Community acquired urinary tract infection (UTI) in women is a prevalent problem in primary care, accounting for approximately eight million ambulatory visits annually in the United States [1]. UTI has several different clinical presentations [1]. Acute uncomplicated UTI (uUTI) occurs in otherwise healthy non-pregnant women with normal genitourinary tract [2]. The current treatment of uUTI is empirical, based on the limited and predictable spectrum of etiological microorganisms [3]. However, as with many community acquired infections, resistance rates to antimicrobials which are commonly used in uUTI is increasing and susceptibility of microorganisms shows significant geographical variations [4–6]. The most important driving factor of resistance is overuse of antimicrobials [4–6]. Increasing antimicrobial resistance complicates uUTI treatment by increasing patient morbidity, costs of reassessment and re-treatment and use of broader spectrum antibiotics. Several studies have demonstrated increasing antibiotic resistance levels in E. coli causing community acquired UTI but most in vitro data come from laboratory based surveys that often do not define the sex, age, clinical syndrome or other data of interest regarding the patients from whom the urine specimens were collected [7]. And also even in the same country the susceptibility patterns of the microorganisms exhibit regional differences [8]. Appropriate knowledge about local and national antimicrobial resistance trends is the utmost importance in order to setup evidence based recommendations in empirical antibiotic treatment of uUTI [8, 9].

We therefore in this prospective observational study aimed to obtain data on the resistance rates of common pathogens in 18-65 years old female patients with uUTI and to determine which empiric antibiotics are prescribed in relevant settings at our university hospital for the outpatient management of community acquired uUTI.

This study shows the distribution of microbial species isolated from patients with uUTI and their resistance rates to antimicrobial agents at a university hospital in Turkey.

As it has previously been reported, we found the majority of patients with uUTI were under 50 years of age and the predominant bacterium was E. coli[11]. The uropathogens isolated in this patient population were similar to those in other comparable studies [12, 13]. It was reported that in postmenopausal women owing to the loss of oestrogen and consequent changes in vaginal flora, the etiological agents in uUTI can be different from premenopausal patients [14–16]. Our data have not revealed such a difference between these two groups of patients.

Main international guidelines recommend empirical therapy in uUTI [17, 18]. The efficacy of such empirical therapy depends on periodic assessment of antimicrobial resistance profiles. Although the spectrum of bacteria isolated from patients with uUTI worldwide has remained largely unchanged in which E. coli is the most prevalent microorganism, there have been significant changes in the resistance patterns of uropathogens over the past few decades and antibiotic resistance has become a major problem in uUTI [13]. Increasing antimicrobial resistance has been documented all over the world [11, 19, 20]. Resistance rates among strains of E. coli isolated from women with uUTI averages 30% for both sulphonamides and ampicillin, varying from 17% to 54% in different countries [11]. Trimethoprim resistance ranges from 11% in Scandinavian countries to 34% in Spain and Portugal. FQ resistance was not found in Scandinavian countries but reaches 20% in southern Europe [11]. Recently Gobernado et al. showed reduced susceptibility of E. coli strains isolated from patients with uUTI to TMP-SMX (26%) and to FQ (16%) in Spain where antimicrobials can be used without restriction [8]. The variability amongst different centres confirms the need for local resistance prevalence data to be available to the practitioner who treats UTI, especially where empirical therapy is being used for urinary infections.

Our study clearly shows that there is a significant increase in TMP-SMX and FQ resistance among E. coli isolates from patients with uUTI in our region which makes the empirical treatment of uUTI a great challenge. This observation is in accordance with recent studies conducted in Spain and Europe [8, 11]. Arslan et al. reported 36% resistance to TMP-SMX and 17% resistance rates to FQ among 288 E. coli isolates from patients with uUTI in Turkey [21]. Also Ozyurt et al. have found 34% resistance to TMP-SMX and 18% resistance to FQ among community-acquired uropathogen E. coli isolates from Istanbul region [22]. The reported rates of resistance among uropathogens may vary depending on whether study sample consist of primarily of outpatients with uUTI or patients with complicated UTI.

Influence of age has previously been shown to have an impact on resistance rates in UTI [20, 21, 23, 24]. Although our study population was younger than comparable studies, E. coli isolates of this study were also more likely to be resistant to ampicillin, ampicillin-sulbactam, amoxicillin-clavulonate, ceftriaxone, gentamicin, and FQ in the patients over fifty years of age. Cefuroxime resistance is the only statistically significant one.

In several studies it has been shown that the prescribing habits of the physicians are the driving factor for the antibiotic resistance [25–27]. Goettsche et al. reported that the resistance against FQ is strongly associated with a high number of prescriptions for this group of antibiotics [25]. Because of aforementioned reasons pharmacological surveillance is an essential part of antimicrobial agent resistance studies. Although the association between antimicrobial agent utilisation and resistance in hospital services is well known, there is a lack of information for the same issue in community acquired infections [28–30].

There are relatively few studies published on variations in treatment for uUTI. McEwen et al. found that 37% of physicians actually prescribe TMP-SMX, closely followed by FQ (32%) and average duration of antibiotic therapy was 8.6 days in the United States [31]. Kahan NR et al. revealed that FQ were the most frequently prescribed drugs (25.57%) in Israel [32]. In our study we found that although not recommended as first line antibiotic, FQ were the most frequent empirically prescribed drugs in our hospital settings for uUTI. In the FQ group, ciprofloxacin was the most commonly prescribed drug and the average duration of the therapy was longer than the recommended 3 days. The prescribed antimicrobial agent and duration of the treatment were not different between age groups.

To our knowledge this is the first study in Turkey which directly evaluates the prescription behaviour of treating physicians on a medical condition. The data have not been collected from a drug surveillance database or from medical records retrospectively without knowledge of patient's clinical situation. The results are based on the actual physician habits, so it does give an accurate description of which antibiotics are prescribed and the duration of therapy. Since uUTI is relatively common, widespread inappropriate prescribing increases resistance among uropathogens. Our resistance rates to FQ among E. coli strains were found to be much higher than other European studies. This may be due to high use of FQ, since it is considered the antimicrobial group of choice in UTI. Inappropriate antibiotic prescribing for UTI was documented in 47.3% of patients in a study from Turkey [33]. In addition to increasing risk of resistance; current prescribing patterns in our hospital increase the medical costs. In this study we also found that newer FQ like moxifloxacin and levofloxacin were also prescribed for the treatment of uUTI. It is known that among susceptible isolates, the more expensive broad-spectrum FQ are not more effective than the cheaper alternatives [1, 12].

FQ should be used with consideration since the resistance to FQ is in increase; rather it ought to be prescribed for treatment of serious infections like connective tissue infections, respiratory tract infections and upper UTI. If conditions allowing use of nonfluoroquinolone drugs for the treatment of uUTI should be encouraged when TMP-SMX is not an option. Since uUTI is relatively easy to cure with limited morbidity, agents like nitrofurantoin and fosfomycin should be used instead of FQ.