|Year : 2015 | Volume
| Issue : 1 | Page : 29-34
Clinical and bacteriological profile of Uti patients attending a north Indian tertiary care center
Ruhi Khan1, Quaiser Saif1, Khan Fatima2, Rizvi Meher2, Haque Faizul Shahzad1, Khan Salamat Anwar1
1 Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Microbiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||23-Jan-2015|
Department of Medicine, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: Urinary tract infection (UTI) is a common cause of morbidity in patients attending our hospital. Recently UTI has become more complicated and difficult to treat because of appearance of pathogens resistant to the commonly used antimicrobial agents. The main aim of the study was to determine the causative agents and antibiotic susceptibility pattern of UTI patients attending our hospital. Materials and methods: A prospective cross sectional study was conducted in asymptomatic and symptomatic UTI patients attending medicine and nephrology clinics of Jawaharlal Nehru Medical College Hospital, Aligarh from June 2012 to July 2014. A total of 1843 patients were investigated for urinary tract infection. Clean catch mid-stream urine specimens collected were subjected to urine culture and sensitivity tests. Results: Significant bacteriuria was detected in 19.3% and 55.4% of asymptomatic and symptomatic patients, respectively. The overall prevalence of significant bacteriuria in both groups was 33.4% with female sex, diabetes, obstructive uropathy, previous instrumentation and chronic kidney disease being the major risk factors. The most common pathogens isolated were Escherichia coli (52.4%) followed by Klebsiella pneumoniae (12.3%), Citrobacter spp (9.1%), Enterococcus (6.9%), Proteus spp (5.3%), Coagulase negative staphylococcus (5.3%) and Staph Aureus(4.0%). Most susceptible antibiotic was Amikacin, Cefoperazone-sulbactum, Piperacillin-tazobactum and Nitrofurantoin for most of the isolates. E. coli which was the main isolate was found to be most susceptible to Amikacin (78.3%), Cefoperazone-sulbactum 72.8%, Piperacillin-tazobactum (70.5%), Gentamicin (69.3%) and Nitrofurantoin (67.3%). Conclusion: This study highlights the common pathogens causing UTI in our area and their antibiotic sensitivity patterns which could help clinicians in starting rational empirical antibiotic therapy for such patients while awaiting urine culture reports.
Keywords: Antibiotic susceptibility, bacteriuria, UTI
|How to cite this article:|
Khan R, Saif Q, Fatima K, Meher R, Shahzad HF, Anwar KS. Clinical and bacteriological profile of Uti patients attending a north Indian tertiary care center. J Integr Nephrol Androl 2015;2:29-34
|How to cite this URL:|
Khan R, Saif Q, Fatima K, Meher R, Shahzad HF, Anwar KS. Clinical and bacteriological profile of Uti patients attending a north Indian tertiary care center. J Integr Nephrol Androl [serial online] 2015 [cited 2018 Dec 19];2:29-34. Available from: http://www.journal-ina.com/text.asp?2015/2/1/29/150009
| Introduction|| |
Urinary tract infection (UTI) is one of the commonest infectious cause of febrile illness in community practice as well as nosocomial infection. 
It has been estimated that 150 million people were infected with UTI per annum worldwide thereby incurring significant morbidity,  which may rise to 75% in the female population by the age of 24, and 15-25% of this group will suffer from a relapse of this disease. , UTI is described as a bacteriuria with or without urinary symptoms. 
Increasing drug resistance due to empirical treatment in UTI needs regular monitoring of the antibiotic susceptibility of uropathogens in a particular area. Various factors such as the type of UTI (complicated or uncomplicated), gender, age, and previous history of antibiotic therapy or instrumentation of each UTI patient should also be considered to find out the correct global data on susceptibility.  Isolated pathogen frequency and antimicrobial resistant rates can vary dramatically even within the same country.  To ensure appropriate therapy current knowledge of the pathogens that cause UTI in an area and their susceptibility pattern is mandatory. 
Therefore, this study was undertaken to identify the associated risk factors, type of organism(s) isolated and their antibiotic sensitivity patterns in patients with UTI attending Medicine and Nephrology clinics of Jawaharlal Nehru Medical College Hospital (JNMCH), Aligarh. Thus the data presented in this study will provide information to clinicians on the selection of appropriate antimicrobial agents for the treatment of patients suffering from UTI.
| Material and methods|| |
A cross-sectional study was conducted at medicine and nephrology clinics of JNMCH from June 2012 to July 2014. Informed consent was taken from all the patients. Patients presenting to the outpatient clinic with complains of fever with or without symptoms of urinary tract infection were screened for significant bacteriuria, by standard loop method on 5% sheep blood agar and teepol lactose agar. Significant bacteriuria was defined as single positive culture of >10 5 cfu/mL of midstream urine. 
For pregnant women with symptoms, a diagnostic criterion of >10 3 organisms/mL of midstream urine in a single culture was taken as significant bacteriuria.  Patients on antimicrobial therapy for UTI or for any other illness within the last two weeks were excluded from the study.
The isolates in significant numbers were identified by using standard biochemical tests.  Antimicrobial susceptibility testing was done for all the isolates using Kirby Bauer disc diffusion method as recommended by CLSI M2-A9.  The antibiotic panels for each group of isolates were selected according to the CLSI guidelines M100-S16  were obtained from HiMedia, India. The antimicrobials tested for the gram negative bacteria were amikacin (30 μg), ofloxacin (5 μg), gentamicin (10 μg), cefixime (5 μg), cefotaxime (30 μg), ceftriaxone(30 μg), cefoperazone (CP) (75 μg), ceftriaxone-salbactam (30/15 μg), cefoperazone-sulbactum (75/75 μg), and nitrofurantoin (300 μg). Pathogens resistant to these drugs were considered multi-drug-resistant and were tested against second line drugs: Piperacillin (100 μg), piperacillin-tazobactam (100:10 μg), tobramycin (10 μg), imipenem (10 μg), polymyxin B (300 μg)and colistin (10 μg) and vancomycin(30 mcg). For Pseudomonas spp.: Piperacillin (100 μg), piperacillin-tazobactam (100:10 μg), tobramycin (10 μg), imipenem (10 μg), ticarcillin (75 μg), polymyxin B (300 μg), and colistin (10 μg) were used.
Screening of possible ESBL production was done by using ceftriaxone (30 μg) and cefoperazone (75 μg). Those isolates with zone diameters less than 25 mm for ceftriaxone and less than 22 mm for cefoperazone were subsequently confirmed for ESBL production. Confirmation was done by noting the potentiation of the activity of cefoperazone in the presence of cefoperazone sulbactum. Induction of AmpC synthesis was based on the disc approximation assay using imipenem as inducer.  Detection of MBL was done by Hodge test and Double Disc synergy test using EDTA. The method was as described by Lee et al.  For Gram-positive isolates: Amikacin (30 μg), gentamicin (10 μg), levofloxacin (5 μg), sparfloxacin (5 μg), erythromycin (15 μg), vancomycin (30 μg), oxacillin (1 μg), tobramycin (10 μg), clindamycin (2 μg), amoxicillin (30 μg), high content gentamicin (120 μg) and high content streptomycin (300 μg). Oxacillin (1 μg) for the detection of Methicillin-resistant S. aureus (MRSA) and 120 μg gentamycin and 300 μg streptomycin disc for detection of high level resistance to aminoglycosides (HLAR) in Enterococci. 
The controls strains used were E. coli ATCC 25922, Pseudomonas aeruginosa ATCC 27853, and Staphylococcus aureus 25922.
Statistical analysis was done using chi-square test and Student's t-test.
| Results|| |
Out of 1843[asymptomatic (n=1245) and symptomatic (n=598)] urine samples collected for the study 616 (33.4%) showed the significant bacteriuria. Isolates are shown in [Table 1].
The mean age in years was 38.3 (15-85 years). Out of 616 UTI patients, 189 were males, mostly elderly and females 427, mostly of reproductive age group as shown in [Table 2].
|Table 2: Age and sex distribution of patients presenting to the OPDs with UTI|
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UTI was present in 444 (72.1%) symptomatic patients while it was seen in only 172 (27.9%) of the asymptomatic patients (P value < 0.03, CI 95% and the degree of freedom is 1). Most of the patients with symptomatic UTI complained of mild fever, increased frequency and burning during micturition along with urgency.
The antibiogram of the isolated pathogens is shown in [Table 3] and [Table 4].
|Table 3: Antibiotic sensitivity pattern of the gram negative pathogens causing UTI|
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|Table 4: Antibiotic sensitivity pattern of the gram positive pathogens causing UTI|
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Escherichia coli alone accounted for (52.4%) of the urinary isolates, followed by Klebsiella pneumoniae (12.3%), Citrobacter species (9.1%) [C. koseri (89.4%) isolates, C. amalonaticus (7.1%), C. freundii (3.5%)] and Proteus mirabilis and Proteus vulgaris together accounting for (5.3%) isolates. In 11(1.8%) urinary specimens Pseudomonas aeruginosa and other Pseudomonas species were isolated. Among the gram positive cocci, Enterococcus faecalis were the predominant isolate accounting for 43(6.9%) of the cases of UTI. Coagulase negative Staphylococci (CONS) were present in 33 (5.3%) UTI patients. On novobiocin sensitivity testing 77.3% of the coagulase negative isolates were Staphylococcus saprophyticus and 22.7% isolates were Staphylococcus epidermidis. S. aureus (4.0%) and Streptococcus species (2.9%) were the other common gram positive organisms causing UTI in patients.
Among the tested antibiotics the highest susceptibility for the Gram negative bacteria was shown by Amikacin, Cefoperazone-sulbactum, Piperacillin-tazobactum, Ceftriaxone-sulbactum followed by Gentamicin, Cefoperazone, Ceftriaxone and Nitrofurantoin. In case of E. coli which was the principal isolate, most susceptible antibiotics were Amikacin 91.3%, Gentamicin 89.5%, Cefoperazone-sulbactum 89.3%, Piperacillin-tazobactum 86.8%, Ceftriaxone-sulbactum 81.1% followed by Cefoperazone 78.0%, Ceftriaxone 73.9% and Nitrofurantoin 72.6%. Enterococcus faecalis which was the most common isolated gram positive organism, showed high susceptibility to Vancomycin (100%), high content gentamicin (88.7%), high content streptomycin (86.4%), and amoxicillin (77.6%). The major risk factors identified were female sex, diabetes, obstructive uropathy, renal calculus, chronic kidney disease, previous instrumentation as shown in [Table 5].
| Discussion|| |
The prevalence of culture positive isolates observed in our study was 33.4% (19.3% and 55.4% of asymptomatic and symptomatic patients, respectively.), which was comparable to the finding of 34.5% by Dash et al. and 36.6% by Mehta et al., However, this was higher as compared to another study conducted by and Mohanty et al. at AIIMS India 14.7%.  The similarities and differences in the type and distribution of uropathogens may result from different environmental conditions and host factors, and practices such as healthcare and education programmers, socioeconomic standards and hygiene practices in each geographical area.
Our study showed a high prevalence of UTI in females 427 (23.2%) patients than in males 189 (10.3%) patients which correlates with other findings which revealed that the frequency of UTI is greater in females as compared to males. , The reason behind this high prevalence of UTI in females is due to close proximity of the urethral meatus to the anus, shorter and wider urethra, sexual intercourse, incontinence, and less acidic pH of vaginal surface and poor hygienic conditions. ,
Women of the reproductive age group formed the main group of adult patients with UTI presenting to the outpatient clinics (81.7% of all UTI in females were detected in women of age 21-50 years.) as seen in a study done by Shaifali et al.  The causes of this increasing incidence of UTI in young age females are high sexual activity, recent use of a diaphragm with spermicide, and a history of recurrent UTI in this age group.  Elderly (>60 years) males had a higher incidence of UTI (38.1%) compared to the elderly females (10.8%), probably due to increased incidence of prostate enlargement and neurogenic bladder with the advancing age  which is similar to other studies. , In our study, 29 (63%) patients with previous or current history suggestive of renal calculus or 48 (66.6%) patients with obstructive uropathy, were diagnosed with UTI. These groups of patients are more predisposed to recurrent episodes of UTI as shown in a study by Bianca et al.  81 (52.6%) diabetic patients were diagnosed with UTI in our study. The risk of developing urinary tract infection in diabetic patients is higher and urinary tract is the most common site for infection.  Changes in host defense mechanisms, the presence of diabetic cystopathy and micro-vascular disease in the kidneys may play a role in the higher incidence of UTI in diabetic patients. 
In our study members of Enterobacteriaceae (52.4%) were the main pathogens isolated. This is in consistence with findings of other studies around the globe in which E. coli was the most frequently reported isolate from patients with community acquired UTIs. ,, Enterobacteriaceae have several factors responsible for their attachment to uroepithelium. The Gram negative aerobic bacterial colonize the uro-epithelial mucosa, with adhesin, pilli, fimbriae and p1-blood group phenotype.  Following E. coli, Klebseilla species (12.3%), Citrobacter species (9.1%) and Proteus species (5.4%) were the other gram negative bacteria causing UTI in the our study. Amongst the gram positive cocci, Enterococcus faecalis (6.3%) were isolated most frequently followed by CONS (4.2%), Staphylococcus aureus (4.0%), Streptococcus species (2.9%) and Pseudomonas (1.8%).
On antimicrobial susceptibility testing, it was noted that both the gram negative bacilli as well as the gram positive cocci showed a significantly high resistance to the β-lactam group of antimicrobials similar to study done by Kothari et al. 
The overall resistance of E. coli to ofloxacin was 79.32% respectively. Fluoroquinolones have a wide variety of indications, permeate most body compartments, and are emperically prescribed mostly, accounting for the emergence of their resistance. Our findings indicate that their indiscriminate use in uncomplicated infections should be strictly curtailed.
Along with this the presence of extended spectrum-β-lactamases in about half of E. coli isolates and around 31% of Klebsiella was noted, which is similar to a study from PGI Chandigarh on complicated UTI  and from Rohtak. 
Among the gram positive cocci, nearly one-third isolates of S. aureus and Coagulase negative Staphylococcus species were found to be methicillin resistant. This is an alarming finding, since these isolates should be considered resistant to all the other currently available β-lactam antimicrobials including cephalosporins and carbepenems. 
Moreover, the methicillin resistant strains of Staphylococci are found to be multidrug resistant as reported by other studies. 
Nitrofurantoin has shown the least resistance for E. coli. Our findings are similar to other Indian studies which have also demonstrated nitrofurantoin as an appropriate agent for first-line treatment of community acquired UTIs. , Aminoglycosides (amikacin, gentamicin, and streptomycin) have also shown a decreasing resistance trend against E. coli from the year 2012 to 2014. Aminoglycosides being injectables are used restrictively in the community-care setting and hence have shown better sensitivity rates.
One alarming finding in our study was the high degree of resistance to third generation cephalosporins (ceftriaxone 29.3%, cefoperazone 21.7%) among all uroapathogens, probably due to ESBL in concordance to study done in Meerut.  The other possible explanation behind this situation is that the 3 rd generation cephalosporin are the most widely used injectable antimicrobials for a myriad of infections. Hence over time organisms have developed resistant mechanisms due to changing their mode of action. Gross disregard for blood and urine culture guided therapy, immunosuppression, compliance to treatment viz. not taking full prescribed course of antibiotics are some other major etiological factors that elevate the chances of MDR infections.  Resistance to cefoperazone/sulbactam and piperacillin/tazobactam for Enterobacteriaceae was low probably reflecting their lower usage for treatment of community acquired infections. Vancomycin is the drug with least resistance to gram positive cocci. An overall 1.31% resistance for vancomycin was observed in gram positive cocci belonging to the Enterococcus species. Given the fact that Nitrofurantoin has no role in the treatment of other infections, it can be administered orally and is highly concentrated in urine; it may therefore be the most appropriate agent for empirical use in uncomplicated UTI.
| Conclusion|| |
The study highlights the fact, regular screening should be done for the presence of symptomatic or asymptomatic bacteriuria in community practice and specific guidelines should be issued for testing antimicrobial susceptibility, since with the emergence of drug resistance amongst the gram positive and gram negative bacteria, the choice of drugs for the treatment of UTI is very limited. However, when empirical treatment is to be started before the culture and sensitivity report can be ensured, than we suggest the use of nitrofurantoin for uncomplicated UTI because it is a relatively cheap drug, given orally, which safe in pregnancy, covers both the gram negative bacilli and the gram positive cocci, and as seen in our study is found to have a good sensitivity profile. For complicated cases aminoglycosides and piperacillin/tazobactam are the preferred agents awaiting culture reports. We suggest that periodic surveys should be done for the prevalence and susceptibility pattern of the common pathogens causing UTI in local regions especially keeping in mind the high risk patients mentioned in our study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]