title: A spatial approach for the epidemiology of antibiotic use and resistance in community-based studies: the emergence of urban clusters of Escherichia coli quinolone resistance in Sao Paulo, Brasil.
abstract: BACKGROUND
  Population antimicrobial use may influence resistance emergence. Resistance is an ecological phenomenon due to potential transmissibility. We investigated spatial and temporal patterns of ciprofloxacin (CIP) population consumption related to E. coli resistance emergence and dissemination in a major Brazilian city. A total of 4,372 urinary tract infection E. coli cases, with 723 CIP resistant, were identified in 2002 from two outpatient centres. Cases were address geocoded in a digital map. Raw CIP consumption data was transformed into usage density in DDDs by CIP selling points influence zones determination. A stochastic model coupled with a Geographical Information System was applied for relating resistance and usage density and for detecting city areas of high/low resistance risk.
  
  
  RESULTS
  E. coli CIP resistant cluster emergence was detected and significantly related to usage density at a level of 5 to 9 CIP DDDs. There were clustered hot-spots and a significant global spatial variation in the residual resistance risk after allowing for usage density.
  
  
  CONCLUSIONS
  There were clustered hot-spots and a significant global spatial variation in the residual resistance risk after allowing for usage density. The usage density of 5-9 CIP DDDs per 1,000 inhabitants within the same influence zone was the resistance triggering level. This level led to E. coli resistance clustering, proving that individual resistance emergence and dissemination was affected by antimicrobial population consumption.
authors.affiliation: Special Microbiology Laboratory, Federal University of São Paulo (UNIFESP), São Paulo, Brazil. carlos.kiffer@gcdois.com.br
authors.forename: Carlos R V
authors.initials: CR
authors.lastname: Kiffer
authors.forename: Eduardo C G
authors.initials: EC
authors.lastname: Camargo
authors.forename: Silvia E
authors.initials: SE
authors.lastname: Shimakura
authors.forename: Paulo J
authors.initials: PJ
authors.lastname: Ribeiro
authors.forename: Trevor C
authors.initials: TC
authors.lastname: Bailey
authors.forename: Antonio C C
authors.initials: AC
authors.lastname: Pignatari
authors.forename: Antonio M V
authors.initials: AM
authors.lastname: Monteiro
mesh_terms: D001938:Brazil / Q000208:ethnology; D002939:Ciprofloxacin / Q000494:pharmacology / Q000627:therapeutic use*; D024881:Drug Resistance, Bacterial / Q000502:physiology*; D004926:Escherichia coli / Q000187:drug effects* / Q000502:physiology; D004927:Escherichia coli Infections / Q000188:drug therapy / Q000208:ethnology; D005260:Female; D024841:Fluoroquinolones / Q000494:pharmacology / Q000627:therapeutic use*; D006801:Humans; D008137:Longitudinal Studies; D012111:Residence Characteristics; D014505:Urban Population / Q000639:trends*
chemical_list: D024841:Fluoroquinolones; D002939:Ciprofloxacin