The Rising ESKAPE Threat in Urinary Tract Infections: Resistance Patterns, MDR Burden, and Empirical Therapy Implications

Introdcution: ESKAPE pathogens, including Enterococcus spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp., along with other major uropathogens such as Escherichia coli, represent a significant antimicrobial resistance burden worldwide. Their significant role in urinary tract infections (UTIs) poses major therapeutic challenges, particularly in resource-limited and geographically distinct settings.To assess the multidrugresistant (MDR) burden, antimicrobial resistance profiles, and prevalence of ESKAPE uropathogens isolated at a tertiary care facility in the Nilgiris region of India. Methods: Between May 2022 and June 2023, 332 culture-positive urine samples were obtained for a prospective cross-sectional analysis. The VITEK-2 Compact system and conventional microbiological techniques were used for identification and antibiotic susceptibility testing. Resistance surveillance and alert generation were conducted using WHONET 5.6. These results led to the development and implementation of an antibiotic policy unique to the hospital as well as recommendations for empirical therapy for the treatment of UTIs. Results: 93.4% of isolates consisted of ESKAPE-associated pathogens and other major MDR uropathogens, with Klebsiella pneumoniae (16.3%) and Escherichia coli (48.8%) being the most common. Ampicillin (59%), Amoxicillin (41%), Ciprofloxacin (42.8%), and Cefotaxime (60.8%) all showed high levels of resistance. Colistin (100%) and Vancomycin (100%) retained complete susceptibility. E. coli (72%), A. baumannii (50%), E. faecalis (64%), and P. aeruginosa (31%) had the highest MDR prevalence. ESBL and fluoroquinolone resistance trends were increasing, according to WHONET alerts. Discussion: The microbiological profiles revealed in this investigation are quite similar to previously reported national and international antibiotic resistance surveillance trends. Escherichia coli remained the leading uropathogen, followed by Klebsiella pneumoniae, Staphylococcus aureus, and other ESKAPE organisms, patterns that closely mirror those reported by the WHO GLASS 2023–2024 surveillance summary Conclusion: The most common cause of UTIs in this area is “ESKAPE pathogens and non- ESKAPE uropathogens such as Escherichia coli”, which have a high MDR burden and considerable resistance. Antimicrobial stewardship initiatives have been reinforced, and empirical therapy has become more appropriate with the adoption of a data-driven, locally relevant antibiotic policy. To maintain treatment efficacy and slow the emergence of resistance, ongoing surveillance and regular policy revisions are still essential.