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2023.08.02.67
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Estimate of the most common bacteria cause of UTI and effective drug in Alrefaai City

Murtadha A. Al‑khegane1,*, Wisam Jasim Abed Ali2, Zainab Ashour3, Dip Turki Ibrahim4, Murtadha K. Najim5, Qais R. Lahhob6,*
1 Department of Pathological Analysis, College of Science, University of Sumer, Dhi Qar, Alrefaai, Iraq.
2 Department of Pathological Analysis, College of Science, University of Sumer, Dhi Qar, Alrefaai, Iraq.
3 Department of Pathological Analysis, College of Science, University of Sumer, Dhi Qar, Alrefaai, Iraq.
4 AlRifaai General Hospital. Iraq.
5 AlRifaai General Hospital. Iraq.
6 National University of Science and Technology, Nasiriyah, Iraq.
Available from: http://dx.doi.org/10.21931/RB/2023.08.02.67

ABSTRACT

Background: Urinary Tract Infection is a worldwide prevalence disease that infects both males and females in different ratios. Escherichia coli is the most infectious pathogen, followed by Klebsiella and Pseudomonas. Through time bacteria increase their resistance to most antibiotics, increasing bacterial prevalence and pathogenesis. Fifty patients with UTI symptoms were randomly selected in Alrefaai Hospital from October 2021 to April 2022. A 10-15 ml urine sample was collected from each patient and cultured to calculate colony forming unit and detect the type of bacteria with biochemical tests. Most patients were female 66% compared to male 34% with age groups 1-30 years 68% and those more than other groups. Escherichia coli is the most prevalent, 54%, while the second one is Staphylococcus aureus 20%, then Coagulase -ve Staphylococcus 14% and less infection was with Klebsiella and Proteus, 6%. Antibiotic Imipenem, Chloramphenicol, Gentamycin, Norfloxacin, Ciprofloxacin and Tobramycin play highly effective roles on most bacteria. We found that most patients with UTI were from the city center and in the age group 1-30 years. The most prevalent pathogens of UTI were Escherichia coli and then Staphylococcus aureus. Almost Imipenem, Chloramphenicol, Gentamycin, Norfloxacin, Ciprofloxacin and Tobramycin are the best effective antibiotics against our study's bacteria.
Keywords: Urinary Tract Infection, Recurrent UTI, Alrefaai city, Antibiotic susceptibility.
INTRODUCTION

Urinary tract infections (UTIs) are severe public health caused by a variety of pathogens with topping bacterial infections in community practice; bacterial infections have a high incidence of morbidity and financial cost  1,2. UTI is a worldwide disease affecting both males and females in different ratios, especially those between 50 and 70. In the Iraqi population, the prevalence rate is 23% for all infections 2. The female is more commonly infected than the male, which puts it at risk of UTI because the female urethra is physically less efficient at blocking the bacterial entrance, also short of the urethra that eases trans bacteria from the anus to the urinary system 3, 1. Many risk factors have a role in increasing the average of infections like diabetic mellitus, hospitalization, pregnancy, hospitalization and stone 4,5; also, neonates with bacteremia are considered as one of the risk groups because of loss of the ability to speak, so parents report fever, lethargy, irritability, poor feeding or vomiting 6. UTIs can affect the lower urinary tract, as well as the upper urinary tract in some cases. The lower UTI infection is called cystitis, which is characterized by symptoms such as dysuria, frequency, urgency, and suprapubic soreness without chills, fever, or back pain. 7, while Symptoms of pyelonephritis, such as loin pain, flank discomfort, fever, or other indicators of a systemic inflammatory reaction, are familiar with upper UTI 8.
The most common pathogenic infectious of the urinary tract is the bacteria in both types' Gram-positive and Gram-negative; the most responsible genus for UTIs infections within Gram-negative is Escherichia coli, followed by Klebsiella, Pseudomonas, and Proteus spp. While the gram-positive groups are Staphylococcus spp and Streptococcus spp.9. Sometimes, no growth of bacteria appears in the bacterial culture of urine despite clinical manifestation and appearing of pus in urine above the normal range; this reflects many influences like using of Antibiotics less than 3 days before sample collection, Mycobacterial infection, Viral infection, Parasite infection and Fungal infection. 10,11. The antibiotic resistance of bacteria is worldwide; some patients use different types of antibiotics without medical consultation, others start treatment with highly effective antibiotics at younger age, and some patients use the drug in a short time12,13. All of these factors facilitate bacterial development and then increase the mechanism of resistance to antibiotics. We aimed to estimate of most prevalent bacteria and the most effective antibiotics on the bacteria.
MATERIAL AND METHOD

Patients
Urine samples were collected from 50 patients with recurrent symptoms of UTI (most of them with upper UTI); a random selection of patient's gender and age was in Alrefaai Hospital from October 2021 to April 2022, and all of them resisted some antibiotics used at the past without healing. The physician sent them to the laboratory to detect the best choice of antibiotic. The patients stopped using antibiotics less than 3 days before urine collection—patients' data such as name, age and address in central or peripheral of Alrefaai city.

Culture
Midstream random urine samples (10 - 15 mL) were collected in sterile disposable containers and transferred to the Microbiology Laboratory of Alrefaai Hospital for culture.
To record the colony-forming units (CFUs) of bacteria in the urine sample manually, bacterial strains were isolated through serially diluting urine samples and spreading on CLED (cystine-lactose-electrolyte deficient) agar then incubated at 37 C for 24 h in an incubator. The colony count cultures ≥ 105CFU/ml were considered significant and included in the study. Colonies were purified using the multiple-streak method and preserved in glycerol stock at -20C for further culturing and characterization experiments.
Preserved and cultured colony was cultured on Blood, and MacConkey agar was prepared according to the manufacturer company (Himedia) 's instruction to differentiate between Gram-positive and Gram-negative bacteria; also, some chemical and biological tests were done to distinguish between bacterial genera.
The antibacterial susceptibility testing of the isolate samples was done using the Kirby-Bauer disk diffusion method 14 on Mueller Hinton agar after streaking of bacteria on its surface; the antibiotics containing discs were from Oxoid.
RESULTS

Of fifty patients there are (66%) were female, and most were in both age groups, 1-15 years and 16-30 years, male was (34%) and also distributed in the same age group. Patients from the center of the city were (78%) while the other (22%) from the Peripheral appear in Table 1.
Central patients were distributed within the 16-30 years age group more than other groups, and the less group was the 31-45 years contain 3 patients; peripheral patients were distributed within the 1-15 years age group more than others and not there any patient within 61-75 years.

Table 1. Selected socio-demographic characteristics and gender of patients with UTI

E.coli is the most prevalent infected pathogen that causes UTI in Alrefaai city with ratio (54%); the second one is Staphylococcus aureus (20%), then Coagulase -ve Staphylococcus  (14%) while less infected is Klebsiella and Proteus (6%) as appear in Figure 1.
Of central patients, 39 are (46%) infected with E.Coli and (23%) with Coagulase-negative Staphylococcus. Spp compared to mostly peripheral patients (82%) infected with E.Coli. Not there mix growth observed in our samples.
     
Figure 1. Type of bacteria in UTI infection
Table 2 describe the age groups of patients and show up the age group 1-15 years and 16-30 years more infected than other groups (34%) for each group, also all types of bacteria in our research and all Proteus present in childhood age group 1-15 years.


Table 2. Frequency Distribution of bacterial infection of the urinary system according to age groups.
   

 
Table 3. Distribution and comparison of bacteria and patients' Age and Gender to Central and periphery groups.
   

Female distribution was 33 (66%) more than the male 17 (34%). Not their significant difference between the Male group of central 12 (30.8%) and periphery 5 (45.5%) from the side and between the female group from central 27 (69.2%) and periphery 6 (54.5%) from the other side. Staphylococcus aureus infects females more than males, while Proteus, Klebsiella and coagulase-negative Staphylococcus spp. Infect only the female in our study as described in Table 3.


Table 4. Resistant and susceptibility rate (%) of isolated uro pathogens.
Several antibiotics resisted by some bacteria, such as E and CL, do not affect Proteus and Klebsiella, Coagulase -ve staphylococcus gonococcus and Proteus resist CFM 100 %, AZM completely resist by Staphylococcus aureus, Coagulase -ve Staphylococcus diplococcus, Proteus and Klebsiella. VA, NA and TE also did not affect Klebsiella, and CTX was 100 % resisted by E.Coli.
Sensitivity tests to the five types of bacteria appearing in the IPM is the broad spread spectrum sensitive antibiotic. C, CN and NOR antibiotics affect more than 50% of isolated bacteria; E.Coli, Proteus and Klebsiella, CIP and TOB affect more than 50% of E.Coli, Proteus, Klebsiella and Coagulase -ve Staphylococcus. Staphylococcus aureus is a highly resistant bacteria for most antibiotics but is sensitive to more than 50% of samples for just VA and TE.
Some antibiotics with shallow sensitivity effects, such as AZM, have less effect on only E.coli (18.52%), while the resistance from all other bacteria, E and NA appear with a low sensitivity spectrum on all types of bacteria.
DISCUSSION

This study provides information about the most prevalent bacteria that cause central and peripheral urinary tract infections in Alrefaai City. Also, please give us an idea about the most effective antibiotic for the five bacteria in our study.
Females were more than males in our sample that suffer from UTI 66 % compared to males 34%, and these results were compatible exactly with most studies like 15,16.
Most UTI patients within age groups 1-15 and 16-30 years, 17% for each one and these results close to 17 in Nigeria that appear age group patients 74.7% with UTI 20-50 years and lowest at >50 years age group 10.3%. Conversely, it differs from the study of 2,18 patients in the age group 41-60 years 59.9% and more than 45 years 64%, respectively. Of patients from the center, 78% were more than peripheral 22%. Patients from the peripheral almost do not use the antibiotic early, so antibiotics are more effective in the first dose.
From 50 samples of uropathogenic bacterial infection, there are 17 (34%) Gram-positive and 32 (66%) Gram-negative. This distribution ratio differs from 15,18 9.68% and 19% for Gram-positive and Gram-negative 90.32% and 81%, respectively. E.coli is the most prevalent pathogen in our study, and almost other studies distributed in most age groups 19.
E.coli was the most prevalent at 54%, while the second was Staphylococcus aureus at 20%, followed by Coagulase -ve Staphylococcus at 14%. Proteus and Klebsiella distribution were Less typical at 6%. This result was compatible with 20,2,15 in E.coli distribution but different in the second pathogen, Klebsiella 18.71% and the low ratio was for Enterobacter spp. In studies of Aboderin in Nigeria and Prakash in India appear, P.aerogenousa and Klebsiella are the second pathogens and this difference with our study 21,15.
Periphery patients infected with E.coli except two; one infected with Staphylococcus aureus and another with Proteus. In central patients, E.coli is also the most prevalent infection at 46.1 %.
E.coli infect both genders in an equal ratio of 23.0% for Central patients; results from the periphery appear the convergence between male 36.36% and female 45.45%, and this is compatible with 22 but different with 23,24,15 that appears the ratio of female infected with E.coli more than male.
The closeness of the urethral meatus to the anus, shorter urethra, sexual intercourse, incontinence, and improper bathroom habits all contribute to the increased prevalence of UTI in females 25,15.
Males have a reduced infection rate due to the length of the urethra, the dry environment around the meatus, and prostatic fluid's antibacterial qualities 20.
Between all antibiotics used in this study (IPM) was sensitive (100%) for all pathogens E. Coli, Staphylococcus aureus, Coagulase -ve Staphylococcus, Proteus and Klebsiella, this result different with 26,27.
E.coli is resistant to most antibiotics 28; in our study, it's resistant to E 88.9%, CL 92.6%, CFM 77.78%, AZM 81.48%, VA 70.37%, NA 70.37%, CTX 100% and TE 74.08%. This result compatible with 15 and 30 in resistance of bacteria to NAL, CTX and CIP, CTX, respectively, different in CIP, TOB, and CTZ that also resistance in study of 15. Also, our study appears compatible with  5.
Proteus resist for E 100%, CL 100%, CFM 100%, AZM 100%, VA 66.67%, NA 66.67%, CTX 66.67%, TE and TOB: 66.67%. The results were completely different, with 28 while 20 compatible in TE and a difference in meager resistance for CN and NA. The study difference in CIP resistance was 58.6 % for Gajdács study 5.
Klebsiella resists E 100%, CL 100%, AZM 100%, VA 100 %, NA 100 %, TE 66.67%, and this result appears different from 15 that appear to resist for CIP and IMP and with 28 in resistance of NA. 30
Staphylococcus aureus resists E 80%, Cl 80%, CFM 90%, AZM 100%, NA 90%, NOR 90%, CTX 90%, CIP 90% and TOB 80%. This result appears compatible with 29,15 and just in CTX with 15. Also, the result compatible with 28 in NA resistance and different in E, CIP, V, CL, CN and C and compatible with Gajdács 5.
Coagulase -ve Staphylococcus resist for E 85.71%, C 71.43%, CFM 100%, AZM 100%, NA 71.43%, CTX 71.43% and TE 85.71%. This result is compatible with 28 in E and NA resistance and different in CIP, V, CL, CN and C. Our Result is compatible with 20 in TE and different in CN, NA, and C, which are less sensitive.
There are significant etiological variables that increase the risk of Multiple Drug Resistance (MDR) infections, including the use of broad-spectrum antibiotics inappropriately (without investigation of antibiotic resistance), Lack of infection control strategies 28, poor hygiene, immunosuppression, and a prolonged stay in the hospital 31.
Low birth weight, premature delivery, cystitis, and pyelonephritis are all possible side consequences of untreated recurrent UTI 32.
CONCLUSION

Our study is the first one in Alrefaai City central and peripheral, estimating the most prevalent bacterial pathogens and antibiotic sensitivity. We found that most of the patients with UTI were from the city center and in the age group 1-30 years. The most prevalent bacteria were E.coli and then Staphylococcus aureus. IPM, C, CN, NOR, CIP and TOB is the best effective antibiotic against all bacteria in our study.
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Received: May 15, 2023/   Accepted: June 10, 2023 / Published: June 15, 2023

Citation:   Al‑Khegane, M.A.; Abed Ali, W.J.; Ashour, Z.; Ibrahim, D.T.; Najim, M.K.; Lahhob , Q.R. Estimate of the most common bacteria cause of UTI and effective drug in Alrefaai City. Revis Bionatura 2023;8 (2) 67. http://dx.doi.org/10.21931/RB/2023.08.02.67
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