Regional variations in antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli in India: findings of a multicentric study highlighting the importance of local antibiograms

Background: Evidence-based prescribing is essential to optimise patient outcomes in cystitis. This requires knowledge of local antibiotic resistance rates. DASH to Protect Antibiotics (https://dashuti.com/) is a multicentric mentorship programme guiding centres in preparing, analysing and disseminating local antibiograms to promote antimicrobial stewardship in community UTI. Here we map the susceptibility profile of Escherichia coli from 22 Indian centres. Methods: These centres spanned 10 Indian States and three Union Territories. Antibiograms for urinary E. coli from the outpatient departments were collated. Standardisation was achieved by regional online training; anomalies were resolved via consultation with study experts. Data were collated and analysed. Findings: Nationally, fosfomycin, with 94% susceptibility (inter-centre range 83-97%), and nitrofurantoin with 85% susceptibility (61-97%) retained widest activity. Susceptibility rates were lower for co-trimoxazole (49%), fluoroquinolones (31%) and oral cephalosporins (26%). Rates for third- and fourth- generation cephalosporins were 46% and 52%, respectively, with 54% (33-58%) ESBL prevalence. Piperacillin-tazobactam (81%) amikacin (88%), meropenem (88%) retained better activity, but one centre in Delhi recorded only 42% meropenem susceptibility. Susceptibility rates were mostly higher in South, West and Northeast India; centres in the heavily-populated Gangetic plains, across North and Northwest India, had greater resistance. These findings highlight the importance of local antibiograms in guiding appropriate antimicrobial choices. Interpretation: Fosfomycin and nitrofurantoin are the preferred oral empirical choices for uncomplicated E. coli cystitis in India, though elevated resistance in some areas is concerning. Empiric use of fluoroquinolones and third generation cephalosporins is discouraged whereas piperacillin/tazobactam and aminoglycosides remain carbapenem-sparing parenteral agents