title: Ciprofloxacin resistance in community- and hospital-acquired Escherichia coli urinary tract infections: a systematic review and meta-analysis of observational studies.
abstract: BACKGROUND
  During the last decade the resistance rate of urinary Escherichia coli (E. coli) to fluoroquinolones such as ciprofloxacin has increased. Systematic reviews of studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli urinary tract infections (UTI) are absent. This study systematically reviewed the literature and where appropriate, meta-analysed studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli UTIs.
  
  
  METHODS
  Observational studies published between 2004 and 2014 were identified through Medline, PubMed, Embase, Cochrane, Scopus and Cinahl searches. Overall and sub-group pooled estimates of ciprofloxacin resistance were evaluated using DerSimonian-Laird random-effects models. The I(2) statistic was calculated to demonstrate the degree of heterogeneity. Risk of bias among included studies was also investigated.
  
  
  RESULTS
  Of the identified 1134 papers, 53 were eligible for inclusion, providing 54 studies for analysis with one paper presenting both community and hospital studies. Compared to the community setting, resistance to ciprofloxacin was significantly higher in the hospital setting (pooled resistance 0.38, 95% CI 0.36-0.41 versus 0.27, 95% CI 0.24-0.31 in community-acquired UTIs, P < 0.001). Resistance significantly varied by region and country with the highest resistance observed in developing countries. Similarly, a significant rise in resistance over time was seen in studies reporting on community-acquired E. coli UTI.
  
  
  CONCLUSIONS
  Ciprofloxacin resistance in E. coli UTI is increasing and the use of this antimicrobial agent as empirical therapy for UTI should be reconsidered. Policy restrictions on ciprofloxacin use should be enhanced especially in developing countries without current regulations.
authors.affiliation: Faculty of Health Sciences, Australian Catholic University, 223 Antill Street, Watson, Australian Capital Territory, 2602, Australia. oyebola.fasugba@myacu.edu.au.
authors.forename: Oyebola
authors.initials: O
authors.lastname: Fasugba
authors.affiliation: Faculty of Health Sciences, Australian Catholic University, 223 Antill Street, Watson, Australian Capital Territory, 2602, Australia. anne.gardner@acu.edu.au.
authors.forename: Anne
authors.initials: A
authors.lastname: Gardner
authors.affiliation: Faculty of Health Sciences, Australian Catholic University, 223 Antill Street, Watson, Australian Capital Territory, 2602, Australia. brett.mitchell@avondale.edu.au.|Faculty of Arts, Nursing and Theology, Avondale College of Higher Education, 185 Fox Valley Road, Wahroonga, New South Wales, 2076, Australia. brett.mitchell@avondale.edu.au.
authors.forename: Brett G
authors.initials: BG
authors.lastname: Mitchell
authors.affiliation: School of Allied Health, Faculty of Health Sciences, Australian Catholic University, 17 Young Street, Fitzroy, Victoria, 3065, Australia. george.mnatzaganian@acu.edu.au.
authors.forename: George
authors.initials: G
authors.lastname: Mnatzaganian
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002939:Ciprofloxacin / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000453:epidemiology; D024881:Drug Resistance, Bacterial; D004926:Escherichia coli / Q000187:drug effects; D004927:Escherichia coli Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D064887:Observational Studies as Topic; D014552:Urinary Tract Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology
chemical_list: D000900:Anti-Bacterial Agents; D002939:Ciprofloxacin