Journal of Babylon University/Pure and Applied Sciences/ No.(9)/ Vol.(22): 2014
Prevalence of Uropathogenic Escherichia coli in Al-Hashymia district of Babylon Province
Oday Mitib Hadi
Medical microbiology/Bacteriology, / College of Health and Medical Technology/Kufa.
Alaa Hashim Al-Maliki
Medical Laboratory Technology/Immunology, Department of Community Health/College of Health and Medical Technology/Kufa.
Mohammed Subhi Mohammed Al-zubaidy
Biotechnology/Cytogenetic. Kufa Institute, Community Health Department.
Yahya Kalil Nihmah
. Microbiology. Al-Hashymia General Hospital, Babylon
Abstract
Urinary tract infections (UTIs) are considered the most common bacterial infections, bacteria are the major causative agent and are responsible for more than 95% of UTIs cases. This study was designed to investigate the prevalence of uropathogenic E. coli isolated from patients with UTIs and evaluate its in-vitro susceptibility patterns to commonly used antimicrobial agent. Seventy six random urine samples were collected from inpatients and outpatients from July to September 2013, and the samples were routinely processed by cultivation on the ordinary media, as well as the susceptibility test of used antibiotics (Tetracycline, Ciprofloxacin, Tobramycin, Amikacin) according to Kirbey – Bauer technique.Incidence of UTIs in different age groups varied from one age group to another, but the highest value was recorded in the age group (10 – 19), it was (30.26%) while the lowest percentage was detected in the age group (50 – 59) years old (1.32%), also results of this study demonstrate significant variation between the rates and types of the bacterial percentages that cause inflammation of the urinary tract. Staphylococcus aureus records the highest proportion it records (45.45%), (69.57%) and (50%) for (1 – 9), (10 – 19) and (20 – 29) years old respectively, while E. coli enrolled the top most ratio, it scores (53.33%), and (50%) for (30 – 39) and (60-69) years old respectively, susceptibility pattern reveals that amikacin is the ideal antibiotic used against E. coli isolates due to the top value (88.5%) of effectiveness. Depending on the previous results we recommend to conduct research including an annual check-ups of antibiotics sensitivity, also we advise the use of molecular biological techniques for the diagnosis, in addition to determine ownership of the resistance gene.
Keywords: Urinary tract infections, antibiotic susceptibility, E. coli.
الخلاصة:
تعتبر الاصابة بالتهابات المسالك البولية (عدوى المسالك البولية) من الالتهابات الأكثر شيوعا، وتعد البكتيريا من العوامل الرئيسة والمسؤولة عن أكثر من 95٪ من حالات عدوى المسالك البولية، وقد تم تصميم هذه الدراسة للتحريعن الإشريكية القولونية المعزولة منالمرضى الذين يعانون من التهاب المسالك البولية ولتقدير حساسيتها للعوامل المضادة للجراثيم الاكثر استعمالامختبريا. تم جمع ستة وسبعون عينة ادرار عشوائيا من المصابين بالتهاب المجاري البولية للمرضى الراقدين و المراجعين للفترة من تموز الى ايلول عام 2013، وتمت معالجة العينات بشكل روتيني عن طريق زراعتها على الاوساطالزراعيةالعامة، فضلا عن اختبار الحساسية للمضادات (الاميكاسين، السبروفلوكساسين، التتراسايكلين و التوبرامايسين)وفقا لتقنية كيربي - باور. أظهرت الدراسة انمعدلحدوثعدوىالمسالكالبوليةفيمختلفالفئاتالعمريةمختلفةمنفئةعمريةالى فئة عمرية أخرى،حيث سجلتأعلى نسبةمن نسب الاصابة فيالفئةالعمرية(10-19)،وكانت(30,26٪)،فيحينتمالكشفعنأدنىنسبةفيالفئةالعمرية(50-59) سنة(1,32٪)،كما اظهرت نتائجهذهالدراسةأيضاتفاوتكبيربينمعدلات ونسب وأنواعالبكتيرياالتيتسببالتهابالمسالكالبولية. اذ سجلت المكوراتالعنقوديةالذهبيةأعلىالنسب(45,45٪)،(69,57٪) و(50٪)للفئات العمرية(1-9)،(10-19) و(20-29) سنةعلىالتوالي،فيحينسجلت الاشريكياالقولونيةأعلىالنسب (53,33٪)،و(50٪) للفئات العمرية (30-39)و (60-69)سنةعلىالتوالي،كشفت فحوص الحساسية عنأنالأميكاسينهو العامل المثاليالمستعملضدالإشريكيةالقولونيةالمعزولةبسببفاعليته العالية(88.5٪) ،اعتماداعلىالنتائجالسابقةنوصيبإجراءالبحوث التيتشملفحوصسنوية (دورية) للمسبباتالمرضية و كذلك اختبار قابليتها على مقاومة المضاداتالحيوية،كمانصحناباستخدامالتقنياتالبيولوجيةالجزيئيةللتشخيص،بالإضافةإلىتحديدامتلاك الجراثيملجيناتالمقاومة للمضادات الحيوية.
الكلماتالرئيسة:التهاباتالمسالكالبولية،الحساسيةللمضاداتالحيوية،الاشريكيا القولونية.
Introduction
Urinary tract infections (UTIs) defined as "the growth of at least 5×104 colony forming units of bacteria in a clear urine specimen" (Palma and Malezoni, 2013).UTIs are responsible for the majority (approximately 40%) of all hospital acquired infection (Önen, et. al.2002), it results in over 1 million physician visits annually affecting from 2.4% to 2.8% of children(Hagerty, et. al. 2008), and can be asymptomatic or symptomatic characterized by a wide spectrum of symptoms ranging from mild irrigative voiding to bacteremia, sepsis, or even death(Ranjbar, et. al.2009). Sign and symptoms include fever, dysuria, and urinary urgency, cloudy or malodorous urine(Arul, et. al.2012).Infection may occur at any part of the genitourinary tract, including urethra, bladder, ureter, renal pelvis, or renal parenchyma (Feld and Matto, 2010) and involve only lower or both lower and upper parts of urinary tract(Khoshbakht, et. al.2013).
Most infections are caused by retrograde ascent of bacteria (the major causative organism and are responsible for more than 95% of UTIs cases) from fecal flora to bladder and kidney via urethra(Khoshbakht, et. al.2013). UTIsare mostly caused by gram negative aerobic bacilli found in gastrointestinal (GI) tract. Included in this family are the E. coli, Klebsiella, Enterobactor, Citrobacter, Proteus and Serratia species. Other common pathogens include Staphylococcus epidermidis, S. saprophyticus and Enterococcus species which presumably result in UTI following colonization of the vagina or perianal skin. Less common organism such as Gardenella vaginalis,Mycoplasma species and Ureaplasma urealyticum may infect patients with intermittent or indwelling catheters(Mao, et. al. 2012). E.coliis the most common cause of urinary tract infections (UTIs), including acute cystitis, pyelonephritis, and urosepsis, three common and clinically distinct UTI syndromes. It is widely accepted that uropathogenic E. coli (UPEC) originatesfrom the distal gut microbiota(Ranjba, et. al. 2009). The aims of this study were to investigate the uropathogenic E. coli isolated from patients with UTI and evaluate its invitro susceptibility patterns to commonly used antimicrobial agents in Babylon province.
Materials and Methods
Seventy six isolates of midstream urine were collected randomly from July to September 2013, isolates obtained from urine specimen(midstream urine) of patients with urinary tract infections in hospitals of Babylon Province. All symptomatic urinary tract infections in both males and females of age groups 1 – 70 years were included in this study. All specimen were cultivated on Mannitol salt agar, MacConkey’s agar, Blood agar. The growing bacteria were purified and then identified using Biomerreux (API) (for both Gram positive and Gram negative bacteria) and (Vitek 2) rapid M. O. identification system depending on the procedures described by manufacturer company.Antibiotic susceptibility patterns were achieved according to Kirbey- Bauer (1966) to the used antibiotics (Tetracycline, Ciprofloxacin, Tobramycin, Amikacin).
Results
The incidence of UTIs in outpatients was demonstrated to be more than inpatients(67 patients) (88.16%) and (9 patients) (11.84%) (Chi- square= 44.263 Asymp. sig.= .000),respectively (figure 1).
Chi- square= 44.263 Asymp. sig.= .000
Figure (1): The percentages of UTIs distributed according to patients status.
Females were more 53 (69.74%) prone to UTIs as compared with males 23 (30.26%) (Chi-square= 11.842 Asymp. sig.= .001) figure (2).
(Chi-square= 11.842 Asymp. sig.= .001)
Figure (2): The percentages of UTIs distributed according to gender.
Figure (3) clarifies that the highest incidence of UTIs patients was (30.26%) in patients with age group (10 – 19)years old, while the lowest incidence was (1.32%) in the age group(50 – 59)years old, while other age groups recorded different ratios, they were (5.26%), (14.47%), (26.32%), (19.74%) and (2.63%) for (60-69), (1-9), (20-29), (30-39), and (40-49), respectively. The statistical analysis washighly significant(Chi-square= 43.368 Asymp. sig.= .000).
(Chi-square= 43.368 Asymp. sig.= .000)
Figure (3): The percentages of UTIsdistributed accordingto age groups.
S. aureus was reported the highest percentage (45.45%) among other bacterial pathogens in the patients with age groups (1 – 9) years old, while other pathogens demonstrated different percentages i.e.K. oxytoca 36.36%, and Proteus spp 18.18% figure (4).
Type of pathogenic bacteria
(Chi-square= 1.273 Asymp. sig.= .592)
Figure (4): The percentages ofpathogenic bacteria isolated from UTIs in (1-9) age group.
Figure (5)and (6)illustrate that S. aureus was the predominant pathogens ((69.57%) and (50%) UTIs patients with age groups (10 - 19) and (20 – 29) years old,respectively), followed by E. coli (21.74% , 25%) for these two age groups, other bacterial pathogens reported different percentages in both (10 – 19) and ( 20 – 29).
Type of pathogenic bacteria
(Chi-square= 26.217 Asymp. sig.= .000)
Figure (5): The percentages ofpathogenic bacteria isolated from UTIs in patientswith(10-19)years old.
Type of pathogenic bacteria
(Chi-square= 19.600 Asymp. sig.= .001)
Figure (6): The percentagesof pathogenic bacteria isolated from UTIs inpatients with (20-29)years old.
E. coli was reported the highest percentage (53.33%), and (50%) in the patients with age groups (30 – 39) and (60 – 69) years old, respectively (figure 7 and figure 8), only one isolate of E. coli and one isolate of S. aureus were recorded in the patients of age groups (40 – 49) and (50 – 59), respectively.
Type of pathogenic bacteria
(Chi-square= 5.200 Asymp. sig.= .074)
Figure (7): The percentages of pathogenic bacteria isolated from UTIs in patients with (30-39) years old.
Type of pathogenic bacteria
(Chi-square=.500 Asymp. sig.= .779)
Figure (8): Thepercentagesof pathogenic bacteria isolated fromUTIs in(60-69)years old.
The antimicrobial potency and spectrum for four selected antimicrobial agents of different classes were used in this study. They were demonstrated to give different strength on the pathogens under test ( E. coli isolates). Table one reported that amikacin got the highest (88.5%) percentages of sensitivity among other antimicrobial agents, while the lowest percentage of effectiveness was scored to tetracycline (4%).
The antibiotic patterns in this study demonstrate that amikacin was the perfect treatment to the urinary tract infection according to the highest value (88.5%) of effectiveness against the isolates under test.
Table (1) : Susceptibility patterns of antibiotics under test against the isolates of E. coli.
IsolateNumber / AK / CIP / TCY / TOB
1 / S / S / R / R
2 / S / R / R / S
3 / S / R / R / R
4 / S / S / R / S
5 / R / S / R / R
6 / S / R / R / R
7 / S / R / R / S
8 / I / R / R / I
9 / S / R / R / R
10 / S / R / S / R
11 / S / R / R / S
12 / S / R / R / R
13 / S / S / R / R
14 / S / R / R / R
15 / S / R / R / S
16 / S / R / R / S
17 / S / R / R / R
18 / S / S / R / R
19 / S / R / R / I
20 / S / R / R / R
21 / S / R / R / R
22 / R / R / R / S
23 / S / S / R / S
24 / S / S / R / R
35 / S / R / R / S
26 / S / R / R / R
(TCY= Tetracycline, CIP= Ciprofloxacin, TOB= Tobramycin, AK= Amikacin, S= sensitive, R= resistance, I= Intermediate sensitivity)
Discussion
UTIs are responsible for the majority of all hospital acquired infections (Palma and Manzoni, 2013).UTIs can be asymptomatic or symptomatic, characterized by a wide spectrum of symptoms ranging from mild irrigative voiding to bacteremia, sepsis, or even death (Feld and Mattoo, 2010). Infection may occur at any part of the genitourinary tract, including urethra, bladder, ureter, renal pelvis, or renal parenchyma(Inabo and Obanibi, 2006). Most infections are caused by retrograde ascent of bacteria from fecal flora to bladder and kidney via urethra, especially in females whom the urethra is shorter and wider(Alsweih, et.al., 2006). Anatomical structure of female urethra and vagina makes them susceptible to trauma during sexual intercourse and bacterial passage through urethra up to the bladder during pregnancy and delivery(Kolawle,et. al. 2009; Lorenzo-Gómez, et. al.2013). Some authors stated that females are 30 times more prone to have UTIs than males, while other authors reported an 8:1 ratio (G. Sibi et. al., 2011). UTIs are caused by pathogenic invasion of the urinary tract which leads to an inflammatory response of the urothelium. The clinical manifestation of UTIs depends upon the portion of the urinary tract involved, the etiologic organism, the severity of the infection and patient's ability to mount an immune response to it(Bankole, et. al., 2011). In this study, there were a significant gender wise data of prevalence of the UTIs as, female were more 53(69.74%) prone to UTIs as compared with males 23 (30.26%), this study partially agreed with Arul Prakasam et al(2012). The prevalence and incidence of UTIs are higher in females than in males due to several clinical factors including anatomic differences, hormonal effects and behavioral pattern. Malnutrition, poor hygiene, low socioeconomic status are associated with UTIs and these factors are rife in rural settings(Boybeyi, et. al., 2013). The study observes that the prevalence of UTIs was high among females (69.74%) than males (30.26%). These results were similar to those results recorded by Arul Prakasam et al (2012), They found that the percentage of UTIs in infections in females (65%) while in males (35%), also Khoshbakht et al (2013) reported similar results, they found that the residence UTIs infections in females (88.7%) while in males (11.3%). Male : Female ratio was reported to be 5.2:1, the percentage of infection in male was (83%) in comparison with females (16.7%), in catheter – associated UTIs patients(Faranjinia, et. al., 2009). Considering the fact the most of infecting organisms are commensals of perianal and vaginal regions, males are less prone to UTIs possibly of their longer urethra and the presence of an antimicrobial substances in prostatic fluid(Nicolle, et. al., 2005). In this study, the highest incidence of UTIs patients was 30% in patients with age group of ( 10 – 19)years, while the lowest incidence was (1%) in the age group (50 – 59)years old . The results of this study disagree with the results recorded by Nicolle et al. (2005), they found that the incidence in aged (25–50)years due to sexual activity(Mirzarazi, et. al., 2013). Mirzarazi et al.(2013) reported is agree with result, they were found that the incidence UTIs is more frequent in older patients (51≤) years in age (Onuoha and Fatokun, 2014). Previous studies demonstrate that the infection with varies one person to another according to age groups. There was no incidence of UTIs in the age group of 31-40 in male patients. Among female patients higher prevalence observed in the age group of 31-40 (27.5%) and 51-60 (26.5%)(Mao, et. al., 2012). The distribution of UTIs among the ages of the antenatal patients showed that age group within the range of 27-32 years recorded the highest incidence of UTIs, whereas those of them above 39 years showed the least incidence as shown in (Table 2) (Arul, et. al.2012).
Table (2) Incidence of UTIs in relation to age among the antenatal patients.
Age group (years) / No.andPercentages (%) of tested samples / No.and
Percentages (%) of positive tests
15-20 / 55 (27.5) / 26 (23.6)
21-26 / 57 (28.5) / 30 (27.3)
27-32 / 58 (29) / 42 (38.1)
33-38 / 22 (11) / 10 (9.1)
39-above / 8 (4) / 2 (1.8)
Total / 200 / 110
The results in present study illustrate thatS.aureus was reported to be the highest percentage (45.45%) among other bacterial pathogens in the patients with age groups (1 – 9) years old, also S. aureus was the predominant pathogens (69.57%) and (50%) UTI patients with age groups ( 10 - 19) and (20 – 29) years old respectively, followed by E. coli (21.74% , 25%) for these two age groups, other bacterial pathogens reported different percentages in both (10 – 19) and ( 20 – 29). E. coli was informed to be the highest percentage (53.33%), and (50%) in the patients with UTIs of the patients with age groups (30 – 39) and (60 – 69) years old respectively, only one isolate of E. coli and S. aureus was recorded in the patients of age groups (40 – 49) and (50 – 59) respectively. The present study suggested that the reason for the difference in the rates of infection of the urinary tract and distributed to the age groups, as well as differing proportions of bacteria isolated, could lead to the number of patients visiting hospitals. Besides personal hygiene intervention may raise the levels of injury and lower levels of the bacteria isolated.The therapeutic decision should be based on accurate and up to date antimicrobial susceptible (Mao, et. al., 2012), other studies reveal that the antibiotic resistance was different from one isolate to another depending on the antibiotic and the isolate under test.Arul Prakasam et al (2012)demonstrate that out of 26 E.coli isolate24 (92.3%)were sensitive to meropenem, 15 (57.69%) to amikacin,11(42.3%) to gentamicin, 8 (30.76%)to cefotaxim,6(23.07%)to ciprofloxacin and norfloxacin and4( 15.38%)to cotrimoxazole,Previous sensitivity patterns clarified that amikacin come after meropenem by its effectiveness(57.69%)this result was prove our finding.The susceptibility to antimicrobial agent depend mainly on the isolate it-self and its ability to accept the resistant horizontally or vertically also some authors suggest that the high resistance of E. coli to commonly used antibiotic may be due to the high prevalence of extended spectrum β-Lactamase strain producing organisms (Arul Prakasam et al 2012), in the last year, the number of reports about appearance of bacteria with antibiotic resistance has increased all over the world. Khoshbakht,R.etal(2013)suggested?
that there are significant geographic differences in the susceptibility of commonly used antimicrobials against UTIs.
Conclusions and recommendations
The incidence of UTIs in out -patients; Females age group (10 – 19) years old, occupies; highest percentages, there were 88.2% ,70%, and 30% respectively.The percentages and types of isolated microorganisms were different from one patient to another depending on patients age groups.Amikacin was the perfect antimicrobial agents to treat the UTIs. Thusfurtherstudies must be done to demonstrate the risk factor affecting the increasing of UTIs rather than gender. Furthermore, molecular detection of bacterial isolates and susceptibility patterns must be achieved as well as the annual determination of bacterial sensitivity in populations as a guideline is to be respected by physicians.
References
Al sweih N., Jamal W.,Rotimi VO.2005“Spectrum and antibiotic resistance of uropathogens isolated from hospital and community patients with urinary tract infections in two large hospitals in Kuwait. Med Princ Pract;14(6):401-407.
Arul Prakasam, K.C., K.G. Dileesh kumar, and M. Vijayan,2012 ″ A cross sectional study on distribution of Urinary Tract Infection and their antibiotic utilization pattern in Kerala″ International J Pharm Tech Research 4(3):1309-1316.
Bankole H. O., Richard O., Mitsan O., Joshua A. Anunibe,2011“ Urinary tract infection in a rural community of Nigeria “ North American J Med Sciences; 3(2): 75-77.
Boybeyi, Ö., Karanak, I., Ciftci, AÖ., Tanyel, FC. And Senocak, ME.2013” Risk factors of catheter – associated urinary tract infections in pediatric surgical patients” Surgical practice.;17: 7-12.
Feld L.G.,Mattoo T.K.2010 “Urinary tract infections and Vesicoureteral Reflux in Infants and Children”. Pediatr Rev;31(11):451-63.
Farajinia, S. Alikhani, MY. Ghotaslou, R. Naghili, B., and Nakhlband, A. 2009 ”Causative agents and antimicrobial susceptibilities of urinary tract infections in the northwest of Iran” Int J Infect Dis; 13: 140-144.
G. Sibi, Aheibam premita Devi, K. Fouzia, Bhimanagouda RPatil.2011“Prevalence, microbiologic profile of urinary tract infection and its treatment with Trimethoprin in diabetic patients” Research J of Microbiol;6(6): 543-551.
Hagerty, J.A.; Maizels, M. and Cheng E. Y. 2008 " Review Article The PIC Cystogram: Its Place in the Treatment Algorithm of Recurrent Febrile UTIs" Hindawi Publishing Corporation Advances in Urology, Article ID 763620, 4 pages.
Inabo H., Obanibi H.(2006)“Antimicrobial susceptibility of some urinary tract clinical isolates to commonly used antibiotics. Afr J Biotechnol;5(5):487-9.
Khoshbakht, R.; Salimi, A.; Aski, H. S. and Keshavarzi, H. 2013 " Antibiotic Susceptibility of Bacterial Strains Isolated From Urinary Tract Infections in Karaj, Iran" Jundishapur J Microbiol; 6(1): 86-90.
Kolawole A., Kolawole O., Kandaki-Olukemi Y., Babatunde S., Durowade K., Kolawole C.2009“ Prevalence of urinary tract infections (UTI) among patients attending Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State, Nigeria, Int J Medicinal Med Sci;1(5):163-7.
Lorenzo-Gómez, M. F. ; Padilla-Fernández, B., García-Criado, F. J.; Mirón-Canelo, J. A.; Gil-Vicente, A.; Nieto-Huertos, A. and Silva-Abuin, J. M.(2013)"Evaluation of a therapeutic vaccine for the prevention of recurrent urinary tract infections versus prophylactic treatment with antibiotics" Int Urogynecol J; 24:127-134.
Mao, B. H.; Chang,Y. F. et al (2012) " Identification of Escherichia coli Genes Associated with Urinary Tract Infections" J Clinical Microbiol. 50(2):449-456.
Mirzarazi, M., Rezatofigh:, S.E., Pourmahdi, M. and Mohajeri, M.R.(2013)″ Antibiotic Resistance of Isolated Gram Negative Bacteria from Urinary Tract Infections (UTIs) in Isfahan. Jundishapur J. Microbiol. 6 (8):2-4.
Nicolle, L., Bradley, S., Colgan, R., Rice, J. C., Schaeffer, A. and Hooton, T.M.2005 “ Infectious disease society of America guidelines for the diagnosis and treatment of symptomatic bacteriuria in adults” Clin Infect Dis, 40: 643-654.
Onuoha, S.C. and Fatokun, K.(2014)″ Prevalence and antimicrobial susceptibility pattern of Urinary Tract Infection (UTI) among pregnant females in Afikpo, Ebonyi state, Nigeria″ American J of life sciences; 2(2):46-52.
Palma, D. D. and Manzoni, G. 2013"Different imaging strategies in febrile urinary tract infection in childhood. What, when, why? J Pediatr Radiol 34: 436-443.
Ranjbar R., Haghi-Ashtiani M., Jafari N.J., Abedini M.2009“ The prevalence and antimicrobial susceptibility of bacterial uropathogens isolated from pediatric patients”. Iranian J Pup Health38(2): 134-138.
Önen,, A.; cigdem, M. K.; Geyik, M. F. et. al. 2002" Epidemiology and control of nosocomial infection in pediatric surgery". J Hosp Infect 52: 166-170.
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