Antibiotic susceptibility profile of uropathogens in rural population of Himachal Pradesh, India: Where We are heading?

Priya Mehrishi; Sameer Singh Faujdar; Satish Kumar; Seema Solanki; Amisha Sharma

doi:10.4103/bbrj.bbrj_102_19

ORIGINAL ARTICLE

Year : 2019 | Volume : 3 | Issue : 3 | Page : 171-175

Antibiotic susceptibility profile of uropathogens in rural population of Himachal Pradesh, India: Where We are heading?

Priya Mehrishi, Sameer Singh Faujdar, Satish Kumar, Seema Solanki, Amisha Sharma
Department of Microbiology, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India

Date of Submission	24-Jul-2019
Date of Decision	08-Aug-2019
Date of Acceptance	27-Aug-2019
Date of Web Publication	10-Sep-2019

Correspondence Address:
Dr. Sameer Singh Faujdar
Department of Microbiology, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan - 173 229, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_102_19

Abstract

Background: Urinary tract infection (UTI) is one of the most common infectious diseases at the community level. To assess the adequacy of the empirical therapy, the prevalence and the resistance pattern of the main bacteria responsible for UTI in the rural community of Himachal Pradesh (HP) was evaluated. Methods: In this retrospective study, all urine samples from patients of the District of Solan, in HP, collected at the Department of Microbiology, Maharishi Markandeshwar Medical College and Hospital during 2014–15 were analyzed. Samples with more than 10⁵ CFU/mL bacteria were considered positive, and for these samples, the bacteria were identified, and the profile of antibiotic susceptibility was characterized. Results: A retrospective analysis of 1878 urine samples over 2-year period at a teaching hospital was carried out according to the standard protocol of urinalysis. The results were processed to obtain the profile prevalence of UTI, the rate of bacterial resistance to antibiotics, the trend of their evolution over time, and the rate of multidrug resistance. Conclusion: Escherichia coli was the most common uropathogen. Amikacin and piperacillin/tazobactam were the most effective antibiotics against uropathogens.

Keywords: Escherichia coli, extended-spectrum β-lactamases, Klebsiella pneumoniae, urinary tract infection, uropathogens

How to cite this article:
Mehrishi P, Faujdar SS, Kumar S, Solanki S, Sharma A. Antibiotic susceptibility profile of uropathogens in rural population of Himachal Pradesh, India: Where We are heading?. Biomed Biotechnol Res J 2019;3:171-5

How to cite this URL:
Mehrishi P, Faujdar SS, Kumar S, Solanki S, Sharma A. Antibiotic susceptibility profile of uropathogens in rural population of Himachal Pradesh, India: Where We are heading?. Biomed Biotechnol Res J [serial online] 2019 [cited 2022 May 21];3:171-5. Available from: https://www.bmbtrj.org/text.asp?2019/3/3/171/266559

Introduction

Urinary tract infections (UTIs) are one of the most common infectious diseases, and nearly 10% of people will experience a UTI during their lifetime. UTIs are the most common infections after upper respiratory tract infections. Although several different microorganisms can cause UTIs, including fungi and viruses, bacteria are the major causative organisms and are responsible for >95% of UTI cases.^[1],[2] UTI is one of the common diseases against which antibiotics are prescribed. Among the uropathogenic bacteria, Escherichia ^{More Details} coli is predominant in both community and nosocomial UTI. However, the diversity of uropathogens is known to vary regionally. Infections are gradually becoming more and more difficult to treat and may lead to therapeutic dead ends. These resistance patterns have shown large interregional variability.^[3],[4] However, because of the evolving and continuing antibiotic resistance phenomenon, regular monitoring of resistance patterns is necessary to improve guidelines for empirical antibiotic therapy. In almost all cases, treatment must be initiated before the final bacteriological results are available, particularly in the outpatient setting. To optimize the use of empiric antibacterial therapy for UTI, the current knowledge of the organisms that cause UTI and their antibiotic susceptibility is essential. However, the information on the etiology and resistance pattern of UTI isolates in Solan district is not known.^[5] Empiric antibiotic therapy is usually based on epidemiological data which are updated and adapted geographically, highlighting the importance of local and regular monitoring of bacterial resistance. Therefore, the aim of this study was to determine the causative agents of UTIs and their susceptibility patterns to commonly used antibiotics in rural patients coming to our Tertiary Care Hospital, Solan.

Methods

This study was conducted in the Department of Microbiology, Maharishi Markandeshwar Medical College and Hospital, Solan. A total of 1878 midstream “clean-catched” urine samples (clinically suspected patients of UTI) were received from various clinical departments. Once the sample was collected, they were cultured on blood agar and cystine–lactose–electrolyte-deficient agar, and isolates from cases with significant bacteriuria (10⁵ CFU/ml) were identified by standard biochemical tests such as Gram stain; catalase test; coagulase test; oxidase test; indole test; Voges–Proskauer test; citrate utilization test; urease production test; triple sugar iron agar; nitrate reduction test; and acid and abundant gas production from glucose, lactose, sucrose, maltose, and mannitol sugar fermentation tests.^[6]

Antimicrobial susceptibility testing

All isolates were screened for antimicrobial susceptibility testing by Kirby–Bauer disc diffusion method on Mueller-Hinton agar (HiMedia) and interpreted as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. A log phase broth culture inoculums of the isolate with a turbidity equivalent to McFarland 0.5 standard (1.5 × 10⁸ CFU/ml) was prepared and lawn cultured on the Mueller-Hinton agar and allowed to dry. Antibiotic discs were applied to the Mueller-Hinton agar surface with the help of sterile forceps.^[7]

Extended-spectrum β-lactamases detection tests

Screening test

All Gram-negative uropathogens were screened for extended-spectrum β-lactamases (ESBLs) by disc diffusion method. In the presumptive test to detect potential ESBL producers, all the isolates were screened for susceptibility to ceftazidime (30 μg) and cefotaxime (30 μg) antibiotic discs (HiMedia, Mumbai). Results were interpreted based on the CLSI guidelines as follows: zones of inhibition of ≤22 mm for ceftazidime and ≤27 mm for cefotaxime indicated ESBL production. The less susceptible or resistant isolates were subjected to confirmatory test.^[8]

Confirmatory test

The ESBL-producing isolates were confirmed by CLSI phenotypic confirmatory test of combined disc assay method. One disc each of ceftazidime (30 μg), ceftriaxone (30 μg), and cefotaxime (30 μg) alone and one in combination with clavulanic acid (10 μg) were placed at a distance of 20 mm on a Muller-Hinton agar plate inoculated with a bacterial suspension of 0.5 McFarland turbidity standards, and incubated overnight at 37°C. The ESBL-producing strains showed ≥5 mm increase in zone diameter for either antimicrobial agent tested in combination with clavulanic acid or its zone when tested alone. E. coli ATCC 25922 was used as quality control strain.^[8]

Results

A total of 1878 urine samples from outdoor and indoor patients were collected and processed. Further data were analyzed with WHONET 5.6 software (WHO, Boston, MA, USA) provided by the World Health Organization. Of 1878 urine samples, maximum were of females [Table 1]. More urine samples were received from the indoor patients compared to the outdoor patients [Table 2].

Table 1: Gender-wise distribution of urine samples

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Table 2: Location-wise distribution of urine samples

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A total of 184 samples had significant bacteriuria and were processed further for identification and antibiotic susceptibility testing. The remaining 1694 samples were either sterile or had nonsignificant bacteriuria. The frequency distribution and type of isolates among 184 uropathogens are listed in [Table 3]. The occurrence of UTI was found to be 9.7%. UTI in the indoor patients was 8.70% which was less as compared to the outpatients, i.e. 11.23%. The occurrence of UTI was higher in females (10.21%) than males (8.63%). All Gram-negative bacterial isolates from the Enterobacteriaceae family were also examined for ESBL production. Of which, 35 E. coli (31.81%) out of 110, 6 Klebsiella pneumoniae (33.33%) out of 18, and 2 Proteus species (40%) out of 5 were ESBL producers.

Table 3: Distribution of urinary isolates

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Antibiogram of all Gram-negative bacterial isolates from Enterobacteriaceae family and nonfermenters and Gram-positive organisms is shown in [Table 4], [Table 5], [Table 6].

Table 4: Antibiotic susceptibility pattern of all Enterobacteriaceae family

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Table 5: Antibiotic susceptibility pattern of nonfermenting Gram-negative bacteria

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Table 6: Antibiotic susceptibility pattern of Gram-positive bacteria

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Discussion

The occurrence of UTI varies between countries and between areas within a single country. In our study, occurrence came out to be 9.7%, which was less compared to other studies occurred in India and abroad.^{[6],[9],[10],[11]} Our results showed less UTI rate of 8.63% in males. This may be due to the higher number of females than males in our study and because males are less prone to UTIs, possibly because of their longer urethra and the presence of antimicrobial substances in prostatic fluid.^[12] The result of our study showed that among the heterogeneous causative organisms of UTI, members of Enterobacteriaceae family are the predominant pathogens. Among Enterobacteriaceae, E. coli (59.78%) is the most prevalent pathogen involved in UTIs, which is similar to the other studies with a range between 40% and 78% followed by K. pneumoniae (9.78%) which was the second most common uropathogen isolated; many other studies have shown the similar finding with different range (11%–17%).^{[13],[14],[15],[16]}Enterococcus (8.69%) was the third most common isolate in our study; other studies also revealed the same results as Enterococcus species being one of the important uropathogens, and on the other side, Acinetobacter baumannii and Candida albicans were the least isolated uropathogens.^{[17],[18],[19]}

In the present study, high prevalence of ESBL production has been reported in K. pneumoniae species (33.33%) followed by E. coli (31.81%). Two isolates (50%) of the Acinetobacter species were also found to produce ESBL. Many other studies have shown almost similar finding with the variation of ESBL production (21%–34%) in E. coli.^{[20],[21],[22],[23]}

The antimicrobial susceptibility pattern of uropathogens varies widely among different regions because it depends on antibiotic exposure to that particular population, antibiotic abuse, and empiric use of antibiotics in UTI. In the context of antibiotic susceptibility pattern, our study revealed imipenem (98.4%) was highly active against members of Enterobacteriaceae followed by amikacin (90.6%) and piperacillin/tazobactam (89.3%). Other authors such as Rakesh et al.,^[24] Cherian,^[25] and Deshpande et al.^[26] also found imipenem and amikacin as the most effective antibiotic against Gram-negative bacilli. In our study, resistant to fluoroquinolones was on higher side as the members of Enterobacteriaceae have shown sensitivity to fluoroquinolones between 31.5% and 39.2%. Other studies have shown wide range of fluoroquinolones sensitivity from 1% to 47%.^{[13],[27],[28],[29]} Nitrofurantoin came out to be more sensitive (84.4%) to members of Enterobacteriaceae family whereas trimethoprim/sulfamethoxazole (TMP/SMX) was found to be less sensitive (40.8%). Compared with the same study done in 2006 and 2011, there was increased antimicrobial susceptibility both of E. coli and other Enterobacteriaceae members to TMP/SMX.^[26],[30]

Meropenem (83.3%), amikacin (80%), and imipenem (77.8%) have shown good activity against nonfermenter isolates, whereas Deshpande et al. found 100% susceptibility to imipenem and Rakesh et al. reported 82.4% susceptibility to imipenem.^[24],[26]

In the present study, nonfermenters showed 70% susceptibility to piperacillin/tazobactam, whereas Baveja et al. reported 76.4% and 66.66% susceptibility to piperacillin/tazobactam by Pseudomonas aeruginosa and Acinetobacter, respectively.^[18] In our study, all the Gram-positive cocci isolates were 100% susceptible to vancomycin, linezolid, and teicoplanin. Rakesh et al. also reported 100% susceptibility to vancomycin and linezolid.^[24]

Conclusion

Due to the fact that the pattern of sensitivity of bacteria to antibiotics varies over time and in different geographical regions, antibiotic treatment of infections should be based on local experience of sensitivity and resistance patterns. In this study, overall, piperacillin/tazobactam and nitrofurantoin were found to be the most sensitive antibiotics, and amikacin and gentamycin were the most appropriate antibiotics, for the empirical therapy of UTIs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Delanghe JR, Kouri TT, Huber AR, Hannemann-Pohl K, Guder WG, Lun A, et al. The role of automated urine particle flow cytometry in clinical practice. Clin Chim Acta 2000;301:1-18.
2.	Hryniewicz K, Szczypa K, Sulikowska A, Jankowski K, Betlejewska K, Hryniewicz W. Antibiotic susceptibility of bacterial strains isolated from urinary tract infections in Poland. J Antimicrob Chemother 2001;47:773-80.
3.	Asseray N, Mallaret MR, Sousbie M, Liberelle B, Schaerer L, Borrel E, et al. Hospital Antibiotherapy: Evaluation of prescribing practices in an inter-hospital network. Med Maladies Infect 2002;32:468-76.
4.	Cullen IM, Manecksha RP, McCullagh E, Ahmad S, O'Kelly F, Flynn RJ, et al. The changing pattern of antimicrobial resistance within 42,033 Escherichia coli isolates from nosocomial, community and urology patient-specific urinary tract infections, Dublin, 1999-2009. BJU Int 2012;109:1198-206.
5.	Edlin RS, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol 2013;190:222-7.
6.	Moroh JL, Fleury Y, Tia H, Bahi C, Lietard C, Coroller L, et al. Diversity and antibiotic resistance of uropathogenic bacteria from Abidjan. Afr J Urol 2014;20:18-24.
7.	Clinical and Laboratory Standard Institute. Performance Standards for Antimicrobial Susceptibility Testing. Wayne, PA, USA: Clinical and Laboratory Standard Institute; 2010.
8.	Clinical Laboratory Standard Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Fifth Informational Supplement Document. 35:M100-S25. Wayne, PA: CLSI; 2015.
9.	Baral P, Neupane S, Marasini BP, Ghimire KR, Lekhak B, Shrestha B. High prevalence of multidrug resistance in bacterial uropathogens from Kathmandu, Nepal. BMC Res Notes 2012;5:38.
10.	Al Benwan K, Al Sweih N, Rotimi VO. Etiology and antibiotic susceptibility patterns of community- and hospital-acquired urinary tract infections in a general hospital in Kuwait. Med Princ Pract 2010;19:440-6.
11.	Prakash D, Saxena RS. Distribution and antimicrobial susceptibility pattern of bacterial pathogens causing urinary tract infection in urban community of Meerut city, India. ISRN Microbiol 2013;2013:749629.
12.	Farajnia S, Alikhani MY, Ghotaslou R, Naghili B, Nakhlband A. Causative agents and antimicrobial susceptibilities of urinary tract infections in the Northwest of Iran. Int J Infect Dis 2009;13:140-4.
13.	Laghawe A, Tripathi A, Saxena SB. Aetiology of urinary tract infection and antimicrobial susceptibility pattern of urinary isolates in tertiary care hospital in central India: A retrospective analysis. Int J Curr Microbiol Appl Sci 2015;4:962-70.
14.	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;33:89-94.
15.	Raz R, Chazan B, Kennes Y, Colodner R, Rottensterich E, Dan M, et al. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis 2002;34:1165-9.
16.	Kothari A, Sagar V. Antibiotic resistance in pathogens causing community-acquired urinary tract infections in India: A multicenter study. J Infect Dev Ctries 2008;2:354-8.
17.	Gupta K, Scholes D, Stamm WE. Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women. JAMA 1999;281:736-8.
18.	Baveja CP, Perween N, Aggarwal P. Urinary tract infections in tertiary care hospital in North India: Etiology and antimicrobial susceptibility pattern. JMSCR 2014;2:2940-6.
19.	Panwar S, Faujdar SS. Prevalence, distribution, risk factors and antifungal susceptibility profiles of Candida species in a tertiary care hospital. Int J Curr Microbiol Appl Sci 2016;5:78-94.
20.	Akata F, Tatman-Otkun M, Ozkan E, Tansel O, Otkun M, Tugrul M. Prevalence of extended-spectrum beta-lactamases produced by nosocomial isolates of Enterobacteriaceae in Trakya university hospital, turkey. New Microbiol 2003;26:257-62.
21.	Gupta V, Yadav A, Joshi RM. Antibiotic resistance pattern in uropathogen. Indian J Med Microbiol 2002;20:96-8. [PUBMED] [Full text]
22.	Gales AC, Sader HS, Jones RN; SENTRY Participants Group (Latin America). Urinary tract infection trends in Latin American hospitals: Report from the SENTRY antimicrobial surveillance program (1997-2000). Diagn Microbiol Infect Dis 2002;44:289-99.
23.	Mathur P, Kapil A, Das B, Dhawan B. Prevalence of extended spectrum beta lactamase producing gram negative bacteria in a tertiary care hospital. Indian J Med Res 2002;115:153-7.
24.	Rakesh K, Dahiya SS, Kirti H, Preeti S. Isolation of human pathogenic bacteria causing urinary tract infection and their antimicrobial susceptibility pattern in a tertiary care hospital, Jaipur, India. Int Res J Med Sci 2014;2:6-10.
25.	Cherian SS, Jacob J, Rakesh PS, Immanuel R. Antibiograms of community-acquired uropathogens from a secondary care rural hospital in Southern India. Int J Ther Appl 2013;13:24-9.
26.	Deshpande KD, Pichare AP, Suryawanshi NM, Davane MS. Antibiogram of gram negative uropathogens in hospitalized patients. Int J Recent Trends Sci Technol 2011;1:56-60.
27.	Arjunan M, Al-Salamah AA, Amuthan M. Prevalence and antibiotics susceptibility of uropathogens in patients from a rural environment, Tamil Nadu. Am J Infect Dis 2010;6:29-33.
28.	Ali A, Tayebah V, Farid K, Tayebah A, Farhad A, Marziaeh A. Antimicrobial susceptibility patterns of community acquired Gram-negative. Uropathogens 2014;8:332-6.
29.	Manjunath GN, Prakash R, Annam V, Shetty K. Changing trends in the spectrum of antimicrobial drug resistance pattern of uropathogens isolated from hospitals and community patients with urinary tract infections in Tumkur and Bangalore. Int J Biol Med Res 2011;2:504-7.
30.	Kim ME, Ha US, Cho YH. Prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in female outpatients in South Korea: A multicentre study in 2006. Int J Antimicrob Agents 2008;31 Suppl 1:S15-8.