Transcript Antibiotic resistance pattern of bacteria in urinary tract infection

Antibiotic resistance pattern of
bacteria in urinary tract infection
Done by :
Hasan Abu Awwad
Yazan AL-Soud
Mustfa AL-Rawi
Mohammad Najdat
Mahmoud AL-saify
Mouaoia AL-Shafie
Contents

Simple introduction

UTI introduction ( Diagnosis , Etiology , 2 ..etc )

Treatment Guidelines

Mechanisms of resistance of major UTI pathogens
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UTI resistance pattern in Jordan
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Antimicrobial Susceptibility testing

Management and recommendations
Time And Region
2002
A
2015
B
C
. Urinary tract infection (UTI)

is an acute or chronic infection, usually bacterial in origin, that may affect
any part of the upper or lower urinary system.

. Infections of the urinary tract represent a wide variety of
syndromes
UTI classification
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anatomic site of involvement
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Lower : urethritis, cystitis, prostatitis
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Upper : Pyelonephritis
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Uncomplicated/Complicated

Complicated UTIs are defined by the FDA as a clinical syndrome
characterized by pyuria and a documented microbial pathogen on culture
of urine or blood
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complicated UTI are those associated with risks of treatment failure

Complicated UTIs may be subdivided into the following 4 categories:
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Structural abnormalities - Calculi, catheters
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Metabolic/hormonal abnormalities - Diabetes, pregnancy
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Impaired host responses - Transplant recipients, patients with AIDS
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Unusual pathogens - Yeast
Epidemiology



Approximately 1 in 3 females will have had a urinary tract infection by age 24
years.
40%-50%of female population will experience a UTI in their life
Geriatrics is age group with the highest risk of UTI
Clinical Presentation of Urinary Tract
Infections (UTIs) in Adults
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Signs and symptoms
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Lower UTI: dysuria(pain on urination), urgency, frequency, nocturia, suprapubic
heaviness ,gross hematuria
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Upper UTI: flank pain, fever, nausea, vomiting, malaise , presence of
costovertebral tenderness
Risk factors
for
men
 homosexuality
 intercourse
with an infected woman,
 lack of circumcision.
 prostate hyperplasia
Risk factors

for women:

sexual intercourse

lack of voiding after intercourse
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


use of a diaphragm
use of spermicidal jellies
pregnancy.
common risk factors for both men and women include:
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DM
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Urologic instrumentation
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Renal transplantation
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Neurogenic bladder
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Urinary tract obstructio
Treatment Guidelines
First line treatment
Nitrofurantoin monohydrate macrocrystals, 100 mg twice daily for 5 days
TMP-SMX, 160/800 mg twice daily for 3 days
Fosfomycin trometamol, 3g sachet in a single dose
Second-line Treatment
Ciprofloxacin, 250 mg twice daily for 3 days
Levofloxacin, 250 mg or 500 mg once daily for 3 days
Amoxicillin-clavulanate, 500 mg/125 mg twice daily for 7 days
Cefpodoxime, 100-mg twice daily for 3 to 7 days
Treat the symptom of dysuria with
Phenazopyridine.
In Case Of Pregnancy UTI

Urinary tract infections are common during pregnancy, and the most
common causative organism is Escherichia coli

Pregnant women should be treated when bacteriuria is identified. The
choice of antibiotic should address the most common infecting
organisms (i.e., gram-negative gastrointestinal organisms).
Pregnant women are at increased risk for UTIs. Beginning in
week 6 and peaking during weeks 22 to 24, approximately 90 percent of
pregnant women develop ureteral dilatation

The antibiotic should also be safe for the
mother and fetus.

Historically, ampicillin has been the drug of
choice, but in recent years E. coli has become
increasingly resistant to ampicillin. Ampicillin
resistance is found in 20 to 30 percent of E. coli
cultured from urine in the out-patient setting.
Nitrofurantoin (Macrodantin) is a good choice because
of its high urinary concentration.

Alternatively, cephalosporins are well tolerated and adequately treat the
important organisms.
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Fosfomycin (Monurol) is a new antibiotic that is taken as a single dose.
Sulfonamides can be taken during the first and second
trimesters but, during the third trimester, the use of
sulfonamides carries a risk that the infant will develop
kernicterus, especially preterm infants.

Other common antibiotics (e.g., Fluoroquinolones and Tetracyclines)
should not be prescribed during pregnancy because of possible toxic
effects on the fetus.
In Case Of Men UTI
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As a general rule, all urinary tract infections (UTIs) in men are considered
complicated. because the urethra is much longer and the distance between
the anus and urethral meatus is greater than in women.

Same As adullt Guidline.

The EAU guidelines state that nitrofurantoin should not be used in men as
it does not reach reliably sufficient tissue concentrations.
In Case Of Pyelonephritis
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Most episodes of uncomplicated pyelonephritis can be treated in the
outpatient setting with an empirical regimen of ciprofloxacin (500 mg twice
daily for 7 days) or levofloxacin (750 mg once daily for 5 days).

If quinolone resistance is a concern, TMP-SMX (160/800
mg twice daily for 14 days) can be used once the
antibiogram shows susceptibility to this medication.
Treatment Of UTI In Children

Acute urinary tract infections are relatively common in children, with 8
percent of girls and 2 percent of boys having at least one episode by seven
years of age. The most common pathogen is Escherichia coli, accounting
for approximately 85 percent of urinary tract infections in children.
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The recommended initial antibiotic for most children
with UTI is trimethoprim/sulfamethoxazole (Bactrim,
Septra).
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Alternative antibiotics include amoxicillin/clavulanate
(Augmentin) or cephalosporins, such as cefixime
(Suprax), cefpodoxime, cefprozil (Cefzil), or cephalexin

Urinary tract infection (UTI) is one of the most common pediatric
infections. It distresses the child, concerns the parents, and may cause
permanent kidney damage.
Identification and molecular characterization
of Escherichia coli blaSHV genes.
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1.
2.
3.
4.
This study identified and molecularly characterized E. coli blaSHV genes
from 490 E. coli strains with multi-drug resistance in a hospital
population.
PCR and molecular cloning and southern blot were performed to assess
functions and localizations of this resistant E. coli gene and the pulsedfield gel electrophoresis (PFGE) was utilized to demonstrate the clonal
relatedness of the positive E. coli strains.
The data showed that 4 of these 490 E. coli strains (4/499, 0.8%) carried
blaSHV genes:
EC D2485 (blaSHV-5)
EC D2487 (blaSHV-5)
EC D2684 (blaSHV-11)
EC D2616 (blaSHV-195, a novel blaSHV)
blaSHV-5 had a high hydrolysis activity to the
broad-spectrum penicillin (ampicillin or
piperacillin), ceftazidime, ceftriaxone,
cefotaxime and aztreonam.
 blaSHV-195 and blaSHV-11 had similar resistant
characteristics with high hydrolysis activities to
ampicillin and piperacillin, but low activities to
cephalosporins.
 The two blaSHV-5 genes were located on a
transferable plasmid (23kb), whereas the other
two blaSHV variants (blaSHV-11 and blaSHV-195)
seemed to be located in the chromosomal
material.
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ciprofloxacin-resistant Escherichia coli
and Klebsiella pneumoniae
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The aims of this study were to investigate the prevalence of qnrA,
qnrB, and qnrS determinants and their molecular characteristics in
ciprofloxacin-resistant isolates of Escherichia coli and Klebsiella
pneumoniae from urinary tract infections (UTI).
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A total of 202 nonduplicated clinical isolates of ciprofloxacin-resistant
E. coli (n = 143) and K. pneumoniae (n = 59) were collected between
July 2005 and August 2006.
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The qnrB gene was detected in 41 of the 202 isolates.
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Among 33 of 59 (55.9%) K. pneumoniae isolates showing qnrB, 29
isolates contained the qnrB4 gene, 3 isolates had the qnrB2 gene, and
1 isolate had the qnrB6 gene and all 8 (5.6%) of E-coli strains
possessed the qnrB4 gene.
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The minimum inhibitory concentrations (MICs) of ciprofloxacin for the
transconjugants were 0.03-2 mug/ml, representing an increase of 4- to
256-fold relative to the recipient, E. coli J53Az(r).
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Resistances to various other antimicrobial agents also were transferred
with the plasmid.
UTI resistance pattern in Jordan
•
In general the pattern is changing according to region and time
•
Retrospective Study was conducted in 2014 in Zarqa city / Jordan
•
3756 urine samples were
collected
392 (10.4%) show positive
urine cultures ( female 81%)
Bacterial isolation and
identification
Pathogen isolates from patients with UTI
Male
patients
Female
patients
% Male
% Female
Total
Escherichia coli
54
263
13.77
67.09
80.86
Klebsiella spp
14
32
3.57
8.16
11.73
Proteus spp
1
15
.25
3.83
4.08
Psudomonas spp
2
8
.51
2.04
2.55
Staphylococcus
aureus
2
1
.51
.25
.76
Baceria
Antimicrobial Susceptibility testing
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14 antibiotics were tested
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eight antibiotics were tested for Gram negative , and six ABs were
tested for Gram positive bacteria
Antibiotics
E.coli
Klebsiella
spp
Proteus
Spp
Psedomonas Staphylococcus
spp
aureus
Cefatoxime
41.46
50
31.25
30.0
Cephalothin
55.06
58.70
50
50.0
Gentamamicin 26.58
17.39
18.75
40.0
Pencillin
66.67
Ampicillin
89.13
62.5
40.0
Erythromycin
100
84.18
Nitrofurantion 10.44
52.21
68.75
40.0
Norfloxacin
34.81
15.21
31.25
Cotrimoxazole 70.89
54.34
Naldixic acid
45.65
66.77
Gentamicin
Vancomycin
0
10.0
Lincomycin
33.33
50
40.0
Teicoplanin
0
37.5
40.0
Cloxaciiln
33.33
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
A similar study was conducted in Jordan in 2008 and published in 2001 , showed Overall, high
E-coli resistance rate was observed for ampicillin (84%), followed by amoxicillin-clavulanic acid
(74.3%), cotrimoxazole (71%), nalidixic acid (47.3%), cephalothin (41%). Lower resistance rates
were observed for amikacin (0%) followed by Cefotaxime (11%), Ceftriaxone (11.7%),
ciprofloxacin (14.5%), Norfloxacin (16.5%), gentamicin (17.3%) cephalexin (20.9%), Ceftazidime
(22.5%), cefixime (29.6%), and cefaclor (32.8%)
FQs and indiscriminate use in empirical treatment , Risk Of E-Coli resistance !
Management and recommendations

We don’t prefer the use of agents that showed high levels of resistance like pencillins and
cotrimoxazole . An agent with a resistance rate above 20% should not be prescribed empirically
.
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This reinforce the use of nitrofurantoin for uncomplicated cystitis
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a warning about increasing of E-coli for FQs and sulfamethoxazole-trimethoprim ! .
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Regular monitoring is required to establish reliable information about susceptibility pattern of
urinary pathogens .