Socio-demographic characteristics
A total of 385 clinically UTI suspected patients were included in the study; of these, 205 (53.2%) were females and majority of the study participants (37.9%) were in the age groups of 16-30 with participants median age of 32 years. Moreover; 60.8% of the participants were from urban and 24.4% were illiterate (Table 1).
Prevalence of Klebsiella species
Out of the 385 study subjects, the overall prevalence of Klebsiella species was 38(9.9%) of which 25(65.8%) Klebsiella pneumonia, 4(10.5%) Klebsiella oxytoca, 6(15.8%) Klebsiella ozaenae and 3(7.9%) Klebsiella rhinoscleromatis species were isolated moreover; 22(57.9%) of the total isolates were from female participants. The frequency distribution of Klebsiella species among health institutions were 25, 8, 5 in Felege-Hiwot referral hospital, Gammby private general hospital and Bahir-dar health center, respectively (figure1).
A multi-variable logistic regression analysis showed that pervious antibiotic use, history of hospitalization and habit of tight dressing were statistically significant for getting UTI at 2.618 (AOR = 2.618, 95% CI: 1.18-6.129), 5.873 (AOR = 5.873, 95% CI: 2.355-14.6) and 15.038 (AOR = 15.038, 95% CI: 1.7-139) times more risk respectively.
Table 1: Socio-demographic characteristics of UTI suspected patients attended at selected Bahir-dar town health institutions, Ethiopia, 2019
Demographic characteristics
|
Categories
|
Number of participants (N)
|
Percentage (%)
|
|
|
Gender
|
Male
|
180
|
46.8
|
|
Female
|
205
|
53.2
|
|
Age group
|
<5
|
20
|
5.2
|
|
6-15
|
44
|
11.4
|
|
16-30
|
146
|
37.9
|
|
31-45
|
116
|
30.12
|
|
46-60
|
53
|
14.3
|
|
>60
|
24
|
6.2
|
|
Level of education
(educational status)
|
Illiterate
|
94
|
24.4
|
|
Primary school
|
86
|
23.3
|
|
Secondary school
|
107
|
27.8
|
|
College and university
|
98
|
25.5
|
|
Health facility
|
Felege Hiwot
|
278
|
72.2
|
|
Gammby
|
87
|
22.6
|
|
Bahir dar health center
|
20
|
5.2
|
|
Residency
|
Urban
|
234
|
60.8
|
|
Rural
|
151
|
39.2
|
|
Occupational status
|
Merchant
|
29
|
7.5
|
|
Housewife
|
112
|
29.1
|
|
Civil
|
102
|
26.5
|
|
Farmer
|
71
|
18.4
|
|
Others
|
71
|
18.4
|
|
Figure 1: Prevalence of Klebsiella species among UTI suspected patients attended at selected Bahir-dar town health institutions, Ethiopia, 2019.
Antimicrobial Susceptibility of Klebsiella species
Klebsiella pneumoniae isolates showed that 20(80%), 19(76%), 19(76%) were resistance to amoxicillin/clavulanic acid, ampicillin and cotrimoxazole respectively. However, were sensitive to 22(88%) meropenem, 18(72%) chloramphenicol, 17(68%) ceftazidime and 16(64%) ciprofloxacin.
Klebsiella ozonae showed that 6(100%), 5(83.3%), and 5(83.3%) were resistance to ampicillin, amoxicillin/clavulanic acid, and cotrimoxazole respectively. However; 5(83.3%) was sensitive to cefotaxime, gentamycin, chloramphenicol, and nitrofurantoin. Moreover; it was 100% sensitive to meropenem.
Klebsiella Oxytoca was 4(100%) resistance to ampicillin however was 4(100%) sensitive to meropenem. Moreover; 75% of the isolates were sensitive to Gentamycin, amoxicillin/clavulanic acid, ciprofloxacin, ceftazidime, chloramphenicol and nitrofurantoin.
Klebsiella rhinoscleromatis was 3(100%) sensitive to cefoxitin and cefotaxime moreover; 66.7% of the isolates were sensitive to gentamycin, chloramphenicol, ceftazidime, meropenem, ciprofloxacin, nitrofurantoin. However, 66.7% were resistance to ampicillin, amoxicillin/clavulanic acid and cotrimoxazole (table 2)
Table 2: Antimicrobial susceptibility patterns of Klebsiella species isolated from UTI suspected patients attended at selected Bahir-dar town health institutions, Ethiopia, 2019
Klebsiella .Isolates
|
Sensitivity
|
AMP
|
GEN
|
AMC
|
CXT
|
CTX
|
CIP
|
MER
|
COT
|
CAZ
|
CHL
|
NIT
|
K. pneumoniae (n=25)
|
S
|
6
(24)
|
11
(44)
|
1
(4)
|
15
(60)
|
15
(60)
|
16
(64)
|
22
(88)
|
5
(20)
|
17
(68)
|
18
(72)
|
13
(52)
|
I
|
0
|
6
(24)
|
4
(16)
|
3
(12)
|
4
(16)
|
4
(16)
|
1
(4)
|
1
(4.)
|
3
(12)
|
4
(16)
|
5
(20)
|
R
|
19
(76)
|
8
(32)
|
20
(80)
|
7
(28)
|
6
(24)
|
5
(20)
|
2
(8)
|
19
(76)
|
5
(20)
|
3
(12)
|
7
(28)
|
K. ozonae (n=6)
|
S
|
0
|
5(83.3)
|
1(16.7)
|
5(83.3)
|
4(66.7)
|
4(66.7)
|
6(100)
|
1(16.7)
|
5(83.3)
|
5(83.3)
|
5(83.3)
|
I
|
0
|
0
|
0
|
00
|
00
|
1(16.7)
|
0
|
0
|
00
|
0
|
0
|
R
|
6(100)
|
1(16.7)
|
5(83.3)
|
1(16.7)
|
2(33.3)
|
1(16.7)
|
0
|
5(83.3)
|
1(16.7)
|
1(16.7)
|
1(16.7)
|
K. Oxytoca (n=4)
|
S
|
0
|
3(75)
|
3(75)
|
2(50)
|
3(75)
|
3(75)
|
4(100)
|
0
|
3(75)
|
3(75)
|
3(75)
|
I
|
0
|
1(25)
|
0
|
1(25)
|
1(25)
|
1(25)
|
0
|
2(50)
|
0
|
0
|
0
|
R
|
4(100)
|
0
|
1(25)
|
1(25)
|
0
|
0
|
0
|
2(50)
|
1(25)
|
1(25)
|
1(25)
|
K. rhinoscleromatis (n=3)
|
S
|
1(33.3
|
2(66.7)
|
1(33.3)
|
3(100)
|
3(100)
|
2(66.7)
|
2(66.7)
|
1(33.3)
|
2(66.7)
|
2(66.7)
|
2(66.7)
|
I
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
R
|
2
(66.7)
|
1
(33.3)
|
2
(66.7)
|
0
|
0
|
1
(33.3)
|
1
(33.3)
|
2
(66.7)
|
33.3
|
1
(33.3)
|
1
(33.3)
|
AMP=Ampicillin; GEN=Gentamycin; AMC=Augmentin; CXT=Cefoxitin; CTX=Cefotaxime; CIP=Ciprofloxacin; MER=Meropenem; COT=Cotrimoxazole; CAZ= Ceftazidime; CHL=Chloramphenicol; NIT=Nitrofurantoin; S= Sensitive; I= Intermediate; R; Resistant
Multi drug resistance pattern
Overall 26(68%) Klebsiella species showed multi-drug resistance to at least three antimicrobial drugs of which 15(57.7%) of Klebsiella pneumonia, 5(19.3%) of Klebsiella ozonea, 3(11.5%) of Klebsiella oxytoca and 3(11.5%) of Klebsiella rhinoscleromatis were found to be multi-drug resistance (table 3).
Table 3: Multi-drug resistance profile of Klebsiella species isolated from UTI suspected patients attended at selected Bahir-dar town health institutions, Ethiopia, 2019.
Antimicrobial pattern
|
Bacterial isolate
|
Total
|
K.pneumoniae (n=25)
|
K.ozonae
(n=6)
|
K. Rhinoscleromatis
(n=3)
|
K. oxytoca
(n=4)
|
AMP,AMC,COT
|
5
|
3
|
2
|
|
10
|
AMP,AMC,CTX
|
|
1
|
|
1
|
2
|
AMP,AMC, CHL
|
|
|
|
1
|
1
|
AMP, AMC, COT, NIT
|
|
|
|
1
|
1
|
AMP, AMC,COT, CHL
|
1
|
|
|
|
1
|
AMP, AMC,COT,CIP
|
|
1
|
|
|
1
|
AMP,GEN,AMC, COT
|
3
|
|
|
|
3
|
CIP,NIT, GEN, MER,CHL
|
|
|
1
|
|
1
|
AMP,AMC, CTX, CIP,COT
|
2
|
|
|
|
2
|
AMP,AMC,CTX,COT,NIT,
|
1
|
|
|
|
1
|
AMP,GEN,AUG,CTX,CIP,COT,NIT
|
1
|
|
|
|
1
|
AMP,NIT,GEN, AUG, CTX,
CIP,MER, COT, CAZ, CHL,
|
2
|
|
|
|
2
|
Total
|
15/25
|
5/6
|
3/3
|
3/4
|
26/38
|
AMP=Ampicillin; GEN=Gentamycin; AMC=Augmentin; CXT=Cefoxitin; CTX=Cefotaxime; CIP=Ciprofloxacin; MER=Meropenem; COT=Cotrimoxazole; CAZ= Ceftazidime; CHL=Chloramphenicol; NIT=Nitrofurantoin; S= Sensitive; I= Intermediate; R; Resistant.
Extended spectrum production patterns of isolated Klebsiella species
Among the total Klebsiella species, 10(26.3%) isolates were ESBL producer. Based on CLSI guideline, 38 isolates were checked for the confirmation of ESBL production by combined disk diffusion method. All ESBL producing species were Klebsiella pneumonia in which 5(50%), 3(30%) and 2(20%) isolates were found in the age group of 16-30, 46-60 and 6-15 years moreover 6(60%) were from female participants. ESBL producing Klebsiella pneumoniae showed, ampicillin (100%), amoxycillin/clavulanic (100%), TMP-SMX (100%), ciprofloxacin (50%), gentamycin (40%), nitrofurantoin (50%), cefoxitin (40%), cefotaxime (50%), ceftazidime (50%) and 2/10(20%) resistance to meropenem and chloramphenicol. Among ESBL producing Klebsiella pneumonia isolates, 1(10%) species was sensitive, 3(30%) intermediate and the remaining 6(60%) were resistance to cefotaxime. However; 3(30%) were sensitive, 2(20%) intermediate and 5(50%) resistance to ceftazidime (table 4).
Table 4: The associations of ESBL patterns with cefotaxime and ceftazidime antibiotics among Klebsiella species isolated from UTI suspected patients attended at selected Bahir-dar town health institutions, Ethiopia, 2019.
Organism
|
Drug
|
ESBL status
|
Sensitive
|
Intermediate
|
Resistance
|
Total
|
Klebsiella pneumoniae
|
Cefotaxime
|
Positive
|
1
|
3
|
6
|
10
|
Negative
|
14
|
1
|
0
|
15
|
Ceftazidime
|
Positive
|
3
|
2
|
5
|
10
|
Negative
|
14
|
1
|
0
|
15
|
Associated risk factor
A multi-variable logistic regression analysis was done to evaluate the associated risk factors for UTI and the result showed that those study participants who had previously use of antibiotic were 2.618 times (AOR = 2.618, 95% CI: 1.18-6.129) more likely to have UTI as compared to their counter parts. Similarly, Patients who had history of previous hospitalization had 5.873 times (AOR = 5.873, 95% CI: 2.355-14.6) and habit of wearing tight dresses had 15.038 times (AOR = 15.038, 95% CI: 1.7-39) more likely to acquire UTI.
Table 5: Predictors of urinary tract infections among UTI suspected patients attended at selected Bahir-dar town health institutions, Ethiopia, 2019
Variables
|
Culture Result
|
COR
(95% CI)
|
P -value
|
AOR
(95% CI)
|
P value
|
Culture positive
N (%)
|
Culture negative
N (%)
|
Sex
|
Male
|
16 (8.9)
|
164 (91.1)
|
0.812 (0.412-1.598)
|
0.546.
|
-
|
-
|
Female
|
22 (10.7)
|
183 (91.1)
|
1
|
-
|
-
|
-
|
Age group
|
<5
|
2 (10)
|
18 (80)
|
1
|
-
|
-
|
-
|
6-15
|
7 (16)
|
37 (82)
|
1.800 (0.294-11.031)
|
0.525
|
-
|
-
|
16-30
|
10 (6.84)
|
136 (93.15)
|
1.057 (0.276-4.052)
|
0.935
|
-
|
-
|
31-45
|
7 (7.2)
|
89 (92.8)
|
2.720 (779-9.503)
|
0.117
|
-
|
-
|
46-60
|
8 (14.5)
|
47 (85.5)
|
2.543
|
0.166
|
-
|
-
|
>60
|
4 (16.7
|
20 (83,3)
|
1.175
|
0.809
|
-
|
-
|
Health facility
|
Felege Hiwot referral hospital
|
25 (9)
|
253 (91)
|
1
|
-
|
-
|
-
|
Gammby private General Hospital
|
8(9.2)
|
79(9.8)
|
3.373
(1.132-10.057)
|
0.029
|
|
|
Bahirdar Health
Center
|
5 (33.3)
|
15(72.7)
|
3.292(.947-11.446)
|
0.061
|
|
|
Residence
|
Urban
|
21 (8.97)
|
213 (91.3)
|
0.777(.396-1.526)
|
0.464
|
-
|
-
|
Ruler
|
17 (11.2)
|
134 (88.8)
|
1
|
-
|
-
|
-
|
Educational status
|
Illiterate
|
13 (13.8)
|
81(86.2)
|
1
|
|
|
|
Primary
|
16 (18.6)
|
70 (81.4)
|
0.702(.316-1.561)
|
0.386
|
|
0.084
|
Secondary
|
4 (3.9)
|
103 (96.1)
|
4.133 (1.928-13.155)
|
0.016
|
|
0.211
|
College & above
|
5 (5.1)
|
93(6.9)
|
2.985 (1.020-8.734)
|
0.046
|
|
0.067
|
|
Occupational status
|
Merchant
|
3 (10.3)
|
26 (89.7)
|
1
|
-
|
-
|
-
|
Housewife
|
13 (11.6)
|
99 (88.4)
|
0.800 (0.188-3.440
|
0.764
|
-
|
-
|
Governmental
|
5 (4.9)
|
97 (95.1)
|
0.703 (.254-1.943)
|
0.497
|
-
|
-
|
Farmer
|
11 (15.5)
|
60 (84.5)
|
1.791 (.525-6.113)
|
0.352
|
-
|
-
|
Others
|
6 (8.5)
|
65 (91.5)
|
0.503 (.175-1.446)
|
0.202
|
-
|
-
|
Previous history of antibiotic use
|
Yes
|
28 (16.9)
|
138 (83.1)
|
4.24 (1.996-9.008
|
0.000
|
2.618
(1.18-6.129)
|
0.027
|
No
|
10 (4.6)
|
209 (96.4)
|
1
|
-
|
-
|
-
|
Previous hospitalization
|
Yes
|
16 (37.2)
|
27(62.8)
|
8.620 (4.054-18.3)
|
0.000
|
5.873
(2.355-14.6)
|
0.000
|
No
|
22 (6.4)
|
320 (93.6)
|
1
|
-
|
-
|
-
|
Patient treated department
|
OPD
|
29 (8.3)
|
322 (91.7)
|
0.250 (.107-.586)
|
0.001
|
|
|
IPD
|
9 (26.5)
|
25 (73.3)
|
1
|
-
|
-
|
-
|
Previous history of UTI
|
Yes
|
17
(19.1)
|
72(80.9)
|
3.092 (1.551-6.165)
|
0.001
|
|
|
No
|
21
(7.1)
|
275(92.9)
|
1
|
-
|
-
|
-
|
Catheteriz-ation history
|
Yes
|
2
(33.3)
|
4(66.7)
|
4.764 (.843-26.919)
|
0.077
|
|
|
No
|
36
(9.5)
|
343(90.5)
|
1
|
-
|
-
|
-
|
Tight closing
|
Yes
|
4
(66.7)
|
2(33.3)
|
20.294
(3.585-144.88)
|
0.001
|
15.038(1.7-139)
|
0.015
|
No
|
34(9)
|
345(90)
|
1
|
-
|
-
|
-
|