Abstract

Background: Urinary tract infections (UTI) with non-specific treatment are leading to drug resistance. Cost-effective empirical therapy demands a brief survey of causative agents with their antibiograms. This study will show the bacterial spectrum and their susceptibility toward drugs which will enable us to make an accurate choice of drugs for empirical therapy.

Aim: The aim of this study is to determine the bacterial profile in UTI and demonstrate its pattern of antimicrobial susceptibility.

Method: This cross-sectional study was conducted in the microbiological lab of Sheikh Khalifa Bin Zayed Al-Nahyan Hospital, Muzaffarabad, Azad Jammu and Kashmir (AJK) from Oct 2017 to Oct 2018. Mid-stream urine received in the Department of Microbiology with symptomatic UTI was considered and inoculated onto Cysteine Lactose Electrolyte Deficient (CLED) agar. Bacterial identification with a series of biochemical tests and diffusion disc-based antimicrobial susceptibility test were done according to standard operating procedures.

Results: Out of 552 samples, 113(20.4%) of the specimens were cultured positive with the majority of females with 80(70.7%) of prevalence while the male were 33(29.3%). E. coli was most frequent bacteria isolated about 49(43.4%) followed by S. aureus 23(20.4%), Klebsiellapneumonia 15(13.3%), Pseudomonas aeruginosa 9(8%), Proteus mirabilis 6(5.3%), Enterobacter spp. 5(4.4%), Citrobacter spp. 3(2.6%), Salmonella 2(1.7%) and Klebsiellaoxytoca 1(0.9%). Gram-negative bacteria showed great susceptibility for Tazobactam-piperacillin, Meropenem, Levofloxacin and Nitrofurantoin. Gram-positive were highly sensitive to Nitrofurantoin, Amikacinand Cefixime. Ampicillin showed the highest resistance rate of 87.4%.

Conclusion: As an empirical treatment, Tazobactam-piperacillin and Meropenem are good choices for gram-negative bacteria while Nitrofurantoin showed high efficacy toward gram-positive bacteria.

Keywords: UTI, sensitivity, resistance, empirical therapy, susceptibility, efficacy.

---

INTRODUCTION

Urinary tract infection (UTI) are still ranked as the most common complaint infection [1]. Each year about 150 million people are affected from this disease [2]. Bacteria infiltration is the major factor in which E. coli has been ranked at top for causing urinary tract infection [3, 4]. In 90% of cases, uropathogenicity is initiated due to contamination of the urinary tract with normal flora of the genitourinary tract and rectum [5]. The international studies showed that this infectious state is more frequent in females and one in every five experiences UTI in her life [6-8].

This problematic event is augmented by the emergence of antimicrobial drug resistance, a major health care issue with inter-regional variability [9]. In developing countries, lack of education, high poverty rate, and poor hygienic practices are the leading factors initiating resistance, while a number of fake and spurious medicines with doubtful quality are also in the circle [10]. These countries have easy access to drugs without a prescription, whose extensive use increases the rate of resistance among the microbial population [11-13]. It is very strenuous to satisfy patient’s health with appropriate empirical therapy. A detailed and brief study is needed to improve the prescription of antibiotics. According to the Infectious Diseases Society of America’s recommendation, it is very important for the physician to obtain local data of resistance patterns in order to monitor the changing susceptibility pattern of pathogens [2].

As there is no organized data on microbiological profile of UTI in an adult in Muzaffarabad, this study will contribute in demonstrating the most sensitive antibiotics for gram-positive and gram-negative bacteria which will guide the physician to select effective therapy and evaluate a detailed antibiogram which may help to avoid unnecessary usage of drugs which return in limitation of drug resistance.

MATERIAL AND METHODS

This cross-sectional study was conducted in the Department of Microbiology at Sheikh Khalifa Bin Zayed Al-Nahyan Hospital, Muzaffarabad, AJK from Oct 2017 to Oct 2018. A well-mixed and non-centrifuged urine sample in a sterile container was inoculated by a urine strip that can deliver up to 0.2µl of urine on Cysteine Lactose Electrolyte Deficient agar plate (Oxoid Ltd, Basingstoke, UK) within 30 mins of collection and incubation at 37°C for 24hrs. Isolate having a pure growth of >105 colony forming units (CFU) was considered to be significant. Isolates were identified on the basis of their physical characters such as colony morphology, presence, and pattern of hemolysis and then by a series of biochemical reactions according to standard practice procedures [14, 15]. All gram-negative rods and enterococci were processed for biochemical test API 10. Antimicrobial sensitivity was performed using Kirby-Bauer disc diffusion technique [16] on Mueller-Hinton agar (OXOID Ltd) according to Standard [17, 18].

On the basis of the zone of inhibition of bacterial growth, susceptibility and resistance pattern of drugs were classified as sensitive, intermediate or resistant [18]. Methicillin-resistant Staphylococcus aureus (MRSA) was detected using cefoxitin disk and the isolate with the zone of inhibition of ≤21mm was confirmed phenotypically to be MRSA.

The study protocol was approved by an ethical review committee of Azad Jammu and Kashmir Medical College, Muzaffarabad. Data was entered and analyzed by using SPSS version 21 and the studied variables were abridged in the form of percentage and frequency.

RESULTS

A total of 552 clinical urine samples were included in this study in which a high presentation of female 314(57%) was seen than male 238(43%). 113(20.4%) of the specimen showed significant growth of uropathogens. A high prevalence of UTI was observed in females 80(70.7%) while in males it was 33(29.3%). Gram- negative bacteria were a dominating group with a high frequency of 90(79.6%) than gram-positive bacteria 23(20.4%). E. coli 49(43.4%) was the most frequent isolate. Fig. (1) illustrated the distribution of isolates.

Table. 1: Antibiogram of Uropathogen toward drugs.

-	Staph aureus		E. coli		Pseudomonas aeruginosa		Proteus mirabilis		Klebsiella pneumoniae
	S	R	S	R	S	R	S	R	S	R
Amikacin	83.3	16.7	65.2	21.7	50	50	0	100	100	0
Ampicillin	14.2	85.8	20.6	75.8	28.5	71.4	0	100	0	100
Augmentin	45	55	22	75.6	0	100	33.3	66.6	10	90
Cefradine	50	50	28.5	71.4	ND	ND	0	100	0	100
Cefixime	75	25	16.6	83.3	ND	ND	ND	ND	33.3	66.6
Ciprofloxacin	41.6	50	32.1	67.8	42.8	57.1	20	80	70	20
Cotrimoxazole	30	70	45.5	54.5	0	100	100	0	44.4	55.5
Ceftriaxone	55.5	44.4	38.4	61.5	0	100	0	100	28.5	71.4
Clarithromycin	42.8	57.2	ND	ND	ND	ND	ND	ND	ND	ND
Cefoxitin	66.6	33.3	100	0	100	0	100	0	66.6	33.3
Doxycycline	70	30	ND	ND	ND	ND	ND	ND	ND	ND
Gentamicin	50	50	100	0	100	0	ND	ND	50	50
Erythromycin	ND	ND	100	0	ND	ND	0	100	0	100
Levofloxacin	40	60	53.8	46.1	75	25	ND	ND	75	25
Imipenem	70.1	29.9	87.1	10.2	100	0	60	40	93.3	6.6
Meropenem	65	35	90.4	9.5	66.6	33.3	100	0	100	0
Nitrofurantoin	85.7	14.2	92.3	3.4	80	20	100	0	90	10
Tazobactum Pipracillin	50	50	96	4	86	14	96	4	100	0
Vancomycin	71.4	28.6	ND	ND	ND	ND	ND	ND	ND	ND

S= Sensitive, R=Resistant, ND=Not Determined

The highest susceptibility of Tazobactam-Piperacillin (99%) was seen in gram-negative bacteria along with Meropenem (81.7%), Levofloxacin (76%), Nitrofurantoin (72.4%) and Imipenem (65%). Nitrofurantoin and Amikacin remained the highest sensitive drugs toward gram-positive bacteria with a sensitivity rate of 85.7% and 83.3% respectively. Table 1 demonstrated the sensitivity and resistance profile.

Out of 23 S. aureus, 18 were tested for cefoxitin of which 33.3% found to be MRSA. S. aureus exhibits high sensitivity for Nitrofurantoin (85.7%), Amikacin (83.3%), Cefixime (75%) Vancomycin (71.4%), Imipenem (70.1) and Doxycycline (70%) with high resistance toward Ampicillin (85.7%) and Co-trimoxazole (70%).

The highly consumable antibiotics showed less susceptibility against gram-positive and negative bacteria. Ampicillin showed the highest resistance rate of 87.4% (Fig. 2).

Fig. (2): Sensitivity percentage of antibiotics against Gram- Positive and Gram-Negative Bacteria. In antibiotic susceptibility test, Erythromycin was not determined in gram positive bacteria while Vancomycin, Doxycycline, and Clarithromycin was not determined in gram negative pathogen.

DISCUSSION

While microbial resistance is increasing, it is very important for a physician to have a look at local antibiogram history before the recommendation of empirical treatment. This study will contribute to providing the data for the distribution of UTI causing agents and their susceptibility towards drugs and will be useful in making guidelines for drug recommendation.

In our study, the overall prevalence of UTI was 20.4%, which is highly near to the study conducted in International Medical College and Hospital, Gazipur and PIMS Hospital, Islamabad with the prevalence of 20.2 and 20.7 respectively [19, 20].

There was a high prevalence of UTI in females than male with 80% of the ration. As reported globally, prevalence of UTI in females was recorded higher than males [21]. This study also explored that gram-negative bacteria are a major factor in this complaint. A study conducted by Ahmed et al. in Jinnah Hospital, Lahore concluded that gram-negative group is causing 81% of UTI [22].

Our investigation isolated E. coli as the most leading UTI causing pathogen with a prevalence of 43.3% which bears a close resemblance in Islamabad 43.2%, while high percentage was reported in Peshawar and Lahore with a ratio of 66% and 76.8% [19, 23, 24]. Our study concluded S. aureus as the second most common pathogen of UTIs. In 2013, a research carried out in Mayo Hospital, Lahore also ranked S. aureus as the second-leading agent causing UTIs while studies in Nigeria and India reported the same results [11, 25, 26]. Thus, these recent findings confirm S. aureus as an important etiologic agent in UTIs. Gram-negative bacteria were highly sensitive to Tazobactam piperacillin, Meropenem and Imipenem, another study showed the same sensitivity pattern in Ethiopia and Lahore [27, 28]. A research conducted in Creek General Hospital, Karachi and tertiary care hospital of Kerala, India rated Nitrofurantoin and Amikacin as highly sensitive drug towards Staph aureus-induced UTI which extends our study [29, 30].

This study revealed that the highly recommended drugs have low efficacy, which is the result of overuse or misuse of drugs. This situation was also seen in Sri Lanka and Ethiopia in which susceptibility Ampicillin, Co-trimoxazole, Ciprofloxacin and Ceftriaxone were recorded low [31, 32]. 85% of UTI cases showed resistance to Ampicillin, that was 76% in a Turkish study [33].

CONCLUSION

This evaluation concluded that females are more vulnerable toward UTI with high portion of gram-negative group while E. coli remains on top. This study alarmed about the high resistance of commonly recommended drugs. Gram-negative should be empirically treated with Tazobactam-piperacillin and Meropenem while gram- positive with Nitrofurantoin and Amikacin.

This study recommends that the hospital should adopt policies for regulation of antibiotic usage and antibiotic stewardship to limit increasing resistance. Empirical treatment should be prescribed by reference to the antibiogram of that area. The patient should be properly guided regarding right usage of drugs. There should be a constant evaluation of antibiotic spectrum of commonly used drugs. Hospitals in collaboration with stakeholders should make a committee to evaluate the quality of drugs launched by a pharmaceutical industry.

AVAILABILITY OF DATA AND MATERIALS

The data used to support the findings of this study is available from the corresponding author upon request.

CONFLICT OF INTEREST

The authors have no conflicts of interest to declare.

ACKNOWLEDGEMENT

The authors acknowledge DOW University of Health Sciences for providing support to this project.

FUNDING

Authors sponsor this research themselves.

REFERENCES

• 1. Barber AE, Norton, JP, Spivak AM. Urinary tract infections: current and emerging management strategies. Clin Infect Dis 2013; 57: 719-24.
• 2. Karlowsky JA KL, Thornsberry C, Jones ME, Sahm D Trends in antimicrobial resistance among urinary tract infection isolates of Escherichia coli from female outpatients in the United States. Antimicrob Agents Chemother 2002; 46: 2540-5.
• 3. Hagan EC1, Mobley HL. Uropathogenic Escherichia coli outer membrane antigens expressed during urinary tract infection. Infect Immun. Aug 2007; 75(8): 3941-9.
• 4. Ramos NL, Sekikubo M, Dzung DT, et al. Uropathogenic Escherichia coli isolates from pregnant women in different countries. J Clin Microbiol 2012; 50(11): 3569-74.
• 5. Mobley HL, Donnenberg MS, Hagan EC. Uropathogenic
• Escherichia coli. EcoSal Plus 2009; 3(2).
• 6. Behzadi P, Behzadi E, Yazdanbod H, Aghapour R, Akbari CM, Salehian OD. A survey on urinary tract infections associated with the three most common uropathogenic bacteria. Maedica (Buchar) 2010; (5): 111-5.
• 7. Behzadi P, Behzadi E. The microbial agents of urinary tract infections at central laboratory of Dr. Shariati Hospital, Tehran, Iran. Turk Klin Tip Bilim 2008; 28: 445-9.
• 8. Hummers-Pradier E, Ohse AM, Koch M, Heizmann WR, Kochen MM. Management of urinary tract infections in female general practice patients. J Fam Prac 2005; 22: 71-7.
• 9. Gupta K, Sahm DF, Mayfield D, Stamm WE. Antimicrobial resistance among uropathogens that cause community acquired urinary tract infections in women: a nationwide analysis. Clin Infect Dis 2001; 33(1): 89-94.
• 10. Fagan M, Lindbæk M, Grude N, et al. Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living in nursing homes versus the elderly living at home: an observational study. BMC Geriatr 2015; 15(1)): 98.
• 11. Manikandan S, Ganesapandian S, Singh M, Kumaraguru AK. Antimicrobial susceptibility pattern of urinary tract infection causing human pathogenic bacteria. Asian J Med Sci 2001; 3: 56-60.
• 12. Kunin CM. Urinary tract infections in females. Clin Infect Dis 1994; 18: 1-12.
• 13. Jacoby GA, Archer GL. New mechanisms of bacterial resistance to antimicrobial agents. New England J Med 1991; 275: 601-12.
• 14. Cheesbrough M. District laboratory practice in tropical countries. 2nd ed. London: Cambridge University Press 2005: 105-14.
• 15. Alemu A, Moges F, Shiferaw Y, et al. Bacterial profile and drug susceptibility pattern of urinary tract infection in pregnant women at University of Gondar Teaching Hospital, Northwest Ethiopia. BMC Res Notes 2012; 25: 5: 197.
• 16. Bauer AW, Kirby WM, Sherris JC, Turk M. Antibiotic susceptibility testing by a standardized single disc method. Am J Clin Pathol 1966; 45: 493-6.
• 17. Patel J TF, Turnidge J, Jorgensen J. Susceptibility test methods: dilution and disk diffusion methods. In: Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D, Eds. Manual of Clinical Microbiology. 10th ed. Washington, DC: ASM Press 2015, 1122-43.
• 18. Wayne P. Performance standards for antimicrobial susceptibility testing; twenty-fourth informational supplement. CLSI Document M100-S24. Washington, DC: American Association for Clinical Chemistry 2014, 50-7.
• 19. Amber M, Shoaib M, Rehman A, et al. Comparative study of causative agents of UTI among indoor, outdoor, children and adult patients of Pakistani Population. Bull Env Pharmacol Life Sci 2016; 5(8): 56-63.
• 20. Yasmeen BHN, Islam S, Islam S, Moyez Uddin M, Jahan R. Prevalence of urinary tract infection, its causative agents and antibiotic sensitivity pattern: a study in Northern International Medical College Hospital, Dhaka. North Int Med Coll J 2015; 7(1): 105-09.
• 21. Dickstein Y, Geffen Y, Andreassen S, Leibovici L, Paul M. Predicting antibiotic resistance in urinary tract infection patients with prior urine cultures. Antimicrob Agents Chemother 2016; 60(8): 4717- 21.
• 22. Sajed AN, Batool U, Iram S, et al. Prevalence of urinary tract infections and their antibiotic sensitivity in tertiary care hospital Lahore. IOSR J Dental Med Sci 2014; 13(12): 2279-861.
• 23. Bashir MF, Qazi J, Ahmad N, Riaz S. Diversity of urinary tract pathogens and drug resistant isolates of Escherichia coli in different age and gender groups of Pakistanis. Trop J Pharm Res 2008; 7(3): 1025-31.
• 24. Nisar A, Bari F, Ishaq MS, Safeer M, Ubaidullah, Rahman U. Prevalence of microorganism causing UTI in patients attending Microbiology Laboratory of Khyber Medical Collage, Peshawar during the year 2013. Khyber J Med Sci 2015; 8(1): 55-7.
• 25. Sabir S, Ahmed AA, Ijaz T, Ali MA, Khan MR, Nawaz M. Isolation and antibiotic susceptibility of E. coli from urinary tract infections in a tertiary care hospital. Pak J Med Sci 2014; 30(2): 389-92.
• 26. Okonko IO, Donbraye-Emmanuel OB, Ijandipe LA, Ogun AA, Adedeji AO, Udeze AO. Antibiotics sensitivity and resistance patterns of uropathogens to nitrofurantoin and nalidixic acid in pregnant women with urinary tract infections in Ibadan, Nigeria. Middle-East J Sci Res 2009; 4: 105-9.
• 27. Bitew A, Molalign T, Chanie M. Species distribution and antibiotic susceptibility profile of bacterial uropathogens among patients complaining urinary tract infections. BMC Infect Dis 2017; 17: 654.
• 28. Sohail M, Khurshid M, Saleem HGM, Javed H, Khan AA. Characteristics and Antibiotic resistance of urinary tract pathogens isolated from Punjab, Pakistan. Jundishapur J Microbiol 2015; 8(7): e19272.
• 29. Kidwai SS NA, Ghaznavi S, Bashir F, Ara J. Antibiotic susceptibility in commonly isolated pathogens from urinary tract infection in a cohort of subjects from low socioeconomic strata. Pak J Med Sci 2017; 33(2): 254-9.
• 30. Bency JAT, Priyanka R, Jose P. A study on the bacteriological profile of urinary tract infection in adults and their antibiotic sensitivity pattern in a tertiary care hospital in central Kerala, India. Int J Res Med Sci 2017; 5: 666-9.
• 31. CN Wijekoon KD, A Pathmeswaran,. Antimicrobial susceptibility patterns and empirical prescribing practices in adult in-patients with urinary tract infection in a tertiary care hospital in Sri Lanka: is there a need for changing clinical practices? Sri Lankan J Infect Dis 2014; 4(1): 9-21.
• 32. Kibret M, Abera B. Prevalence and antibiogram of bacterial isolates from urinary tract infections at Dessie Health Research Laboratory, Ethiopia. Asian Pac J Trop Biomed 2014; 4(2): 164-8.
• 33. Yüksel S, Oztürk B, Kavaz A, et al. Antibiotic resistance of urinary tract pathogens and evaluation of empirical treatment in Turkish children with urinary tract infections. Int J Antimicrob Agents 2006; 28(5): 413-6.