UROPATHOGENS AND THEIR RESISTANCE PATTERN IN URINARY TRACT INFECTION CASES OF TERTIARY CARE HOSPITAL, BHOPAL

Objectives: Urinary tract infections (UTIs) are an increasing public health problem caused by various uropathogens. To assess the adequacy of empirical therapy, an antibiogram of the bacteria responsible for UTI in patients coming to the tertiary hospital, Bhopal was evaluated for 13 months. Methods: In this prospective and observational study, all urine samples from patients of a tertiary care hospital collected at the Department of Microbiology, Peoples College of Medical Sciences and Research Centre, Bhopal, from January 2014 to January 2015 were processed. A sample with more than 10 5 CFU/mL of bacteria was considered positive, the bacteria were identified, and antibiotic susceptibility profile was characterized. Results: A total of 283 urine samples from suspected UTIs were analyzed, for which identification of bacteria and antimicrobial susceptibility testing were done. Overall, 56.53% were culture positive with a predominance of female patients (70.62%). Females 26–35 years old and males ≥46 years old showed maximum culture positivity. Escherichia coli (55.7%) was the most commonly isolated microorganism, followed by Klebsiella pneumoniae (24.8%). Isolated uropathogens were predominantly resistant to Ampicillin, Amoxycillin clavulanic acid, Cefotaxime, Ceftazidime, Cotrimoxazole, and Nalidixic acid. Conclusion: Our study confirms a global trend toward increased resistance to most antibiotics. We emphasize the formulation of antibiotic policy for a particular geographical area. E. coli was the most common uropathogen. Nitrofurantoin, Fluoroquinolones, Amikacin, and Piperacillin/tazobactam were the most effective antibiotics against uropathogens


INTRODUCTION
Urinary tract infections (UTIs) are the second most common infectious disease in a community and accounts significant cause of morbidity too.Approximately 150 million cases of UTIs are diagnosed each year [1].Bacteriuria with urinary symptoms is known as UTI, and it is divided into two types: Simple UTI and complicated UTI.Uncomplicated UTIs are common in healthy adults.Persons with renal disorders such as obstructions, calculi, catheterization, and transplantation are more prone to complicated UTIs.
Because female urethra is less effective at preventing bacterial entry, UTI is more common in women [2].UTI is commonly seen in females because of bacterial colonization in the vagina, sexual activity, and pregnancy [3].UTI is caused by bacteria, fungi, parasites, and viruses, but bacteria alone accounts for more than 95%.UTI is commonly caused by Gram-negative bacteria, such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus species.Among Gram-negative, 75-95% of cases of UTI are caused by E. coli.Grampositive bacteria, Staphylococcus aureus, Staphylococcus saprophyticus, and Enterococcus species are most commonly responsible for UTIs [4].
Broad-spectrum antibiotics have been very effective in the management of UTIs; therefore, they are commonly prescribed.Today's scenario is that inappropriate use and over-the-counter availability of antibiotics have led to the global emergence of antibiotic resistance against uropathogens [5].
Frequently changing antimicrobial susceptibility patterns and the emergence of multidrug-resistant (MDR) bacterial pathogens are the leading cause of morbidity and mortality.Microbial isolation in UTIs and their antibiotic susceptibility is crucial before starting empirical treatment and also for the prevention of the emergence of antimicrobial resistance.
Few studies have been reported from Madhya Pradesh on uropathogenic antibio grams.The purpose of this study was to identify common uropathogens and their resistance patterns in suspected UTI cases attending a tertiary care hospital in Bhopal.
processed for the identification of bacterial species using standard microbiological techniques, such as Gram staining, colony morphology, and biochemical testing [6].

Statistical analysis
Data were collected in Microsoft Excel and result was analyzed and expressed in percentages and Pearson Chi-square test.

RESULTS
A total of 283 urine specimens from outpatients and inpatients were received during the study period, out of which 140 samples (49.46%) were from male patients and 143 samples (50.53%) were from female patients showing symptoms of UTI.Out of the total sample received, 160 were culture-positive.Hence, the overall prevalence of UTI was 56.53%.In this study, most of the uropathogens were recovered from female patients (70.62%) and male patients (42.14%), as shown in Table 1.Various predisposing factors contribute to the higher prevalence of UTIs among women.
Culture proven UTI patients showed Chi-square test statistically significant (p<0.05) at a 95% level of the confidence interval.The Chisquare test values were  2 =23.3617; degree of freedom=1; p<0.00001.The result was significant at p<0.05.
Comparative analysis of UTI in both genders in all age groups (Tables 2 and 3) shows a higher prevalence of UTI among females than in males in 15-45 age groups, but in ≥46 years age group, the preponderance was seen in males.
In females, age group of 26-35 years had an 87.8% prevalence of UTI; however, in males, the highest susceptible age group to UTI was ≥46 years (86.6%).
Variables for infected males and non-infected males the Pearson Chisquare test values were as follows: 2=57.0002;degree of freedom=1; p<0.00001.As per Table 2, the result was significant at p<0.05.
For the infected and not infected female patient's variable, the Chisquare test values were  2 =18.553; degree of freedom=1; p≤0.000338.As per Table 3, the result was significant at p<0.05.
According to Fig. 3, dominant bacteria among 149Gramnegativeuropathogens E. coli were found to be 55.7%, followed by K. pneumoniae 24.8%.Other organisms, such as P. aeruginosa and Proteus vulgar, are represented 11.4% and 8%, respectively.
The prevalence of the most dominant bacteria E. coli as per Table 5 shows 41.9% in females and 16.4% in males.The Pearson Chi-square  Antibiotic resistance of isolated Gram-negative uropathogens shown in Table 6 has the highest percentages of resistance against most of the tested antibiotics, with more than 50% resistance to broad-spectrum antibiotics.However, a low level of resistance has been observed for Gram-negative agents against Carbapenems.
In our study, the highest resistance was observed against E. coli to almost all the tested antibiotics which were in the range of 10-60%, except Carbapenems.
K. pneumoniae showed nearly 30% resistance to third-generation cephalosporins.The observed resistance for K. pneumoniae was 8% against Amikacin whereas Carbapenems were found to be 100% sensitive.
P. aeruginosa showed nearly 50% resistance to Ciprofloxacin and Ceftazidime.All P. aeruginosa isolates were sensitive to Imipenem and Meropenem.
This massive increase in antibiotic resistance is a result of the overuse of these antibiotics for the treatment of different infections in our region without checking culture sensitivity.This alarming situation is the leading cause of MDR infection among UTIs.
According to Table 6, Gram-positive isolates were completely sensitivity to Linezolid, Teicoplanin, and Vancomycin.
S. aureus showed 62.5% resistance to Cefoxitin and Cotrimoxazole and 50% to Norfloxacin.Nitrofurantoin turned out to be effective with S. aureus as it showed 12.5% resistance only.
CONS is resistant to Norfloxacin and Cotrimoxazole by 50%.
Enterococcus species were sensitive to all tested antibiotics.

DISCUSSION
Correct bacterial isolate identification and antibiotic selection assist clinicians in the effective management of bacterial UTI.Our study describes the distribution and antibiotic resistance pattern of microbial species isolated from populations with suspected UTIs.During the study period, 283 urine samples from different age groups and both genders were analyzed, out of which 160 (56.53%) were culture positive, which is at par with other studies.Our findings are also in agreement with this generalization and rightly coincide with a study done by Waske et al. [8] and Prakash and Saxena et al. [9].This study gives an insight into UTIs, one of the most common infections leading to an antibiotic prescription from a tertiary care hospital.About 70.62% of female patients were culture positive, compared to 42.14%, of male patients, indicating UTI is more common in females as revealed in other studies [10].Long urethra and bacteriostatic prostatic secretions are the cause of low percentage of UTI in males [11].
UTIs are common in women, and often associated with significant morbidity and mortality.Various predisposing factors contribute to the higher prevalence of UTIs among women and may affect women of all age groups, especially sexually active ones [13].This could be because of the highest prevalence rate of 87.8% observed in the 26-35 years age group.It is followed by 15-25 years (82%), then 36-45 years (54.5%), and lowest among the ≥46 years age (50%).UTI is more common in females than males during adolescence and adulthood because of high sexual activity [14].
Males above 46 years showed an 86.6% incidence of UTI which is similar to the study by Smita et al. [15].In male, prostate enlargement and neurogenic bladder seen with advancing age are major causes of increased incidence of UTI [16].
In our study, Gram-negative bacilli constituted 93.1% of the total bacterial isolates, while Gram-positive cocci constituted 6.8%.Isolated uropathogens were E. coli followed by K. pneumonia which is similar to many other studies from India, such as Majumder et al., 2018 [17].
E. coli (55.7%) was the most prevalent bacteria involved in UTIs, which is similar to the other studies with a range between 40% and 78%.Second most common uropathogen isolated was K. pneumoniae (24.8%) which was much higher than other studies with a range between 11% and 17% [18,19].
Moreover for the clinician to treat UTIs as they are left with only a few drugs.Our study revealed that carbapenem was highly active against members of Enterobacteriaceae followed by Amikacin and Piperacillin/ tazobactam.Similar findings were drawn by Rakesh et al. [20] and Deshpande et al. [21].

P. aeruginosa has shown 100% susceptibility to Imipenem and
Meropenem which is at par with Deshpande et al. 2011 [17].In our study, resistance to Piperacillin Tazobactam by P. aeruginosa was found to be nearly 30% which coincides with that of Baveja et al. 2014 [22].
Easily availability of antibiotics might be responsible for antibiotic resistance.Physicians prescribing antibiotics without laboratory confirmation may be one of the causes of increasing resistance in UTI isolates.The study by McEwen et al. found that physicians prescribe Trimethoprim-sulphamethoxazole 37% and Fluoroquinolones 32% [23].
In our study, from all the Gram-positive cocci isolated, 100% were susceptible to Vancomycin, Linezolid, and Teicoplanin which was at par with Rakesh et al. 2014 [20].
It is a common trend to treat uncomplicated UTIs with a short course of empirical oral antibiotics.Microbiological evaluation of UTI is done only in complicated UTIs.Overall, Gram-negative isolates showed a higher resistance pattern in comparison to Gram-positive isolates in the present study.

Table 3 : Prevalence of UTI among the different age groups of female UTI patients Age group Total female
*Values are statistically significant by Pearson Chi-square test; P<0.05.UTI: Urinary tract infection

Table 1 : Culture proved among UTI patients
*Values are statistically significant by Pearson Chi-square test; P<0.05.UTI: Urinary tract infection

Table 2 : Prevalence of UTI among the different age groups of male UTI patients Age group Total male
*Values are statistically significant by Pearson Chi-square test; P<0.05.UTI: Urinary tract infection

Table 5 : Comparison of demographic variables with the prevalence of E. coli. (n=83) Variables Category E. coli. present E. coli. absent Prevalence (%) X2 p-value
*Values are statistically significant by Pearson Chi-square test; P<0.05.E. coli: Escherichia coli years, 57.60%; 26-35 years, 53.80%) and middle-aged patients (36-45 years, 42.2%) which differs from the other studies.Devki et al. in West Bengal found the highest incidence of UTI among the 20-40 years (55.62%.)age group , organisms such as Pseudomonas spp., Proteus spp.S. aureus, CONS, and Enterococcus spp.represented 11.4%, 8%, 7.2%, 2%, and 1%, respectively.The highest prevalence of Gram-negative organisms was seen in our study.The scale of bacterial uropathogens, on other hand, varies with topographical location and characterization of the patients UTIs Empirical use and overuse of antibiotics in UTIs are responsible for antibiotic resistance.Due to increasing resistance, it has been difficult