Emergence of multidrug resistant uropathogenic Escherichia coli ( UPEC ) strains isolated from a hospital in Bangladesh

Emergence of multidrug resistant uropathogenic Escherichia coli (UPEC) strains isolated from a hospital in Bangladesh Md. Abdullah Yusuf*, KM Shahidul Islam, Sanya Tahmina Jhora, AKM Shamsuzzaman, Md. Zakiur Rahman 1 Department of Microbiology, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh. 2 Department of Microbiology, Dhaka Medical College, Dhaka, Bangladesh. 3 Principal, Mugda Medical College, Dhaka, Bangladesh. 4 Communicable Disease Control, Directorate General of Health Sciences, Ministry of Health & Family Welfare, Dhaka, Bangladesh. 5 Department of Microbiology, Monno Medical College, Manikgonj, Bangladesh


Introduction
The uropathogenic Escherichia coli (UPEC) strains are responsible for 70-90% of acute cystitis (1).UPEC causes UTI in both male and female.However, it has been established that UTI is more common among women as compared to men (2).
The increasing incidence of infections causes the difficulties for the proper management of UTI due to antibiotic resistant E. coli (6).Currently emergence of E. coli causing UTIs are reported which are resistant to cephalosporins, fluoroquinolones, and trimethoprim.This has created an especially clinical significant due to limited therapeutic options (7).Center for Disease Control (CDC) has published that three or more than any three groups of antibiotics which are resistant to E. coli is designated as multidrug resistant (MDR) E. coli.This group of bacteria is difficult to treat.There is no antibiotic policy in this country.This leads to the development of drug resistance to a large group of antibiotics.Therefore, it is very important to detect these MDR UPEC isolated from both community as well as the hospital settings.The purpose of the present study was to detect the MDR UPEC isolated from a hospital in Dhaka city.

Material and methods
This retrospective study was conducted at a private multidisciplinary hospital in Dhaka city with 200 bed capacity situated at the center of the city.This study was carried out from July 2013 to December 2013 for a period of 6 (six) months.All the patients presenting the clinical features of UTI at any age with both sexes who were attended in the outdoor patient Department (OPD) or admitted in the indoor patient department (IPD) of the hospital were included as the study population.Patients without significant pus cell within urine, patients under antibiotic therapy were excluded from this study.Urine was collected in a sterile container with full aseptic precaution in a standard procedure.E. coli was isolated and identified by standard laboratory methods by using MacConkey's agar, Cysteine Lactose Electrolyte Deficient (CLED) agar media and Kligler Iron Agar (KIA) media for biochemical test; antibiotic sensitivity testing was performed by Kirby Bauer's disk diffusion method by using 7 (seven) groups of antibiotics.The diameter of zone of inhibition was measured to interpret the sensitivity pattern according to CLSI (2016).In this study 7 groups of antibiotics were analyzed which were quinolones, cephalosporins, aminoglycosides, macrolides, carbapenes, sulfonamides and nitrofurantoin Statistical analysis was performed by the Statistical Program for Social Science (SPSS, Version 19.0, USA).The qualitative data were expressed in frequency and percentage and the quantitative data were expressed as mean and standard deviation.The associations of quantitative data between the two groups were performed by Student's t test.Overall resistant pattern of uropathogenic E. coli to different antibiotics had been calculated by multiple responses.A p value less than 0.05 has been taken as level of significance.Confidence interval was considered at the 95 % level.

Results
A total number of 57 UPEC E. coli was isolated and identified of which 9 (15.8%)cases were from male and the rest 48 (84.2%) cases were from female.Majority were in the age group of 20 to 60 years which was 36 (63.2%) cases followed by more than 60 years of age group which was 14 (24.6%)cases.The relationship between age group of the patients and the sex difference was statistically significant (p=0.038)(Table 1).(8).Therefore, the emergence of multidrug resistance in E. coli becomes a global concern.Furthermore, the drug resistance is due to extendedspectrum β-lactamases (ESBLs) especially CTX-M family (9).In this study a total number of 57 UPEC were isolated and identified of which 15.8% cases were from male and the rest 84.2% cases were from female.These findings indicate that the UPEC are commonly affected the women.This is in favour of the occurrence of high UTI among the female.Bashir et al. (10) have reported that female are more commonly suffering from UTI and E. coli is the most common pathogen.It has been established that UTI will be occurred five times among the women in their lifetime and the reasons for this are also revealed.There is some traditional first-line antibiotics used for treating serious infections which are caused by UPEC and these include penicillins, cephalosporins, monobactams, carbapenems, fluorquinolones as well as aminoglycosides (15).Therefore, the frequent use of these first-line agents causes the development of

Table 1 .
Age and gender distribution of the study population (n=57).

Table 2 .
Distribution of multidrug resistant UPEC according to number of antibiotics.
(14)efore, this statement is in consistent with the present study result.UTI can occur at any age; however, the most common age is the reproductive age group(11).In this context the present study result shows that the majority are in the age group of 20 to 60 years which is 36 (63.2%) cases followed by more 68 than 60 years of age group which is 14 (24.6%)cases.The relationship between the age group of the patients and the sex difference was statistically significant (p=0.038).Similar to the present study result Magliano et al.(12)have reported that young age group are the most vulnerable group in the causation of UTI and this group has frequently infected by different bacteria mostly gram negative.Resistant to four groups, five groups, six groups and seven groups of drugs were found in 17.5% (95% CI 7.64 to 27.36%), 14.0% (95% CI 4.99 to 23.01%), 10.5% (95% CI 2.54 to 18.46%) and 8.8% (95% CI 1.45 to 16.15%) uropathogenic E. coli respectively.The total number of MDR UPEC was 92.9% (95% CI 86.23 to 99.57%).Similarly Zhanel et al.(14)have done a study to find out the MDR UPEC and have found a high frequency among the urinary isolates.This result is in favour of the present study findings.