120 URINARY TRACT INFECTIONS CAUSED BY ESCHERICHIA COLI

Ruckdeschel, H. Knothe and H. U. Eickenberg. Munich Fu- turamed Verlag, pp. 563-569, 1984.

18. F'reheim, L. C., Cuevas, T. A. and Rocaforte, J. S.: Antiacid interference with ciprofloxacin for complicated urinary tract infections in elderly patients. Proceeding of the 1986 ICAAC, American Society for Microbiology, abstract 665, 1986.

EDITORIAL COMMENT

This report from Spain on the emergence of ciprofloxacin-resistant E. coli forebodes the occurrence of a similar problem in the United States. Spain is one of many countries outside North America and Northern Europe where antibiotics are available without prescrip- tion. Uncontrolled use of antibiotics in Spain has led to an increase in frequency of quinolone resistant E. coli from less than 1% in 1988 to as high as 8.1% in 1991. The problem will not be solved by newer derivatives, since there is virtual complete cross-resistance among the quinolones. The observation that the highest frequency of resist- ance to quinolones was observed in older patients and those with recurrent, complicated urinary infections and indwelling catheters is not surprising. This event wcum with all drugs.

Even more distressing is the report of high rates of resistance of urinary isolates to ampicillin, amoxicillidclavulanate and tri- methoprim-sulfamethoxazole. Spain also has the dubious distinction of the highest rates in the world of Streptococcus pneumoniae resist- ant to penicillin, tetracycline, chloramphenicol and erythromycin.' The message is clear. Excess and inappropriate use of antimicro-

bial drugs inevitably leads to accelerated emergence of resistant microbes. Stated succinctly, "use them and lose them." The quino- lones are currently among the most heavily promoted, overused and abused drugs in all medical and surgical specialties. They should be reserved for patients who might truly benefit, and only when the invading microbes are resistant to older and less expensive drugs. The lesson from the experience in Spain is clear. We must block any effort by the pharmaceutical industry to permit over the counter purchase of systemic antimicrobial drugs in the United States.

Calvin M. Kunin Department of Medicine University Hospitals Columbus, Ohio

1. Fenoli, A, Martin Bourgon, C., Munoz, R., Vicioso, D. and Casal, J.: Serotype distribution and antimicrobial resistance of Strep- tococcus pneumoniae isolates causing systemic infections in Spain, 1979-1989. Rev. Infect. Dis., 13: 56, 1991.

REPLY BY AUTHORS

We agree with Doctor Kunin that efforts to improve the use of antibiotics should be seriously considered in many nations. It is well known that the patterns of antibiotic use in a community determine the resistance profiles of microorganisms isolated even in healthy populations.' However, other factors should be considered for the emergence of antibiotic resistant bacteria. Inappropriate therapies (insufficient dosage, drug interactions and incomplete antimicrobial courses of therapy) and select populations with factors that lead to recurrent infections are other determinants involved in the selection of resistant clones of bacteria. Those arguments might explain, at least in part, the widespread emergence of multiple drug resistant Mycobacterium tuberculosis reported in the United state^.^

Regarding our study, quinolone derivatives currently might be used extensively as initial therapy for urinary tract infections, as- suming complete susceptibility of urinary pathogens to these drugs. Due to this fact, a number of patients with urinary symptoms might be treated empirically with quinolones in the absence of physicians requesting urine cultures. Our study shows that physicians treating patients with urological abnormalities should not rely on the com- plete susceptibility of E. coli to quinolones when treating urinary tract infections. They should receive information regarding the sus- ceptibility patterns of Enterobacteriaceae in their areas and urine cultures should be requested before using quinolones empirically.

REFERENCES

1. Lester, S. C., del Pilar Pla, M., Wang, F., Perez Schael, I., Jiang, H. and O'Brian, T. F.: The carriage of Escherichia coli resist- ant to antimicrobial agents by healthy children in Boston, in Caracas, Venezuela, and in &in Pu, China. New Engl. J. Med., 323 285, 1990.

2. Murray, B. E.: Can antibiotic resistance be controlled? New Engl. J. Med., 330 1229, 1994.