Are we treating Urinary Tract Infections, right??

Are we treating Urinary Tract Infections, right??

Overview

  • Post By : Kumar Jeetendra
  • Source: MBI Bureau
  • Date: 23 February, 2018

Infections are as old as mankind. The discovery of antibiotics gave us the power to control infections. Bacteriae were smarter to develop ways to escape action of antibiotics and that’s what we now call as Antibiotic resistance. The antibiotic resistance spread far and wide and currently is one of the main concerns plaguing the medical fraternity. Antibiotic resistance has forced us to treat common infections with stronger and costlier antibiotics. This means the patient has to spend more in terms of buying costlier antibiotics and also for the extended hospital stay in some cases. Millions of dollars are spent every year to devise methods to combat antibiotic resistance. International agencies like the CDC& WHO have worked out the reasons for the emerging antibiotic resistance. Few reasons postulated by experts are misuse of antibiotics, uncontrolled over the counter sale of antibiotics and use of antibiotics in animal husbandry.

Indian perspective

The way ahead is to devise a uniformNational antibiotic policy so that few life saving antibiotics are reserved at the times of need. India has already taken its baby steps towards formation of an antibiotic surveillance network. Initially the data available from the premier institutes like PGI Chandigarh, AIIMS, JIPMER& CMC Vellore will be analysed.

India has realised the need to take steps to prevent further spread of antibiotic resistance. The way ahead is to devise a uniformNational antibiotic policy so that few life saving antibiotics are reserved at the times of need. India has already taken its baby steps towards formation of an antibiotic surveillance network. Initially the data available from the premier institutes like PGI Chandigarh, AIIMS, JIPMER& CMC Vellore will be analysed. In the next stage all antibiotic resistance data will be collected from Government Medical colleges and hospitals. The need to involve all the private institutions has been well recognised and will be involved as well. By analysing the whole data a presumptive antibiotic policy can be drafted so that the clinician can handle the patients better.

Urinary tract infections

There are many types of infections affecting human beings. The most common is the urinary tract infection (UTI). UTI is more common in females. UTI can be classified as upper and lower UTI. CAUTI (Catheter Associated Urinary Tract Infection) emerged along the advent of medical devices came. The medical advances have given us better life expectancy but along with it rises spread of infections within the hospital. Such a urinary infection which a patient acquires in a health care set up after 48hours of admission is termed as Nosocomial UTI. In most cases it is due to the lapses in infection control. Hand washing is considered the most important step in order to prevent inadvertent transmission of infection by health care workers.

The culprits

The main cause of urinary tract infection in India remains to be the members of Enterobacteriaceae family. This is followed by members of Pseudomonas family, Staphylococcus aureus and Enterococcus sp. Among the members of Enterobacteriaceae,

Escherichia coliremains the most important pathogen causing uncomplicated UTI. E.coli infections are more common in women which may be attributed to the anatomical proximity to the gastrointestinal tract which harbours E.coli as a commensal. Klebsiella pneumoniae is the next most commonly isolated gram negative bacteria from the same family. A few infections are also caused by Klebsiellaoxytoca, Proteus mirabilis, Proteus vulgaris and Citrobacter sp. Among the gram positive bacteriae Staphylococcus aureus and Enterococcus are responsible for few uncomplicated UTI’s.

Compilation of our resistance profile of E.coli

We analysed the antibiotic sensitivity profile of E.coli isolates collected from urinary specimens from January to December 2017. This study was carried out at Azeezia Medical College in Kollam district of Kerala. Clean catch midstream urine samples (CCMSU) were collected and processed using standard protocols. A total of 1152 urine samples were received during the study period. 610 (52.9%) samples did not grow any bacteria. 148 samples grew E.coli.Klebsiella pneumoniae were isolated from 67 samples. Enterococci were isolated from 27 samples followed by Staphylococcus aureus from 16 samples.



Minor isolations were Enterobacter aerogenes, Pseudomonas aeruginosa, candida sp. Semi- quantitative cultures were carried out on Blood agar and MacConkey agar supplied by Himedia labs, Mumbai.

The antibiotic sensitivity was carried out on monobacterial first isolates of E.coli with more than 1,00,000 CFU/Ml (Significant bacteruria). A total of 132 samples of E.coli were selected for analysis. The isolates were then subjected to Antibiotic sensitivity testing as per Clinical and Laboratory Standards Institute (CLSI) 2017 guidelines. The Antibiotic sensitivity testing was done on Meullerhinton agar. Standard strain American Type Culture Collection (ATCC) strain of E.coli 25922 was used as a control.

The isolates were tested for sensitivity to the following discs Ampicillin(10μg), Gentamicin(10μg), Tobramycin (10μg), Amikacin (30μg), Ciprofloxacin(5μg) Levofloxacin(5μg) Cotrimoxazole(1.25/23.75μg) Amox-Clavulanic Acid(20/10μg) Piperacillin-Tazobactum(100/10μg) Norfloxacin(10μg) Amikacin(30μg) Cefuroxime( 30μg), Ceftriaxone (30μg), Ceftazidime(30μg), Ceftazidime- Clavulanic Acid(30/10μg), Cefotaxime(30μg) Imipenam(10μg), Tetracycline(30μg), Nitrofurantoin(300μg). The sensitivity was recorded and reported as per the CLSI 2017 guidelines. The results are shown below.,

Discussion: Evidence based .

The current national policy suggests use of Nitrofurantoin 100mg B.D for 7days or Cotrimoxazole 960mgBD for 3-5days or Ciprofloxacin 500mg BD for 5days as first line of treatment for uncomplicated cystitis. Alternatively cefuroxime 250mg can be prescribed twice daily for 3-5days. Acute uncomplicated pyelonephritis can be managed with Amikacin 1gm OD or Gentamicin 7mg/kg/day. Alternatively Piperacillin-Tazobactun 4.5gm QID or Cefaperazone –sulbactum 3gm IV BD or Etrapenam 1g IV OD may be prescribed. Complicated pyelonephritis can be managed using Piperacillin-Tazobactun 4.5gm QID or Amikacin 1gm OD or Cefaperazone –sulbactum 3gm IV BD.

If resistance has been observed previously to these antibiotics Imipenam or Meropenam may be given at a dose of 1GM IV 8th hourly. Acute prostatitis can be managed using Doxycycline 100mg BD or Cotrimoxazole 960mg BD. The above mentioned guidelines are intended to help the clinician to manage the patient till urine culture and sensitivity reports are available. These guidelines lay specific emphasis on urine culture and sensitivity. Based on the urine sensitivity report of the patient the clinician can take a well informed decision of down scaling the antibiotic.

It is recommended that every health care facility form an antibiotic policy of their own as resistance pattern varies in different geographical areas. This policy can be updated once in six months. Conservation of antibiotics is the topmost priority in view of emerging antibiotic resistance in India. This is coupled with the fact that there are no promising antibiotics in the pipeline for management of such resistant infections. One important measure which can prevent infections is proper hand washing with a non alcoholic disinfectant as per the WHO protocol. Let’s all join hands to handle the menace of antibiotic resistance and provide our patients anevidence based cure....

About Author

Dr. Riyaz Sheriff, Dr. Prasobh KK

Dr. Riyaz Sheriff, Dr. Prasobh KK

Dr.Riyaz Sheriff M.B.B.S., M.D Assistant Professor, Department of Microbiology , Azeezia Institute of Medical Sciences & Research Kollam, Kerala Co-author Dr.Prasobh KK Ph.D., Associate Professor , Department of Microbiology Azeezia Institute of Medical Sciences & Research Kollam, Kerala