Urinary Tract Infections (UTI) Among Patients at the

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Mediterranean Journal of Medical Sciences
Volume 1, Issue 1, October 2014: 7-12
Original Paper
Urinary Tract Infections (UTI) Among Patients at the
University Hospital Center "Mother Theresa", Tirana,
Albania.
Selam Shkurti*
*Department of Emergency, University Hospital Center "Mother Theresa", Tirana, Albania.
Abstract
Background & objectives: The resistance of bacteria causing urinary tract infection (UTI) to
commonly prescribed antibiotics is increasing both in developing as well as in developed
countries. Resistance has emerged even to more potent antimicrobial agents. The primary
objective of the study was 1) to detect the prevalence rate of bacterial infection among urinary
isolates from patients having UTI and 2)to detect prevalence rate of drug resistance among
pathogen isolate from patients having UTI.
Methods: Early morning mid-stream urine samples were collected using sterile, wide
mouthed container with screw cap tops. On the urine sample bottles were indicated name, age,
sex, and time of collection along with requisition forms.
Results:. Significant association (P<0.001) of prior use of antibiotics in males, UTI in adults,
gynaecological surgery in females, obstructive uropathy in males and complicated UTI in
females with the occurrence of UTI with ciprofloxacin resistant Escherichia coli was noted.
Significant association was noted in females with prior antibiotics, with prior urological
surgery and in males with prior complicated UTI. Fluoroquinolone resistance was found to
increase with age.
Interpretations & conclusions: Ciprofloxacin resistance has emerged due to its frequent use.
This resistance was seen more in the in-patients, elderly males and females. Also the
resistance to other antibiotics was also high. Increasing antibiotic resistance trends indicate
that it is imperative to rationalize the use of antimicrobials in the community and also use
these conservatively.
Key words: Ciprofloxacin - Escherichia coli - minimum inhibitory concentration - urinary tract
infection
1.
Introduction
Urinary tract infections (UTIs)
are amongst the most common
infections encountered in clinical
practice. In Albania symptomatic
urinary tract infections (UTI)
occur in as many as 30 000 visits
to emergency units and 500
hospitalizations annually.
The commune bacterial agent
involved in causing UTI is
Escherichia
coli,
from
the
Enterobacteriaceae family in at
Mediterranean Journal of Medical Sciences V1, I1 October 2014: 7-12
least 59% of cases. Other less
common
pathogens
include
Klebsiella, Proteus, Enterobacter
spp, etc.
To be mentioned that the
distribution of pathogens that
cause UTI is changing. There are
several factors and abnormalities
of UTI that interfere with its
natural resistance to infections.
These factors include sex and age
disease,
hospitalization
and
obstruction in urinary tract.
The treatment of UTIs varies
according to the age of the patient,
sex, underlying disease, infecting
agent and whether there is lower
or
upper
urinary
tract
involvement. Diagnosis of UTI
often
requires
laboratory
examination of a urine sample in
addition to clinical evaluation.
Although
many
guidelines
indicate that the culture of urine is
not required in most cases of
uncomplicated cystitis[1], the
laboratory in UHC Mother
Teresa, accepts all such requests
from patients to send samples on
all suspected UTI.
With the increasing trend of
antibiotic-resistance in E. coli, the
management of urinary tract
infections is likely to become
complicated
with
limited
therapeutic options.
©2014 Mediterranean Center of Medical Sciences
2.
8
Material & Methods
Study site: The study was carried
out in the Department of
Emergency, University Hospital
Center "Mother Theresa", Tirana,
Albania from November 2006 to
September 2007.
This was an analysis of data
generated from the records of
consecutive
urine
samples
received in the laboratory during
the study period.
Analysis of the data was carried
out focusing on the age, gender,
whether admitted or not, whether
received prior antibiotic therapy,
any surgical or gynaecological
intervention performed in the
recent past, and any history of
urinary tract infection in the past.
The antibiotic susceptibility data
of all isolates were also reviewed
and analyzed. Samples received
included mid-stream clean catch
urine, suprapubic aspirate, urine
collected from Foley’s catheter
and from the nephrostomy tube
under sterile precautions, in
patients who had undergone
percutaneous
nephrostomy.
Samples were processed and
isolates were identified as per
standard methods 14. All urine
samples were inoculated onto
cysteine
lactose
electrolyte
deficient (CLED) medium using a
calibrated loop (volume-0.005 ml)
and were incubated for 18-24 h at
37˚C. Wet mount preparations
S. Shkurti
9
dissolved in sterile distilled water
as per the recommendations. The
antibiotic was used immediately
after reconstitution. The different
concentrations of the drug
analyzed were 0.5 to 256
μg/ml15,16. ATCC E. coli 25922
was inoculated on each plate as
the growth control. The growth
control was read first followed by
the MICs of the test strains.
Statistical
analysis:
Statistical
©
software SPSS 19.0 (IBM SPSS
Statistics Base,) were used to
analyze the data.
were also made from all urine
samples to look for pus cells and
epithelial cells. Depending upon
the number of the colonies grown
on the CLED medium, the
interpretations of urine culture
were made as insignificant (<50
colonies), doubtful significance
(>50 - <500 colonies) and
significant (≥500 colonies) with
due clinical correlation as per
recommendations. The antibiotic
susceptibility testing of the
isolated bacteria was carried out
by the Kirby Bauer method.
Determination of minimum inhibitory
concentration
(MIC): The MIC testing was
Table 1. Frequency of bacterial pathogens isolated from positive cultures
Organisms
Male
Escherichia coli
Enterobacter spp
Klebsiella spp
Proteus spp
Pseudomonas spp
Staphylococci spp
Others
Total
97 (55.42)
24 (13.71)
12 (7.05)
10 (5.71)
8 (4.57)
7 (4)
17 (9.71)
175 (100)
performed as per guidelines. The
MIC interpretive standards for
the susceptibility categories were
as
per
the
recommended
breakpoints by the Clinical
Laboratory Standards Institute
(CLSI)
for
ciprofloxacin16.
Ciprofloxacin hydrochloride was
obtained from. The antibiotic was
Female
3.
338 (64.75)
73 (13.98)
39 (7.47)
29 (5.55)
19 (3.63)
12 (2.29)
12 (2.29)
522 (100)
Total
435 (62.41)
97 (13.91)
51 (7.31)
39 (5.59)
27 (3.87)
19 (2.72)
29 (4.16)
697 (100)
Results
A total of 2876 patients (1627
women [56.58%] and 1249 men
[43.42%]), aged from younger
than 1 month to 91 years (mean
21.7 years), were studied. In
evaluation of studied specimen,
697 samples (522 females and 175
http://www.mcmscience.org
Mediterranean Journal of Medical Sciences V1, I1 October 2014: 7-12
males) had positive culture result
and there was a statistically
significant
relation
between
gender and UTI (p=0.005).
Wet mount microscopy for
presence of bacteria or pus cells in
significant amount per field had
sensitivity, specificity, positive
predictive value (PPV) and
negative predictive value (NPV)
of 83, 58, 44 and 89 per cent,
respectively
in
detecting
infections.
Of the 2876 culture positives, E.
coli was the most common (59%)
isolate. (Table I).
4.
Discussion
Ciprofloxacin and ofloxacin are
the most extensively used
fluoroquinolones
for
the
treatment of UTIs. This study
showed that E. coli was the
commonest pathogen causing
complicated and uncomplicated
UTI as described previously[1]
[3]. There are several organisms
known to cause UTIs, including
P. aeruginosa, S. saprophyticus,
S.epidermidis, Enterococcus spp,
P. mirabilis, Klebsiella spp.,
Citrobacter spp, etc. as reported by
earlier workers[4]. This study also
demonstrates the emergence of E.
faecalis and the non-fermenters
Acinetobacter spp and Pseudomonas
spp as major uropathogens
especially in the patients admitted
in the hospitals, more so in the
©2014 Mediterranean Center of Medical Sciences
10
intensive care units. Such findings
have
been
documented
elsewhere[5-16]. The percentage of
isolates of E.coli resistant to
ampicillin was found to be as
much as 80 per cent in our set up.
Such high levels of resistance to
ampicillin have been quoted by
many other studies from different
parts of Albania[5]. Our MIC
results
showed
that
fluoroquinolone
resistance
increased
significantly
with
patient’s age. An MIC of 256
μg/ml was noted in the age group
of >60 yr of age. There could be
two explanations for this. Firstly,
as a consequence of frequent
exposure to fluoroquinolones
resulting from the treatment of
repeated infections in elderly
leads to increase in MIC of
fluoroquinolone19.
Secondly,
unlike urinary tract infections
(UTIs) in females, UTIs in males
are frequently complicated and are
more likely to require prolonged
antimicrobial therapy, especially
in
the
elderly,
potentially
explaining the fluoroquinolone
the higher MIC[25].
S. Shkurti
11
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