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Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis

Richard Colgan,^1* James R. Johnson,² Michael Kuskowski,² and Kalpana Gupta^3,4,

Department of Family Medicine, University of Maryland, Baltimore, Maryland,¹ Departments of Medicine and Psychiatry, University of Minnesota, and VA Medical Center, Minneapolis, Minneapolis,² Yale University, New Haven, Connecticut,³ VA Medical Center, West Haven, Connecticut⁴

Received 11 September 2007/ Returned for modification 6 November 2007/ Accepted 4 December 2007

Emerging antimicrobial resistance among uropathogens makes the management of acute uncomplicated cystitis increasingly challenging. Few prospective data are available on the risk factors for resistance to trimethoprim-sulfamethoxazole (TMP-SMX), the drug of choice in most settings. In order to evaluate this, we prospectively enrolled women 18 to 50 years of age presenting to an urban primary care practice with symptoms of cystitis. Potentially eligible women provided a urine sample for culture and completed a questionnaire regarding putative risk factors for TMP-SMX resistance. Escherichia coli isolates were tested for clonal group A (CGA) membership by a fumC-specific PCR. Of 165 women with cystitis symptoms, 103 had a positive urine culture and were eligible for participation. E. coli was the predominant uropathogen (86%). Fifteen (14.6%) women had a TMP-SMX-resistant (TMP-SMX^r) organism (all of which were E. coli). Compared with the women who had a TMP-SMX-susceptible organism, women in the TMP-SMX^r group were more likely to have traveled (odds ratio [OR], 15.4; 95% confidence interval [CI], 4.4 to 54.3; P < 0.001) and to be Asian (OR, 6.1; 95% CI, 1.0 to 36.4; P = 0.048). CGA was also independently associated with TMP-SMX resistance (OR, 105; 95% CI, 6.3 to 1,777.6; P = 0.001). No association with TMP-SMX resistance was demonstrated for the use of either TMP-SMX or another antibiotic in the past 3 months or with having a child in day care. Among these women with acute uncomplicated cystitis, Asian race and recent travel were independently associated with TMP-SMX resistance. TMP-SMX^r isolates were more likely to belong to CGA. Knowledge of these risk factors for TMP-SMX resistance could facilitate the accurate selection of empirical therapy.

Published ahead of print on 17 December 2007.

Present address: VA Boston HCS and Boston University School of Medicine, 150 S. Huntington Ave., MAV151, Boston, MA 02130.