THE SPECTRUM OF DIFFERENT PATHOGENS CAUSING URINARY

TRACT INFECTIONS IN HOSPITALIZED & NON

HOSPITALIZED PATIENTS

INTRODUCTION
Urinary tract infection (UTI) is most common infectious presentation in hospital
acquired and community acquired infections since long time. There are an
estimated 150 million urinary tract infections per annum worldwide and cost the
global economy in excess of 6 billion US dollars. 3A limited and predictable
spectrum of organisms is responsible urinary tract infections. Among both
outpatients and inpatients, Escherichia Coli is the primary urinary tract
pathogen, accounting for 75% to 90% of both side - hospital acquired and
community acquired UTI.
Urinary tract infection is one of the common infections in the Indian
community. Distribution and susceptibility of UTI-causing pathogens change
according to time and place. This study was conducted to determine the
distribution and antimicrobial susceptibility of uropathogens in the Indian
community as well as to determine the effect of gender and age on the etiology
of bacterial uropathogens. Clean catch midstream urine samples were collected
from 288 patients of the age ranging from 15 to 48 years. Antimicrobial
susceptibility was performed on all isolated bacteria by Kirby Bauers disc
diffusion method. The multiple antibiotic resistance (MAR) index of each
1

antibiotic was calculated. The UTI prevalence was 53.82% in patients; however,
the prevalence was significantly higher in females than in males (females:
73.57%; males: 35.14%; P = 0.000). Females within the age group of 26-36
years and elderly males of 48 years showed higher prevalence of UTI. Gram
negative bacteria (90.32%) were found in high prevalence than Gram positive
(9.68%). Escherichia coli (42.58%) was the most prevalent gram negative
isolate. Nitrofurantoin (78.71%) was found the most resistant drug among all
uropathogens. Tested carbapenems were found the most susceptible drug
against isolated uropathogens which showed 92.26% and 84.52% susceptibility,
respectively.
UTIs are often treated with different broad spectrum antibiotics when one with a
narrow spectrum of activity may be appropriate because of concerns about
infection with resistant organisms. Fluoro quinolones are preferred as initial
agents for empiric therapy of UTI in area where resistance is likely to be of
concern. This is because they have high bacteriological and clinical cure rates,
as well as low rates of resistance, among most common uropathogen. The
extensive uses of antimicrobial agents have invariably resulted in the
development of antibiotic resistance, which, in recent years, has become a major
problem worldwide. The Infectious Diseases Society of America also
recommends that physicians obtain information on local resistance spectrum of
organisms cause urinary tract infections and that ongoing surveillance be
conducted to monitor changes in susceptibility of uropathogens. This study is
2

conducted to compare the frequency and drug resistance pattern in E. Coli

isolated from patients with community acquired and hospital acquired UTIs at
our setup as well as identification of ESBL producer strains. This study is
important for clinician in order to facilitate the empiric treatment of patients and
management of patients with symptoms of UTIs. Moreover, the data would also
help authorities to formulate antibiotic prescription policies.
Urinary tract infection (UTI) is the commonest bacterial infectious disease in
community practice with a high rate of morbidity and financial cost. It has been
estimated that 150 million people were infected with UTI per annum worldwide
which costing global economy more than 6 billion US dollars. UTIs is described
as a bacteria with urinary symptoms. UTI can affect lower and sometimes both
lower and upper urinary tracts. The term cystitis has been used to define the
lower UTI infection and is characterized by symptoms such as dysuria,
frequency, urgency, and suprapubic tenderness. The presence of the lower UTI
symptoms does not exclude the upper UTI which is often present in most UTI
cases. The treatment of UTI can be classified into uncomplicated and
complicated on the basis of their choice of treatment. UTI is more common in
females than in males as female urethra structurally found less effective for
preventing the bacterial entry. It may be due to the proximity of the genital tract
and urethra and adherence of urothelial mucosa to the mucopolysaccharide
lining. The other main factors which make females more prone to UTI are
pregnancy and sexual activity. In pregnancy, the physiological increase in
3

plasma volume and decrease in urine concentration develop glycosuria in up to

70% women which ultimately leads to bacterial growth in urine. Also in the
nonpregnant state the uterus is situated over the bladder whereas in the pregnant
state the enlarged uterus affects the urinary tract. Sexual activity in females also
increases the risk of urethra contamination as the bacteria could be pushed into
the urethra during sexual intercourse as well as bacteria being massaged up the
urethra into the bladder during child birth. Using a diaphragm also causes UTI
as it pushes against the urethra and makes the urethra unable to empty the
bladder completely and the small concentration of urine left in the bladder leads
to the growth of bacteria which ultimately causes UTI.
The spectrum of bacteria causing complicated UTI is much broader than of
those causing uncomplicated UTI. However, the most commonly encountered
microorganisms are Gram negative bacteria including Escherichia coli,
Citrobacter spp., Enterobacter aerogenes, Pseudomonas aeruginosa & Proteus
vulgaris whereas Klebsiella spp., Staphylococcus aureus, and Salmonella spp.
are found rarely.
Detection of the microbial etiology of infections, including nosocomial UTIs,
provides important information in day-to-day decision-making in individual
hospitals regarding potential outbreaks, unusual pathogens, antimicrobial
resistance, and local trends in the etiology of infections. On the other hand,
selection of an appropriate antibiotic for treatment of these infections is

dependent to knowledge of both causative pathogens, including drug-resistant

organisms, and their antimicrobial susceptibility pattern.
Diabetes mellitus (DM) has long been considered to be a predisposing factor for
urinary tract infection (UTI) and the urinary tract is the principle site of the
infection in diabetics with increased risk of complications of UTI. The
mechanisms which potentially contribute to UTI in these patients are defects in
the local urinary cytokine secretions (IL-8, IL-6), increased adherence of the
microorganisms to the uroepithelial cells, partly due to a changed and lowered
Tamm Horsfall protein, and granulocyte dysfunction, possibly as a result of an
abnormal intracellular calcium metabolism. On the other hand, hyperglycemia
facilitates the colonization and growth of variety of organism.
The most common cause of UTI in men and women with and without DM is
Escherichia Coli. In non-diabetic male and female, the frequency of organism
causing UTI are: Escherichia coli 31.4% & 58.2%, Enterococcus spp. 9.4% &
6.5%, Pseudomonas spp. 17.2% & 4.7% respectively. The organisms causing
UTI in diabetic female are Escherichia coli 54.1%, Enterococcus spp 8.3%,
Pseudomonas spp 3.9%, while in diabetic male it is 32.5%, 9.4%, 8.5%
respectively. Antimicrobial resistance among bacteria causing UTI is increasing.
Few data are available on microbiology of UTI in diabetic and non-diabetic
patients.
Extended-spectrumbeta-lactamase(ESBL) producing members of the family
Enterobacteriaceae are resistant to penicillin, narrow- and extended-spectrum
5

cephalosporins, and aztreonam. ESBL-producing organisms are also frequently

resistant to aminoglycosides, trimethoprim-sulfamethoxazole, and quinolones.
Until recently, most infections caused by ESBL-producing Escherichia
Coli (ESBLEC) or Klebsiella pneumoniae had mostly been described as
nosocomially acquired or nursing home related. However, some recent data
suggest that infections due to ESBL-producing organisms might be an emergent
problem in outpatients in different countries, but detailed epidemiological data
were not collected in most of those studies. Moreover, the clinical relevance and
the epidemiology of these infections outside nursing homes have not been
studied.
In a recent nationwide study of ESBL-producing organisms in Spain, 93% of
ESBL producing K. pneumoniae strains were isolated from inpatients, while
51% of ESBL producing E. coli (ESBLEC) strains were isolated from
outpatients. Consequently, we conducted the study described in this report, in
which we describe and analyze the clinical features and the epidemiology of
infections due to ESBLEC in nonhospitalized patients.
Traditional surveillance has long been established as an essential component to
any infection prevention and control programme, despite the fact that it can be
costly to implement and time consuming to conduct. In the UK, there are
mandatory surveillance systems for several HCAI, such as Clostridium difficile
(since January 2004) and meticillin resistant staphylococcus aureus (MRSA)
bloodstream infections (since early 2001). Surveillance of catheter-associated
6

urinary tract infections (CA UTI) is now performed as part of an initiative

launched by the UK Department of Health in January 2011 in order to reduce
patient harm. However, despite the high burden that HCA UTI represents to the
NHS, this surveillance scheme is voluntary, focuses exclusively on CA UTI, and
is still in its infancy. The potential utility of innovative HCA UTI surveillance
tools is apparent, with current work focusing on the development of automated
systems to identify UTI using traditional clinical definitions. Hospitals routinely
collect and store large amounts of administrative data, including information on
admissions, microbiology, diagnoses and procedures. Although this wealth of
data has not been widely exploited for HCAI surveillance, integrative
approaches towards the more effective use of administrative data are being
pioneered. Determining the utility of established risk factors for HCA UTI
within administrative hospital data presents the opportunity to develop and test
innovative surveillance tools with the potential to enhance traditional
surveillance of UTI within the healthcare environment.

LITERATURE REVIEW
Stevenson et al. (2000) compared negative and positive predictive values for
coding data to HAI surveillance data and found that three of every four HAIs
identified by codes did not meet infection surveillance criteria developed by the
CDC/NHSN. Comparison of surveillance data and coded UTIs was not

undertaken in this review, but it is anticipated that the same deficiencies

identified here would also be present in that review.
A number of performance improvement projects surrounding the reduction of
CAUTIs include routine use of bladder scanners. In a recent study by Saint et
al., bladder scanners were used in less than one-third of study hospitals.
A multivariate analysis reviewed by Salgado et al. reported five risk factors
associated with the later development of a caution: 1) duration of
catheterization, 2) catheter care violations, 3) absence of systemic antibiotics, 4)
female gender, and 5) older age.
Indwelling urinary catheters (IUC) have been used in the healthcare industry
since the 19th century for treating both women and men of all ages (Carr, 2000).
These catheters are used to manage urinary incontinence and retention, reducing
postoperative bladder dysfunction related to anesthesia, surgery, and immobility
(Wald, Ma, Bratzler, & Kramer, 2008). According to Wald et al. (2008), IUCs
are frequently used to measure accurate urinary output in critically ill patients
and patients with severe skin problems who experience full thickness wound
and pressure ulcers. In addition, IUCs are used with patients with multiple
sclerosis and spinal cord injuries as well as patients who receive large-volume
infusions or diuretics during surgery and improvement comforts for end of life
care.
The only site of the human body where E. coli is regularly found as a colonizer
is the intestinal tract where it represents the most prevalent (cultivable)
8

facultative anaerobic bacteria species. (Whlilliams Smith 1965). E. coli and

other Enterobacteriaceae are able to synthesize a wide range of vitamins invitro.
There is no doubt that intestinal bacteria contribute to the vitamin requirements
of many animals, but no evidence has yet been presented that this is also true for
man. In contrast, the fact that gastrointestinal disturbances are relatively rare in
patients who receive drugs that have no or minimal activity against anaerobes,
but good activity against facultative anaerobes (e.g. quinolones). It has been
observed that in patients treated with antimicrobials (e.g. ampicillin) that
eliminate anaerobic, as well as facultative anaerobic bacteria (Wollschlagger et
al 1987), suggests that facultative anaerobes are not a very important component
for maintaining the gastrointestinal equilibrium. On the other hand,
colicinogenic E. coli have been suggested as one of the significant factors of
gastrointestinal tract protection in the course of Shigellosis(Burse et
al.1979).The period of Shigella excretion was significantly reduced if an
appropriate colicinogenic E. coli strain was present in the intestinal flora of
patients.

NOTEWORTHY CONTRIBUTIONS IN THE FIELD OF PROPOSED

WORK
IUCs are the leading cause of nosocomial infections in medical and surgical
patients in the United States (Saint et al., 2013). Patients risk of acquiring a
CAUTI increases with extended usage and inappropriate insertion and
9

maintenance (Saint, Kaufman, Thompson, Rogers, & Chenoweth, 2005).

CAUTI best practice guidelines have been designed to serve as a concise
resource for healthcare providers. These guidelines offer a framework to
prioritize how often medical professionals should use IUCs while also directing
proper application and maintenance of the device, thereby decreasing CAUTI
rates.
Klevens et al. (2007) These costs are primarily associated with diagnosis and
treatment that encompass microbiology studies, labs, diagnostic tests,
medications, and intravenous supplies, ultimately decreasing fiscal year
revenues.
McKibben et al. (2005) estimated that each day a patient is hospitalized; there is
a 3-7% chance that the patient will acquire a CAUTI. The U.S. Department of
Health and Human Services Action Plan to prevent HAIs calls for a 25%
reduction in the number of symptomatic CAUTIs per 1,000 urinary catheterdays in the hospital as a national prevention target (Fakih et al., 2012). In
January 2012, CMS began requiring acute care hospitals participating in their
Inpatient Prospective Payment System (IPPS) to report CAUTIs in adult and
pediatric intensive care units (Fakih et al., 2012). During October 2012, CMS
also required reporting of CAUTIs throughout inpatient rehabilitation facilities
with the proposed data made available for the public at large (CMS, 2010).
Yoon et al. (2013) stated that despite long term placement of IUCs, hospitals are
not properly auditing catheterized patients, and providers are not aware that
10

their patients actually have an IUC. Fakih et al. (2008) showed a decrease in
CAUTI rates by increasing nurse and physician awareness of the infection.
Discussions initiated by Ridenour and Trautman (2009) indicated that nurses
have a direct impact on patient safety and care, including the outcomes of best
practice initiatives and decision-making. In a review of nursing strategies to
decrease CAUTIs, Bernard, Hunter, and Moore (2012) found that nurse-led
interventions, systematic monitoring of patients and reminders to physicians of
patients with IUCs, assisted in decreasing CAUTI rates. Additionally, the results
suggested further research is needed to assess the benefits targeted at the
education of nurses about the effects of IUC cessation (Bernard et al., 2012).
Crouzet et al. (2007) the ultimate goal of nursing research is to develop a body
of knowledge to support and advance nursing practices (Reed & Lawrence,
2008), which projects the outcomes of this experiment to add to the body of
literature concerning nursing knowledge, assessment, and improving practices
through nursing education to decrease CAUTI rates.
Cravens & Zweig (2000) IUCs are known to cause many health problems such
as urinary tract or kidney infections, septicemia, urethral injury, skin
breakdown, bladder stones, hematuria, and after years of catheter use, bladder
cancer can develop with possibility of death. Urinary tract infection may present
as asymptomatic bacteriuria, acute cystitis (bladder infection) or pyelonephritis
(kidney infection). Asymptomatic bacteriuria occurs in 2% to 10% of all

11

pregnancies. If untreated, up to 30% of mothers may develop acute cystitis and

up to 50% acute pyelonephritis.
E Coli is the most common pathogen associated with asymptomatic bacteriuria
(> 80% of isolates). Staphylococcus saprophyticus is the second most frequently
cultured uropathogen while other Gram-positive cocci, such as group B
streptococci, are less common. Other organisms include Gram-negative bacteria
such as klebsiella, proteus or enterobacteriaceae. Asymptomatic bacteriuria has
been associated with low birth weight and preterm birth.
Obstruction to the flow of urine in pregnancy leads to stasis and increases the
likelihood that pyelonephritis will complicate asymptomatic bacteriuria (AB).
Antibiotic treatment is effective in reducing the risk of pyelonephritis in
pregnancy. There is no clear consensus in the literature on antibiotic choice or
duration of treatment for urinary tract infection. Urinary tract infection is one of
the important causes of morbidity and mortality in Indian population, affecting
all age groups across the life span. Anatomically, urinary tract is divided into an
upper portion composed of kidneys, renal pelvis, and ureters and a lower
portion made up of urinary bladder and urethra. UTI is an inflammatory
response of the urothelium to bacterial invasion that is usually associated with
bacteriuria and pyuria. UTI may involve only the lower urinary tract or both the
upper and lower tract.

12

RESEARCH METHODOLOGY OF THE STUDY

Research Methodology is a way to systematically solve the research problem, it
not only takes the research methods but also consider the logic behind the
methods. The study of Research Methodology for developing the project gives
us the necessary training in gathering materials and arranging them,
participation in the field work when required, and also provides training in
techniques for the collection of data appropriate to particular problems. In this
study, we will use normative survey method.
DATA COLLECTION
Primary Data
The primary data was collected by means of a survey. Questionnaires were
prepared and filled up the questionnaires. The questionnaire contains questions
which reflect on the type and quality. The response of the library is recorded.
The filled up information was analyzed to obtain the required interpretation and
the findings.
Secondary Source
In order to have a proper understanding of the library services of a dept. study
was done from the various sources such as book and the articles from various
researches and newspapers, magazines, internet etc.
EXPECTED OUTCOMES OF THE STUDY
13

The expected outcomes of this study will be to determine the spectrum of

different pathogens causing urinary tract infectins in hospitalized and non
hospitalized patients. It will also discuss the rate of ESBL producing Gramnegative bacteria causing nosocomial UTI in our referral teaching hospital as
well as their susceptibility pattern to the most commonly used antimicrobials to
identify the most appropriate antibiotic treatments for these infections.

REFERENCES
Asian Development Bank. 2005. Key Indicators 2005: Labor Markets in
Asia: Promoting Full, Productive, and Decent Employment. Manila:
ADB.

14

 Aderem A, Adkins JN, Ansong C, Galagan J, Kaiser S, Korth MJ, et al. A

systems biology approach to infectious disease research: innovating the
pathogen-host research paradigm. MBio. 2011; 2(1):e00325-e00310.
Boja ES, Rodriguez H. The path to clinical proteomics research:
integration of proteomics, genomics, clinical laboratory and regulatory
science. Korean J Lab Med. 2011; 31(2):61-71.
Bleakley, Hoyt. 2003. Disease and Development: Evidence from the
American South.Journal of the European Economic Association 1.2-3:
376-86.
Chakraborty, Shankha, Chris Papageorgiou, and Fidel Perez-Sebastian.
2007. Diseases and Development. Mimeo: University of Oregon
Department of Economics.
Gersovitz, Mark and Jeffrey S. Hammer. 2004. The economical control of
infectious diseases. The Economic Journal 114(492): 1-27.
Gersovitz, Mark and Hammer, Jeffrey S. 2005. Tax/subsidy policies
toward vector-borne infectious diseases. Journal of Public Economics
89(4): 647-674.
Heston, Alan, Robert Summers and Bettina Aten. 2002. Penn World Table
Version 6.1, Center for International Comparisons at the University of
Pennsylvania (CICUP).
Tauil PL. Perspectivas de controle de doencas transmitidas por vetores no
Brasil. Rev Soc Bras Med Trop.2006; 39(3):275-277.
Siqueira-Batista R, Gomes AP, Calixto-Lima L, Vitorino RR, Peres MC,
Mendona EG, et al. Sepse: atualidades e perspectivas. Rev Bras Ter
Intensiva. 2011; 23(2):207-216.
15

 Siqueira-Batista R, Mendonca EG, Gomes AP, Vitorino RR, Miyadahira

R, Alvarez-Perez MC, et al. Atualidades proteomicas na sepse. Rev Assoc
Med Bras. 2012; 58(3):376-382.
Yang L, Guo S, Li Y, Zhou S, Tao S. Protein microarrays for systems
biology. Acta

Biochim

Biophys

Sin

(Shangai) 2011;

43(3):161-

171. Review.
Yura K, Yamaguchi A, Go M. Coverage of whole proteome by structural
genomics observed through protein homology modeling database. J
Struct Funct Genomics. 2006; 7(2):65-76.

16