Complicated UTIs are a major health concern that necessitates the detection of uropathogens and their susceptibility patterns to avoid antibiotic misuse. Local surveillance for bacterial resistance is critical for creating effective antimicrobial stewardship guidelines (7).
According to new research, the COVID-19 pandemic has altered the resistance patterns of various bacteria due to antibiotic misuse for the treatment of viral illness. Awareness of the resistance patterns of the most common uropathogens is essential for providing quality of practice in overcoming these infections (8).
The current study mainly utilised clinical data from our filing system to show the frequency of uropathogens associated with UTIs and their antibiotic response profiles to routinely used antibiotics in the Urology department at Al-Azhar University Hospital in Damietta, Egypt, between January 2021 and December 2021.
In the present study, the microbiological identification of infection was diagnosed in 30% (766/2581) of the urine culture samples. The current findings are supported by the conclusions of many previous studies in Nigeria (9) and Central Europe (10). In contrast, some studies have reported higher prevalence rates of 45% (11) and 70.83% (12). This discrepancy may be explained by variation in research population characteristics, environmental circumstances, and techniques.
As in prior research, the majority of UTI patients (63.4%) were females. This is to be expected, and it is similar to the findings of other research. This is explained by the difference in the anatomy of the female urinary tract compared to the male, which allows bacteria to easily access the bladder from the urethral meatus and perineum (13).
UTIs etiological agents and antibiotic susceptibility or resistance patterns vary by geographical region, age, and sex (14). As expected, 99% of UTIs were of bacterial origin, with Gram-negative bacteria being the cause in 591 (77.1%), similar to prior published data with somewhat varying percentages (9).
In this study, frequent pathogens were isolated. E. coli was the most common pathogen, representing 340 (44.4%) of the uropathogen, followed by S. aureus 136 (17.8%) and Klebsiella spp. 106 (13.8%). These findings were consistent with previous reports both in Egypt (11) and other different nations, e.g. Germany (15).
The current study confirmed earlier research that females were infected with E. coli at a greater incidence (48.0%) than males (38.2%) (16). Only P. aeruginosa was more prevalent in males than in females. This is in line with that reported by Mirsoleymani et al. (17).
Resistance among bacterial uropathogens to routinely used antibiotics has developed, leaving clinicians with limited alternatives for UTIs treatments. Due to the lack of novel antibiotics, infections generated by antimicrobial-resistant bacteria are related to increased treatment failure rates, increased hospitalizations, higher costs, and death (3).
In this study, among the tested antibiotics, the lowest resistance rate was 26.9% for piperacillin-tazobactam, followed by cefoxitin (28.8%), cefepime (31.4%), meropenem (36.1%), and ceftriaxone (36.5%). Given that for empiric therapy of severe infections, resistance rates should not exceed 10% (18), and our lowest resistance rate was 26.9%, we have few alternatives in urosepsis. However, these antibiotics should be considered, alone or in combination, for the initial empiric management of severe UTIs. On the other hand, the highest levels of resistance were recorded for erythromycin (79.7%), gentamicin (76.9%), teicoplanin (75%), and TMP/SMX (71.6%). As a result, these antibiotics are not recommended to be used as empirical treatment for UTIs (18). The levels of resistance and sensitivity of different antibiotics varied between studies, but the current findings were closely related to those observed by Mirsoleymani et al. (17).
The resistance rate for carbapenems tested in our study was 36.1% for meropenem and 64% for imipenem. Such high rates of resistance are in agreement with previous studies in Egypt (19). It has been attributed to the production of carbapenemase genes, of which blaNDM and blaOXA genes are predominant in the Middle East and Egypt (20).
For aminoglycosides, gentamicin resistance varied by country, with Turkey having the highest rate of resistance (94.5%) (21). In comparison, India has substantially lower rates of resistance (32.6%) (22). In our work, gentamicin had the highest rate of resistance among tested antibiotics (76.9%), consistent with this report from Egypt (23). For amikacin, our rate of resistance (50.3%) was followed by previous reports (21).
Resistance rates for quinolones were (48.4%) and (40.6%) for ciprofloxacin and levofloxacin, respectively. These rates were consistent with those reported by Labah et al. (12) but were lower than those reported by the Abdelkhalik group (23).
Also, for Beta-lactam antibiotics, the current study showed resistance rates of 67.2%, 59%, and 52.4% for amoxicillin-clavulanic acid, ceftazidime, and cefuroxime, respectively, which was in agreement with previous reports (12) (23).
Finally, resistance rates for narrow-spectrum antibiotics (TMP-SMX and nitrofurantoin), which are frequently used for uncomplicated UTIs, were 71.6% and 58.2%, respectively. These rates agreed with those reported by Labah et al. (12). Controversially, Randrianirina et al. (24) noted higher sensitivity to TMP-SMX. These differences in the results can be attributed to the emergence of resistant strains due to their recurrent misuse.
MDR is defined as pathogens resistant to one or more antibiotics in two or more classes of antibiotics (6). Infections caused by MDR organisms have extremely limited therapeutic options. In our work, MDR was more prevalent among Gram-negative bacteria (26.6%) compared to 13.8% in Gram-positive ones. Labah et al. recorded MDR (58.26%) in Gram-negative bacteria (12).
The higher rates of resistance to tested antibiotics in our study are of great concern. They may be the result of inadequate infection control strategies and the misuse of these life-saving drugs. Antibiotics were administered to 49.8% of patients treated in outpatient healthcare institutions, and antibiotics were available without a prescription (19).
Furthermore, expanding evidence clearly indicates the transmission of resistance, especially through chicken meat, which has the highest levels of contamination by resistant germs since antimicrobials are frequently used in veterinary care for infection prevention and treatment, and antimicrobial-resistant bacteria have been detected in veterinary isolates in Egypt (25).
Limitations of this study:
- Because this study was focused on a single health institution, it may not accurately reflect the overall condition of the community.
- Due to restricted laboratory resources, anaerobic bacteria, fungi, and viral agents that cause UTIs were not examined.
- Because sensitivity rates differ among healthcare institutions, the results may not be predictive and replicable in other healthcare institutions.
- There might be some observational errors, particularly when assessing the antibacterial inhibition zone.
Regarding these limits, the study gives sufficient updated information on UTIs, antimicrobial susceptibility profiles, and related variables.