Dynamic association of antimicrobial resistance in urinary isolates of Escherichia coli and Klebsiella pneumoniae between primary care and hospital settings in the Netherlands (2008–2020): a population-based studyResearch in context

Background: It is unclear whether changes in antimicrobial resistance (AMR) in primary care influence AMR in hospital settings. Therefore, we investigated the dynamic association of AMR between primary care and hospitals. Methods: We studied resistance percentages of Escherichia coli and Klebsiella pneumoniae isolates to co-amoxiclav, ciprofloxacin, fosfomycin, nitrofurantoin and trimethoprim submitted by primary care, hospital outpatient and hospital inpatient settings to the Dutch National AMR surveillance network (ISIS-AR) from 2008 to 2020. For each bacterium–antibiotic combination, we first conducted multivariable logistic regressions to calculate AMR odds ratios (ORs) by month and healthcare setting, adjusted for patient-related factors and a time term. Second, multiple time series analysis was done using vector autoregressive models including the (log) ORs for each bacterium–antibiotic combination. Models were interpreted by impulse response functions and Granger-causality tests. Findings: The main AMR association was unidirectional from primary care to hospital settings with Granger-causality p-values between