This Article  • Abstract  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (216)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

Kalpana Gupta, MD, MPH; Delia Scholes, PhD; Walter E. Stamm, MD

JAMA. 1999;281:736-738.

ABSTRACT
Context  Guidelines for the management of acute uncomplicated cystitis in women that recommend empirical therapy in properly selected patients rely on the predictability of the agents causing cystitis and knowledge of their antimicrobial susceptibility patterns.

Objective  To assess the prevalence of and trends in antimicrobial resistance among uropathogens causing well-defined episodes of acute uncomplicated cystitis in a large population of women.

Design  Cross-sectional survey of antimicrobial susceptibilities of urine isolates collected during a 5-year period (January, May, and September 1992-1996).

Setting  Health maintenance organization.

Patients  Women aged 18 to 50 years with an outpatient diagnosis of acute cystitis.

Main Outcome Measures  Proportion of uropathogens demonstrating in vitro resistance to selected antimicrobials; trends in resistance over the 5-year study period.

Results  Escherichia coli and Staphylococcus saprophyticus were the most common uropathogens, accounting for 90% of the 4342 urine isolates studied. The prevalence of resistance among E coli and all isolates combined was more than 20% for ampicillin, cephalothin, and sulfamethoxazole in each year studied. The prevalence of resistance to trimethoprim and trimethoprim-sulfamethoxazole rose from more than 9% in 1992 to more than 18% in 1996 among E coli, and from 8% to 16% among all isolates combined. There was a statistically significant increasing linear trend in the prevalence of resistance from 1992 to 1996 amongE coli and all isolates combined to ampicillin (P<.002), and to cephalothin, trimethoprim, and trimethoprim-sulfamethoxazole (P<.001). In contrast, the prevalence of resistance to nitrofurantoin, gentamicin, and ciprofloxacin hydrochloride was 0% to 2% among E coli and less than 10% among all isolates combined, and did not change significantly during the 5-year period.

Conclusions  While the prevalence of resistance to trimethoprim-sulfamethoxazole, ampicillin, and cephalothin increased significantly among uropathogens causing acute cystitis, resistance to nitrofurantoin and ciprofloxacin remained infrequent. These in vitro susceptibility patterns should be considered along with other factors, such as efficacy, cost, and cost-effectiveness in selecting empirical therapy for acute uncomplicated cystitis in women.

INTRODUCTION

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

The management of acute uncomplicated cystitis, one of the most common community-acquired infections in women, has dramatically changed in the managed care era.¹ In many clinical settings, urine cultures are no longer performed and women with symptoms of acute cystitis are treated empirically.^1-4 The rationale for this strategy is based on the narrow spectrum of etiologic agents causing acute cystitis and knowledge of their antimicrobial resistance patterns. To date, however, most studies reporting antimicrobial resistance have been based on surveys of laboratory isolates, generally without correlation with clinical or epidemiological factors such as the presence and nature of symptoms, age, sex, and whether the infection was complicated. Data from such laboratory-based studies do not provide the information needed to select empirical therapy for women with uncomplicated urinary tract infections (UTIs). To address this issue, we determined the prevalence of and trends in antimicrobial resistance among uropathogens isolated from a large and well-defined population of female health maintenance organization (HMO) enrollees who presented with acute uncomplicated cystitis.

METHODS

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

Computerized outpatient visit forms from women aged 18 to 50 years seen at the outpatient linics or emergency departments of the Group Health Cooperative of Puget Sound (GHC), Seattle, Wash, that were coded with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of acute cystitis were crossmatched by patient identification number with a computer database of urine isolates and antimicrobial susceptibility test results. To be included, a urine culture had to be positive for at least 10³ colony-forming units per milliliter (CFUs/mL) of a single uropathogen within 2 days before or after an outpatient visit that resulted in an ICD-9 diagnosis of acute cystitis. To obtain the final desired sample size, as well as seasonal representation, isolates from January, May, and September of each year from 1992 through 1996 were included. Isolates from women with a previous episode of acute cystitis in the same month, hospitalization in the 30 days preceding or subsequent to the visit date, or diabetes were excluded.

We randomly selected 150 medical charts for review to validate the accuracy of the visit diagnosis and laboratory data. Because a clinical practice guideline for empirical therapy of acute uncomplicated cystitis, using trimethoprim-sulfamethoxazole as the primary drug, was instituted at GHC in 1995 and 1996, we selected 100 charts from these years to assess whether cultures obtained then included more women for whom empirical therapy had failed.

Cultures and antimicrobial susceptibility tests were performed on clean-catch midstream urine specimens collected at the outpatient clinics, transported to a central laboratory at GHC, and quantitatively cultured using a standard calibrated loop technique.⁵ Susceptibility testing was done using the Kirby-Bauer disk diffusion method.⁶ Resistant and intermediate isolates were grouped together for analysis in this study.

Because not all organisms are tested for susceptibility to each antimicrobial agent, we calculated the proportion of resistant organisms based on the number of organisms actually tested for each antimicrobial agent each year. Significance tests for trends in resistance over time were performed using the ² test for linear trend in binomial proportions.⁷

RESULTS

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

A total of 4342 urine isolates from 4082 patients who made clinic visits for acute cystitis were included in the study. Review of 142 charts (8 of the 150 randomly selected charts were not available) confirmed that more than 95% of the visits were for uncomplicated cystitis; clinical evidence of pyelonephritis or recurrent cystitis was found in 4.9% of reviewed charts. Only 2 of 100 charts from 1995 and 1996 revealed a recent guideline treatment failure, confirming that more than 95% of cultures obtained in the study represented episodes of acute uncomplicated cystitis. The etiologic uropathogen identified in the laboratory database was confirmed in 100% of the chart reviews.

The causative uropathogens included Escherichia coli (86%), Staphylococcus saprophyticus (4%), Proteus species (3%), Klebsiella species (3%), Enterobacter species (1.4%), Citrobacter species (0.8%), and Enterococcus species (0.5%). Other less-frequent isolates in aggregate caused 1.3% of infections. There were no significant changes in the distribution of uropathogens seen during the 5-year study.

More than 20% of E coli isolates were resistant to ampicillin, cephalothin, and sulfamethoxazole in each year studied (Table 1). On the other hand, only 0% to 2% of E coli isolates and less than 10% of all isolates combined were resistant to ciprofloxacin hydrochloride, gentamicin, or nitrofurantoin in any study year. Resistance of E coli to trimethoprim and trimethoprim-sulfamethoxazole was essentially parallel throughout the study years and rose from 9% in 1992 to 18% in 1996. The resistance patterns of all isolates combined were similar to those of E coli alone, except for ampicillin and nitrofurantoin, for which there was a higher prevalence of resistance when combining all isolates. The increasing linear trend in the prevalence of resistance among both E coli and all isolates from 1992 through 1996 was statistically significant for ampicillin, cephalothin, trimethoprim, and trimethoprim-sulfamethoxazole (Table 1). The overall prevalence of antimicrobial resistance among the individual non–E coli species is shown in Table 2.

View this table: [in this window] [in a new window] Table 1. Percentages of Urinary Isolates From Women With Acute Uncomplicated Cystitis Resistant to Selected Antimicrobial Agents*

View this table: [in this window] [in a new window] Table 2. Percentage of Non–Escherichia coli Isolates From Women With Acute Uncomplicated Cystitis Resistant to Selected Antimicrobial Agents, 1992-1996*

COMMENT

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

We used the automated databases available at GHC to define a large population of women with acute uncomplicated cystitis and link each patient visit with the microbiological data of interest. The accuracy of this approach was confirmed by medical record review, which demonstrated greater than 95% concordance between the computer-generated and manual review, and by the consistency of both etiologic agents and susceptibility profiles from year to year.

Although several factors influence the choice of an antimicrobial agent for empirical therapy of acute cystitis, the in vitro susceptibilities of common uropathogens clearly are an important consideration. The high prevalence of resistance to the 2 -lactams we studied, ampicillin and cephalothin, has long been appreciated^8-13 and precludes their use in empirical treatment. Of considerably greater concern is the increasing prevalence of resistance to trimethoprim and trimethoprim-sulfamethoxazole that we observed. Similar trends have also been reported among urinary isolates from women attending outpatient clinics whose more detailed clinical status was unknown.^8-9 These data suggest that trimethoprim and trimethoprim-sulfamethoxazole, which are now commonly used as first-line regimens in the treatment of acute cystitis,^{3, 14} may not be acceptable choices for empirical therapy for much longer. Although the effect of in vitro resistance to trimethoprim-sulfamethoxazole on clinical outcome needs further study, in our view, neither trimethoprim nor trimethoprim-sulfamethoxazole should be used empirically when the prevalence of resistance among cystitis isolates exceeds 15% to 20%.

The 2 oral agents with the best in vitro susceptibility profiles in our study (and, thus, candidates for empirical therapy if trimethoprim-sulfamethoxazole cannot be used) were nitrofurantoin and ciprofloxacin. Nitrofurantoin remains highly active against E coli and most non–E coli isolates and is a reasonable option for empirical therapy. However, cure rates with 3-day regimens of nitrofurantoin have been lower than those seen with trimethoprim-sulfamethoxazole or fluoroquinolones,¹⁵ so 7 days of therapy may be required to achieve higher cure rates. Ciprofloxacin, which we tested as a representative of the fluoroquinolone class of antimicrobials, remains highly active against both E coli and non–E coli isolates in vitro. Although other studies have reported increasing fluoroquinolone resistance among E coli,^12-13 we did not identify any such isolates in this patient group. For this reason, as well as the high clinical cure rate and cost-effectiveness of short-course fluoroquinolone regimens in treating acute cystitis,^{3, 15} these drugs will likely be used more frequently as trimethoprim-sulfamethoxazole resistance becomes increasingly prevalent. Of obvious concern is the likelihood that increased use of fluoroquinolones for the treatment of acute cystitis in women will promote the emergence of resistance to these drugs.

In conclusion, these data demonstrate a significant increase in the prevalence of resistance to several commonly used antimicrobial agents among a large group of isolates from women with well-defined episodes of acute uncomplicated cystitis. When selecting empirical therapy for such patients, in vitro susceptibility patterns of common uropathogens such as those reported here must be considered along with other factors, such as expected efficacy, adverse effects, cost, cost-effectiveness, and selection of resistant strains. The continued evolution of antimicrobial resistance among community-acquired isolates is worrisome and mandates both further surveillance and new approaches to slow the emergence of resistance.

AUTHOR INFORMATION

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

Funding/Support: This study was supported in part by a grant from the National Institutes of Health, Bethesda, Md (DK 53369), and by a grant from Procter & Gamble Inc, Cincinnati, Ohio.

Previous Presentation: This article was presented in part at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy, San Diego, Calif, September 25, 1998.

Acknowledgment: We gratefully acknowledge Jane Grafton for database management and programming and Fred Heidrich, MD, MPH, for helpful review and comments on the manuscript.

Financial Disclosure: Dr Stamm has served as a consultant for Procter & Gamble Inc, Cincinnati, Ohio.

Corresponding Author and Reprints: Walter E. Stamm, MD, Division of Allergy and Infectious Diseases, University of Washington, 1959 NE Pacific St, BB1225, Box 356523, Seattle, WA 98195 (e-mail: lft{at}u.washington.edu).

Author Affiliations: Department of Medicine/Division of Allergy and Infectious Diseases, University of Washington School of Medicine (Drs Gupta and Stamm), and the Center for Health Studies, Group Health Cooperative of Puget Sound (Dr Scholes), Seattle.

REFERENCES

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

1. Hooton TM, Stamm WE. Diagnosis and treatment of acute uncomplicated urinary tract infection. Infect Dis Clin North Am. 1997;11:551-581. FULL TEXT | WEB OF SCIENCE | PUBMED 2. Patton JP, Nash DB, Abrutyn E. Urinary tract infection. Med Clin North Am. 1991;75:495-512. WEB OF SCIENCE | PUBMED 3. Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med. 1993;329:1328-1334. FREE FULL TEXT 4. Bacheller CD, Bernstein JM. Urinary tract infections. Med Clin North Am. 1997;81:719-730. FULL TEXT | WEB OF SCIENCE | PUBMED 5. Koneman EW, Allen SD, Janda WM, et al. Color Atlas and Textbook of Diagnostic Microbiology. 4th ed. Philadelphia, Pa: JB Lippincott Co; 1992:77-83. 6. Bauer AW, Kirby WMM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol. 1966;45:493-496. WEB OF SCIENCE | PUBMED 7. Rosner B. Fundamentals of Biostatistics. 4th ed. Belmont, Calif: Wadsworth Publishing Co; 1995:397-398. 8. Gruneberg RN. Changes in urinary pathogens and their antibiotic sensitivities, 1971-1992. J Antimicrob Chemother. 1994;33(suppl):S1-S8. 9. Maartens G, Oliver SP. Antibiotic resistance in community-acquired urinary tract infections. S Afr Med J. 1994;84:600-602. PUBMED 10. Weber G, Riesenberg K, Schlaeffer F, Peled N, Borer A, Yagupsky P. Changing trends in frequency and antimicrobial resistance of urinary pathogens in outpatient clinics and a hospital in southern Israel, 1991-1995. Eur J Clin Microbiol Infect Dis. 1997;16:834-838. FULL TEXT | WEB OF SCIENCE | PUBMED 11. Jinnah F, Islam MS, Rumi MA, Morshed MG, Huq F. Drug sensitivity pattern of E. coli causing urinary tract infection in diabetic and non-diabetic patients. J Int Med Res. 1996;24:296-301. PUBMED 12. Thomson KS, Sanders WE, Sanders CC. USA resistance patterns among UTI pathogens. J Antimicrob Chemother. 1994;33(suppl):S9-S15. 13. Winstanley TG, Limb DI, Eggington R, Hancock F. A 10 year survey of the antimicrobial susceptibility of urinary tract isolates in the UK: the Microbe Base Project. J Antimicrob Chemother. 1997;40:591-594. FREE FULL TEXT 14. Kunin CM. Urinary tract infections in females. Clin Infect Dis. 1994;18:1-12. WEB OF SCIENCE | PUBMED 15. Hooton TM, Winter C, Tiu F, Stamm WE. Randomized comparative trial and cost analysis of 3-day antimicrobial regimens for treatment of acute cystitis in women. JAMA. 1995;273:41-45. FREE FULL TEXT

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Fosfomycin tromethamine as second agent for the treatment of acute, uncomplicated urinary tract infections in adult female patients in The Netherlands?
Knottnerus et al.
J Antimicrob Chemother 2008;62:356-359.
ABSTRACT | FULL TEXT  

Evolution of bacterial susceptibility pattern of Escherichia coli in uncomplicated urinary tract infections in a country with high antibiotic consumption: a comparison of two surveys with a 10 year interval
De Backer et al.
J Antimicrob Chemother 2008;62:364-368.
ABSTRACT | FULL TEXT  

Validation of a Decision Aid to Assist Physicians in Reducing Unnecessary Antibiotic Drug Use for Acute Cystitis
McIsaac et al.
Arch Intern Med 2007;167:2201-2206.
ABSTRACT | FULL TEXT  

Infection Risk with Nitrofurazone-Impregnated Urinary Catheters in Trauma Patients: A Randomized Trial
Stensballe et al.
ANN INTERN MED 2007;147:285-293.
ABSTRACT | FULL TEXT  

Biofilm exclusion of uropathogenic bacteria by selected asymptomatic bacteriuria Escherichia coli strains
Ferrieres et al.
Microbiology 2007;153:1711-1719.
ABSTRACT | FULL TEXT  

Antibiotic resistance of coliform organisms from community-acquired urinary tract infections in Zenica-Doboj Canton, Bosnia and Herzegovina
Uzunovic-Kamberovic
J Antimicrob Chemother 2006;58:344-348.
ABSTRACT | FULL TEXT  

Current antibiotic therapy for isolated urinary tract infections in women.
Kallen et al.
Arch Intern Med 2006;166:635-639.
ABSTRACT | FULL TEXT  

Antibiotic Resistance Patterns in Children Hospitalized for Urinary Tract Infections
Lutter et al.
Arch Pediatr Adolesc Med 2005;159:924-928.
ABSTRACT | FULL TEXT  

Risk Factors Associated with Acute Pyelonephritis in Healthy Women
Scholes et al.
ANN INTERN MED 2005;142:20-27.
ABSTRACT | FULL TEXT  

Effects of Intrapartum Penicillin Prophylaxis on Intestinal Bacterial Colonization in Infants
Jaureguy et al.
J. Clin. Microbiol. 2004;42:5184-5188.
ABSTRACT | FULL TEXT  

Urinary Tract Infections During Pregnancy
Le et al.
The Annals of Pharmacotherapy 2004;38:1692-1701.
ABSTRACT | FULL TEXT  

Treatment of Uncomplicated Urinary Tract Infections in an Era of Increasing Antimicrobial Resistance
Miller and Tang
Mayo Clin Proc. 2004;79:1048-1054.
ABSTRACT  

Clinical Microbiology of Bacterial and Fungal Sepsis in Very-Low-Birth-Weight Infants
Kaufman and Fairchild
Clin. Microbiol. Rev. 2004;17:638-680.
ABSTRACT | FULL TEXT  

Use of administrative healthcare claims to examine the effectiveness of trimethoprim-sulfamethoxazole versus fluoroquinolones in the treatment of community-acquired acute pyelonephritis in women
Carrie et al.
J Antimicrob Chemother 2004;53:512-517.
ABSTRACT | FULL TEXT  

Prevalence of dfr genes associated with integrons and dissemination of dfrA17 among urinary isolates of Escherichia coli in Korea
Yu et al.
J Antimicrob Chemother 2004;53:445-450.
ABSTRACT | FULL TEXT  

Prenatal screening for group B streptococcal infection: gaps in the evidence
Gilbert
Int J Epidemiol 2004;33:2-8.
FULL TEXT  

The Siderophore Receptor IroN of Extraintestinal Pathogenic Escherichia coli Is a Potential Vaccine Candidate
Russo et al.
Infect. Immun. 2003;71:7164-7169.
ABSTRACT | FULL TEXT  

Acute Uncomplicated Urinary Tract Infection in Women
Fihn
NEJM 2003;349:259-266.
FULL TEXT  

A 65-Year-Old Woman With Acute Cough Illness and an Important Engagement
Gonzales
JAMA 2003;289:2701-2708.
FULL TEXT  

Prior antimicrobial drug exposure: a risk factor for trimethoprim-sulfamethoxazole-resistant urinary tract infections
Metlay et al.
J Antimicrob Chemother 2003;51:963-970.
ABSTRACT | FULL TEXT  

Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991-1999
Steinman et al.
ANN INTERN MED 2003;138:525-533.
ABSTRACT | FULL TEXT  

Bacterial susceptibility to oral antibiotics in community acquired urinary tract infection
Prais et al.
Arch. Dis. Child. 2003;88:215-218.
ABSTRACT | FULL TEXT  

Trimethoprim-Sulfamethoxazole Revisited
Masters et al.
Arch Intern Med 2003;163:402-410.
ABSTRACT | FULL TEXT  

Clinical management of urinary tract infection in women: a prospective cohort study
Fahey et al.
Fam Pract 2003;20:1-6.
ABSTRACT | FULL TEXT  

An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO{middle dot}SENS Project
Kahlmeter
J Antimicrob Chemother 2003;51:69-76.
ABSTRACT | FULL TEXT  

Trends in Incidence and Antimicrobial Resistance of Early-Onset Sepsis: Population-Based Surveillance in San Francisco and Atlanta
Hyde et al.
Pediatrics 2002;110:690-695.
ABSTRACT | FULL TEXT  

Trends in Antimicrobial Resistance among Urinary Tract Infection Isolates of Escherichia coli from Female Outpatients in the United States
Karlowsky et al.
Antimicrob. Agents Chemother. 2002;46:2540-2545.
ABSTRACT | FULL TEXT  

Short compared with standard duration of antibiotic treatment for urinary tract infection: a systematic review of randomised controlled trials
Michael et al.
Arch. Dis. Child. 2002;87:118-123.
ABSTRACT | FULL TEXT  

Adherence to Evidence-Based Therapy: Some Practical Problems
Ghosh et al.
Arch Intern Med 2002;162:1310-1311.
FULL TEXT  

Urinary tract-derived Escherichia coli resistant to co-trimoxazole in Japan, where the drug is seldom used for treating acute urinary tract infections
Ishihara et al.
J Antimicrob Chemother 2002;49:881-882.
FULL TEXT  

Development of a P1 phagemid system for the delivery of DNA into Gram-negative bacteria
Westwater et al.
Microbiology 2002;148:943-950.
ABSTRACT | FULL TEXT  

The Impact of Empirical Management of Acute Cystitis on Unnecessary Antibiotic Use
McIsaac et al.
Arch Intern Med 2002;162:600-605.
ABSTRACT | FULL TEXT  

National Patterns in the Treatment of Urinary Tract Infections in Women by Ambulatory Care Physicians
Huang and Stafford
Arch Intern Med 2002;162:41-47.
ABSTRACT | FULL TEXT  

Antibiotic failure in the treatment of urinary tract infections in young women
Lawrenson and Logie
J Antimicrob Chemother 2001;48:895-901.
ABSTRACT | FULL TEXT  

Widespread Distribution of Urinary Tract Infections Caused by a Multidrug-Resistant Escherichia coli Clonal Group
Manges et al.
NEJM 2001;345:1007-1013.
ABSTRACT | FULL TEXT  

Increasing Antimicrobial Resistance and the Management of Uncomplicated Community-Acquired Urinary Tract Infections
Gupta et al.
ANN INTERN MED 2001;135:41-50.
ABSTRACT | FULL TEXT  

Development of a PCR Assay for Identification of Staphylococci at Genus and Species Levels
Martineau et al.
J. Clin. Microbiol. 2001;39:2541-2547.
ABSTRACT | FULL TEXT  

Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women
Kontiokari et al.
BMJ 2001;322:1571-1571.
ABSTRACT | FULL TEXT  

Prior trimethoprim use and trimethoprim-resistant urinary tract infection: a nested case-control study with multivariate analysis for other risk factors
Steinke et al.
J Antimicrob Chemother 2001;47:781-787.
ABSTRACT | FULL TEXT  

Multidrug-Resistant Urinary Tract Isolates of Escherichia coli: Prevalence and Patient Demographics in the United States in 2000
Sahm et al.
Antimicrob. Agents Chemother. 2001;45:1402-1406.
ABSTRACT | FULL TEXT  

Risk Factors for Antibiotic-Resistant Escherichia coli Isolated from Hospitalized Patients with Urinary Tract Infections: a Prospective Study
Sotto et al.
J. Clin. Microbiol. 2001;39:438-444.
ABSTRACT | FULL TEXT  

Asymptomatic Bacteriuria -- Important or Not?
Nicolle
NEJM 2000;343:1037-1039.
FULL TEXT  

Development of a Rapid PCR Assay Specific for Staphylococcus saprophyticus and Application to Direct Detection from Urine Samples
Martineau et al.
J. Clin. Microbiol. 2000;38:3280-3284.
ABSTRACT | FULL TEXT  

A Canadian National Surveillance Study of Urinary Tract Isolates from Outpatients: Comparison of the Activities of Trimethoprim-Sulfamethoxazole, Ampicillin, Mecillinam, Nitrofurantoin, and Ciprofloxacin
Zhanel et al.
Antimicrob. Agents Chemother. 2000;44:1089-1092.
ABSTRACT | FULL TEXT  

Molecular Epidemiologic Approaches to Urinary Tract Infection Gene Discovery in Uropathogenic Escherichia coli
Zhang et al.
Infect. Immun. 2000;68:2009-2015.
ABSTRACT | FULL TEXT  

Comparison of Ciprofloxacin (7 Days) and Trimethoprim-Sulfamethoxazole (14 Days) for Acute Uncomplicated Pyelonephritis in Women: A Randomized Trial
Talan et al.
JAMA 2000;283:1583-1590.
ABSTRACT | FULL TEXT  

Increasing Prevalence of Antimicrobial Resistance Among Uropathogens
Daniels et al.
JAMA 1999;282:325-326.
FULL TEXT  

Antimicrobial Resistance Growing Among Uropathogens
JWatch Women's Health 1999;1999:13-13.
FULL TEXT  

Treating Cystitis: Changing Patterns of Antimicrobial Resistance
JWatch Emergency Med. 1999;1999:15-15.
FULL TEXT  

Antibiotic Resistance Increasing in Urinary Tract Pathogens
JWatch Infect. Diseases 1999;1999:11-11.
FULL TEXT  

Antimicrobial Resistance Growing Among Uropathogens
JWatch General 1999;1999:2-2.
FULL TEXT