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Vol. 3 No. 4:2 doi: 10.3823/739

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Distribution of bacterial uropathogens and their susceptibility patterns over 12–year (20012013) West Bank, Palestine

Ahmad M. Zaid
Medicare-Medipal laboratoriesRamallah, West Bank, Palestine National Authority. *  Correspondence:


Background. The increased emergence of new resistant strains in most human
pathogens has become one of the most serious global health threat. Empirical treatment of urinary tract infections (UTI’s) has become difficult in many parts of world. Therefore, local susceptibility patterns of uropathogens is of great importance to achieve cure and reduce the misuse of empirical antibiotics. This study presents the incidence of uropathogens and their antimicrobial susceptibility patterns in West bank of Palestine .

Methods. A total of 16,883 urine culture samples were included in this retrospective study. The incidence of recovered uropathogens was estimated over 12-year in the examined urine samples, as well as the sex and age groups of the patients. Antimicrobial susceptibility was performed for all identified bacterial isolates.

Results. A total of 6.539 /16,883 (38.7% ) urine culture samples showed significant bacterial growth. The common isolates were E. coli, coagulase negative Staphylococci, Streptococcus spp, S aureus, and Klebsiella spp, and their frequencies were 47%, 19.6%, 18.4%, 4.9%, 2.9%, respectively. Gram positive uropathogens showed susceptibility towards amoxi/clav, cefuroxime ,cephalothin , culpha /trimethoprim, nitrofurantoin, ciprofloxacin, ofloxacin and norfloxacin as follow: 83.9%, 80.1%, 70.1%, 36.6%, 65.1, 57.6%, 51.6%, 47.8%, respectively. While Gram negative uropathogens were susceptible to ciprofloxacin, ofloxacin, norfloxacin, cefuroxim, nitrofurantoin, sulpha/trimethoprim, nalidixic acid, and amoxi/clav 76.1%, 71.8%, 72.9%, 64%, 67.5%, 48.7%, 57.6%, 42.1%, respectively.

Conclusions. This retrospective study shows high rates of antimicrobial resistance This article is available from:
to all commonly used anti-urinary tract infection drugs, and demonstrates the importance to monitor the incidence of common uropathogens and their antimicrobial susceptibility patterns before starting treatment.

Urinary tract infections (UTIs) have an estimated occurrence of 150 million infections each year worldwide (1). In the USA, UTI’s account for more than 7 million outpatient visits annually. Total costs for management of UTIs exceed one billion dollars in USA (2). Gram negative aerobic bacteria represent the majority of uncomplicated UTI’s, with E. coli incidence rate (70-95%) , while the most commonly isolated gram positive aerobic bacteria are coagulase negative staphylococci accounts for around 5 to 10% (3-4). © Under License of Creative Commons Attribution 3.0 License

Most pathogens of the urinary tract are coming from fecal normal flora that colonize the peri-urethral area and vagina in females. Due to continuous and increased emergence of new bacterial resistance strains, antimicrobial susceptibility patterns of uropathogens are of great importance for successful treatment of UTIs. Local data on antimicrobial susceptibility patterns is becoming more necessary in countries where there is antimicrobial abuse especially when these: drugs can be obtained without medical prescription from pharmacies (5).


2) 92(76. Furthermore.2) 107(29) Klebsiella spp. Plates were incubated for Table 1.9) 22(77.(%) 148(31.7) 313(33.8) 76(57.6) 262(69.1) * No(%): Total number and percentage of each bacteria isolates 2 © Under License of Creative Commons Attribution 3.9) 491(25.1) 51(70.7) S . Growth of more than one type of bacteria was considered contamination and neglected . A recent published study showed limited data from one local area (6)..5) 79(79.1) 408(75.7) Proteus spp.7) 31(71) 100(28) 86(59.4) 425(73. Staphylase test and their biochemical profile including Triple Sugar Iron (TSI).9) 440(77.3) 165(60) 52(7.1) 1465(29.5) 26(57.4) 1534(77) 475(71. Urine Culture and identification of bacterial isolates Most specimens were mid-stream clean catch urine collected upon request of examining physician.9) 97(71.8) 54(72. nalidixic acid.(%) 278(76.2) 1923(59. other antibiotics were used less frequently and were mentioned in table 1.3) 85(50. Oxidase test.883 urine culture samples investigated over twelve years period (April 2001. Inoculation of plates was done by using one micro liter disposable calibrated loops.6) 27(88. cephalothin.2) 1638(79. sulphamethoxazole-trimethoprim (SXT) and nitrofurantoin.3) 90(62.9) 2477(74. No.8) 124(54.5) 55(90.3) 2386(66.(%) 1077(79.8) 94(47.2) 575(55.3) 602(51. ampicillin.5) 69(62.iMedPub Journals 2013 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. and not all cultured samples were examined for urinalysis.4) 713(59.9) 153(49) 85(61. No.3) 68(76.3) 242(46. to March 2013). cip rofloxacin.2) 2488(49.9) 520(55.2) 160(53. few local data on antimicrobial susceptibility patterns and epidemiology of uropathogens among Palestinian population were reported.The antimicrobials diffusion discs were obtained from (Bioanalyse.3823/739 Our Site: http://www.6) 1083(40.5) C. cefaclor. Distribution of antimicrobial susceptibility for the main uropathogens. After incubation.1) 24(58.2) 250(73. ceftriaxone. 24-48 hours at 37oC. cephlexin.1) 62(40. cefixime. ceftazidime.5) 26(69. norfloxacin. Sulphour-Indole-Mannitol (SIM). Identification of bacterial isolates was based on the Gram staining characteristics of the bacteria. Methyl-Red (MR) and VogesProskauer (VP)./Trime.5) 212(7.3) Streptococcus spp. gentamicin.imedpub.7) 1164(79.2) 1071(76.7) 1018(85. Antimicrobial susceptibility test All bacterial isolates were tested for their susceptibility to antimicrobials using modified Kirby-Bauer technique and guidelines used in England (7). Yenimahalle .2) 60(70) 442(50.8) 557(60.3) 227(74.(%)* 2571(43) 1755(44) 666(72.2) 154(43. Material and methods This retrospective study is based on data obtained from the records of 11 centers of Medicare-Medipal laboratories.1) 801(61) 286(10.3) 76(85. the urine cultures considered to be negative when bacterial growth was lower than 103 CFU/ To our best knowledge. Citrate. amoxicillin-clavulanic acid.9) 173(46.7) 258(8. 3 No. Data included 16. Urine samples were cultured on both 5% blood agar and MacConkey›s culture plates. No.2) 21(81) 112(78. This study investigated large numbers of cultured UTI specimens which have been received over the last 12 years covering the whole Palestinian population of West Bank region.6) 107(8.9) 702(16.3) 22(27.5) 175(52.4) 18(72.6) 83(6) 226(69.7) 81(34. appearance of colonies on agar.(%) 1028(91.0 License . Urease.N. 4:2 doi: 10.cotrimoxazole..5) 894(61. Antimicrobials tested were the following: amikacin. positive when pure growth was higher than 105 CFU/mL.1) 720(64.S No.2) 173(56. Antibiotics Amox / Clav Cefaclor Cefixime Cefotaxime Ceftazidime Ceftriaxone Cefuroxime Cephalexin Cephalothin Ciprofloxacin Gentamycin Nalidixic Acid Nitrofurantoin Ofloxacin Sulpha.6) 76(77. cefotaxime.Ankara / Turkey).aureus No.9) 22(18. coli No. Catalase test.6) 160(58.1) 61(52.1) 968(67. E .2) 976(30.ofloxacin.(%) 116(60.

5% vs 0. coli represented the vast majority of gram negative bacterial isolates (83.9%). (42. and other less frequent uropathogens. There is a significant in the incidence (P < 0. with overall (47%) of all bacteria isolated from urine samples obtained from patients suspected to have UTI. Distribution of bacteria isolates detected in urine cultures © Under License of Creative Commons Attribution 3.7% vs 46. The results of antimicrobial susceptibility patterns of uropathogen isolates are shown in table 1. E.1%).9% vs 1. aureus (11. Pseudomonas spp.8%).(3.coli represented (83.2%).1% vs 17.8. (1. Citrobacter spp .4%).9%).Gram negative isolates accounted for 3627 (57. Result A total number of 6.1%). Citrobacter spp.3823/739 Our Site: http://www. (1. (2.9 vs 16. & coagulase negative staphylococci (20. coli( 50. Discussions This study shows generally that the results of bacterial isolates from urine cultures are much similar to other recent findings published in the neighboring country of Jordan (8-10).imedpub. Also.0 License 3 .4%).7% ) was positive for a significant and pure bacterial growth from urine samples over the 12-year period. and its incidence was significantly higher among males than females ( 50.05) was observed in females than males due to infection with Streptococci spp. 4:2 doi: 10. This result is different than findings reported from Turkey and Jordan ( 3. Klebsiellaspp(3.6%).iMedPub Journals 2013 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. followed by Klebsiella spp.6%). where women more often develop urinary tract infections due to E. (1.1%). and Pseudomonas IBM-SPSS software (version 17 for Windows) was used to calculate the frequencies. while Gram positive isolates accounted for 2730 (42. (5.7% vs 46.8%) in males compared to females.05) of E. cross-tables.9%). but a significant incidence (P < 0. followed by Streptococci spp. However. Proteus spp. Enterobacter spp.2%) of all Gram negative isolates. (3. (18.9).883 (38.1%). Figure 2 shows the distribution of gender and uropathogen isolates. Escherichia coli is still the leading uropathogen. The distribution of bacterial isolates is shown in figure 1 . 3 No. it is important to note that most of our patients developed community ac- Figure1.coli. E . and risk estimations. Gram positive bacterial isolates are dominated by coagulase negative staphylococci (CNS) (46%).539/ 16.3%) .3 %).5%). and S.1% vs 1.

whereas less susceptibility rate was detected against ciprofloxacin.1%) and similar to many other studies worldwide ( 3. The incidence rates of Klebsiella spp..3%). 3 No.10.imedpub. nitrofuratoin. cephalexin. In general. 16.12 ).8%). While the incidence rate of S. are often associated with hospitalized patients and cause complicated cystitis and pyelonephritis (13). Proteus spp.coli was moderately susceptible to ciprofloxacin. respectively.9. (12 ).8%.0 License 4 . sulpha/trimethoprim and cephalexin ( Table 1).com/ Figure 2. quired urinary tract infection ..6%) was common among females (20. and Pseudomonas spp. as cause of UTIs in this study were low and similar to many other studies (9-10). Gender distribution of uropathogen isolates.coli was found among children (62.15. Remarkable high incidence of E. the incidence rate of Streptococcus species (18..3%) especially among sexually active young persons.14).. These results may reflect the fact that UTI is remarkably increased among sexually young active age groups as reported by Vincent et al. and sulpha/trime ( Table 1). cefuroxime and nalidixic Acid.3823/739 Our Site: http://www.3%). ( Table 1). 17.1%) and elderly (55. Age groups also did not show significant difference in incidence of these organisms among males and females as indicted by other studies (5. and Pseudomonas spp. while imipenem has the highest activity (93. Enterobacter spp. 23.9%) was much similar among males and females (5.4%). The results of this study demonstrated that E. cefuroxime and nitrofuratoin... Acinetobacter spp. The same observation is noticed with CNS which caused more UTIs among females compared to males (20.5% vs 4. It is well established that these bacteria spp.4) was slightly higher among females than males (18. imipenem used mainly in hospitalized patients. Gram positive bacteria showed better susceptibility rates in vitro to commonly used drugs in UTIs such as amoxi/Clav .. Young adults and adolescents females had the highest incidence rates of CNS isolates (24.9 vs. The other Gram-negative isolates (Klebsiella spp. Enterobacter spp. Pantoea spp. all bacterial isolates from urine culture samples showed the lowest susceptibility in vitro to ampicillin (28. While E. 4:2 doi: 10. The low susceptibility to amoxi/clav and sulpha/trimethoprim in this study is similar to the results reported from Jordan and other Middle East countries (8. The present study demonstrates that the incidence rate of coagulase negative staphylococci (CNS)(19.8%). Citrobacter spp.aureus (4. Other bacterial isolates were found in(<1%) including citrobacter spp.. cephalothin. These three species are often associated with hospitalized patients and less with community acquired UTI.) showed more resistance © Under License of Creative Commons Attribution 3.2%) when compared to other age groups. Moreover. Serratia spp .1% vs.coli isolates have the lowest susceptibility to the following drugs: amoxi/clav.16).11.iMedPub Journals 2013 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. However.

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