Research Article Ofloxacin and Nitrofurantoin sensitivity pattern In Patients of Urinary Tract Infection
(UTI) at a tertiary care teaching hospital
Dharmesh Devmurari1*, Chand Miyaan Kamal2, Shambhu Nath Singh3, Amit Kumar4
1*Department of Microbiology, Gujrat Adani Institute of Medical Sciences, Bhuj, Gujarat.
2Department of Pharmacology, SMMH Government Medical College, Saharanpur, India
3Department of Pharmacology, Darbhanga Medical College and Hospital, Bihar.
4Department of Pharmacology, Teerthanker Mahaveer Medical College __________________________________________________
Abstract
Introduction: UTIs are the second most common bacterial infection in present population.
Women are more prone to UTI than Male. Uropathogenic Escherichia coli is responsible for
>80% of community acquired UTIs.
Aims: The present study was carried out to compare sensitivity / Resistance between Ofloxacin and Nitrofurantoin in UTI patients.
Methods: This was a prospective, cross-sectional, observatory study conducted on patients (n = 200) suffering from Urinary Tract Infection from March 2014 to February 2015 at the Department of Microbiology and Department of Pharmacology, Teerthanker Mahaveer Medical College and Research Centre (TMMC & RC), at a tertiary care teaching hospital, in Moradabad, Uttar Pradesh, India.
Results: UTI was much more common in females (61%, n=122) than in males (39%, n=78).
The most common organism isolated was E. coli, 47%(n=94), followed by Klebsiella 34.5%(n=69), staphylococcus 7.5%(n=15), Proteus, pseudomonas 4%(n=8) and enterococcus 3%(n=6). E. coli was highly sensitive to the Ofloxacin 18% (n=36).
Conclusion: Sensitivity pattern of the antimicrobial was found to be more in Nitrofurantoin (57%) was found to be more sensitive than Ofloxacin (40.5%) for the treatment of UTI.
Keywords: Nitrofurantoin, Ofloxacin, Antimicrobial agents, Sensitivity
Copyright: © publisher IABCR. This is an open access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
UTIs are the second most common bacterial infection in present population. UTIs are one of the important causes of morbidity and mortality in Indian population, affecting all age group across the life span. Nevertheless, it is a difficult to accurately assess the incidence of UTIs, because they are not reportable diseases in the United States. This situation is further complication by the fact that accurate diagnosis depend upon both the presence of symptoms and a positive urine culture, although in the most outpatient setting this the diagnosis is made without the benefit of culture. Women are significantly are more likely to experience UTI than man.
Nearly 1 in 3 women will have had at least 1 episode of UTI requiring antimicrobial therapy by the age of 24 years.
Catheter-associated UTI is the Most common nosocomial infection, according for >1 million case in hospital and nursing home. [1]
Uropathogenic Escherichia coli is responsible for >80% of community acquired UTIs, with most other infection caused
by Staphylococcus saprophyticus, Klebsiella pneumonia, Proteus mirabilis and Enterococcus faecalis. [2] The organism that caused urinary tract infection is those, which are normally present in renal area. E.coli, Klebsiella and Enterobacteria account for 90% of urinary tract infection. [3]
Proteus, Coagulase Negative Staphylococcus and Pseudomonas also cause urinary tract infection. [4]
UTI is defined by a combination of clinical feature and the presence of bacteria in urine. It is also defined by the presence of more than 100,000 colony –forming unit of single bacteria in culture in urine. The clinical feature of UTI may include both specific and nonspecific signs and symptoms. Accurate diagnosis and treatment of UTI is essential to limit its associated morbidity, mortality and to avoid prolonged or unnecessary use of antibiotics. [5]
Antibiotics for empiric treatment of uncomplicated UTI
include First-line antibiotic:
trimethoprim/Sulphamethoxazole (Cotrimoxazole) in Received: 12 Aug 2015
Revised: 14 Aug 2015 Accepted: 18 Aug 2015
*Correspondence to:
DrDharmesh Devmurari Address: Department of Microbiology, Gujrat Adani Institute of Medical Sciences, Bhuj, Gujarat.
Email:
communities with resistance rates for E coli less than 20%.
Avoid in women who have been treated within 6 months, as they are more likely to have resistant organisms. [6]
Second-line antibiotics: or first-line in resistant communities:
Nitrofurantoin.
Fluoroquinolones, such as ciprofloxacin, Levofloxacin, Norfloxacin, and Ofloxacin. Their efficacy is comparable to co-trimoxazole, but increasing resistance rates have been noted. [7]
Alternates: third-generation Cephalosporin’s, Nitrofurantoin, Fosfomycin.
The following should not be used unless indicated by individual patient culture Sensitivities: first- or second- generation cephalosporin, Ampicillin and amoxicillin with Clavulate. [8]
Single-dose regimens: Although single-dose therapy using β- lactams, trimethoprim-sulfamethoxazole, trimethoprim, and Fluoroquinolones have shown high cure rates, single-dose therapy is associated with a high rate of recurrence within 6 weeks of initial treatment. Reinfection may be due to the failure of single-dose treatment to eradicate gram-negative pathogens from the perianal area. Amino penicillin and first- generation cephalosporin’s have shorter half-lives, which may contribute to their lower efficacy compared with other agents. [9]
In the treatment of urinary tract infections, the resolution of bacteraemia has been correlated with the concentration of the antimicrobial agent in the urine rather than serum levels. [10]
All the antimicrobial agents approved for the treatment of urinary tract infections achieve inhibitory urinary concentrations that significantly exceed serum levels.
Nitrofurantoin, a chemotherapeutic compound of the Nitrofuran family, was introduced into clinical practice in 1952. Nitrofurantoin is a synthetic antimicrobial derived from furan by the addition of a nitro group and a side chain containing hydantoin. Nitrofurantoin is a weak acid and its solubility is affected by PH. [11]
Nitrofurantoin spectrum of in vitro susceptibility includes the majority of Escherichia coli, Citrobacter species, group B Streptococci, Enterococci, Staphylococcus aureus, S.
epidermidis, Klebsiella pneumoniae and Enterobacter species. [11] Thus, its antibacterial spectrum is broad and is particularly effective against the main Uropathogen, hence its use for the treatment of urinary tract infections (UTI). In a recent study, the susceptibility for E. coli was 99.5%. High susceptibility of E. coli clinical isolates to Nitrofurantoin
(2.3% resistance rate), compared to
trimethoprim/sulfamethoxazole (29%) or ciprofloxacin (24.2%) was recently confirmed.[12] However, Nitrofurantoin is less susceptible against Gram-negative pathogens other than E. coli, such as Klebsiella spp. (69.2%) or Enterobacter
spp. (63%). There is no activity against Proteus spp. or P.
Aeruginosa. [13]
Ofloxacin is a synthetic antibiotic of the Fluoroquinolones drug class considered to be a second-generation Fluoroquinolones.[14] Ofloxacin is a broad-spectrum antibiotic that is active against both Gram-positive and Gram-negative bacteria. Susceptible bacteria:
Therefore the present study was carried out to compare sensitivity / Resistance between Ofloxacin and Nitrofurantoin in UTI patients attending in Teerthanker Mahaveer Medical College and Research centre, Moradabad U.P.
Method Study setting
This was a prospective, cross-sectional, observatory study conducted on patients (n = 200) suffering from Urinary Tract Infection from March 2014 to February 2015 at the Department of Microbiology and Department of Pharmacology, Teerthanker Mahaveer Medical College and Research Centre (TMMC & RC), at a tertiary care teaching hospital, in Moradabad, Uttar Pradesh, India. Patients were recruited on the basis of inclusion and exclusion criteria.
A total of 200 urine samples were collected and then transported to the Microbiology laboratory for culture and antimicrobial sensitivity test. Analyzation of data was carried out on focusing on the gender, age, isolation of bacteria, gram staining and Antimicrobial sensitivity.
Data collection
Analyzation of data was carried out on focusing on the gender, age, isolation of bacteria, and the antibiotic sensitivity data of all isolates was also reviewed and analysed.
Using a calibrated loop (volume - 0.005ml) streaking was done on cysteine lactose electrolyte
The isolated organism from culture plate was then assessed for antimicrobial susceptibility test by disk diffusion method in Muller Hilton agar. Comparison was done by measuring the zone of inhibition between two antibiotics i.e. Ofloxacin and Nitrofurantoin.
Ethical approval
Ethical approval for the study was obtained through the Medical research and Ethics Committee at the Teerthanker Mahaveer Medical Collage and Research Centre (TMMC &
RC).
Data analysis
Data were coded, checked for completeness and consistency.
Then the data were entered and analysed into the computer by using Microsoft excel and SPSS 16.0.
Comparative study of two antibiotics was done by using t-
test.
Results
The study reveals that urinary tract infection (UTI) was much more common in females (61%, n=122) than in males (39%, n=78). The female sufferers were found more within the age group of (30-39) years (n=36), followed by the age group (20-29) years (n=34), and males patients were found more within the age group of (50-59) (n=20) years, followed by the age group (60-69) 7 %( n=14) (Table 1).
The incidence of UTI was maximum in age group (20-29) year (23%, n=46), followed by the age group (30- 39) (21%, n=42), followed by the age group (50-59) (19%
,n=38), followed by the age group (40-49) (14% ,n=28), followed by the age group (10-19 & 60-69) (7% , n=14), followed by the age group (<10) (6%, n=12), and age group (70-79 & 80-89) years had the last percent 2,1% (n=2,4) respectively (Table 1, Fig. 1).
Table 1: Demographic details of UTI patients
The most common organism isolated was E. coli, 47%(n=94), followed by Klebsiella 34.5%(n=69), staphylococcus 7.5%(n=15), Proteus, pseudomonas 4%(n=8) and enterococcus 3%(n=6) (Table 2, Fig. 2).
Table 2: Total no. Of isolated organism obtained from urine Sample (n=200)
Nitrofurantoin was found sensitive in n=114 (57%) cases.
E.coli were found highly sensitive to the Nitrofurantoin n=65 (32.5%) samples, followed by the Klebsiella n=27 (13.5%) samples, staphylococcus 5.5%(n=11) cases, Proteus 3%(n=6) sample, pseudomonas 1.5%(n=3) sample and enterococcus were least sensitive in 1%(n=2) sample (Table 3, Fig. 3).
Prevalence of Ofloxacin sensitivity against Uropathogens was found to be 40.5% (n=81). E. coli were sensitive to the ofloxacin 18% (n=36) in out of 94 sample, followed by the Klebsiella 14% (n=28) in out of 69 sample, staphylococcus 3%(n=6) in out of 15sample, pseudomonas 2.5%(n=5) in out of 8 sample, Proteus 1.5% (n=3) in out of 8 sample and enterococcus were least sensitive 1.5% (n=3) in out of 6 sample (Table 4, Fig. 4).
Table 3:- distribution of isolated bacteria which sensitive to the nitrofurantoin
Table 4:- distribution of isolated bacteria which sensitive to the Ofloxacin
Table 5:- compare the sensitivity between Ofloxacin and nitrofurantoin drugs.
Age range (years)
No. of Patien t (n)
Male NO.
%
Female NO.
%
Total (%)
<10 12 6(3%) 6(3%) 6%
10-19 14 6(3%) 8(4%) 7%
20-29 46 12(6%) 34(17%) 23%
30-39 42 6(3%) 36(18%) 21%
40-49 28 8(4%) 20(10%) 14%
50-59 38 20(10%) 18(9%) 19%
60-69 14 14(7%) 0 7%
70-79 4 4(2%) 0 2%
80-89 2 2(1%) 0 1%
TOTAL 200 78(39%) 122(61%) 100%
S.no. Organism Male Female Total
1 E.coli 40 54 94
2 Klebsiella 23 46 69
3 Proteus 0 08 08
4 Enterococcus 4 02 06
5 Pseudomonas 4 04 08
6 Staphylococcus 7 08 15
7 Total 78 122 200
Organism Sensitive Resistance Total
E.coli 65 29 94
Klebsiella 27 42 69
Proteus 6 2 8
Enterococcus 2 4 6
Pseudomonas 3 5 8
Staphylococcus 11 4 15
Total 114 86 200
Organism Sensitive Resistance Total
E.coli 36 58 94
Klebsiella 28 41 69
Proteus 3 5 8
Enterococcus 3 3 6
Pseudomonas 5 3 8
Staphylococcus 6 9 15
Total 81 119 200
S.
no
Organism Nitrofu rantoin
Ofloxacin Total
1 E.coli 65 36 94
2 Klebsiella 27 28 69
3 Proteus 6 3 08
4 Enterococcus 2 3 06
5 Pseudomonas 3 5 08
6 Staphylococcus 11 6 15
7 Total 114 81 200
Fig. 1: Showing the cases of UTI according to age group of patients
Fig. 2: Total no. of isolate organism obtained from urine sample
Fig. 3: Distribution of isolated bacteria which are sensitive to Nitrofurantoin.
Fig. 4: Distribution of isolated bacteria which are sensitive to Ofloxacin.
Fig. 5: Comparison of sensitivity between Ofloxacin and Nitrofurantoin drugs.
Discussion
The present study revealed that urinary tract infection (UTI) was much more common in females 61% (n=122) than in males 39% (n=78). The female sufferers were mostly found within the age group of (30-39) years (18%, n=36), followed by the age group (20-29) years 17% (n=34), whereas in males, patients reported were mainly found within the age group of (50-59) years (10%, n=20), followed by the age group (60-69) (7%, n=13) (Table 1, Fig. 1). This fact was in accordance with the previous study done by the Jha N1, et al who showed that Urinary tract infection (UTI) was much more common in females than in males. Female sufferers were 53-80% and males were 20-47%, however, in hospital Tribhuwan University Teaching Hospital, Maharajgunj. The female population was 80% and male was 20%. [15]
A study done by the Dash M et al. Showed that most of the UTI patients was female patients in the age range of 20-30 years with highest prevalence rate (27.8%) and then the least was found in age group more than 80 years, this might be
due to reason that female in the reproductive age groups has a high prevalence rate of UTI and similarly the incidence of symptomatic UTI is high in sexually active young women.
[16]
There for based on the result from our study the demographic data showed that the sex and age of the patients was similar to the study done by the Jha N1, et al and slightly similar to the study done Dash M et al. [15,16]
For the pathogenic organism in UTI patients:- The present study showed that the most common organism was E. coli 47% (n=94), followed by Klebsiella 34.5%(n=69), followed by staphylococcus 7.5%(n=15),followed by proteus and pseudomonas 4%(n=8) and enterococcus 3%(n=6). Similar findings were produced by Thapa P et al who showed that E.
coli (65.12%) was the most common pathogen causing UTI followed by Staphylococcus species (11.63%), Proteus species (6.98%), and Klebsiella species (6.4%). [17]
There for based on the result from the our study showed that the pathogenic organisms of the patients of UTI was slightly similar to the study done by the Jha N1, et al and P Thapa et al. [15,17]
For the sensitivity of antimicrobial agents :- The present study showed that the antimicrobial sensitivity of Nitrofurantoin in the urine culture of the UTI patients were 57% (n=114) sample in out of 200 sample, Among them E.coli were 32.5%(n=65) sensitive in out of 94 sample, followed by the Klebsiella were 13.5%(n=27) in out of 69 sample, followed by the staphylococcus were 5.5%(n=11) in out of 15 sample, followed by the Proteus were 3%(n=6) in out of 8 sample followed by the pseudomonas were 1.5%(n=3) in out of 8 sample and enterococcus were 1%(n=2) in out of 6 sample.
Whereas the antimicrobial sensitivity of Ofloxacin in the urine culture of the UTI patients were 40.5% (n=81) sample in out of 200 sample, Among them E. coli were 18% (n=36) in out of 94 sample, followed by the Klebsiella were 14%
(n=28) in out of 69 sample, followed by the staphylococcus were 3%(n=6) in out of 15sample, followed by the pseudomonas were 2.5%(n=5) in out of 8 sample, followed by the Proteus were 1.5% (n=3) in out of 8 sample, and enterococcus were 1.5% (n=3) in out of 6 sample.
Previous study for the sensitivity of antimicrobial in patients of UTIs, done by the Amit Raj Sharma et al showed that the Majority of E. coli showed susceptibility towards nitrofurantoin (94.5%) followed by ciprofloxacin and Ofloxacin with the susceptibility of 50.5% for each drug. [18]
There for based on the result from the our study showed that the sensitivity pattern of the antimicrobial was found to be slightly more in Nitrofurantoin (57%) than in their comparative antimicrobial Ofloxacin (40.5%) for the treatment of the patients of UTI which was slightly similar to the study done by the Sharma AR et al and Thapa P et al.
[17,18] [Table 5, Fig. 5]
And hence we suggest that physician should provide the use of Nitrofurantoin in the treatment of Urinary tract infection patients gives better result than Ofloxacin in the same patients for the requirement of the better results.
Conclusion
Therefore based on the result from our study we concluded that the sensitivity pattern of the antimicrobial was found to be more in Nitrofurantoin (57%) than in their comparative antimicrobial Ofloxacin (40.5%) for the treatment of the patients of UTI.
And also prescribing use of Nitrofurantoin was cost effective then Ofloxacin. Hence we suggest that physician should prescribe Nitrofurantoin in the treatment of Urinary tract infection.
The present study emphasizes the need for constant monitoring failure the treatment and sensitivity of Uropathogen in the region to commonly used anti-microbial agents. Before starting the empirical therapy, knowledge of etiology, predisposing, factors and susceptibility pattern of the Uropathogen is essential to avoid the irrational antibiotics usage. There is a need for developing specific guideline for antibiotics usage for UTI in India.
Limitation of our study is that sample size (n=200) of our study is small & sample is collected from one centre only.
Small sample size study cannot confirm that Nitrofurantoin is better than Ofloxacin. For confirmation of drug sensitivity, samples should be collected from many centres and sample size should also be large.
What this study adds:
1. What is known about this subject?
Ofloxacin was more sensitive against gram negative bacteria.
2. What new information is offered in this study?
Nitrofurantoin was found to be more sensitive than Ofloxacin for the treatment of UTI.
ACKNOWLEDGEMENTS Declared none.
CONFLICTS OF INTEREST None declared FUNDING No funding source.
ETHICS COMMITTEE APPROVAL Approved
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Cite this paper as:
Devmurari D, Kamal CM, Singh SN, Kumar A.
Ofloxacin and Nitrofurantoin sensitivity pattern In Patients of Urinary Tract Infection (UTI) at a tertiary care teaching hospital. Int Arch BioMed Clin Res.
2015 Aug; 1(1):17-22
