INTRODUCTION:

Urinary tract infections (UTIs) are one of the most common types of infectious, accounting approximately 150–250 million cases universally each year^1-2. UTIs can influence the different parts of the urinary tract in both males and females. However, many studies showed the IUT incidence are higher among women than among men because of their physiology^3-4. Almost 50–60% of all women suffer of UTI at least once in the course of their life⁵.

In fact, most of UTI cases are caused by bacteria but certain fungi and viruses can rarely responsible of this infection.

Escherichia coli is considered as the primary reason of UTI, followed by Klebsiella, Staphylococcus, Pseudomonas, Proteus and Enterococcus species⁶.

Several risk factors related to UTI include gender, age, sexual activity and obesity^7-11. The prevalence of IUT increase with age. The prevalence in women aged above 65 years is approximately 20% while It is roughly 11% in the overall population¹². The association diseases increase the severity of UTIs.

To treat UTI, oral antibiotics were recommended as amoxicillin-clavulanate, nitrofurantoin, first or second generation cephalosporins, ttrimethoprim-sulfamethoxazole or fluoroquinolones, In complex UTI cases, parenteral antibiotic were used including second generation cephalosporins, third generation cephalosporins (cefotaxime, ceftriaxone), aminoglycosides (gentamycin, amikacin).

Unfortunately in most UTIs, antibiotics were unnecessarily or inappropriately prescribed. These inappropriate uses of antibiotic led to UTI caused by bacteria resistant to common antibiotic making the treatment of UTI more difficult^13-26. Therefore, the aim of this study was to demonstrate the resistance of urine bacteria isolates from adult UTI patients in Syria to antibiotics.

MATERIALS AND METHODS:

In the laboratory, urine samples were collected in sterile urine containers. To detect and identify microrganisms causing UTI, blood and MacConkey agar plates were used in the culture study of urine samples. 24 hours after the incubation of urine samples at 37°C, colony forming units CFU were counted. If CFU greater than 100,000/ml, antibiotic sensitivity tests were then carried out using Mueller Hinton Agar (MHA). The level of antibiotics susceptibility of bacteria was determined by measuring the zone of inhibition.

The studied antibiotics discs include; amikacin 30μg, gentamycin 10μg, nitrofurantoin 300μg ceftriaxone 30µg, ciprofloxacin 30μg, imipenem 10μg, nalidixic acid 30μg, norofloxacin 10μg, cefpodoxime 30μg, cefuroxime 30μg, cefotaxime 30μg, cephalexin 30μg, cephalothin 30μg, cefixime 5μg, Amoxicillin-clavulanic acid 30μg and trimethoprim-sulfamethoxazole 75μg.

RESULTS:

A total of 111 urine samples from adult patients were collected in the laboratory between August 2020 and June 2021. As expected, the prevalence of UTI was higher in females than in males. 68% of collected urine samples were from female patients over 18 years of age (75 patients) and 32% from male patients over 18 years of age (39 patients). These results are in agreement with many studies which demonstrated that women are more susceptible to suffer from UTI than men because of their physiology^4,27.

In order to better understand the antibacterial susceptibility, adult patients were stratified by gender and age and classified into two groups: group 1 (between 18 and 50 years of age) and group 2 (above 50 years). There was no significant difference of UTI prevalence between groups 1(between 18 and 50 years of age: 15% males and 35% females) and group 2 (above 50 years: 17% males and 33% females).

The culture results of total urine samples revealed that E. coli was the first cause for the UTIs 70% followed by Klebsiella pneumonia 23%, and by others bacteria like Enterobacter and beta-hemolytic streptococcus 7%^28,29. Similar results was observed in another study performed by Al-Ahmad et al. 2017 at Al-Assad and Tichreen University Hospital, Lattakia, Syria. They found similar prevalence for E. coli 67% and for to Klebsiella 23%. These results were also in concordance with other studies from Saudi Arabia conducted by Ahmed et al. They also found that the most prevalent urinary tract pathogens were E. coli and K. pneumonia³⁰.

Although the E. coli was the first cause of UTIs, the proportion in males (61%) was lower than in females (75%). The prevalence of Klebsiella infections for males was higher 33%, than that for females 19%. These results were similar to those obtained by Alhambra et al. for UTI patients in China. They found that E. Coli proportion in men was lower than in women³¹.

Susceptibility of urine bacteria isolates:

Various oral and parenteral antibiotics routinely used to treat UTIs were evaluated in this study including cephalosporins, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole and other agents. The tested sixteen antibacterial drugs were amikacin (AMK), gentamycin (GEN), nitrofurantoin (NTF), ceftriaxone (CFR), ciprofloxacin (CPF), imipenim (IMP), nalidixic acid (NAL), Norofloxacin (NOF), cefpodoxime (CFP), cefuroxime (CFO), cefotaxime (CFT), cephalexin (CFL), cephalothin (CFH), cefexime (CFX),), amoxicillin-clavulanic acid (AMC), trimethoprim-sulfamethoxazole (TMS).

The susceptibility results for different antibiotics against the 111 bacteria isolates of UTI patients demonstrated that 99.1 % of urine bacteria isolates were resistant to at least 2 antibiotics (110/111). A high rate of resistance (≥ 50%) was observed among isolated urine bacteria to ten antibiotics. While only six antibiotics has a rate of resistance below 50% (figure 1).

Figure 1: Percent of studied antibiotic en function of resistance rate among isolated urine bacteria from UTI patients.

Figure 2 present the susceptibility of 111 bacteria isolates tested against 16 antibiotics. Amikacin and imipenem showed the highest activity (about 100%) for bacterial urine isolates whatever the pathogen caused the infection. These results were in accordance with those obtained by Alhambra et al.. They found that all the strains of urinary pathogens were susceptible to imipenem and amikacin³¹.

Amikacin and imipenim had the highest activity against all urinary pathogens with 0% resistance. For the both pathogens ( Klebsiella and E. Coli), a high rate of resistance to antibiotics was found. The observed high rate of resistance may be due to inappropriate usage of antibiotics to treat UTIs. For instance, the E. Coli and kleibsiella specific resistance to trimethoprim and sulfamethoxazole were 81% and 73% respectively. The comparison of resistance rates between E. coli and Klebsiella to antibiotics showed that E. coli were more resistant to cefpodoxime, ciprofloxacin and. The E. coli resistance rates exceeded those observed for kleibsiella by 21% for cefpodoxime, 20% for ciprofloxacin and 15% for cephalothin (figure 3). kleibsiella were more resistant to amoxicillin and clavulanic acid and nitrofurantoin (figure 3). The kleibsiella resistance rates exceeded those observed for E. coli by 23% for amoxicillin and clavulanic acid and 20% for nitrofurantoin. For other antibiotics, of E. coli and kleibsiella showed comparable resistance rates. This results are in agreement with other studies showed difference of resistance rates of E. coli and kleibsiella. For instance, the study performed by Hrbacek at al. showed that resistance to cefuroxime varied between E. coli (above 10%) and Klebsiella (above 30%).

Figure 3: Difference of resistance rates between Klebsiella and E. Coli.

Antibiotic Resistance of bacteria by gender and age:

Gender and age are risk factors related to UTIs. The resistance to antibiotic may be vary between female and males or en function of age. Therefore we compared the rate of resistance of bacteria urine isolates by gender and age (table 2).

Table 2: rate of resistance of bacteria isolate by age and gender.

Antibiotics	R %
	Age		gender
	18-50	>50	females	males
AMK	0	0	0	0
AMC	31	55	38	51
CFT	56	90	75	73
CFX	91	93	90	97
CFP	76	92	87	80
CFR	39	69	58	45
CFO	38	62	74	78
CFL	93	92	94	90
CFH	94	96	100	82
CPF	43	56	51	46
GEN	20	3	11	11
IMP	0	0	0	0
NAL	73	84	79	78
NTF	33	28	28	34
NOF	46	63	56	48
TMS	73	76	77	70

Female are more susceptible to suffer of UTIs than men. higher prevalence of UTIs among female may led to higher resistance to antibiotics than males. To highlight the effect of gender on rate of resistance, a comparison of resistance rates of bacteria isolates to antibiotics was performed between men and women (figure 4). The gender has a little effect on rate of resistance to antibiotics. For example, The rate of resistance to amoxicillin and clavulanic acid was 38% among female patients and 51% among male patients (the difference 13%). For other antibiotics, resistance rates were close (the difference < 20%).

Figure 4: Difference of resistance rates between female and male UTI patients.

The prevalence of IUT increase with age and the rate of resistance may be also increase with age. Therefore, UTI patients were classified into two groups: group 1 (18-50 years) and group 2 (above 50 years). The resistance rates were assessed by comparing susceptibility results to antibiotic between these two age groups.

To ceftriaxone, cefotaxime, amoxicillin and clavulanic acid, cefuroxime, ciprofloxacin, cefpodoxime and norfloxacin the resistance increased by age groups (figure 5). The difference of resistance rate was higher among UTI patients above 50 years of age by at least 10% than UTI patients from 15 to 50 years of age. For instance, resistance rate for cefotaxime was 90% among > 50 years UTI patients and 56% among 15- 50 years UTI patients and the difference of resistance rates between two age groups was 35%. The difference of resistance rates between two age groups were for ceftriaxone (31%), amoxicillin and clavulanic acid (24%), cefuroxime (24%), norfloxacin (17%), cefpodoxime (16%), ciprofloxacin (12%) and nalidixic acid (10%). Aother studies find that ressistance to antibiotics increase with age groups, For instance, Guillermo et al. found that E.coli resistance to ciproﬂoxacin increased with age patients. It was high among adults (11.8%) and elderly outpatients (29.1%)³².

For trimethoprim and sulfamethoxazole, cefexime, cephalexin, nitrofurantoin, the resistance rates between two groups were similar (the difference less than 10%).

It was surprising that urine Isolated bacteria were more resistance to gentamycin, aminoglycoside antibiotic, among UTI patients aged between 18 and 50 years (20%) than among those older than 50 years (3%) and the difference of resistance rates was 17%.

Figure 5: Difference of rate of resistance between UTI patients (18-50 years) and UTI patients older than 50 years.

DISCUSSION:

In Syria, as in many other countries, antibiotics are available over the counter. The ability to purchase antibiotics without any need to a prescription may lead to overuse or inappropriate use by the public. Sometimes, antibiotic are used in the absence of infections. These inappropriate uses of antibiotic lead to growing list of infections sometimes impossible to treat as antibiotics become less effective. The Antibiotic resistance is widespread and one of the biggest public health challenges of our time.

UTIs is one of the most common types of infection diseases in Syria and across the world. Antibiotic resistance of UTIs bacteria isolates was reported by several study across the globe. In vitro susceptibility of sixteen antibiotic commonly used to treat UTIs in Syria was evaluated in this study.

The obtained results revealed high overall resistance rates of urinary bacteria isolates for 13 antibiotics (resistance rates ≥20%). Amikacin and imipenem proved high activity with resistance rate 0%. Gentamycin was efficient with overall resistance rate 11%. The resistant bacteria may result from the incorrectly prescribed antibiotics including choice of agent, or duration of antibiotic. The best example is the first choice antibiotic to treat UTIs is rimethoprim and sulfamethoxazol. The observed overall resistance rates was higher than those obtained in various studies conducted in Saudi Arabia and Sultanate Oman. These studies revealed an overall resistance to this antibiotic of 49.4% in Saudi and 47% in Oman^30,33, which are lower than that obtained in our study 75%. This higher resistance rate is due to the inappropriate use of this antibiotic^34-36.

The susceptibility antibiotic may vary with the bacteria infection types. The comparison of susceptibility of E. Coli and Klebsiella showed a difference of resistance rates to antibiotics. This difference may exceed 20%.

The patient gender has little effect on bacteria resistance rates. Bacteria resistance rates increased with age due to the inappropriate usage of antibiotics.

CONCLUSION:

The results showed a good in vitro antibacterial activity of amikacin, imipenem and gentamycin against urine bacteria isolates. Moderate and high resistance rates was observed to first, second cephalosporins, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole and other agents. Multi-antibiotic resistance was found. 99.1% of urine bacteria isolates were resistant to at least 2 antibiotics. Due to these finding antibiotics sales should be regulated and not sale without prescription in Syria.

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Received on 24.10.2021 Modified on 08.01.2022

Research J. Pharm. and Tech 2022; 15(10):4727-4732.

DOI: 10.52711/0974-360X.2022.00794

Antibiotic		AMK	IMP	GEN	CFR	NTF	CPF	NOR	AMC	CFP	CFO	NAL	CFT	TMS	CFH	CFL	CFX
R%	*Klebsiella*	0	0	12	39	44	45	46	60	70	75	75	77	81	85	91	95
R%	*E.Coli*	0	0	7	59	24	52	52	37	91	74	79	70	73	100	92	92