Shalamar Medical & Dental College,

Lahore

Research Topic

PREVALENCE OF MULTI DRUG RESISTANT ESCHERICHIA

COLI FROM URINARY ISOLATES IN TERTIARY CARE
HOSPITAL, LAHORE , PAKISTAN

Community Medicine 4th year MBBS

Batch C
PREVALENCE OF MULTI DRUG RESISTANT ESCHERICHIA
COLI FROM URINARY ISOLATES IN TERTIARY CARE
HOSPITAL, LAHORE , PAKISTAN

Research work was done at Shalamar Medical and Dental College, Lahore.
Waqar , Humza, 2015038, 4th year MBBS, Batch C, Department of Community Medicine,
Shalamar Medical and Dental College, Lahore.
Jamshed, Junaid, 2015045,4th year MBBS, Batch C, Department of Community Medicine,
Shalamar Medical and Dental College, Lahore
Khan, Jawad Khurshid, 2015044,4th year MBBS, Batch C, Department of Community Medicine,
Shalamar Medical and Dental College, Lahore
Fatima, Huma, 2015037,4th year MBBS, Batch C, Department of Community Medicine,
Shalamar Medical and Dental College, Lahore

Aftab, Javeria, 2015043,4th year MBBS, Batch C, Department of Community Medicine,

Shalamar Medical and Dental College, Lahore
Naeem, Mahad, 2015049,4th year MBBS, Batch C, Department of Community Medicine,
Shalamar Medical and Dental College, Lahore
Hussain, Ibtahaj, 2014039,4th year MBBS, Batch C, Department of Community Medicine,
Shalamar Medical and Dental College, Lahore
Saeed, Irfan, 2015041,,4th year MBBS, Batch C, Department of Community Medicine, Shalamar
Medical and Dental College, Lahore

Correspondence:

Humza Waqar
MBBS 2015-038,4th year MBBS, Batch C, Department of Community Medicine, Shalamar
Medical and Dental College, LahoreTelephone: +92 4337393195Mobile: +92 312 4424084
Email: humzawaqar09@gmail.com

Acknowledgements:

The author would like to thank Dr. LuqmanFarrukhNagi (Assistant Professor Community
Medicine)
 Abstract

Objective: To find out the prevalence of multidrug resistant E.Coli was analyzed in urine
samples of patients with urinary tract infections visiting a diagnostic laboratory in Lahore,
Pakistan.

Design: The study design was Cross Sectional

Setting: A total of 300 isolate of E.Coli were obtained from 1126 positive culture isolates. 100
isolates were randomly selected with 58 males and 42 females among the sample. The age varied
from 2 months to 99 years with maximum isolates from age group 40-59 years.

Results: Maximum resistance was seen towards Ampicillin (95%) and the minimum resistance
was seen towards Colistin(2%) and Amikacin(2%). Among other drugs tested for resistance were
CoTrimoxazole (82%), Ciprofloxacin (82%), Cephalosporins, Imipenem(5%),
Nitrofurantoin(13%).

Conclusion:E.Coli resistance is much higher in Pakistan compared to reports from Western

Literature.The high prevalence of multidrug resistant UTIs call of monitoring of cases of drug
resistant infections and appropriate changes in selection of drugs for empirical treatment.
Empirical treatment should be advised according to susceptibility patterns.

Keywords: Antimicrobial Resistance, Escherichia Coli, Multidrug resistance, Urinary tract

infections.
 Introduction

Infections have been the major cause of disease throughout the history of human populations.
With the introduction of antibiotics, it was thought that this problem should disappear. However,
bacteria have been able to evolve to become antibiotic resistant. (1)

Antimicrobial resistance, the ability of (pathogenic) bacteria to withstand the action of

antibiotic drugs, has recently been rated of having an impact on humans similar to that of
global climate change. Indeed, during the last years medicine has faced the development of
highly resistant bacterial strains. (2)
The emergence of pathogens with a variety of resistance mechanisms has intensified the
challenges associated with infection control and treatment strategies. Therefore, prudent use of
currently available antimicrobial agents, as well as implementing measures to limit spread of
resistance is paramount.
An important member of the normal intestinal micro flora of humans and other mammalsfew
microorganisms are as versatile as Escherichia Coli.Urinary tract infections (UTIs) are the
most common bacterial infections and Escherichia coli is the most prevalent cause of UTIs. (3)
Empirical treatment of UTIs in the developed countries is based on the susceptibility data
originated from the local surveillance schemes . However, countries like Pakistan do not have
any surveillance system to provide reference guidelines for empirical therapy. Thus errors are
expected in most of the estimates for empirical therapy for UTIs in such conditions. These errors
lead to further strains of multi drug resistant bacteria. (4)

Pharmacovigilance in the form of surveillance of antibiotic use is being done in 90% of the
countries worldwide through the WHONET program developed by WHO. However, the data
comes from a limited area of the globe. Data from every part of the world is required, so that
there is geographical representation of every region. A major hurdle in quantifying the extent of
antimicrobial resistance is the fact that there are several known microbes, that may turn out to be
resistant to one or more of the several known antimicrobial agents. The global action plan
initiated by WHO, if implemented successfully will definitely reduce AMR and will help in
evaluating treatment interventions. (5)
The aim of this study was to determine the prevalence of antimicrobial resistance, ong E.
coli isolates from UTI patients from Pakistan.
 Methodology

Sampling Technique:
Convenience Sampling technique was used.
Sample Size:

This study consisted of 100 patients selected from a population of 1126.

Study Variable:
The records of the patients were collected and relevant variables were extracted. The variables
included age, date of admission, gender and resistance to antibiotics.
Study Design:

This was a Cross Sectional Study

Study Duration:
Duration was from February 2018 to November 2018
Study Setting:
Patients who have had Culture and Sensitivity Testing done from Shalamar Hospital Laboratory

Questionnaire:
Non Structured Questionnaire was used.
Data Collection and Analysis:
Data was collected and analyzed in MS EXCEL
Ethical Consideration:
Personal identity of the patient will not be revealed and prior relevant authorization has been
taken from IRB.
 Results

Altogether 100 samples were compared for antibiotic resistance, the highest resistance was seen
towards Ampicillin(95) and Amoxicillin Clavulonic Acid (89) and 2nd and 3rd generation
Cephlosporins. Of particular interest was the resistance to Ciprofloxacin (82) which is used as
empirical therapy for uncomplicated and complicated cases of E.Coli cystitis. Drugs which are
considered to be 1st line for treatment like Nitrofurantoin were found to be resistant in 13 cases,
while Cefuroxime (72) and Ceftriaxone (83) also showed high resistance. Least resistance was
seen towards Colistin (2) and Amikacin (2), followed by Imipenem(5), Tigecycline(6) and
Meropenem(7).

Gender Percentage
Male 42%
Female 58%

Age Group Percentage Samples

0-19 14%
20-39 13%
40-59 31%
60-79 33%
80-99 9%
 Resistant Isolutes Percentage

Ampicillin 95 95%
Amoxicilin + Clavulonic acid 89 89%

Co Trimoxazole 82 82%

Cefuroxime 72 72%
Ciprofloxacin 82 82%

Ceftriaxone 83 83%
Cefotaxime 83 83%

Pipercillin Tazobactam 60 60%

Tigecycline 6 6%

Imipenem 5 5%

Meropanem 7 7%
Colistin 2 2%

Amikacin 2 2%

F-Nitrofurantoin 13 13%
Nalidixic acid 67 67%

Gentamicin 37 37%
 Percentage Resistant

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Discussion

MDR in UPEC causing UTIs is an emerging and serious public health problem and results in
treatment failure. This study provides current information about the antimicrobial resistance
pattern in E. coli isolates from patients’ urine samples in Shalamar Hospital, Lahore, Pakistan.

Based on the results of the present study, there is a high resistance rate to the commonly used
antibiotics in the E. coli isolates. We found that 89% of the isolates were MDR E.Coli while 82%
were resistant to more than 8 antibiotics. A significant resistance was seen against Co
Trimoxazole 82% which is recommended by many guidelines as drug for UTI treatment.(6) In
addition, Ciprofloxacin recommended for UTIs, showed high resistance in data from other
surveys and European countries according to Annual report of the European Antimicrobial
Resistance Surveillance Network in 2012.(7) Use of Nalidixic Acid for treatment of UTIs may
be the reason for high rate of resistance i.e. 67%.Resistance was also noted for Nitrofurantoin
(13%) which is considered a 1 st line antibiotic.(8)
According to experts, resistance level >20% is used as a cut-off in guidelines on UTIs, so these
antibiotics should not be recommended for the treatment of UTIs. Low resistance was seen
towards Meropanem(7%) and Imipanem( 6%). Least resistance was seen towards Amikacin and
Colistin (2%). Based on our results, the extremely high percentage of isolates showed an MDR
phenotype.
Some socioeconomic and behavioral factors can contribute to antibiotic resistance such as
misuse of antimicrobial agents by hospital physicians or unskilled practitioners and easy access
to antibiotics without a prescription.(9) These increasing and varying resistance patterns could
lead to change in therapeutic strategies. The successful empirical initial treatment is based on
susceptibility and resistance patterns obtaining from local data(10). Since these susceptibility
patterns are constantly changing and may vary in different geographical regions and institutions,
regular monitoring of antimicrobial agents resistance seems necessary to formulate standard
treatment guidelines for empirical therapy(11).

Conclusion

It is concluded that antibiotic resistance is very common in uropathogenicE.Coli in Pakistan. In

most cases the resistance is seen to multiple drugs. In developing countries like Pakistan proper
surveillance for antibiotic use and resistance is very essential to curb this growing trend of
multidrug resistant microbes. Proper guidelines should be issued to clinicians for the treatment
strategies of urinary tract infections.

Conflict of Interest:
We declare that there was no conflict of interest.
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