MULTIDRUG RESISTANT PATHOGENS IN URINARY TRACT INFECTIONS

Urinary tract infections are considered as the most commonly diagnosed and treated bacterial infections [14, 17]. Bladder and urethra represent the most prevalent sites of infection. Women are more prone to have UTIs than men, with an incidence rate of 50-60% for females and 13% for males [12, 13]. Enterobacteriaceae are the most common cause of UTIs in both community and healthcare settings [3].

Uncomplicated UTIs are treated with antibiotics [20]. The increased utilization of antibiotics has contributed to greater resistance (in other word, multiresistant) among urinary pathogenic bacteria to many antibiotics that are typically used in UTIs treatment [19]. Therefore, this study was aimed to detect the presence of multidrug resistant uropathogens in UTIs.

A total of 325 specimens (midstream urine) were collected from patients in different ages (6-76) years, with clinical symptoms suspected to be UTI. A routine direct microscopy was performed, and then inoculation was done on MacConkey’s agar. After incubation, the isolated colonies were identified by standard methods, as well as by API 20E system. The Antimicrobial susceptibility test was carried out by the disk diffusion method (Kirby-Bauer's technique) on Muller-Hinton agar. The tested antibiotics were selected as they are the antibiotics of choice in the treatment of UTI [4].

The current study demonstrates the presence of multidrug resistant urinary pathogens recovered from 200 (61.5%) urine specimens gave positive urine cultures. The existence of specimens gave negative urine cultures was also observed, 100 (31%). Such result was also documented in other studies [5, 9], attributed this to the presence of other pathogens, fungi and viruses, or slow growing organisms, or organisms that cannot be grow on ordinary culture media. The results were shown in table 1.

Table 1  

Distribution of the cultured isolates (N = 325)

Escherichia coli was the most commonly isolated organism, followed by Klebsiella spp., and Enterobacter spp. The present findings were in accordance with other studies [11, 15]. Other uropathogens, like Proteus spp., Pseudomonas spp., Morganella morganii, and Acinetobacter baumannii were also isolated in this study. These isolates have been reported as agents of UTIs in another study [1].

The antimicrobial susceptibility profile of the isolated uropathogens was shown in table 2. The isolates exhibited a wide difference in their susceptibility toward the tested antibiotics. High levels of sensitivity were seen towards imipenem and amikacin (100%), followed by nitrofurantoin (71%). Whereas, high resistant were seen against ampicillin (92%), augmentin (86%), and trimethoprim-sulfamethoxazole (83%), nalidixic acid and cefoxitin (79.5%) for each, piperacillin (74.5%), and cefotaxime (69.5%). These findings were also been reported by other researchers [6, 8, 10, 18]. Lower rates of sensitivity and resistant were also noticed toward other tested antibiotics.

Our results revealed that the isolates of Klebsiella spp., Pseudomonas spp., Acinetobacter baumannii, and Morganella morganii shows multiresistant feature toward more than five antibiotics used in conventional therapy. These finding were in accordance with other studies demonstrated such feature among such urinary pathogens [2, 7, 16].

Table 2  

Antimicrobial susceptibility profile of the isolates (N=200).

We can truly conclude that in treatment of UTIs, the choice of antibiotics is quite narrow today due to the wide scale resistance that showed by common UTI pathogens. Ampicillin and trimethoprim-sulfamethoxazole which were considered as effective drugs against uropathogens are now rarely prescribed as empirical therapy, but it is clear that imipenem, amikacin, and nitrofurantoin are good choices in outpatients treatment.

List of references

1.     Adedeji, B.A. and Abdulkadir, O.A. Etiology and antimicrobial resistance pattern of bacterial agents of urinary tract infections in students of Tertiary Institusions in Yola Metropolis; Advanced Biology Research. 2009, 3 (3-4): P. 67-70.

2.     Eshetie, S.; Unakal, C.; Gelaw, A.; Ayelign, B.; Endris, M.; and Moges, F. Multidrug resistant and carbapenemase producing Enterobacteriaceae among patients with urinary tract infection at referral Hospital, Northwest Ethiopia. Antimicrobial Resistance and Infection Control. 2015, 4 (12): P. 1-8.

3.     Gupta, K.; Hooton, T.M.; Naber, K.G.; et al., “International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the infectious diseases society of America and the European society for microbiology and infectious diseases,” Clinical Infectious Diseases. 2011, 52 (5): P. e103-e120.

4.     Health Protection Agency. Investigation of Urine. UK Standards for Microbiology Investigations. 2012. B 41, Issue 7.1: P.1-41. Available from http://www.hpa.org.uk/SMI/pdf.

5.     Kareem, I.J. and Raheed, I.Y. Antibiotic Susceptibilities of Gram Negative Aerobic Bacteria Isolated from Urinary Tract Infections in Community. Iraqi J. Medical Sciences. 2011, 9 (4): P. 295-300.

6.     Kebira, A.N.; Ochola, P.; and Khamadi, S.A. Isolation and antimicrobial susceptibility testing of Escherichia coli causing urinary tract infections; Applied Biosciences. 2009, 22: P. 1320-1325.

7.     Khawcharoenporn, T.; Vasoo, S.; and Singh, K. Urinary Tract Infections due to Multidrug-Resistant Enterobacteriaceae: Prevalence and Risk Factors in a Chicago Emergency Department. Emergency Medicine International. 2013, Article ID 258517, 7 pages.

8.     Kiffer, C.R.; Kuti, J.L.; Eagye, K.J.; Mendes, C.; and Nicolau, D.P. Pharmacodynamic profiling of imipenem, meropenem and ertapenem against clinical isolates of extended-spectrum beta-lactamase producing Escherichia coli and Klebsiella spp. from Brazil; International J. Antimicrobial Agents. 2006, 28 (4): P. 340-344.

9.     Mahmood, M.A. Prevalence and Antimicrobial Susceptibility of Pathogens in Urinary Tract Infections. J. Al- Nahrain University. 2011, 14 (4): P. 146-152.

10. Moyo, S.J.; Aboud, S.; Kasubi, M.; Lyamuya, E.F.; and Maselle, S.Y. Antimicrobial resistance among producers and non – producers of extended spectrum beta – lactamases in urinary isolates at a tertiary Hospital in Tanzania; BMC Research Notes. 2010, 3: P. 348.

11. Muhammed, A.; Muhammed, F.; Muhammed, A-H.; Imam, H.; Imam, A-S.; and Muhammed, R. A prospective study of patterns of urinary tract infections and antibiotic sensitivity in rural setting of Mirpurkhas; Muhammed Medical College. 2010, 1 (1): P. 10-14.

12. Naber, K.G.; Cho, Y.H.; Matsumoto, T.; and Schaeffer, A.J. Immunoactive prophylaxis of recurrent urinary tract infections: a meta-analysis. International J. Antimicrob Agents. 2009, 33 (2): P. 111-119.

13. Nicole, W. and Jon, D.M. Deciphering Dysuria. Emergency Medicine International. 2008, 40 (9): P. 29.

14. Nicolle, L.E. Managing recurrent urinary tract infections in women. Womens Health (Lond Engl). 2005, 1 (1): P. 39-50.

15. Ozumba, U.C. Increasing incidence of bacterial resistance to antibiotics by isolates from the urinary tract; Niger. International J. Clinical Practice. 2005, 8 (2): P. 107-109.

16. Pallett, A. and Kieran, H. Complicated urinary tract infections: practical solutions for the treatment of multiresistant Gram-negative bacteria. J. Antimicrobial Chemotherapy. 2010, 65 Suppl 3: P. 25-33.

17. Rahn, D.D. Urinary tract infections: contemporary management. Urol Nurs. 2008, 28 (5): P. 333-341, Quiz 342.

18. Rajesh, K.R.; Mathavi, S. ; and Priyadarsni, R.I. Prevalence of antimicrobial resistance in uropathogens and determining empirical therapy for urinary tract infections; International J. Basic and Applied Medical Sciences.2010, 1 (4).

19. Salvatore, D.J. and Resman-Targoff, B.H. Treatment Options for Urinary Tract Infections Caused by Extended- Spectrum Β-Lactamase-Producing Escherichia coli and Klebsiella pneumonia. J. Academic Hospital Medicine. 2015, 7 (1).

20. Schaeffer, A.J.; Foxman, B.; and Tracy, E. Urinary tract infections in adults, J: National Kidney and Urological Diseases information clearing house publication No. 07-4807. 2007.