ANTIBIOTIC RESISTANCE OF ESCHERICHIA COLI ISOLATED FROM URINARY TRACT INFECTIONS PATIENTS IN THREE IRAQI GOVERNORATES DURING 2011 2012: A COMPARATIVE STUDY

ANTIBIOTIC RESISTANCE OF

ESCHERICHIA COLI

ISOLATED

FROM URINARY TRACT INFECTIONS PATIENTS IN THREE IRAQI

GOVERNORATES DURING 2011- 2012: A COMPARATIVE STUDY

1

*Hawraa A. A. Al-Dahhan, 2Esraa Sameer Muhana, 3Ali Abdul Hussein Al-Fatlawy

1

*Dr. Assis. Prof., 2Ass. Researcher and 3M.Sc. Lecturer,

Kufa University/Collage of Science/Lab. Investagation.

ABSTRACT

This study was conducted into three Iraqi governorates (Baghdad,

Babylon, Al-qadysia) during two years (2011-2012) , in which a total of

2162 urine specimens were collected from out and in patient with

urinary tract infection. Babylon city appeared to be the high percent of

E.coli isolated during 2011 (68.4) and 2012 (68.8) followed by

AL-qadysia (63%, 65.1%) and Baghdad (50.7, 60%), respectively. In

Baghdad high E.coli isolate (25.2%) in (41-50) age group, while in

Babylon and in al-qadysia the high E.coli isolated in age group (21-30)

in aperecent 20.9% and 20.8% , respectivly. baghdad show a high

e.coli isolate (25.3%) in (41-50) age group , while babylon and al-

qadysia appeared in (1-10) and (21-30) in apercentes 12.8% and 20.5% respectivly. Females

show a high perecent of isolate than male during the tow years in three cities. In Baghdad the

highest resistance of e.coli appeared to nitrofuranton (45.1%) and cotrimoxazol (45.1%)

during 2011, while e.coli appered high resistance to cn (34.4%) ctr (22.8%) and ctp (20.3%)

during 2012. E.coli isolated from babylon govornorate hospital during 2011 found to be the

high resistance to ampicillin (24.2%), while the high resistance to amx (30.3%) and amp

(29.4%) during 2011. The antibiogram of E.coli isolated from al-qadysia governorate hospital

during 2011 and 2012 appeared high resistance to cip (15.1%). Amx(3.1%) and ctx(0.8%)

show less antibiotic resistance by E.coli during 2011 and 2012.

KEYWORDS: E.coli, urinary tract infections, antibiotic resistance.

7105 – 2277 ISSN Research Article . 257 -246 Volume 5, Issue 7,

*Corresponding Author Dr. Hawraa A. A. Al-Dahhan

Dr. Assis. Prof. Kufa

University/Collage of

Science/Lab. Investagation. Article Received on

10 May 2016,

Revised on 30 May 2016, Accepted on 20 June 2016

INTRODUCTION

Urinary tract infections (UTIs) are among the most common bacterial infections (Foxman,

2002), causing significant morbidity and mortality and costing the healthcare system of the

United States well over a billion dollars annually (Russo & Johnson, 2003).They can involve

any age group and are often followed by recurrences which increase the risk of long term

kidney lesions. UTI is nearly 10 times more common in females than in males (except in

elderly males) and affects 10% to 20% of all females at least once Urinary infections are

frequently caused by enterobacteria. UTIs result from ascending infection by a single

gram-negative, enteric bacterium, such as Escherichia coli, Klebsiella, Proteus, Enterobacter,

Pseudomonas, or Serratia. E. coli is responsible for about 70% to 80% of all the

uropathogens (Peterson et al., 2007).

Escherichia coli occupying the first place in their etiology. Most community-acquired UTIs

are due to uropathogenic E. coli (UPEC) infections (Donnenberg & Welch, 1996). UPEC

(Uropathogenic E. coli) is one of the main causes of urinary tract infections. It is part of the

normal flora in the gut and can be introduced many ways. In particular for females, the

direction of wiping after defecation (wiping back to front) can lead to fecal contamination of

the urogenital orifices. Anal sex can also introduce this bacteria into the male urethra, and in

switching from anal to vaginal intercourse the male can also introduce UPEC to the female

urogenital system. For more info see databases at the end of the article or UPEC

pathogenicity (Mittelman et al.,1997).

UPEC are uniquely endowed with various virulence traits, enabling them to survive and grow

in urine and other extraintestinal environments. The abilities of UPEC to grow

extraintestinally may enable them to cause a variety of diseases, not just urinary tract ones. In

case of E. coli, the epidemiological, experimental and clinical studies have established the

role of multiple virulence factors of E. coli like adhesions operative through type-I fimbriae

and P fimbriae, O serotypes, K1 capsule, serum resistance, hemolysins, cytotoxic nectrotizing

factor (CNF) and siderophores (enterochelin and aerobactin) in relation to uncomplicated and

complicated UTIs (Lee et al.,2007).

The selection and spreading of the strains resistant to the antibiotics is a clinical aspect of

great importance in the present period, requiring the continual monitoring of this fenomenon

complicated UTIs are anatomic defects, vesicouretic reflux (VUR),obstruction, surgery,

metabolic diseases like diabetes mellitus and generalized immunosuppression especially in

patients of organ transplant (Tenea and Dorabat, 2008). Catheterization of urinary tract is one

of the most common factor which predisposes the host to complicated UTIs (Bobos et al.,

2010).

In this study we performed a local surveillance search involving 3 various hospitals in 3

different governorate in Iraq from 2011 to 2012 in order to compare the results relating to

the antibiotic resistance of E.coli isolated from patients with UTI in this period.

MATERIALS AND METHODS Patients and specimens collection

This study was conducted into three Iraqi governorates (Baghdad, Babylon, Al-qadysia)

during two years(2011-2012), in which a total of 2162 urine specimens were collected from

out and in patient with urinary tract infection (most data obtained from hospital). Specimens

were collected with their medical record reviewed for each patients which including name,

age, gender, address and data of collection . All specimens were incubated into macConkey

agar, blood agar plates and incubated at 37c under aerobic conditions.

Identification of bacteria

The bacteria identify according to the diagnostic producers recommended by macfaddin

(2000) and Mims et. al. (2008). the identification of bacteria as established according to the

culture and morphological characteristic, including to the shape of colonies, lactose

fermentation or non-lactose fermenter, appearance pigment production. etc. Morphological &

biochemical test include the catalase test, oxidase test, indole production test, mp. vp.,

Simmon citrate test, triple sugar iron agar test.

Antibiotic susceptibility test

The susceptibility test of E.coli was carried out against antibiotic using the disk diffusion

method on MHA (Bauer et al, 1966).two- ml of brain heart infusion broth have been

inoculated with an isolated colony of the test bacteria and incubated for 24 hours at 37c. After

that, the turbidity of bacterial suspension has been adjusted turbidity of McFarland (0.5)

standard tube. The resulting zone of inhibition have been measured by using a ruler and

compared with zones of inhibition determined by CLSI (2012) and to decide the

RESULTS AND DISCUSSION

3.1 Isolation and Identification of E. coli

Table (1) show the distribution of E.coli isolated from three different hospitals in three

different Iraqi cities during 2011 and 2012. In which Babylon city appear the high percent of

E.coli isolated during 2011 (68.4) and 2012 (68.8) followed by AL-qadysia (63%, 65.1%)

and Baghdad (50.7, 60%) respectively.

The high percent of E.coli isolated from Babylon and Al-qadysia compared with Baghdad

may be due to the high number of hospitals in Baghdad in which the patients may be

attenuated to there and in this study data obtained from one hospital. In the other hand, the

result in this study show increase of E.coli isolated in 2012 than 2011 in all three cities (table

1), these may be due to the increase antibiotic resistance of this bacteria by increased use of

antibiotics.

UTIs account for more than 7 million visits to physicians’ offices and well over 1 million

hospital admissions in the United States annually (Stam and Hooton, 1993). French

epidemiologic studies evaluated its annual incidence at 53,000 diagnoses per million persons

per year, which represents 1.05% to 2.10% of the activity of general practitioners (Pinson et

al., 1994). In the United States, the annual number of diagnoses of pyelonephritis in females

was estimated to be 250,000 (Meyrier, 2007).

Further, Rodrigues-Siek et al., (2005) revealed that UPEC and APEC have similarities in

their serogroups, virulence genotypes and assignments to phylogenetic groups, supporting the

hypothesis that poultry may be a vehicle for E. coli capable of causing human urinary tract

disease.

Although it is widely accepted that the source of E. coli causing most UTIs is the colonic

flora of affected individuals (Salyers & Whitt, 1994), there is no consensus as to the source of

the urovirulent clones inhabiting the colon. Although some UTIs might involve sexual

transmission (Johnson & Delavari, 2002) or exposure to the excreta of dogs with UTIs

(Johnson et al., 2000), the major source of these urovirulent clones is unknown.

Alzahrani and Gherbawy(2011). Reveled that the overuse of antibiotics in human medicine

and agriculture is a growing concern for public health. Overuse combined with inadequate

encoding antibiotic resistance in surface waters, river sediments and the feces of wild animals

exposed to waste residuals. The multiple resistance of bacteria against antibiotics resulted

from the fact that domestic and industrial waste were emitted into threw away without

clarifying and so affect the underground water resources.

Table (1): The distribution of E.coli isolated from three different hospital in three different cities during 2011 and 2012

2012 No.of Samples 2011 No.of Samples

Region E.coli E.coli

% No. % No. 60.0 241 416 50.7 226 446 Baghdad 68.8 119 173 68.4 91 133 Babylon 65.1 244 375 63.0 385 619 AL-Qadysia

3.2 distrtbution of E.coli according to age group and sex

The patients age in this study organized into sex groups(table2 and 3). Table (2) show the

distribution of e.coli, isolated from three different cities in three different hospitals during

2011 according to age group. In this table appear to be high e.coli isolate (25.2%) in (41-50)

age group. While in babylon and in al-qadysia the high e.coli isolated in age group (21-30) in

aperecent 20.9% and 20.8%, respectivly.

Table (3) illustrate the distribution of e.coli isolated from three different cities in three

different hospital during 2012. In which baghdad show a high e.coli isolate (25.3%) in

(41-50) age group, while babylon and al-qadysia appeared in (1-10) and (21-30) in apercentes

12.8% and 20.5% respectivly.

The distribution of E.coli isolated from UTI patient in three cities according to sex during

2011 and 2012 where appeared in table(4) and in figure(1_a) and figure (1_b). in both figures

females show a high perecent of isolate than male during the tow years.

The incidence of UTI is higher among females, in whom it commonly occurs in an

anatomically normal urinary tract. Conversely, in males and children, UTI generally reveals a

urinary tract lesion that must be identified by imaging and must be treated to suppress the

cause of infection and prevent recurrence (Meyrier, 2007). Reinfections and relapses are

common in women who develop uncomplicated UTI. Understanding the pathogenesis of UTI

More than 70% of the tested strains were isolated from urinary tract infections in women. The

same situation was reported by many other authors (Akram et al., 2007; Hori et al., 2007).

The increased incidence of the urinary infections in women is conditioned by favouring

anatomic factors, by hormonal changes and by the urodynamic disturbances occurring with

age (Hatieganu et al. 2010).

Our study consistent with other studies (Kang et al. 2011; Ghadiri et al. 2012) they have

beenextensively reported that adult women have a higher prevalence of UTI than men

because of anatomic and physical situations.

Table (2). the distribution of E.coli isolated from three different cities in three different hospitals during 2011 according to age group

AL-Qadysia Babylon

Baghdad

Age group _%

NO. % NO. % NO. 11.4 44 13.2 12 5.3 12 1---10 15.6 60 14.3 13 14.6 33 11---20 20.8 80 20.9 19 18.6 42 21---30 19.7 76 16.5 15 13.7 31 31---40 19.2 74 17.6 16 25.2 57 41---50 13.2 51 17.6 16 22.6 51 -60 50----385 226 Total

Table (3): the distribution of E.coli isolated from three different cities in three different hospital during 2012 according to age group

Age group Baghdad Babylon AL-Qadysia

NO. % NO. % NO. %

1---10 21 8.7 26 21.8 36 14.8

11---20 43 17.8 46 13.4 48 19.7

21---30 32 13.3 22 18.5 50 20.5

31---40 33 13.7 17 14.3 47 19.3

41---50 61 25.3 20 16.8 31 12.7

51---60 51 21.2 18 15.1 32 13.1

total 241 119 244

Table (4): The distribution of E.coli isolated from three different cities in three different hospitals UTI patient according to sex during (2011 -2012)

Region

2011 2012

E.coli E.coli

Total No. of E.coli

Male Female Total No.

of E.coli

Male Female

No. % No. % No. % No. %

Baghdad 226 100 44.3 126 55.8 241 93 38.9 148 61.1

Babylon 91 38 41.8 53 58.2 119 53 44.5 66 55.5

2011

Figure(1-a)The distribution of E.coli isolated from three different cities in three different hospitals UTI patient according to sex during(2011)

2012

Figure(1-b)The distribution of E.coli isolated from three different cities in three different hospitals UTI patient according to sex during(2012)

3.3 Antibiotic resistance of E.coli

Table(5) and figure (2) show antibiogram of E.coli isolated from baghdad governorate

hospital during 2011 and 2012. in which the highest resistance of E.coli appeared to

(38.5%) and ampicillin (21.7%) during 2011, while E.coli appered high resistance to CN

(34.4%) CTR (22.8%) and CTP(20.3%) during 2012. E.coli show less resistance to TOP

(7.1%) and NIT(1.7%) during 2011 and 2012 respectively. Fig.(4)shows the antibiotic

resistance of E.coli to antibiotic on MHA.

Table(5) and fig.(3). Show antibiogram of E.coli isolated from babylon govornorate hospital

during 2011 and 2012 E.coli found to be the high resistance to ampicillin (24.2%),

amoxicillin (23.1%) and CN (23.1%) during 2011 while high resistance to AMX (30.3%),

AMP (29.4%) and CN (18.5%) during 2011. E.coli appeared less resistance to CTR (9.9%)

and COT (11.8%) during 2011 and 2012, respictivly in babylon city.

The antibiogram of E.coli isolated from al-qadysia governorate hospital during 2011 and

2012 were showing in table (5) and figure (4). Since E.coli appeared high resistance to CIP

(15.1%) during 2011. and 24.2%, 17.2% and 15.2% CTR, NA and NT, respectivly.

AMX(3.1%) and CTX(0.8%) show less antibiotic resistance by E.coli during 2011 and 2012.

Quinolones are one of the most widely used antibiotics in the community for the treatment of

UTI and it is this unfortunate excessive use of the agent that has led to a considerable and

worrying increase in the rate of E. coli resistant isolates in many countries(NickEL, 2007).

The increase in quinolone resistance among community- acquired urinary E. coli is a cause of

concern. Fosfomycin, mecillinam and nitrofurantoin have preserved their overall in vitro

efficacy and represent effective options when dealing empirically with these common

conditions.

Worldwide, quinolones are being used as the most common antimicrobial for all UTIs, both

complicated and. An appropriate antibiotic for treating UTI must be bactericidal and conform

to the general specifications: firstly, its pharmacology must include, in case of oral

administration, rapid absorption and attainment of peak serum concentrations; second, its

excretion must be predominantly renal; thered; it must achieve high concentrations in the

renal or prostate tissue; Finally, it must cover the usual spectrum of enterobacteria with

reasonable chance of being effective on an empirical basis(Meyrier, 2007).

The highest resistance rate of E. coli isolate which was obtained from urine samples was

against nalidixic acid followed by cotrimoxazole, ciprofloxacin and ampicillin, respectively

as a long time in our hospital. In this study, amikacin and imipenem had thewidest coverage

against E. coli isolates (97.5%).

In a recent surveillance study in Iran, Ahsan et al. (2011) reported that the highest resistance

rate of E.coli isolates which were obtained from various clinical specimens at 11 hospitals

was against tetracycline followed by amoxicillin and penicillin, respectively.

Table (3): the resistance to antibiotics during three different cities in three different hospital in (UTI) patient during 2011-2012.

Figure (2): Antibiogram of E.coli isolated from Baghdad governorate hospital during 2011-2012.

Antibiotics Baghdad Babylon AL-Qadysia

Types Symbol 2011(226) 2012(241) 2011(91) 2012(119) 2011(385) 2012(244)

NO. % NO. % NO. % NO. % NO. % NO. %

Ampicillin AMP 49 21.7 21 8.7 22 24.2 35 29.4 12 3.1 9 3.7

Amoxicillin AMX 5 2.2 19 7.92 21 23.1 36 30.3 17 4.4 19 7.8

Cephatexin CTX 18 8 46 19.1 11 12.1 18 15.1 13 3.4 2 0.8

Naledix acid NA 40 17.7 43 17.8 15 16.5 19 16.0 39 10.1 42 17.2

Gentamycin CN 90 39.8 83 34.4 21 23.1 22 18.5 58 15.1 33 13.5

Nitrofunt NIT 102 45.1 4 1.7 14 15.4 17 14.3 40 10.4 37 15.2

Cotrimaxazol COT 102 45.1 27 11.2 12 13.2 14 11.8 18 4.7 14 5.7

Ceftriaxone CTR 39 17.3 55 22.8 9 9.9 15 12.7 42 10.9 59 24.2

Ciprofloxacin CIP 87 38.5 49 20.3 14 15.4 20 16.8 61 15.8 35 14.3

Figure (3): Antibiogram of E.coli isolated from Babylone governorate hospital during 2011 and 2012.

Figure (4) Antibiotic resistance of E.coli isolated from UTI on MHA medium

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