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SHORT COMMUNICATION
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 204-206

Drug-resistant Gram-negative bacilli in urinary tract infection: A need for strict antibiotic prescription policy


Department of Microbiology, G B Pant Hospital, New Delhi, India

Date of Web Publication26-Dec-2012

Correspondence Address:
Abha Sharma
Department of Microbiology, G B Pant Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.105090

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  Abstract 

Introduction: The etiology of urinary tract infections (UTIs) and the antibiotic resistance of uropathogens have been changing over the past years. This retrospective study was conducted to survey the resistance pattern of Gram-negative uropathogens to first-line agents for UTIs; this would be helpful for the clinicians to facilitate the empiric treatment and management of patients with UTI and maybe useful for the formulation of guidelines of antibiotic policies. Materials and Methods: Isolated uropathogens were tested against ampicillin-sulbactam, amikacin, ceftriaxone, cefotaxime, cefoperazone, gentamicin, norfloxacin, ofloxacin, piperacillin-tazobactam, and imipenem. Result: A total of 2,146 urine samples were cultured, of which 448 samples were positive for Gram-negative bacilli. The most common Gram-negative isolate was Esherichia coli (52%) followed by Klebsiella pneumoniae (17.6%) and Pseudomonas aeruginosa (12.9%). E. coli was found to be most resistant to ampicillin-sulbactam (90.1%), followed by norfloxacin (76.3%), and most sensitive to imipenem. P. aeruginosa was least resistant to amikacin (27.5%). Overall resistance to imipenem is less than 20% among the Gram-negative uropathogens except Acinetobacter spp. and P. aeruginosa. Conclusion: Ofloxacin and amikacin are recommended as the drugs of choice for the empirical treatment of UTI, whereas specific treatment should be based on the etiological agent isolated in the urine culture. There is a strict need for developing specific guidelines for antibiotic prescriptions for UTI in India.

Keywords: Drug resistance, UTI, antibiotic policy


How to cite this article:
Dogra V, Sharma A, Mishra B, Thakur A, Loomba PS. Drug-resistant Gram-negative bacilli in urinary tract infection: A need for strict antibiotic prescription policy. Int J Health Allied Sci 2012;1:204-6

How to cite this URL:
Dogra V, Sharma A, Mishra B, Thakur A, Loomba PS. Drug-resistant Gram-negative bacilli in urinary tract infection: A need for strict antibiotic prescription policy. Int J Health Allied Sci [serial online] 2012 [cited 2019 Sep 20];1:204-6. Available from: http://www.ijhas.in/text.asp?2012/1/3/204/105090


  Introduction Top


Urinary tract infections (UTIs) are a frequent problem worldwide. About 150 million people [1] are diagnosed with UTI each year. Esherichia coli is the primary Gram-negative organism, accounting for 75 to 90% of the UTI isolates. [2],[3] Resistance to commonly prescribed antibiotics for UTI is an expanding global problem both in developed as well as developing countries. [4] The etiology of UTI and the antibiotic resistance of uropathogens have been changing over the past years, both in community and nosocomial infections. [5],[6] This retrospective study was conducted to survey the resistance pattern of Gram-negative uropathogens to first-line agents for UTI, in a superspeciality hospital of New Delhi. Our data would be helpful for the clinicians to facilitate the empiric treatment and management of patients with UTI and maybe useful for the formulation of guidelines for antibiotic policies.

All Gram-negative bacteria isolated from urine samples between January 2011 and December 2011 were included. A total of 2,146 urine samples were received for culture by the microbiology laboratory. Routine culture was performed on MacConkey and blood agar. Gram-negative isolates from cases with significant bacteruria [>10 5 cfu/mL (cfu: Colony forming units)] were identified and antimicrobial susceptibility testing was done by the Kirby-Bauer method. Microbial percentage resistance to first-line agents was calculated. Isolated uropathogens were tested against ampicillin-sulbactam, amikacin, ceftriaxone, cefotaxime, cefoperazone, gentamicin, norfloxacin, ofloxacin, piperacillin-tazobactam, and imipenem.

A total of 2,146 urine samples were cultured, of which 448 samples were positive for Gram-negative bacilli. Among the culture-positive cases, 250 (55.8%) were males and 198 (44.1%) were females. Most of the patients (350) were admitted in the intensive care unit (ICU) (78.1%) and were catheterized (300; 66.9%). The remaining samples (98; 21.8%) were mainly from patients admitted in the wards or attending outpatient departments (OPDs). Seven different types of Gram-negative uropathogens were isolated [Table 1]. The most common Gram-negative isolate was E. coli (52%) followed by Klebsiella pneumoniae (17.6%) and Pseudomonas aeruginosa (12.9%).
Table 1: Etiology of UTI

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The antibiotic resistance pattern of the etiological agents is shown in [Table 2]. E. coli was found to be most resistant to ampicillin-sulbactam (90.1%) followed by norfloxacin (76.3%), and most sensitive to imipenem. Similarly for all other organisms also, the maximum resistance was shown for ampicillin-sulbactam, that is, Klebsiella (98.7%), Acinetobacter (91.3%), Proteus (80.7%), Citrobacter (98.7%), Enterobacter (100%), and P. aeruginosa (98.7%). K. pneumoniae seemed to be least resistant to imipenem (13.9%). Acinetobacter and Proteus, in comparison, were least resistant to piperacillin-tazobactam (21.7 and 3.8%, respectively), whereas Citrobacter was again least resistant to imipenem (18.5%) and P. aeruginosa was least resistant to amikacin (27.5%). The overall observation shows that almost three-fourths of the isolates were resistant to multiple drugs. Among the oral antibiotics commonly used for primary care (ampicillin-sulbactam, norfloxacin, and ofloxacin), it seems that percentage resistance was slightly less for ofloxacin in comparison to others.
Table 2: Percentage resistance pattern of etiological agents of UTI

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Overall resistance to imipenem is less than 20% among the Gram-negative uropathogens except Acinetobacter spp. and Pseudomonas aeruginosa which are most resistant to imipenem despite the fact that imipenem is a carbapenem antibiotic, which is highly active against P. aeruginosa and Acinetobacter.

This study shows the isolation and antimicrobial resistance pattern of Gram-negative uropathogens. E. coli remains the most common organism isolated from urine samples as observed in this study and already depicted by other studies. [7],[8] The development and spread of bacterial resistance to multiple antibiotics especially oral antibiotics due to the injudicious use of antimicrobial agents is recognized as a major problem globally. The clinicians are in a dilemma with limited treatment options available, more importantly for the management of complicated UTIs and nosocomial UTIs frequently seen in catheterized patients in the ICU setting. The present study demonstrates extremely low susceptibility of Gram-negative uropathogens to first-line agents, that is, ampicillin-sulbactam, cephalosporins, gentamicin, and norfloxacin. Among the common oral antibiotics, least resistance was observed for ofloxacin. So, ofloxacin can possibly be recommended as the drug of choice for the empirical treatment of uncomplicated UTI because as demonstrated by our data, the percentage resistance for ampicillin-sulbactam and norfloxacin are quite high and therefore cannot be used for empirical treatment in the current setting. In the present study, comparatively, Gram-negative uropathogens were less resistant to amikacin, piperacillin-tazobactam, and imipenem. Other studies [7],[9],[10] have also reported similar findings. It has been seen that amikacin is generally effective against Enterobacteriaecae. E coli and Pseudomonas were found to be less resistant to amikacin (27.8 and 27.5%, respectively). Piperacillin-tazobactam was found to be least resistant against Proteus spp. (3.8%). It can be stated that amikacin could be recommended as empirical therapy for complicated UTIs. Piperacillin-tazobactam and imipenem are kept as reserve drug options because the increasing resistance to imipenem in Acinetobacter and Pseudomonas calls for a check on the indiscriminate use of imipenem for the treatment of UTI. The changing antibiotic sensitivity of uropathogens with time and emergence of multiple-drug resistance in them is a matter of concern. In India, there are no clear-cut recommendations on how frequently antimicrobial surveillance should be done. Studies depicting the local resistance pattern of uropathogens should be done periodically so as to assist the policy makers to formulate and assess policies for antibiotic prescriptions in India.

Ofloxacin and amikacin are recommended as the drugs of choice for the empirical treatment of UTI, whereas specific treatment should be based on the etiological agent isolated in urine culture and its in vitro susceptibility pattern. There is a strict need for developing specific guidelines for antibiotic prescriptions for UTI in India and directing the attention of the authorities to the development of increasing antibiotic resistance of uropathogens.

 
  References Top

1.Stamm WE, Norrby SR. Urinary tract infections: Disease panorama and challenges. J Infect Dis 2001;183(Suppl 1):S1-4.  Back to cited text no. 1
[PUBMED]    
2.Gupta K, Hooten TM, Stamm WE. Increasing antimicrobial resistance and the management of uncomplicated community acquired urinary tract infections. Ann Intern Med 2001;135:41-50.  Back to cited text no. 2
    
3.Nicolle LE. Epidemiology of urinary tract infection. Infect Med 2001;18:153-62.  Back to cited text no. 3
[PUBMED]    
4.Finch RG. Antibiotic resistance. J Antimicrob Chemother 1998;42:125-8.  Back to cited text no. 4
[PUBMED]    
5.Manges AR, Natarajan P, Solberg OD, Dietrich PS, Riley LW. The changing prevalence of drug-resistant E coli clonal groups in a community: Evidence for community outbreaks of urinary tract infections. Epidemiol Infect 2006;134:425-31.  Back to cited text no. 5
[PUBMED]    
6.Kahan NR, Chinitz DP, Waitman DA, Dushnitzky D, Kahan E, Shapiro M. Empiric treatment of uncomplicated urinary tract infection with fluoroquinolones in older women in Israel: Another lost treatment option? Ann Pharmacother 2006;40:2223-7.  Back to cited text no. 6
[PUBMED]    
7.Akram M, Shahid M, Khan AU. Etiology and antibiotic resistance pattern of community-acquired urinary tract infection in JNMC Hospital Aligarh, India. Ann Clin Microbiol Antimicrob 2007;6:4.  Back to cited text no. 7
[PUBMED]    
8.Bahadin J, Teo SS, Mathew S. Aetiology of community-acquired urinary tract infection and antimicrobial susceptibility patterns of uropathogens isolated. Singapore Med J 2011;52:415-20.  Back to cited text no. 8
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9.Ahmed AA, Osman H, Mansour AM, Musa HA, Ahmed AB, Karrar Z, et al. Antimicrobial agent resistance in bacterial isolates from patients with diarrhea and urinary tract infection in the Sudan. Am J Trop Med Hyg 2000;63:259-63.  Back to cited text no. 9
[PUBMED]    
10.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.  Back to cited text no. 10
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