Introduction

Urinary tract infections are the most common bacterial infection obtained in a community and hospital setting (Foxman, 2010). This is a world-wide problem, and it is calculated that about 150 million people each year infected by UTIs and costing the global economy more than 6 billion US dollars (Gonzalez & Schaeffer, 1999) UTI can occur in all age groups in both male and female (Huh, 2016). But females are more infected than the male because of their short urethra, pregnancy and contraception (Harrington & Hooton, 2000). It was estimated that about 50-60% of females suffer from at least one episode of UTI during their lifespan (Foxman, 2002). Because of UTI, Hospital admission and economy cost are increasing commonly (Cove-Smith & Almond, 2007; Foxman, 2002).

A large number of organisms that is responsible for urinary tract infection. The common gram-positive uropathogens are Staphylococcus saprophyticus, Enterococcus faecalis, Staphylococcus aureus (Kline & Lewis, 2016) and common gram-negative uropathogens are Escherichia coli, Psuedomonas spp. Proteus sp., Klebsiella pneumoniae and Enterobacter species (Foxman, 2010; Griebling, 2005; Wilson & Gaido, 2004). But the most common uropathogen is Escherichia coli (Chang & Shortliffe, 2006).

Antibiotics resistance in bacteria is increasing worldwide. The bacteria are becoming highly drug-resistant (HDR) to conventionally used antibiotics (Taneja, Rao, Arora, & Dogra, 2008). There is multiple drug resistance cases documented in both outdoor patients and admitted patients. These varies are according to geographical circumstance erroneous use of antibiotics and play a serious role in the emergence of the drug-resistant uropathogens (Rockville, 2008; Tadesse et al., 1950). Mainly, ESBLs is a group of plasmid-encoded enzymes that provide resistance to third-generation cephalosporins group antibiotic drugs (Paterson & Bonomo, 2005; Stedt et al., 2015) ESBLs are presented into groups that are TEM, SHVand CTX-M genes.CTX-M enzymes are the most common extended beta-lactamase (Lahlaoui, Khalifa, & Moussa, 2014; Malloy & Campos, 2011).

Aims

The aim of this study is to know the prevalence of different uropathogens, their antibiogram and ESBL resistance among uropathogens.

Materials and Methods

This study was conducted at the period of September 2018 to February 2019. Early morning, Clean-catch, Mid-stream urine sample was collected in a sterile, screw capped, leak proof container from patient as per standard operating guidelines. Urine sample was collected from both OPD and catheter patient and transport to microbiology laboratory.

Samples were inoculated on the MacConkey Agar (HiMedia) and Cysteine Lactose Electrolyte Deficient medium (CLED Agar, HiMedia)by semi-quantative method Kass and incubated for 24 hr. At 37°C temperature. If culture was negative, then we further re-incubated for next 24 hours. In culture-positive cases colony count in ≥10⁵CFU/ml and identification of organisms done by the gram staining and panel of a biochemical test as per the standard microbiological procedure.

The antimicrobial susceptibility test was done on Mueller Hinton Agar (HiMedia) by Kirby-Bauer disk diffusion method according to Clinical and Laboratory Standards Institute (CLSI, 2011). All Enterobactericeae organisms were further tested by combined disk test for the ESBL detection Ceftazidime (30µg) and Ceftazidime Clavunic acid (30/10µg) were placed on the MH Agar and incubated at 37°C for 24hrs. Ceftazidime Clavunic acid zone size was ≥5mm increase comparison to the Ceftazidme considered as ESBL is present (CLSI, 2012) (Escherichia coli ATCC 25922 strains, used as negative control), Figure 1.

Double disk synergy test (DDST): Five antibiotics were applied for detection of ESBL producer, ceftazidime-clavulanic acid (AMC/20/10µg) placed in center of the MH agar and around ceftazidime clavulanic acid, azteronam (ATZ/30µg), cefotaxime (CTX/30µg), ceftriaxone (CTR/30µg) and ceftazidime (CAZ/30µg) were placed at the distance of 1.5cm and incubated for 37°C for 24hrs. After incubation increased zone size were considered as ESBL producer.

Results and Discussion

Total 618 urine samples were processed from the OPD and IPD patients of CIMS hospital. In this study, out of the 618 samples, 247(39.96%) urine samples had significant bacteremia. Among the UTI cases 164(66.4%) females and 83(33.6%) were male patients (Table 1). So, female:male ratio was (1.97:1). As shown in (Table 1) UTI was more prevalent in the age (year) group of 21-30, as 65 out of 247 patients (26.3%) and followed by 45 above ≥61 years (18.2%) and 19 children below ≤10 years (7.7%).

Total of 267 uropathogens were isolated. Where we found more than one organism in 20 samples. Among the uropathogens Gram-negative 178 (66.67%) followed by Gram-positive bacteria were 89 (33.33%) and Non-albicans candida 05 (1.87%). The most common uropathogens was Escherichia coli 111 (41.57%) followed by Enterococcus sp. 49 (18.4%) and Pseudomonas sp. 29 (10.9%), as shown in (Table 2).

Among the gram-negative uropathogens E. coli was highly resistant to ampicillin 87 (78.4%) and ofloxacin 72 (64.9%), whereas imipenem 15 (13.5%) was least resistant (as shown in (Table 3).

Among the gram-positive organisms, Enterococcus spp. were highly resistant to ciprofloxacin 30 (61.2%) followed by Ampicillin 22 (44.9%) and least resistant were vancomycin and linezoilid 02 (4.08%) followed by piperacillin tazobactam 10 (20.4%) and high level gentamycin (HLG) 20 (40.8%) as shown in (Table 4).

Among the Enterobacteriaceae, out of 141, 81 (57.45%) were ESBL producers. Among all the ESBL producers E. coli 59 (41.84%) was the most frequent uropathogens observed, followed by Klebsiella spp. 12 (8.51%), Enterobacter spp. 06 (4.26%), as shown in (Table 5).

Among the ESBL producer, E. coli 53 (89.8) was the highest resistant to ampicillin followed by ofloxacin 51 (86.4%), cefotaxime 48 (81.4%) and ciprofloxacin 46 (78.0%). Least resistance was observed to imipenem 11 (18.6%) and piperacillin tazobactam 12 (20.3%) as shown in (Table 6).

Urinary tract infections (UTIs) are the most common bacterial infection in the world. UTIs can occur in all age groups. ESBL (Extended Spectrum Beta lactamase) and multiple drug resistance producing bacteria have made the treatment difficult. In our study UTI was most common at the age 21-30, 65(26.3%) shown in (Table 1), UTI cases were more common in adult than other age groups (Alanazi, Alqahtani, & Aleanizy, 2018). In this study, UTI cases was most common in female 164(66.4%) as shown in (Table 1) because of the short urethra, use of contraceptive, poor hygiene, pregnancy and sexual (Agbo, 2016). In these cases, gram-negative bacteria 178(66.67%) is common than gram-positive bacteria 89(33.33%). Another study also showed the same frequency of uropathogens (Chaudhary & Mahadeva, 2013).

The E. coli 111(41.7%) is the most common uropathogens found in our study. Similar to our finding in other studies, the E. coli was the most common uropathogens 56.5%, 52.4% and 53.8% respectively (Chaudhary & Mahadeva, 2013; Patel, Taviad, Sinha, Javadekar, & Chaudhari, 2012; Yusuf, Yahaya, Saleh, Saleh, & Hakeem, 2017) Enterococcus sp. was the second most common uropathogens 49(18.4%) whereas 16.91% and 3.03% observed in Moradabad (Kumar, Umar, Sudhir, Navdeep, & Raees, 2016). In another study, Klebsiella pneumoniae was the second most common uropathogens, 12.1% (Srinivas, 2014).

In our study 81(57.45%) ESBL producers found whereas, in other studies, the prevalence of ESBL producers has been documented, (33%), (38.6%), (64.7%) and 34.71% respectively (Alqasim, Jaffal, & Alyousef, 2018; Aruna & Mobashshera, 2012; Bhandari, Pant, Poudel, & Sharma, 2016; Murthy, Murthy, & Pradhan, 2018).

Among the ESBL producers, E. coli 59 (41.84%) was the most frequent organisms, as shown in (Table 6). In similar studies, the prevalence of E. coli was most prevalent in Singapore (33%), Hong Kong (48%) and India 60% as reported by (Hsueh et al., 2011) 37.87% Saudi Arabia (Alqasim et al., 2018).

Klebsiella spp. 12(8.51%) was second most common ESBL producer in our study, in around Bilaspur , Chhattisgarh, whereas reported in south Mumbai Klebsiella pneumoniae (27.5%) (Mathur, Kapil, Das, & Dhawan, 2002) and in Channai Klebsiella pneumoniae (37%) (Gururajan, Kaliyap, & Ramasamy, 2011) were commonest.

An increasing rate of ESBL producing bacteria which are causing serious UTI in the society, hospitals even world-wide because of the limit to treatment choice and increases the disease. In our study, antibiogram pattern resistance were found to more in ESBL producers as a comparison to Non- ESBL producers. In our study, E.coli was most multi-drug resistant found among the Enterobacteriaceae. Among ESBL producers, the most resistance were ampicillin 72(88.9%) and ciprofloxacin 20(69.1%) as shown in (Table 6), whereas around 90% - 72.05% resistance and (Aruna & Mobashshera, 2012) and least resistance to imipenem 15(18.5%) whereas in other studies 3.6% and 09% were respectively reported (Bhandari et al., 2016; Hassan, Jamal, & Kamal, 2011).

Conclusion

We observed that E. coli is the most common uropathogens and ESBL producing organisms and responsible for the complicated UTI and treatment difficulty. This study the high drug resistance were amoxicillin clavulanic acid, ampicillin and ciprofloxacin least imipenem resistance. Need to take an urgent action and make new strategies against the ESBL producers.