Urinary Tract Infection and Antibiotic Resistance among Pregnant and Non-pregnant females in UAE

 

Samir Issa Bloukh1, Nageeb A. Hassan1, Rand S. AlAni1, Sabrina Ait Gacem2*

1Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, UAE.

2Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Ajman University,

Ajman, UAE.

*Corresponding Author E-mail: sabrinaaitgacem@yahoo.com

 

ABSTRACT:

Background: Urinary tract infection (UTI) is an infection that can take place in both genders and anywhere within the urinary tract and results from certain microorganisms such as bacteria which are the most common cause of UTI. In case it was a bacterial infection the physician usually administers antibiotics depending on the nature of the UTI and in some cases antibiotic resistance might occur. Objectives: To determine the prevalence of urinary tract infection in pregnant and non-pregnant women in UAE, distribution of bacteria which cause UTI and its sensitivity and resistance to antibiotics. Methods: A Cross-sectional study was carried out.  A total of 300 women results were retrospectively analyzed in the study. Results: From those 300 study participants (39%) were pregnant and (61%) non-pregnant. The percentage of resistance in the uropathogens in pregnant patients was more (69.49%) compared to those in non-pregnant patients (56.59 %). The pathogens distribution shows that the most common pathogen is Escherichia Coli (58%). This study shows that E. coli has high resistance to Amoxicillin. Conclusion: Pregnant women are more susceptible to UTI in comparison to non-pregnant women and the main cause of UTI is the E.coli bacteria. The highest uropathogen resistance was against amoxicillin, while the antibiotic of choice for UTI treatment is ciprofloxacin due to its high sensitivity. UTI needs to be detected and treated promptly since treatment has shown its efficiency in preventing pregnancy related complications.

 

KEYWORDS: Urinary, Infection, Pregnant, E.coli, Resistance, Antibiotic Leftover.

 

 

INTRODUCTION:

The urinary tract is usually made of the kidneys, ureters, urine bladder and urethra. Urinary tract infection (UTI) is an infection that can take place anywhere within the urinary tract and mostly involve the bladder and the urethra, which are in the lower part of the urinary tract. Even though UTIs in the upper part of the urinary tract are experienced, they are usually rare, but they are more severe1. UTI is an infection occurring for both genders and results from certain microorganisms such as bacteria which are the most common cause of UTI although there have been cases caused by fungi and rare cases caused by viruses also2.

 

The most common cause of urinary tract infection or cystitis is Escherichia coli (E.coli) which is a normal flora of intestines of living organisms and does not cause any complications when it is there, normal habitat, but when it finds its way to the urinary tract, it leads to infections. Infection of the urinary tract usually happens when microscopic elements of stool find their way into the urinary tract. On the other hand, cystitis is an inflammation of the urinary bladder and happens when bacteria enter the bladder and start multiplying, leading to bladder infections2.

 

The treatment of UTI depends on the causative agent of the infection. In most cases that have been reported, the causative agent of UTI is bacteria and is usually treated with antibiotics while UTIs caused by the virus are treated with antiviral and the fungal UTIs are treated using antifungals1.

 

 

The form of antibiotics that are used in treating bacteria depends on the part of the urinary tract that has been affected. UTI infection of the lower part is usually treated using oral antibiotics while the UTIs affecting the upper part of the urinary tract are treated using intravenous antibiotics1.

 

There are different antibiotics that are used in treating UTIs according to the severity of infection. For simple infections, the drugs that have been recommended include sulfamethoxazole/trimethoprim, fosfomycin, nitrofurantoin, cephalexin, and ceftriaxone. Antibiotics such as ciprofloxacin and levofloxacin have not been recommended for treatment of simple UTIs since they are aimed at treating only complicated UTI3.

 

When a patient is diagnosed with UTI for the first time, the physician usually administers antibiotics depending on the nature of the UTI. However, if a UTI reoccurs after a short period of time after the clinical administration, there are a number of recommendations that the doctor might make3. The doctor might recommend low-dose antibiotics usually lasts for six months or longer4. A doctor may also recommend self-diagnosis where the patient has to stay in touch with the doctor. A physician may also recommend a single antibiotic dose after any sexual contact especially if the infections are caused by sexual intercourse. For post-menopausal patients with recurrent UTIs, the physician usually recommends vaginal estrogens5.

 

To our knowledge there is a lack of studies in UAE addressing the prevalence of urinary tract infections and antibiotic resistant, therefore the study aims to assess the prevalence of urinary tract infections among pregnant and non-pregnant women and to estimate the bacterial population and antibiotic sensitivity among these women with urinary tract infections.

 

MATERIAL AND METHODS:

The study design  was a cross-sectional retrospective study which was conducted in the clinical laboratories in UAE at emirate of Sharjah and Ajman. All culture and antibiotic susceptibility tests of patients already diagnosed with UTI were collected from the period of January to December 2017.

 

The sample size for this study was n=300. In order to control any confounding and external validity, both pregnant and non-pregnant women’s laboratory results were studied. The lab test results were used to obtain the most reliable data samples in which the Urine Culture & Sensitivity (C&S Urine) testing was done on various antibiotics to determine which of the bacteria spp. are resistant or sensitive to the list of the antibiotics that are commonly prescribed to women in UAE to treat UTI. In order to assess individual patient's response and sensitivity to the brand of antibiotic used for the treatment of UTI, the tests were repeated for each patient for all the antibiotics prescribed for the treatment, and the response under each treatment levels was measured and recorded in addition to finding the most suitable and effective antibiotics in the treatment of urinary tract infection in women.

 

Sample collection involved laboratory diagnostic methods and the records showed mid-stream (“clean catch”) urine specimen collected from each patient. Bacterial isolation and identification was performed according to standard procedures of Feingold and Martin. The study involved different age groups with a UTI infection in both pregnant and non-pregnant women in which urine culture and sensitivity analysis was performed.

 

Antibiotic Sensitivity Assay:

The cultures from urine were used for antimicrobial sensitivity testing after their identification by gram staining and other biochemical procedures that determined the organisms. The urine sample is cultured on blood agar and MacConkey's agar for the growth of bacteria. The culture is labeled and then incubated for 24 hours at 37°C.

 

Ethical Considerations:

An ethical approval from the ethical committee was obtained for the current study.

 

The study involved patient’s data that were evaluated and analyzed using the Statistical Package for the Social Sciences (SPSS) and Microsoft Excel (Version 2003).

 

RESULTS:

The data analysis for the raw data obtained from the stored records of the clinical laboratories in UAE at the emirate of Sharjah and Ajman, were processed. Descriptive statistics of the ages of the studied samples included in the study analyzed. The distribution of the their age skewed to the left and the most frequent patients sample age group was between 19 and 35 years old (Fig. 1).

 

Fig. 1: The majority of patients (n=148) were in the age group between 19 and 35 years old.

The distribution of the diagnosed patients by the pregnancy tilted towards the non-pregnancy with approximately twice the proportion of the pregnant (39%) as those reporting no pregnancy (61%) during the study (Fig. 2). The results also show that the majority of the isolates in pregnant and non-pregnant women showed resistant to the administered antibiotics, but the percentage of the resistant bacterial isolates was more in the pregnant patients (69.49%) compared to those in non-pregnant patients (56.59 %) (Fig. 3).

 

Fig. 2: Pregnant participants represented the proportion of the pregnant 118 (39%) and the majority were non- pregnant 182 (61%) during the study.

 

Fig. 3:  The results showed that the percentage of the resistance was more in the pregnant patients (69.49%) compared to non-pregnant patients (56.59 %).

The results in Sharjah and Ajman in this study showed that the most commonly used antibiotic, is Co-Amoxiclav (6.99%) and table 1 represent the drugs that were involved in the process of sensitivity testing such as Ampicillin, Vancomycin, Augmentin, penicillin, gentamycin, Streptomycin, and Erythromycin amongst others (Table 1).

 

The most frequent causative pathogen of UTI is Escherichia coli (58%) followed by Klebsiella, Streptococcus: (Streptococcus group B, Streptococcus agalactiae and group D, Streptococcus faecalis), Staphylococcus: (Staphylococcus aureus, Staphylococcus spp.) 22%, 8% and 4% respectively (Fig. 4). The results show that the E.coli was the most commonly isolated pathogen (Fig. 5) whether the woman is pregnant or not (for pregnant women n=74), (for non- pregnant women n=100), followed by the Klebsiella  (for pregnant women, n=25), (for non-pregnant, n=40) then the other pathogens.

 

Fig. 4: The most frequent causative pathogen of UTI is Escherichia coli (58%) followed by Klebsiella, Streptococcus: (Streptococcus group B and group D, Streptococcus agalactiae), Staphylococcus: (Staphylococcus aureus, Staphylococcus spp.) 22%, 8% and 4% respectively.


 

Table 1: The distribution of Antibiotics used

Antibiotic Generic

Percentage (%)

Antibiotic Generic

Percentage (%)

CO-AMOXICLAV (AMC)

6.99%

CEFPODOXIME (CPD)

4.94%

AMPICILLIN (AM)

6.55%

CO-TRIMOXAZOLE (SXT)

4.57%

CEFAZOLIN (CZ)

5.73%

LEVOFLOXACIN (LE)

4.32%

CIPROFLOXACIN (CIP)

5.67%

CEFIXIME (CFM)

4.20%

CEFUROXIME (CXM)

5.38%

AMIKACIN (AK)

3.29%

CEFACLOR (CF)

5.07%

TETRACYCLINE (TE)

3.12%

CEFTRIAXONE (CRO)

5.04%

OFLOXACIN (OFX)

2.81%

CEFDINIR (CDR)

5.00%

GENTAMYCIN (CN)

2.77%

CHLORAMPHENICOL (C)

2.63%

LINEZOLID (LNZ)

2.03%

NITROFURANTON (F)

2.38%

ERYTHROMYCIN (E)

1.98%

PENICILLIN (P)

2.05%

NORFLOXACIN (NOR)

1.96%

CLINDAMYCIN (DA)

1.90%

PIPERACILLIN/ TAZOBACTAM

1.49%

IMIPENEM (IPM)

1.90%

PIPERACILLIN

1.10%

CEFTAZIDIME (CAZ)

1.76%

CEFEPIME (FEP)

0.85%

CEFOXITIN (FOX)

1.61%

AMPICILLIN/SULBACTAM (A/S)

0.60%

VANCOMYCIN (VA)

0.17%

TOBROMYCIN (TOB)

0.02%

AMPICILLIN/SULBACTAM

0.06%

MOXIFLOXACIN (MO)

0.02%

 

 

DOXYCYCLINE

0.02%

 

Fig. 5: The results show that E.coli was the most commonly isolated pathogen in both pregnant and non- pregnant women.

 

The E. coli resistance to antibiotic test shows that the E. coli has high resistance to amoxicillin with 39% and also high resistance to ampicillin with 31% followed by Nitrofurantoin, Tetracycline and SXT (15%, 10% and 5%) respectively. The ciprofloxacin showed the highest effect on the pathogens on urine culture so it is one of the best treatments for UTI, followed by Nitrofurantoin. It was noticed that the amoxicillin did not show any effect on the pathogens, which means it has the higher resistance and no sensitivity (Fig. 6 and Fig. 7).

 

Fig. 6: The E. coli resistance to antibiotic test shows that the E. coli has high resistance to amoxicillin with 39% and also high resistance to ampicillin with 31% followed by Nitrofurantoin, Tetracycline and SXT (15%, 10% and 5%) respectively.

 

Fig. 7: The ciprofloxacin showed the highest effect on the pathogens on urine culture so it is one of the best treatments for UTI, followed by Nitrofurantoin.

 

DISCUSSION:

The study involved 300 females both pregnant and non-pregnant who visited the clinic for help regarding UTI infection. The results indicate that 39% of pregnant women were susceptible to UTI infection which can either come as pathogenic, invasive microbes or the risk increased because of the pressure on the bladder which lead to blockage in the urine draining. The bacteria are of different species and strains and they include normal flora such as Escherichia coli, Klebsiellas and others like streptococcus group B, streptococcus group D, while the invasive and pathogenic kinds are also present and they include staphylococcus aureus and other staphylococcus spp.

 

In a study conducted by researchers in 1998, aiming at studying the antibiotics that were most effective in treating UTI. However, there are major drawbacks from the results, which affect the contribution of the study to understanding recurrent UTI and antibiotic resistance6. One of the major drawbacks is that the subjects that were studied only had uncomplicated UTI and it was difficult to be able to understand the relation between the use of specific antibiotic and the chances of the UTI recurring within the subject. However, the studies provided limelight on some of the antibiotics that are no longer effective in treating UTI among women. Additionally, the studies conducted did not provide any relation between the anatomical and physiological structures and the failure of some of the antibiotics to be effective on some of the patients. Different UTI patients have different anatomical and physiological structures, which provide a different environment for the effectiveness of an antibiotic.

 

Most of the drugs that were used in the study were very efficient in the treatment of the UTIs. However, it is emerging from the study that even normal flora are becoming uncontrollable and resisting the antibiotics available in the market. From our results it is evident that drugs such as Ciprofloxacin, Nitrofurantoin and tetracycline are efficient in controlling most of the bacterial infections of the UTI. However, Ciprofloxacin is the best at the moment as it inhibits the growth of most of the urinary tract infections. The resistance pattern was high for Amoxicillin and Ampicillin and these results were similar to a study held in 2011 in Ethiopia7.

 

From the study, it was evident that the prevalence of antibiotic resistance was more manifested in the uropathogens of pregnant women as compared to non-pregnant women. The high resistance among the uropathogens of pregnant women can be explained by the physiological change that results from the pregnancy, like the increase in plasma and reduction in the concentration of urine that lead to development glycosuria in up to more than two-thirds of women, a factor that eventually leads to bacterial growth in urine. Another explanation to the difference between the antibiotic resistance in the uropathogens of pregnant and non-pregnant can be attributed to the fact that during the non-pregnancy state, the uterus is located far above as compared to during pregnancy when the uterus becomes enlarged, and it descends affecting the urinary tract. The implication of the situation of the bacteriuria is that such high occurrence of UTI among the pregnant cases increases the risk factors for both the unborn child and the mother.

 

The most common cause of the simple UTI is Escherichia coli which account for nearly 74 to 99 percent of all infections. This longitudinal study of 300 UTI patients found that E. coli was the only causative pathogen in 58% of cases followed by Klebsiella, Streptococcus and Staphylococcus (22%, 8% and 4%) respectively which is similar to a study on pregnant women attending the antenatal clinic in Kanpur, India8.The results were also similar to a recent study held in 2019 in Atlanta stating that the most frequent isolates were Escherichia coli (52%) and Klebsiella pneumoniae (15.6%)9. Similarly it was observed in a recent study in 2018 held in Germany that the main pathogens were Escherichia coli (64.2%) followed by Klebsiella pneumoniae (12.4%)10.

 

Authors should discuss the results and how they can be interpreted in perspective of previous studies and of the working hypotheses. The findings and their implications should be discussed in the broadest context possible. Future research directions may also be highlighted.

 

CONCLUSION:

The study shows that the pregnant women with UTI have higher resistance uropathogens to the antibiotic and they are more susceptible to UTI than the non-pregnant. E.coli is the main bacteria to cause UTI and the best antibiotic to treat UTI is ciprofloxacin while amoxicillin showed no effect.

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

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7.      Getenet B, Wondewosen T. Bacterial uropathogens in urinary tract infection and antibiotic susceptibility pattern in Jimma University specialized Hospital. Ethiopia. Ethiop J Health Sci. 2011; 21(2): 141-146.

8.      Sujatha R, Manju N. Prevalence of Asymptomatic Bacteriuria and its Antibacterial Susceptibility Pattern among Pregnant Women Attending the Antenatal Clinic at Kanpur, India. J Clin Diagn Res. 2014; 8(4):1–3.

9.      Watkins R, Van DD. Current trends in the treatment of pneumonia due to multidrug-resistant Gram-negative bacteria. F1000 Research. 2019; 8:121.

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Received on 19.01.2020           Modified on 07.03.2020

Accepted on 04.05.2020         © RJPT All right reserved

Research J. Pharm. and Tech. 2021; 14(1):461-465.

DOI: 10.5958/0974-360X.2021.00084.6