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Epidemiology of urinary Escherichia coli from a population-based surveillance in three U.S. counties, August 2023

Published online by Cambridge University Press:  06 October 2026

Joshua M. BrandenburgOpen the ORCID record for Joshua M. Brandenburg[Opens in a new window],
Latasha CurtisOpen the ORCID record for Latasha Curtis[Opens in a new window],
Ruben E. RaymondOpen the ORCID record for Ruben E. Raymond[Opens in a new window],
Uzma AnsariOpen the ORCID record for Uzma Ansari[Opens in a new window],
Davina E. CampbellOpen the ORCID record for Davina E. Campbell[Opens in a new window],
Amy S. GargisOpen the ORCID record for Amy S. Gargis[Opens in a new window],
Alyssa G. KentOpen the ORCID record for Alyssa G. Kent[Opens in a new window],
Susannah L. McKayOpen the ORCID record for Susannah L. McKay[Opens in a new window],
Erin C. Parker and
Rebecca Longson
...Show all authors
Joshua M. Brandenburg
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Latasha Curtis
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Ruben E. Raymond
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Uzma Ansari
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Davina E. Campbell
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Amy S. Gargis
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Alyssa G. Kent
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Susannah L. McKay
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Erin C. Parker
Affiliation:
California Emerging Infections Program, Oakland, USA
Rebecca Longson
Affiliation:
California Emerging Infections Program, Oakland, USA
Gillian Smith
Affiliation:
Georgia Emerging Infections Program, Atlanta, USA
Jesse T. Jacob
Affiliation:
Georgia Emerging Infections Program, Atlanta, USAEmory University School of Medicine, Atlanta, USA
Paulina A. Rebolledo
Affiliation:
Emory University School of Medicine, Atlanta, USA
Ghinwa Dumyati
Affiliation:
New York Emerging Infections Program and University of Rochester Medical Center, Rochester, USA
Hsioa Che Looi
Affiliation:
New York Emerging Infections Program and University of Rochester Medical Center, Rochester, USA
Julia Tellerman
Affiliation:
New York Emerging Infections Program and University of Rochester Medical Center, Rochester, USA
Alice Y. Guh
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
Heather N. Grome*
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, USA
*
Corresponding author: Heather N. Grome; Email: qds9@cdc.gov

Abstract

Population-based surveillance of urinary Escherichia coli was conducted in three U.S. counties. Findings included high incidence among females and older adults, resistance to recommended urinary tract infection treatments, and O serotypes common among invasive disease. The study emphasizes the value of understanding the epidemiology and resistance profiles to guide treatment.

Information

Type
Concise Communication
Information
Antimicrobial Stewardship & Healthcare Epidemiology , Volume 6 , Issue 1 , 2026, e317
Creative Commons
Creative Common License - CCCreative Common License - BY
To the extent this is a work of the US Government, it is not subject to copyright protection within the United States. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America.
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© Centers for Disease Control and Prevention (CDC) and the Author(s), 2026

Introduction

Escherichia coli is a leading global cause of urinary tract infections (UTIs) including complications such as pyelonephritis, bacteremia, and community-onset sepsis. Reference Bonten, Johnson and van den Biggelaar1 Additionally, increasing rates of antibiotic resistance in urinary E. coli (uEc) substantially increase the societal burden of these common infections. Reference Kaye, Gupta and Mulgirigama2

Recent U.S. surveillance rarely characterizes the full epidemiology of community-associated uEc, particularly across all antimicrobial susceptibility phenotypes. 3 This pilot expands understanding of uEc burden by providing recent, population-based data and broad O-serotype characterization across all phenotypes through one month of active surveillance conducted by the Centers for Disease Control and Prevention’s (CDC’s) Emerging Infections Program (EIP).

Methods

Population- and laboratory-based surveillance for uEc was conducted during one month (August 2023), due to the resource-intensive nature of the surveillance, in three U.S. counties (Alameda County, California; Fulton County, Georgia; and Monroe County, New York) with a total estimated population of 3.4 million people.

Cases were identified through automated testing instruments (ATIs) or laboratory information systems of all urine cultures from the clinical laboratories serving residents of the three surveillance counties. We defined a case as the first E. coli of any phenotype isolated from urine in a resident of the surveillance counties over a 30-day period. Data collectors at each site recorded demographics on all case-patients and attempted to review medical records of a random sample of 400 cases to collect data on underlying conditions, healthcare exposures, and presence of UTI, bacteremia, and septic shock using a standardized case report form (CRF) (see supplementary materials). We assigned cases epidemiologic classifications: community-associated, healthcare-associated community-onset, or hospital-onset (see supplementary materials).

Minimum inhibitory concentrations from antimicrobial susceptibility testing (AST) results from clinical lab ATIs or from the medical record were collected on the CRF. Carbapenem resistance was defined as resistance to ≥1 carbapenem and extended-spectrum β-lactamase (ESBL)-production as resistance to ≥1 extended-spectrum cephalosporin and without carbapenem resistance. For cases with completed CRFs, an isolate was submitted to CDC for whole genome sequencing (WGS) analysis and in silico serotyping at the CDC laboratory (see supplementary materials).

We calculated one-month incidence rates per 100,000 population using aggregate 2023 U.S. Census county population estimates. Incidence rates by demographic subgroups were calculated using stratum-specific denominators. We conducted data analyses using R v4.4.0 (https://cran.r-project.org/).

This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy (See for example 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.). This activity was also reviewed by participating EIP sites, and either was deemed non-research or received IRB approval with a waiver of informed consent.

Results

We identified 5,742 cases in August 2023 with a crude one-month incidence rate of 166.4 per 100,000 population (Table 1). Incidence was higher among females than males (280.0 vs 44.6 per 100,000), higher among infants (<1 yr) than children aged 1–17 years (79.9 vs 39.1 per 100,000), and increased with age among adults, ranging from 117.7 per 100,000 in adults aged 18–39 years to 802.5 per 100,000 in those aged ≥80 years old (Table 1).

Table 1.

Demographic characteristics and associated incidence rates and clinical characteristics of urinary Escherichia coli cases, 3 U.S. Counties, August 2023

A table summarizing demographic characteristics and clinical features of urinary E. coli cases in three U.S. counties.
Table 1. Long description

A table with 5,742 cases of urinary E. coli in three U.S. counties in August 2023. The table has 4 columns and 66 rows. Column headers are No. Cases, % Cases, One-month incidence rate per 100,000, and 2023 Census population estimates. Row labels include Total cases, Cases with completed case report forms, Demographic characteristics among total cases, Patient sex, Race, Ethnicity, Age, Clinical characteristics among cases with completed case report forms, Epidemiologic classification, Charlson Comorbidity Index, median (range), Underlying conditions, Associated infection types, and Signs and symptoms associated with urine cultures. Row 1: Total cases, 5,742, 100, 166.4, 3,449,775. Row 2: Cases with completed case report Forms, 1,199, 20.9, --, --. Row 3: Demographic characteristics among total cases (n = 5,742), --, --, --, --. Row 4: Patient sex, --, --, --, --. Row 5: Female, 4,922, 85.7, 280.0, 1,758,111. Row 6: Male, 755, 13.1, 44.6, 1,691,664. Row 7: Missing value, 65, 1.1, --, --. Row 8: Race, --, --, --, --. Row 9: White, 2,737, 47.7, 151.4, 1,808,280. Row 10: Black, 1,087, 18.9, 139.1, 781,229. Row 11: Other, 523, 9.1, 60.8, 860,266. Row 12: Unknown, 1,395, 24.3, --, --. Row 13: Ethnicity, --, --, --, --. Row 14: Non-Hispanic or Latino, 4,265, 74.3, 146.7, 2,907,857. Row 15: Hispanic or Latino, 739, 12.9, 136.4, 541,918. Row 16: Unknown, 738, 12.9, --, --. Row 17: Age, --, --, --, --. Row 18: <1 year, 29, 0.5, 79.9, 36,301. Row 19: 1-17 yr, 255, 4.4, 39.1, 652,897. Row 20: 18-39 yr, 1,298, 22.6, 117.7, 1,102,778. Row 21: 40-59 years, 1,242, 21.6, 137.3, 904,477. Row 22: 60-79 years, 1,921, 33.5, 309.3, 620,205. Row 23: 80 years, 996, 17.3, 802.5, 124,117. Row 24: Clinical characteristics among cases with completed case report forms (n = 1,199), --, --, --, --. Row 25: Epidemiologic classification, --, --, --, --. Row 26: Community-associated, 869, 72.5, --, --. Row 27: Healthcare-associated, community-onset, 325, 27.1, --, --. Row 28: Hospital-onset, 3, 0.3, --, --. Row 29: Unknown, 2, 0.2, --, --. Row 30: Charlson Comorbidity Index, median (range), 0 (0-10), --, --, --.

a Other: Includes Asian, American Indian or Alaskan Native, Native Hawaiian or Other Pacific Islander, or ≥2 races reported.

b Patient age missing for one case.

c Epidemiologic Classification defined as Hospital-onset: Urine obtained ≥ 3 days after hospital admission; Healthcare-associated, community-onset: Urine obtained in a non-hospital setting or<3 days after hospital admission with selected healthcare exposures (hospitalization, surgery, residence in a long-term care facility or long-term acute care hospital) in the prior year, chronic dialysis, or with an indwelling device in the 2 days prior to culture; Community-associated: Urine obtained in a case-patient without any of the healthcare risk factors described.

d Cases may have>1 underlying condition reported.

e Recurrent UTI as documented in the medical record.

f Neurologic Condition includes cerebral palsy, chronic cognitive deficit, epilepsy/seizure/seizure disorder, multiple sclerosis, neuropathy, Parkinson’s disease, and others.

g Cardiovascular disease includes cerebrovascular accident, transient ischemic attack, congenital heart disease, congestive heart failure, myocardial infarction, and peripheral vascular disease.

h Gastrointestinal disease includes diverticular disease, inflammatory bowel disease, peptic ulcer disease, and short gut syndrome.

i Malignancy includes hematologic and solid organ (metastatic and non-metastatic).

j Skin condition includes burn, decubitus or pressure ulcers, surgical wound, and other chronic ulcer or chronic wound.

k Cases may have>1 associated infection type reported.

l Urinary tract infection defined as documented in the medical record.

m Pyelonephritis as documented in the medical record, and presented as a subset of the UTI count.

n Includes case-patients with no or unknown (22/1197; 1.8%) signs or symptoms or those with other signs or symptoms not listed in the table, which would not have been captured by the standardized case report form. Signs and symptoms reported are limited to those captured on the case report form.

o Colony counts reported as a range up to 100,000 CFU/ml (e.g., “10 to 100,000” was included).

Of 1,199 cases with a completed CRF, 869 (72.5%) were community-associated. Of these, 1,116 (93.1%) had UTI documented (Table 1), including 42 (3.8%) with bacteremia, and pyelonephritis was documented in 70 (5.8%) cases, including 11 (15.7%) with bacteremia. Quantitative urine culture results were available for 1,103 (98.8%) of 1,116 cases with UTI. Most (821/1,103 [74.4%]) had cultures with ≥105 colony-forming-units per milliliter (CFU/mL). Among the 282 cultures < 105 CFU/mL, 223 (79.1%) of 282 cases had UTI signs or symptoms (Table 1). A urinary catheter was present within two days before specimen collection for 77 (6.4%) cases.

Among cases with AST results (eTable 1), 1.5% (13/839) were resistant to nitrofurantoin, 63.1% (424/672) were resistant to trimethoprim-sulfamethoxazole, and 20.0% (192/961) were resistant to a fluoroquinolone (ciprofloxacin or levofloxacin). None showed resistance to all first-line recommended oral antibiotics for UTI. Reference Gupta, Hooton and Naber4,Reference Trautner, Cortes-Penfield and Gupta5 Separately, 12.3% (147/1,199) were ESBL-producing; none were carbapenem resistant.

A total of 939 isolates were submitted to CDC for WGS and in silico O serotyping; 100 unique serotypes were identified, most frequently O25B (115; 12.2%), O6 (98; 10.4%), and O2 (84; 8.9%) (Table 2). These three serotypes accounted for approximately 30% of the distribution of O serotypes across all reported age and sex strata. Serotype O25B was more prevalent in males than females (20.1% [28/139] vs 10.8% [86/795]), despite the increased frequency among females, and in case-patients aged ≥60 years compared with <60 years (16.1% [68/422] vs 9.1% [47/517]).

Table 2.

Predicted O serotypes by in silico serotyping from whole genome sequencing of urinary Escherichia coli isolates tested at the U.S. Centers for Disease Control and Prevention, 3 U.S. Counties, August 2023 (n = 939)

A table comparing the distribution of O serotypes in Escherichia coli isolates across different age and sex groups.
Table 2. Long description

A table comparing the distribution of O serotypes in Escherichia coli isolates across different age and sex groups. The table has 11 columns and 22 rows. Column headers are: O serotype, Total (n = 939), %, Age < 60 yr (n = 517), %, Age ≥ 60 yr (n = 422), %, Male (n = 139), %, Female (n = 795), %. Row 1: O25B, 115, 12.2, 47, 9.1, 68, 16.1, 28, 20.1, 86, 10.8. Row 2: O6, 98, 10.4, 54, 10.4, 44, 10.4, 13, 9.4, 85, 10.7. Row 3: O2, 84, 8.9, 50, 9.7, 34, 8.1, 18, 12.9, 66, 8.3. Row 4: O75, 69, 7.3, 41, 7.9, 28, 6.6, 10, 7.2, 57, 7.2. Row 5: O1A, 66, 7.0, 38, 7.4, 28, 6.6, 7, 5.0, 59, 7.4. Row 6: O16, 48, 5.1, 31, 6.0, 17, 4.0, 6, 4.3, 42, 5.3. Row 7: O15, 28, 3.0, 17, 3.3, 11, 2.6, 5, 3.6, 23, 2.9. Row 8: O4, 27, 2.9, 12, 2.3, 15, 3.6, 4, 2.9, 23, 2.9. Row 9: O8, 27, 2.9, 13, 2.5, 14, 3.3, 3, 2.2, 24, 3.0. Row 10: O22, 22, 2.3, 14, 2.7, 8, 1.9, 2, 1.4, 20, 2.5. Row 11: O17/O44/O77, 19, 2.0, 14, 2.7, 5, 1.2, 2, 1.4, 17, 2.1. Row 12: O46, 18, 1.9, 8, 1.5, 10, 2.4, 1, 0.7, 17, 2.1. Row 13: O13, 16, 1.7, 3, 0.6, 13, 3.1, 2, 1.4, 14, 1.8. Row 14: O18, 16, 1.7, 6, 1.2, 10, 2.4, 4, 2.9, 12, 1.5. Row 15: O86, 16, 1.7, 11, 2.1, 5, 1.2, 2, 1.4, 14, 1.8. Row 16: O153, 15, 1.6, 13, 2.5, 2, 0.5, 1, 0.7, 14, 1.8. Row 17: O117, 14, 1.5, 9, 1.7, 5, 1.2, 1, 0.7, 13, 1.6. Row 18: O18ac, 14, 1.5, 8, 1.5, 6, 1.4, 2, 1.4, 12, 1.5. Row 19: O99, 11, 1.2, 10, 1.9, 1, 0.2, 0, 0.0, 11, 1.4. Row 20: O25A, 10, 1.1, 4, 0.8, 6, 1.4, 1, 0.7, 9, 1.1. Row 21: Other, 163, 17.4, 96, 18.6, 67, 15.9, 19, 13.7, 143, 18.0. Row 22: Unknown/not detected, 43, 4.6, 18, 3.5, 25, 5.9, 8, 5.8, 34, 4.3.

a Closely related O serotypes are reported as a group.

b Other category includes counts of 9 or less for the following O serotypes: O7, O9, O9/O101, O9a, O10, O11, O12, O13/O129/O135, O17, O17/O44, O17/O77, O19, O21, O23, O26, O29, O32, O33, O34, O39, O45, O49, O54, O55, O61, O62, O65, O66, O78, O80, O81, O82, O83, O85, O87, O88, O89, O91, O93, O96, O98, O101, O102, O104, O105, O107, O108, O109, O112, O115, O120, O123, O124, O125ac, O128, O128ac, O131, O132, O136, O139, O145, O147, O148, O150, O152, O153/O178, O154, O157, O159, O160, O161, O163, O169, O170, O173, O175, O181, O184, O185, O188.

Discussion

Through active population- and laboratory-based surveillance, we measured a one-month incidence rate of uEc as 166 per 100,000 population among residents of three surveillance sites, consistent with the high incidence reported in other studies based on urine culture data Reference Bruxvoort, Bider-Canfield and Casey6 and nearly 27 times the rate of invasive E. coli infections when extrapolated to a three-month incidence rate. Reference Grome, Brandenburg and Kent7 Incidence was six-fold higher among females compared to males, seven-fold higher among those ≥80 years old compared to 18–39 years old, and among children, incidence was higher among infants <1 year. These findings align with previously identified populations shown to have elevated uEC rates. Reference Bonten, Johnson and van den Biggelaar1,Reference Bruxvoort, Bider-Canfield and Casey6,Reference Shaikh, Morone, Bost and Farrell8

Although the CRF did not include all possible UTI signs or symptoms, nearly one-third of cases with a CRF had none reported. This finding may indicate that urine cultures are sometimes collected without clear clinical indication. Reference Nicolle, Gupta and Bradley9 Positive urine cultures may prompt treatment without clinical evidence of UTI, leading to unnecessary antibiotics for asymptomatic bacteriuria and increased antimicrobial resistance. Reference Nicolle, Gupta and Bradley9 In addition, among those tested, nearly two-thirds of cases were trimethoprim-sulfamethoxazole resistant and one-fifth were fluoroquinolone resistant, which may limit effectiveness of these first-line recommended antibiotics to treat UTIs. Reference Gupta, Hooton and Naber4,Reference Trautner, Cortes-Penfield and Gupta5 Nearly one in eight cases were caused by ESBL-producing E. coli. These findings highlight the importance of appropriate urine culturing and AST of cultures to inform treatment.

Isolate testing revealed a wide diversity of O serotypes, with nearly one-third of the distribution attributable to O25B, O2, and O6. Notably, O25B, which was more common among males and case-patients 60 years and older, is often associated with the global pandemic clone sequence type 131. Reference Rogers, Sidjabat and Paterson10 Furthermore, the most prevalent O serotypes in our study were similar to those reported for invasive E. coli infections, which are often secondary to urogenital infection. Reference Grome, Brandenburg and Kent7 Prevention efforts aimed at reducing UTIs caused by E. coli may reduce rates of invasive E. coli bacteremia and sepsis.

This study has several limitations. First, uEc burden is likely underestimated, since our case definition required a positive culture and did not capture purely clinical or non-culture-based diagnostics; data availability from commercial laboratories also varied by state. Second, CRFs and isolate submissions were available for only a subset of cases and may not accurately reflect the overall epidemiology, resistance, or strain diversity, although random sampling was performed to minimize bias. Third, signs and symptoms may be underreported because CRF response options were not exhaustive. Fourth, one month of surveillance prevented assessment of temporal variation. Finally, findings may not be nationally generalizable, although participating counties represent three distinct U.S. regions.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/ash.2026.10809.

Acknowledgements

We thank the staff at the clinical and public health laboratories and EIP sites that contributed to this pilot, which allowed this study to take place. We also thank the CDC Biotechnology Facility for their laboratory testing and isolate characterization at CDC.

Financial support

This work was supported by the CDC through the Emerging Infections Program (cooperative agreement CDC-RFA-CK17-1701)

Competing interests

All authors report no potential conflicts of interest.

References

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Figure 0

Table 1.Demographic characteristics and associated incidence rates and clinical characteristics of urinary Escherichia coli cases, 3 U.S. Counties, August 2023Table 1 long description.

Figure 1

Table 2.Predicted O serotypes by in silico serotyping from whole genome sequencing of urinary Escherichia coli isolates tested at the U.S. Centers for Disease Control and Prevention, 3 U.S. Counties, August 2023 (n = 939)Table 2 long description.

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