Distinct individual and community-level drivers of extended-spectrum beta-lactamase-producing Enterobacterales urinary tract infections.

OBJECTIVE: Compare characteristics of community-associated (CA) versus healthcare-associated (HCA) extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) urinary tract infection (UTI) cases and assess associations between ESBL-E UTI prevalence and census-tract social vulnerability. DESIGN: Retrospective cohort study. SETTING: Monroe County, NY, January 2020-December 2023. PATIENTS: Population surveillance of first urinary ESBL-E isolate among county residents. METHODS: ESBL-E, defined as resistance to ≥1 third-generation cephalosporin, was identified from inpatient and outpatient urinary specimens. Demographic, clinical, and healthcare exposure data were abstracted; cases were classified as CA or HCA using standardized definitions. Addresses were geocoded to census tracts and linked to CDC Social Vulnerability Index (SVI) scores. Characteristics were compared using χ2 and Wilcoxon tests. Generalized linear models assessed associations between SVI themes and ESBL-E prevalence by epidemiologic classification. RESULTS: Of 3,100 ESBL-E UTI cases, 1,621 (52.3%) were CA and 1,468 (47.4%) HCA. CA cases were younger (median 56 vs 71.5 years), more often female (89.5% vs 68.4%), and less medically complex than HCA cases. HCA prevalence increased with SVI score, while CA prevalence remained stable across SVI levels. The HCA association was mainly driven by SVI Theme 2 (household composition/disability; P = .0011). CONCLUSIONS: CA and HCA ESBL-E UTIs exhibit distinct epidemiology. No association was observed between SVI and CA ESBL-E UTI prevalence. HCA prevalence increased with social vulnerability, largely driven by SVI Theme 2, potentially reflecting healthcare exposure and medical complexity. Factors driving CA ESBL-E differ, and ESBL-E reduction efforts should consider broader structural and community factors beyond those captured by the SVI.