About my role in ARLG

I am a recipient of an Early Stage Investigator Seed Grant from ARLG on creating an outpatient-specific antibiogram to guide treatment for urinary tract infections (UTI).

My colleagues and I have long wondered whether the antibiograms obtained based on mostly hospitalized or emergency room patients are relevant to women we see in our primary care clinics for uncomplicated cystitis. We received ARLG funding to answer this exact question, creating a strain collection from all patients walking into two of our primary care clinics with acute cystitis.

Primary care patients with uncomplicated UTI are often treated empirically without culture, while urine cultures are typically collected from patients with complicated UTI. Another challenge to delivering guidelines-based care for UTI in primary care is that susceptibilities for fosfomycin (a first-line agent) are not routinely performed. Estimating the prevalence of resistance in UTI in a random sample of patients with uncomplicated and complicated UTI is critical for empiric treatment and stewardship.

Impact of these ARLG studies

The study is underway in two Harris Health System safety net clinics serving an international population. Of 1,052 urine cultures collected so far, 236 (22%) had no growth, 519 (49%) grew only mixed urogenital flora (contaminated), 245 (23%) were positive with >10,000 CFU/mL, and 52 (5%) were positive with <10,000 CFU/mL.

Our interim analysis showed that common uropathogens had a high prevalence of resistance to trimethoprim-sulfamethoxazole (33%) and ciprofloxacin (23%). Resistance rates were higher in patients from Mexico or Central America than in those born in the United States (U.S.) For example, susceptibility of uropathogens to trimethoprim-sulfamethoxazole was 82% in patients born in the U.S. versus 61% in patients from Mexico or Central America (P value =0.03). Susceptibility to fosfomycin (restricted in our system) was 100%. We are also planning to perform a multivariate regression analysis to study the independent effects of country of origin, age, sex, factors suggesting complicated infection (e.g., urologic abnormalities), comorbidities, prior admission to hospital, dialysis, prior urine culture results, and recent antibiotic use on the risk of resistant organisms.

Benefits of ARLG

The data from this ARLG-funded project will inform submission of three grant proposals in the works all devoted to improving diagnostic and antibiotic stewardship for UTI in primary care. In particular, the results from the ARLG-funded work support the groundwork necessary for a wide-scale implementation of best antibiotic practices for treating urinary tract infection (UTI) in the 11 community health centers of Harris County.

An added benefit of the ARLG funding was the opportunity to get to know some of the ARLG leadership, in particular Anthony Harris, MD, MPH, who served on my mentoring team for this project.