillin, trimethoprim-sulfamethoxazole, tetracycline, streptomycin, and chloramphenicol), in preschool children from 4 urban settings in Bolivia and Peru (2). We report the results of a second cross-sectional study, conducted in 2005, that evaluated the evolution of antimicrobial-drug resistance in the studied areas.
We studied healthy children 6–72 months of age from each of 4 urban areas: 2 in Bolivia (Camiri, Santa Cruz Department; Villa Montes, Tarija Department) and 2 in Peru (Yurimaguas, Loreto Department; Moyobamba, San Martin Department). The study design, sampling and inclusion criteria, methods, and ethical issues were the same as those of the baseline study (2). The study was carried out over 4 months (September–December 2005), the same seasonal period as in the previous study. No significant differences in sex ratios were found among children enrolled from the different areas, whereas minor differences were found for age. No statistical differences were found between the 2002 baseline study and the 2005 study results in terms of numbers of children (3,193 vs. 3,174) and sex ratios (0.94 vs. 0.95) (Table). Statistical analyses were performed by using Stata 9.0 (Stata Corp., College Station, TX, USA). Logistic regression models were used to compare the antimicrobial-drug resistance rates in 2002 and 2005, considering the combined influences of age, sex, city, and country.
Data from the 2005 survey confirmed high resistance rates for ampicillin, trimethoprim-sulfamethoxazole, tetracycline, streptomycin, and chloramphenicol. The differences in resistance rates observed between 2002 and 2005 for these drugs, although sometimes statistically significant, are probably of limited epidemiologic relevance due to the high rates of antimicrobial-drug resistance found in the E. coli population in both surveys. The most relevant finding of the 2005 survey was the remarkable increase since 2002 in the resistance rates to fluoroquinolones and expanded-spectrum cephalosporins (Table). Molecular analysis showed that the dramatic increase in rates of resistance to expanded spectrum cephalosporins was mostly the result of dissemination of CTX-M-type extended-spectrum β-lactamase determinants (3). Concerning the association between sex and resistance rates, the higher resistance rates observed for some agents and in some settings for boys in the baseline study were not confirmed, except in 1 case (kanamycin in Camiri, p = 0.04) (2). Analysis by age (not performed for amikacin due to low numbers of resistant isolates) confirmed the occurrence of higher resistance rates for the youngest age group and an overall decreasing trend by age for all agents, except ciprofloxacin and gentamicin. For these 2 agents, resistance rates increased, although not significantly (p = 0.95 and p = 0.55, respectively) (2). Although we did not specifically address factors potentially involved in this phenomenon, we will address them in future investigations.
Increasing resistance to fluoroquinolones and expanded-spectrum cephalosporins among E. coli clinical isolates has been observed in several parts of the world and complicates the management of infections (4,5). Recently, intestinal colonization with fluoroquinolone-resistant or extended-spectrum β-lactamase–producing E. coli of nonhospitalized persons has been described as an emerging phenomenon (6–9). Although the exact clinical implications of this phenomenon are not clearly established, colonization by these resistant strains is a public health threat at the community and hospital levels (8,9). The reasons for the increased prevalence of fecal carriage of these resistant E. coli strains by children from the studied areas are not clear. Data collected about household use of antimicrobial drugs excluded previous use of fluoroquinolones and expanded-spectrum cephalosporins (C. Kristiansson et al., unpub. data). The increased prevalence of resistant E. coli strains in preschool children most likely reflects increased exposure within a contaminated household setting, in the food chain, or both (6,8,10).
Our findings support the need to continue monitoring the evolution of resistance in commensal E. coli, to evaluate the effects of these important reservoirs of resistance genes distributed in the community, to investigate the epidemiologic relationship with clinical isolates, and to define the role of the food supply. Investigation into whether carriage of resistant strains in adults correlates with data on antimicrobial-drug use in hospitals and in the community would also be of interest.
We thank other members of the ANTRES Study Group for their support: Ruth Arias, Vieri Boddi, Paolo Bonanni, Blanca Huapaya, Oscar Lanza Van den Berghe, Mattias Larsson, Luis Pacheco, Victor Suarez, Esteban Salazar, and Christian Trigoso. We thank Stefano Rosignoli for assisting with statistical analysis.
The study was carried out within the research activities of the ANTRES project, supported by the European Commission, International Scientific Cooperation Projects for Developing Countries program, Contract ICA4-CT-2001-10014.
- World Health Organization. Global strategy for containment of antimicrobial resistance [cited 2006 Nov 10]. Geneva: The Organization; 2001. Available from http://www.who.int/drugresistance/en
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Table of Contents – Volume 14, Number 2—February 2008
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Alessandro Bartoloni, Dipartimento Area Critica Medico Chirurgica, Clinica Malattie Infettive, Università di Firenze, Ospedale di Careggi, Viale Morgagni 85, I-50134, Firenze, Italy;