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Multi Drug Resistant Pathogens Causing Urinary Tract Infection in Children at Kathmandu Model Hospital

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Abstract Introduction: Antibiotic resistance of urinary tract pathogens has increased globally. Updated knowledge of the antibiotic resistance patterns of uropathogens in the health institutes is important for the selection of an appropriate empirical antimicrobial therapy. The aim of this study was to evaluate the multi drug resistant urinary isolates in the children from 1 to15 years and evaluate the options for empiric antibiotic therapy. Materials and Methods: The study was conducted from December 2011 to May 2012 in the Bacteriology laboratory, Kathmandu Model Hospital. Urine samples received in the laboratory were processed for routine, culture and its sensitivity. The antimicrobial susceptibility of bacterial isolates was determined following Clinical and Laboratory Standard Institute (CLSI) recommended Kirby-Bauer Disc Diffusion method. Results: Of the total 372 urine samples received in the laboratory, 60 (16.13%) showed significant growth; of which 55.0 % (33/60) were MDR isolates. Escherichia coli were the predominant isolate from urine sample. Out of 49 Escherichia coli isolates, 27 (45.0%) were Multi drug resistant. Enterococcus faecalis (N=3) was the most predominant Gram positive isolate and 66.67 % (2/3) of this organism were multi drug resistant. Among the first line drugs used against gram negative isolates, nitrofurantoin was the most effective drug followed by quinolones, while among the second line drugs; meropenem was the most effective drug followed by chloramphenicol and amikacin, whereas; nitrofurantoin (100%) was the most effective drug for Gram positive isolates followed by norfloxacin and cefotaxime. Conclusion: High percentages of multi drug resistant uropathogens were revealed in children. Nitrofurantoin was found to be the most effective drug for gram positive, gram negative and multi drug resistant isolates.
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Original Article
<233>J. Nepal Paediatr. Soc.
Multi Drug Resistant Pathogens Causing Urinary Tract
Infections in Children at Kathmandu Model Hospital
Shrestha B1, Gurubacharya RL2, Maharjan B3, Shrestha S4
1Basudha Shrestha, MSc. Microbiology, Consultant Microbiologist, Department of Pathology, 2Dr. Rajesh Lal Gurubacharya,
MBBS, MD, Chief of Paediatric Services, Consultant Paediatrician, Department of Paediatric Medicine, 3Dr. Basanta
Maharjan, MPH, Community Health Development Program, 4Sanjit Shrestha, BMLT, Senior Laboratory Technologist,
Department of Pathology. All from Kathmandu Model Hospital, Kathmandu, Nepal.
Address for correspondence: Basudha Shrestha, E-mail: basudha111@hotmail.com
Abstract
Introduction: Antibiotic resistance of urinary tract pathogens has increased globally. Updated knowledge
of the antibiotic resistance patterns of uropathogens in the health institutes is important for the selection
of an appropriate empirical antimicrobial therapy. The aim of this study was to evaluate the multi drug
resistant urinary isolates in the children from 1 to15 years and evaluate the options for empiric antibiotic
therapy. Materials and Methods: The study was conducted from December 2011 to May 2012 in the
Bacteriology laboratory, Kathmandu Model Hospital. Urine samples received in the laboratory were
processed for routine, culture and its sensitivity. The antimicrobial susceptibility of bacterial isolates was
determined following Clinical and Laboratory Standard Institute (CLSI) recommended Kirby-Bauer Disc
Diffusion method. Results: Of the total 372 urine samples received in the laboratory, 60 (16.13%) showed
significant growth; of which 55.0 % (33/60) were MDR isolates. Escherichia coli were the predominant isolate
from urine sample. Out of 49 Escherichia coli isolates, 27 (45.0%) were Multi drug resistant. Enterococcus
faecalis (N=3) was the most predominant Gram positive isolate and 66.67 % (2/3) of this organism were
multi drug resistant. Among the first line drugs used against gram negative isolates, nitrofurantoin was
the most effective drug followed by quinolones, while among the second line drugs; meropenem was the
most effective drug followed by chloramphenicol and amikacin, whereas; nitrofurantoin (100%) was the
most effective drug for Gram positive isolates followed by norfloxacin and cefotaxime. Conclusion: High
percentages of multi drug resistant uropathogens were revealed in children. Nitrofurantoin was found to
be the most effective drug for gram positive, gram negative and multi drug resistant isolates.
Key words: Children, Multi drug resistance, Empirical antimicrobial therapy, Escherichia coli
Introduction
Urinary tract infection (UTI) is de ned as bac teriuria
along with urinary symptoms and is identi ed by
growth of a signi cant number of organisms of single
species in the urine. Urinary tract infections are common
medical problems in children and are important cause
of morbidity. UTI during childhood varies by age and
gender. UTI commonly a ects boys during the  rst year of
life1,but thereafter 3-5% of girls are a ec ted1, increasing
to 10% by the teenage years2. Although several di erent
microorganisms can cause UTI, including fungi and
viruses, bacteria are the major causative organisms and
responsible for more than 95% of UTI cases3. Treatment
of urinary tract infections is compromised worldwide by
the emergence of bacteria that are resistant to multiple
antibiotics4. Overuse and use of incomplete course of
antibiotics as well as empirical antimicrobial therapy has
been the major contributing factor in the development
of Multi Drug Resistant(MDR) bacteria5.
Multidrug resistance is de ned as resistance to
two or more di erent structural classes of antimicrobial
agents6. There is growing concern regarding the
resistance to uropathogens to antibiotics. The clinical
impact of drug resistance may be great or insigni cant,
depending on the level of resistance, the site of infection,
and the availability of e ective, nontoxic therapeutic
alternatives7. This prospective study was conducted to
identify UTI due to multidrug resistant uropathogens
among children and to evaluate empiric antibiotic
therapy.
September-December, 2012/Vol 32/Issue 3
doi: http://dx.doi.org/10.3126/jnps.v32i3.6771
<234> J. Nepal Paediatr. Soc.
Materials and Methods
This is the prospective study conducted at
Kathmandu Model Hospital on Pediatric patients (1-15
years) attending for the treatment of suspected UTI
case. Three hundred and seventy two urine samples
were examined from clinically suspected urinary tract
infection during the research period of six months
(December 2011- May 2012) using culture and sensitivity
tests. All the patient or parents of the patient were
instructed carefully for collection of morning mid-
stream urine specimens. They were given a sterile, dry
and clean collection bottles for urine collection. All the
urine specimens were processed within 30 minutes of
collection.
Culture of all urine specimens was done on 5%
Blood Agar and Mac Conkey Agar plate utilizing semi-
quantitative culture method (Fig 1). Shaking with hand
to ensure a uniform suspension of bacteria vigorously
mixed the urine specimens. Then, an inoculating loop of
standard dimension was used to take up approximately
xed and known volume (0.001ml) of mixed urine and
placed on the center of the plate. The drop was spread in
a line and then over the entire surface of the agar plate.
After inoculation, the culture plates were incubated in
an inverted position at 37oC for 24 hours.8 After 24 hours,
the numbers of colonies were counted on each plate,
which was multiplied by 1000 to calculate the number
of organisms per ml in the specimen. Samples showing
105 or more organisms per ml of urine were taken as
signi cant. Colony counts less than this was considered
as non-signi cant8.
Gram’s staining and various biochemical tests
identi ed pure culture of bacterial growth. Di erent
biochemical media used were Triple Sugar Iron Agar,
Sulphite Indole motility Agar, Urease agar, Simmons’s
Citrate Agar, Methyl Red / Voges Proskauer Test and
Oxidation Fermentation medium. Catalase, Coagulase
and Oxidase Tests were also performed. The antibiotics
used as  rst line drugs for Gram negative bacteria were
Amoxycillin (10 mcg), Cefotaxime (30 mcg), Cipro oxacin
(5 mcg), Ce xime (5 mcg), Cotrimoxazole (1.25/23.75
mcg), Nor oxacin (10 mcg), Nitrofurantoin (300 mcg)
and O oxacin (5 mcg) and those used for Gram positive
bacteria were; Amoxycillin (10 mcg), Cefotaxime (30
mcg), Cipro oxacin (5 mcg), Nor oxacin (10 mcg),
Cotrimoxazole (1.25/23.75 mcg), Nitrofurantoin (300
mcg), Gentamicin (10 mcg) and Ceftriaxone (30
mcg). The antibiotics used as second line drugs were
Ceftriaxone (30 mcg), Ceftazidime (30 mcg), Gentamicin
(10 mcg), Amikacin (30 mcg), Chloramphenicol (30 mcg),
Piperacillin/Tazobactam (100/10 mcg), Cefoperazone/
Sulbactam (50/50 mcg) and Meropenem (10 mcg). All
the antibiotics were tested by Kirby Bauer’s Disc Di usion
Technique. The colonies picked up and suspended in
Nutrient broth and adjusted turbidity to 0.5 Mc Farland
standard.
Within 15 minutes, a sterilized cotton swab was
dipped into the adjusted suspension. Carpet culture was
done by streaking the swab over the entire sterile Mueller
Hinton agar plate (Fig 2). The antibiotic impregnated
discs were placed on the surface of the agar plate and
then incubated at 37oC for 18 hours9. The di erent
inhibition zones were measured and interpreted the
results on the basis of zone size compared with standard
interpretive table given by manufacturer. The organisms
which showed resistant to all  rst line antibiotics except
Nitrofurantoin were tested for second line drugs.
Fig 1: Signi cant Growth of E. coli in Mac Conkey Agar
Fig 2: Antibiotic Susceptibility Test of MDR E. coli in Mueller Hinton
Agar
Multi Drug Resistant Pathogens Causing Urinary Tract Infections in Children at Kathmandu Model Hospital
<235>J. Nepal Paediatr. Soc.
Results
Of the 372 urine samples processed, 60 (16.13%)
samples showed signi cant growth where as majority
of samples i.e. 284 (76.34%) showed no growth and 28
(7.53%) showed growth of no signi cance (Table 1).
Out of 372 patients, 192 (51.61%) were male, while
180 (48.39%) were female. Of the total samples, 350
(94.09%) were from outdoor patients, 7 (1.88%) were
from indoor patients and 15 samples (4.03%) were from
emergency Department. The age group of 1-5 years had
the maximum requests of 179 (48.12%) for urine culture,
while the age group 11-15 years was second with 102
(27.42%) requests. Age group of 6-10 years was the least
with 91 (24.46%) request.
The age and gender wise distribution of children
with UTI is shown in Table 2. UTI was commonly found
in young female children of age 1-5 years. MDR isolates
were common in young children (46.67%) of the 1-5
years age group. Children of age group 6-10 years
showed three (5.0%) and age group 11-15 years showed
only two (3.34%) MDR isolates. Of the total MDR isolates,
31.67 occurred in young female children of age 1-5 years.
UTI was signi cantly high in female children (p=0.004) in
comparison to male. There was no signi cant di erence
seen in MDR infection between male and female (p=0.8).
However, the signi cant di erence was seen in MDR
infection between age group 1 to 5 and above 5 year’s
group (p=0.0001)
Gram negative bacteria were predominant;
constituting 56 (93.33%) of the total 60 isolates
and 33(55.0%) were MDR. Among Gram negatives,
Escherichia coli were the most frequently isolated species
with 49 (81.67%). Gram positive organisms constituted
only 4 (6.67%) of total isolates, and 2 (3.33%) of them
were MDR. Both MDR isolates were Enterococcus faecalis
(Table 3).
Table 3: Pattern of microbial isolates
Organisms No. of Isolates
(%) MDR (%)
Gram Positive Bacteria
Staphylococcus
epidermidis
Enterococcus faecalis
1(1.67)
3(5.0) 2 (3.33)
TOTAL (Gram Positive) 4 (6.67) 2(3.33)
Gram Negative Bacteria
Escherichia coli
Citrobacter spp.
Enterobacter aerogenes
Enterobacter cloacae
Proteus vulgaris
Salmonella Paratyphi A
49 (81.67)
2 (3.33)
2(3.33)
1(1.67)
1(1.67)
1(1.67)
27(45.0)
1(1.67)
1(1.67)
1(1.67)
1(1.67)
0
TOTAL (Gram Negative) 56 (93.33) 33 (55.0)
Grand Total 60 (100)
Among the common antibiotics used as  rst
line against gram negative isolates, nitrofurantoin
showed a susceptibility of 55/56 (98.21%). Quinolones
(Cipro oxacin, Nor oxacin and O oxacin) followed
Nitrofurantoin with susceptibility of 38/56 (67.86%).
Among the second line antibiotics used, Meropenem
was found to be most e ective drug with susceptibility
of 16/17 (94.12%) followed by chloramphenicol and
Amikacin with a susceptibility of 15/17 (88.24%). Most of
the Gram negative isolates i.e. 45 (80.36%) were resistant
to Amoxycillin (Table 4, 5).
Among the gram positive isolates, Nitrofurantoin
was the most e ective drug with susceptibility of
4/4 (100%) which was followed by Cefotaxime and
Nor oxacin (Table 6).
Out of 60 isolates, 24 (40.0%) isolates were resistant
to >3 drugs where as only 3 isolates of Escherichia coli
and one isolate of Salmonella Paratyphi were sensitive
to all antibiotics used. Among 56 gram negative isolates,
31(51.67%) isolates were MDR whereas of the 4 gram
positive isolates, 2 (50.0%) isolates were MDR (Table 7).
Table 1: Growth pro le of urine sample
Specimen Total no.
of samples
Signi cant Growth No Signi cant Growth No Growth
No. % No. % No. %
Urine 372 60 16.13 28 7.53 284 76.34
Table 2: Age and gender wise distribution of infected patients with MDR isolates
Age Group (yrs)
Growth with MDR isolates
Total MDR (%)Male Female
Isolates (%) MDR (%) Isolates (%) MDR (%)
1-5 14 (23.33) 9 (15.0) 24 (40.0) 19 (31.67) 28 (46.67)
6-10 2 (3.33) 0 9(15.0) 3 (5.0) 3 (5.0)
11-15 3 (5.0) 1 (1.67) 8 (13.33) 1 (1.67) 2 (3.34)
Total 19 (31.67) 10 (16.67) 41 (68.33) 23 (38.33) 33 (55.0)
Shrestha B et al
<236> J. Nepal Paediatr. Soc.
Table 4: Antibiotic Susceptibility Pattern of Gram-negative Isolates towards  rst line antibiotics
Antibiotic used Susceptible Intermediate Resistant Total
Frequency % Frequency % Frequency %
Amoxycillin 9 16.07 2 3.57 45 80.36 56
Cefotaxime 26 46.43 2 3.57 28 50.0 56
Cipro oxacin 38 67.86 2 3.57 16 28.57 56
Cotrimoxazole 28 50.0 1 1.79 27 48.21 56
Ce xime 33 58.93 1 1.79 22 39.28 56
Nitrofurantoin 55 98.21 0 0 1 1.79 56
Nor oxacin 38 67.86 2 3.57 16 28.57 56
O oxacin 38 67.86 1 1.79 17 30.35 56
Table 5: Antibiotic Susceptibility Pattern of gram negative isolates towards second line antibiotics
Antibiotic used Susceptible Intermediate Resistant Total
Frequency % Frequency % Frequency %
Amikacin 15 88.24 0 0.00 2 11.76 17
Gentamicin 10 58.82 0 0.00 7 41.18 17
Chloramphenicol 15 88.24 0 0.00 2 11.76 17
Ceftriaxone 1 5.88 0 0.00 16 94.12 17
Ceftazidime 1 5.88 1 5.88 15 88.24 17
Cefoperazone/Sulbactam 11 64.71 2 11.77 4 23.52 17
Piperacillin/Tazobactam 13 76.47 1 5.88 3 17.65 17
Meropenem 16 94.12 0 0.00 1 5.88 17
Table 6: Antibiotic Susceptibility Pattern of Gram-positive Isolates
Antibiotic used Susceptible Intermediate Resistant Total
Frequency % Frequency % Frequency %
Amoxycillin 2 50.0 0 0 2 50.0 4
Cipro oxacin 2 50.0 1 25.0 1 25.0 4
Cotrimoxazole 2 50.0 0 0 2 50.0 4
Cefotaxime 3 75.0 0 0 1 25.0 4
Nor oxacin 3 75.0 0 0 1 25.0 4
Nitrofurantoin 4 100.0 0 0 0 0 4
Gentamicin 2 50.0 0 0 2 50.0 4
Ceftriaxone 2 50.0 0 0 2 50.0 4
Table 7: Status of antibiotic resistance among MDR isolates
Organism Total
Isolates
Resistance to
0
Drug
1
Drug
2
Drugs
MDR isolates
2 Drugs
(di erent classes)
3
Drugs
> 3
Drugs Total %
Escherichia coli 49 3 18 7 7 0 20 27 45.0
Citrobacter spp 2 0 1 0 0 0 1 1 1.67
Ent. aerogenes 2 0 1 0 0 0 1 1 1.67
Ent. Cloacae 1 0 0 1 1 0 0 1 1.67
Proteus vulgaris 1 0 0 1 1 0 0 1 1.67
Salmonella Paratyphi 1 1 0 0 0 0 0 0 0
Staph. epidermidis 1 0 1 0 0 0 0 0 1.67
E. faecalis 3 0 0 0 0 0 2 2 3.33
Total 60 4 21 9 9 0 24 33 55.04
Multi Drug Resistant Pathogens Causing Urinary Tract Infections in Children at Kathmandu Model Hospital
<237>J. Nepal Paediatr. Soc.
Discussion
The emergence of multi drug resistance in
uropathogens is of great public health concern.
Prevalence of these organisms varies according to
species, antibiotic use and geographical area. The
increasing prevalence of infections caused by antibiotic
resistant bacteria makes the empirical treatment of UTIs
di cult. In the current study, we isolated 60 (16.13%)
uropathogens among 372 urine culture samples. The
study demonstrates that E. coli (81.67%) remains the
leading uropathogen responsible for UTIs which was
supported by several previous studies.10,11 The frequency
of UTI is greater in female children as compared to
male10,11,12 and our results were similar to these reports
showing 68.33% of patients were female.
Paediatric UTI causing bacteria are becoming
increasingly resistant to commonly used antibiotics such
as  uroquinolones and third generation cephalosporins.
Cotrimoxazole (Trimethoprim-sulphamethoxazole),
uroquinolones, or nitrofurantoin are recommended
for empirical treatment of uncomplicated UTI13,14.
However, several reports from worldwide indicated the
excessive increase in the emergence of trimethoprim-
sulphamethoxazole resistant E. coli15,16. Cotrimoxazole
was replaced by  uroquinolones and cephalosporins
because of high level of resistance to this drug but
unfortunately after sometime resistance to these drugs
was also detected and published. Our study also showed
the similar  ndings with 28.5-30.35% resistance to
quinolones, 39.2-50.0% resistance to cephalosporins
and 48.21% resistance to cotrimoxazole for gram
negative isolates17. The results showed a considerable
increase in resistivity of gram negative isolates to
amoxycillin (80.36%) which was supported by several
studies11,12,18. Nitrofurantoin demonstrated better
activity against gram negative (98.21% susceptible) as
well as gram positive isolates (100.0% susceptible), in
agreement with data published by others17,18,19. The high
level susceptibility of uropathogens to nitrofurantoin
may be the narrow spectrum of activity, narrow tissue
distribution (low or undetectable serum concentration)
and limited contact with bacteria outside the urinary
tract20. According to our study, the  rst line antibiotics to
be used for the treatment of UTI is nitrofurantoin.
In our study, we de ned those organisms as MDR
which were resistant to two or more di erent structural
classes of antibiotics6. According to this, 33 (55.0%)
MDR isolates were detected. Of the 33 MDR isolates,
27(45.0%) were E. coli. This result was supported by
previous other studies21,22,23. Our study demonstrated
the highest resistance to Ceftriaxone (94.12%) among
17 MDR isolates. This may be due to the production of
ESBL enzymes or other resistance mechanisms which
could not be addressed because of limited resources.
The resistance to cephalosporin is explained though the
enzymatic mechanisms and e ux pumps24. It has been
reported that pathogenic E. coli isolates have relatively
high potential for developing resistance.25 Among the
antibiotics used in the second line, meropenem was the
most active drug with susceptibility of 94.12% followed
by amikacin and chloramphenicol with susceptibility
of 88.24%. These  ndings reveals stronger propensity
of uropathogens towards multiple drugs resistance
limiting few therapeutic options for the treatment.
Conclusion
The results of the present study suggest that
prevalence of MDR E. coli is alarmingly high and the most
appropriate  rst line oral antibiotic for empiric treatment
of uri nary tract infection at our hospital is nitrofu rantoin
and meropenem, amikacin and chloramphenicol as
second line agents. Antibacterial resistance patterns
need to be up dated periodically to ensure proper
empiric treatment of UTI.
Acknowledgements: None
Funding: None
Con ict of Interest: None
Permission of IRB: Yes
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Multi Drug Resistant Pathogens Causing Urinary Tract Infections in Children at Kathmandu Model Hospital
How to cite this article ?
Shrestha B, Gurubacharya RL, Maharjan B, Shrestha S. Multi Drug Resistant Pathogens Causing Urinary Tract Infections in
Children at Kathmandu Model Hospital. J Nepal Paediatr Soc 2012;32(3):233-238.
... In a similar study conducted by Patel P 12 , E.coli was found to be highly sensitive to gentamicin, amikacin and piperacillin -tazobactam . Our study showed nitrofurantoin having lesser resistance to gram negative bacilli when compared to ampicillin and cotrimoxazole which was observed in other studies also 10,15,16 . As E. coli resistant to trimethoprim -sulphamethoxazole and Fluoro quinolones has become more common, nitrofurantoin has become an important oral agent in the treatment of uncomplicated urinary tract infection 17 . ...
... Among 123 MDR isolates, maximum isolates (75%) were E.coli. Similar studies conducted elsewhere also showed that maximum MDR isolates were seen in E.coli 10,19,20 . Since E.coli is the major causative organism causing UTI across age group, various drugs are being used in hospitals empirically for treating E.coli which leads to drug resistance ...
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Urinary tract infection (UTI) is one of the commonest medical problems in children. It can distress the child and may cause kidney damage. Prompt diagnosis and effective treatment can prevent complications in the child. But treatment of UTI in children has now become a challenge due to the emergence of multidrug resistant bacteria. Aims & Objectives: To know the bacteriological profile and susceptibility pattern of urinary tract infections in children and to know the prevalence of multidrug resistant uropathogens. Materials & Methods: A retrospective analysis was done on all paediatric urine samples for a period of one year. A total of 1581 samples were included in the study. Antimicrobial susceptibility testing was done on samples showing significant growth by Kirby-Bauer disc diffusion method. Statistical analysis: Prevalence and pattern were analyzed using proportions and percentages. Results: E.coli was the most predominant organism (56%) causing UTI in children followed by Klebsiella sp (17%). Fifty three percent of gram negative organisms isolated from children were found to be multidrug resistant. Majority of E. coli isolates were found to be highly resistant to Ampicillin (91%) and Cotrimoxazole (82%) and highly sensitive to Imipenem (99%) and Amikacin (93%). Conclusion: Paediatric UTI was common in children less than 5 years of age. Gram negative bacteria (E. coli and Klebsiella sp) were more common than gram positive bacteria. Our study revealed that multidrug resistance was higher in E.coli.
... [36] Shrestha et al. reported 66.67% of enterococci as MDR in urine from the neighbouring country Nepal. [37] In concurrence to most other studies from India, linezolid was found to be the most effective drug. [27,28,31] Less resistance was also showed towards nitrofurantoin and these two drugs can be the affectively used for treatment of UTI by MDR enterococci in this region. ...
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Purpose: Enterococci express high degree of resistance towards wide range of antibiotics. Production of biofilm and many virulence factors along with drug resistance makes it difficult to eradicate the infection from urinary tract. The present study detected the expression of such factors including biofilm production by multidrug-resistant (MDR) enterococci. Materials and methods: Drug susceptibility of 103 uropathogenic enterococci was performed followed by estimation of minimum inhibitory concentration of high-level gentamicin and vancomycin by microbroth dilution method. Vancomycin-resistant genes were detected by multiplex polymerase chain reaction. Production of virulence factors such as haemagglutination, caseinase, lipase, gelatinase, haemolysin and β-lactamase was detected by phenotypic methods in MDR strains. Biofilm production was detected by calcofluor-white fluorescence staining and semi-quantitative adherence assay. Results: 45% and 18.4% of the isolates were high-level gentamicin-resistant and vancomycin-resistant enterococci (VRE), respectively. vanA gene was detected in 14 and vanB gene in 5 strains. Biofilm, caseinase and gelatinase were the most expressed virulence factor. Expression of caseinase, gelatinase and lipase was significantly higher in Enterococcus faecalis (P < 0.05). Expression of haemagglutination, gelatinase and haemolysin among the vancomycin-resistant isolates was significantly higher (P < 0.05). Conclusion: VanA and vanB are the prevalent genotypes responsible for vancomycin resistance. The high prevalence of MDR enterococcal strains producing biofilm and virulence determinants raises concern. asa1, hyl, esp, gelE, cyl and other genes are known to express these factors and contribute to biofilm formation. Most uropathogenic enterococci expressed biofilm at moderate level and can be detected effectively by calcofluor-white staining. No correlation was noted between vancomycin resistance and biofilm production.
... 75% (n=6) of Enterococcus and 50% (n=1) of Citrobacter were MDR. Proteus, Citrobacter, and Enterococcus as MDR highly aligned with the finding in other study [41]. ...
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... There are studies showing high resistance to these organisms which could be due to increasing drug resistance seen worldwide. [19,20] Ampicillin was found to be highly resistant(77%) to enterobactericeae in our study. Various studies have shown similar pattern where ampicillin was found to be highly resistant. ...
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Urinary Tract Infection (UTI) is one of the most common infectious diseases and people of all age-groups and geographical locations are affected. The impact of disease is even worst in low-resource developing countries due to unaware of the UTIs caused by multidrug-resistant (MDR) pathogens and the possibility of transfer of MDR traits between them. The present study aimed to determine the prevalence of MDR bacterial isolates from UTI patients, the antibiotic resistance pattern and the conjugational transfer of multidrug resistance phenotypes in Escherichia coli (E. coli). Two hundred and nineteen bacterial isolates were recovered from 710 urine samples at Kathmandu Model hospital during the study period. All samples and isolates were investigated by standard laboratory procedures. Among the significant bacterial growth (30.8%, 219 isolates), 41.1% isolates were MDR. The most prevailing organism, E. coli (81.3%, 178 isolates) was 38.2% MDR, whereas second most common organism, Citrobacter spp. (5%, 11 isolates) was found 72.7% MDR. Extended-spectrum β-lactamase (ESBL) production was detected in 55.2% of a subset of MDR E. coli isolates. Among the 29 MDR E. coli isolates, plasmids of size ranging 2-51 kb were obtained with different 15 profiles. The most common plasmid of size 32 kb was detected in all of the plasmid-harbored E. coli strains. The majority of E. coli isolates investigated for the multidrug resistance transfer were able to transfer plasmid-mediated MDR phenotypes along with ESBL pattern with a frequency ranging from 0.3 × 10-7 to 1.5 × 10-7 to an E. coli HB101 recipient strain by conjugation. Most of the donor and recipient strain showed high levels of minimum inhibitory concentration (MIC) values for commonly-used antibiotics. The high prevalence of multidrug resistance in bacterial uropathogens was observed. Particularly, resistance patterns were alarmingly higher for amoxycillin, co-trimoxazole, flouroquinolones and third-generation cephalosporins, which necessitate the re-evaluation of first and second line therapies for UTI. In addition, conjugational co-transfer of MDR phenotypes with ESBL-positive phenotypes was observed in MDR E. coli.
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