European Journal of Cardiovascular Medicine

Urinary Tract Infections are defined by the presence of a growth of more than 10⁵ colony forming units (CFU) of bacteria per ml of urine. In urine sample obtained by supra pubic aspiration or in-and-out catheterization and in samples from a patient with an indwelling catheter, colony count of 10²-10⁴/ml generally indicates infection. UTIs, the most common bacterial infections originating from community or hospital settings. ^[1,2] These infections pose a notable public health concern, with around 150 million cases diagnosed annually resulting in economic losses exceeding 6 million. ^[3]

UTIs can impact any part of the urinary system—urethra, bladder, ureters, and kidneys yet primarily affecting the lower urinary tract. The complications of UTIs vary depending on which part of the urinary system is affected. UTIs may manifest with or without symptoms, which can range from acute to chronic, and the severity of infection can vary from mild to severe.^[4] The clinical presentation of UTIs is influenced by factors such as the type of the causative agent, the severity of infection and the immune response of the individual.^[5] While UTIs affect both sexes, females are more susceptible than males, due to anatomical and physiological differences such as a shorter urethra, the absence of prostatic secretion, pregnancy, and fecal contamination of the urinary tract.^[6] Most UTIs involve gastrointestinal bacteria, likely stemming from contamination of the rectal area and subsequent spread to the urethra and bladder.^[7]

UTIs in pregnancy lead to poor outcomes in both the mother and child, including preterm labour. The perinatal morbidity and mortality rate of preterm babies is 2-7 times higher in comparison to term pregnancies. A preterm neonate experiences numerous problems both during and after delivery. ^[8,9]

In this context, empirical antibiotic therapy is commonly administered, necessitating knowledge of prevalent uropathogens and their susceptibility to commonly used antibiotics. Treatment complexity increases when risk factors like advanced age, comorbidities, and immunosuppression are present. Physicians often opt for broad-spectrum antibiotics instead of specific ones due to concerns about organism resistance. Resistance has developed due to factors like poor patient compliance and incomplete antibiotic courses. ^[10,11] Globally, studies have revealed shifting patterns in UTI causes, yet research on UTIs and antibiotic resistance patterns in India is limited compared to other countries. Understanding current uropathogen trends and antibiotic susceptibilities is crucial for developing guidelines for empirical UTI treatment while awaiting culture sensitivity results. ^[12,13]

Hence the present study is planned to determine the clinico- microbiological profile & drug susceptibility pattern of bacterial pathogens causing UTI to help us avoid the risk factors possible to lower the rate of UTI especially the nosocomial UTI.

The present record based cross sectional study was conducted among clinically confirmed cases of urinary tract infection in a tertiary care hospital during the period of November 2018 to October 2019. Ethical approval was obtained from the institutional ethical committee prior to the commencement of the study. Since it was a record-based study, patient’s informed consent was not required.

Data was collected from laboratory records regarding the prevalence, microbiological profile of the clinically confirmed cases of urinary tract infection patients. Sample size(n) was calculated by using the formula

[n=4pq/d²],

where p is prevalence,

q=100-p,

d is allowable error.

Prevalence(p) is 34%(T.S. Shailaja et al, urinary culture positive prevalence is 34%) [14], q=66%,

d= 5%;

 n= (4x34x66)/1.75²

so n is approximately around 3000. Hence the sample size was 3000.

The cases were selected on the basis of following inclusion and exclusion criteria:

Inclusion criteria

With fever (>38 ⁰C) and chills, Patient showing one or more of the following symptoms:  Burning micturition, increased frequency, urgency of urine, dysuria and pain lower abdomen / flank pain/ supra pubic pain.

Exclusion criteria

Patients already on antibiotic treatment (duration of more than 7 days)

The demographic and clinical history of patients were noted from the medical records. The variables studied were pathogen isolated and their drug sensitivity pattern using the Kirby- Bauer disk diffusion method. Significant bacteriuria was considered as presence of more than 1,00,000 CFU/ ml of urine. Study tool used for the analysis were SOP for identification. Grey colonies on Blood agar& lactose or non-lactose fermenter on Mac conkey agar. Gram negative bacilli- NLF or LF. Biochemical tests performed were Oxidase test, Indole test, Urease test, Citrate test& Triple sugar iron test. The Antibiotics used in Kirby – Bauer disk diffusion method for Antibiotic susceptibility testing were according to the current guidelines of Clinical and laboratory standards institute (CLSI).

Hemodynamically stable UTI patients were initially treated with oral fluoroquinolones or cephalosporins. For hemodynamically unstable cases, third-generation cephalosporins were administered intravenously. If symptoms persisted after 72 hours and culture revealed ESBL-producing organisms, patients were transitioned to parenteral carbapenem therapy. The standard antibiotic course lasted 7 days, with an additional 48-hour extension if fever persisted beyond this period.

Statistical Analysis

Data collected was entered in Microsoft excel 2020 and analyzed using trial SPSS version 25. Descriptive statistical procedures like percentage, mean and standard deviation were applied.

Out of 3000 samples processed, 345 samples yielded growth of uropathogens demonstrating the prevalence of 11.5%. (Figure 1)

The mean age of patients was 52.34±4.7 years. Pediatric patients comprised of total 7.1% of total patients. Maximum patients were in the age group in 60 to 69 years (25%) and 50 to 59 years (23.5%). Female patients (61.7%) were higher in number as compared to male patients (38.3%) as shown in table 1.

Table 1 Demographic data of patients

The most common symptoms were Dysuria (33.5%), Fever (30.6%), Pollakiuria (16.5%), Pain in abdomen (8.9%), Anuria (7.5%), Hematuria (6%) and Oliguria (5.4%) as shown in figure 2.

Figure 2 Symptoms of urinary tract infection

ESBL-producing Escherichia coli (43.2%), Non ESBL producing Escherichia coli (23.4%), ESBL-producing Klebsiella pneumoniae (9.5%), Non ESBL producing Klebsiella pneumoniae (5.8%), and Pseudomonas aeruginosa (10.6%) were the most prevalent microorganisms in UTI patients as shown in table 2.

Table 2 Distribution of Uropathogens

 The Antimicrobial potency and spectrum for nine selected antimicrobial agents of different classes against the UTI pathogens recorded in the study is shown in Table 3. Meropenem had the least resistance (3.4%), followed by Amikacin (25%), and Nitrofurantoin (27.9%). A high rate of resistance was recorded against Ciprofloxacin, Norfloxacin and Ofloxacin (75.2%).

Table 3 Resistance pattern of the uropathogens to various antibiotics

While UTI is prevalent in developing nations, only 345 out of 3000 suspected cases (11.5%) were confirmed by culture in the current study, highlighting the importance of urine culture for definitive diagnosis. The low rate of culture positivity observed could be attributed, in part, to nonspecific symptoms like fever and abdominal pain. Self-administration of short course antibiotic before giving urine sample for culture & sensitivity. Interestingly, our findings suggest that the presence of combinations of these symptoms increases the likelihood of UTI compared to individual symptoms alone.

In a study conducted by Little et al., increased frequency was identified as the most common symptom in acute uncomplicated UTI.^[15] Sepahi et al. found that fever, pain, irritability, dysuria, and hematuria were the primary clinical presentations of UTI in children with urolithiasis, which was consistent with the findings in the present study.^[16] However, the reliability of using these symptoms alone to predict UTI is questionable. Individually, none of the symptoms were sufficiently sensitive to detect most UTIs. Even when two or more symptoms were considered together, their predictive value remained low. These findings suggest that clinical presentation plays a minimal, if any, role in diagnosing UTI, underscoring the importance of urine culture for accurate diagnosis.

The uropathogen profile observed in our study aligns with findings from another research. ^[17,18] However, there are conflicting reports regarding the impact of diabetes on the profile and antibiotic sensitivity patterns of uropathogens. While Stapleton noted significant differences in the organisms causing UTI in diabetic patients compared to nondiabetics, Bonadio et al. found no such distinction. Our study results echo the latter findings. ^[19,20]

ESBL-producing cases vary across different studies and regions.^[21,22] In our study, 52.7% of isolates were ESBL-producing, a higher rate compared to some previous studies in India. This poses challenges in empirical therapy as ESBL producers do not respond well to standard treatments, leading to increased morbidity, mortality, and treatment costs. Alternative therapies like carbapenems or drugs such as fosfomycin may be necessary.^[23]

The Antibiotic susceptibility pattern revealed quinolones as least effective antibiotic against uropathogens, with increasing resistance rates observed over time. Carbapenems showed the highest sensitivity, followed by aminoglycosides, although resistance to these drugs was also noted. The emergence of carbapenem-resistant organisms is concerning, as these strains are adept at evading antibiotics through various mechanisms. ^[24-26]

Given the growing challenges of multidrug-resistant organisms, there's a pressing need for alternative and cost-effective treatment options. Improved outcomes have been reported with empirical antibiotic therapy in sepsis, suggesting a similar approach could benefit UTI treatment. Decision support systems may aid in determining empirical antibiotic therapy, potentially leading to standardized treatment protocols. However, regional variations in prevalent organisms and antibiotic susceptibility patterns must be considered for effective implementation. ^[27,28]

Clinical presentation indeed plays a minor role in diagnosing UTI. Escherichia coli remains the most common organism causing UTI in the community, but the concerning rise in resistant ESBL producing species warrants attention. Although the resistance pattern is not markedly different from global trends, it is continuously escalating due to the rampant misuse of antibiotics. Urgent decisions are required regarding antibiotic policies for UTI, especially in conditions like CAUTI and strict measures must be implemented to uphold their effectiveness. Failing to do so may leave us vulnerable to these resistant organisms in the near future.

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