531 Journal of Rawalpindi Medical College (JRMC); 2021; 25(4): 531-534 Original Article Cathetar Related Antimicrobial Resistance Pattern in Intensive Care Unit Patients: A Single Centre Study Romana Bibi1, Rafi Ullah2, Muhammad Izhar3, Sijad-ur-Rehman4, Kainaat Sheikh5, Kalsoom Essa Bhattani6 1 Resident Officer, Department of Gynaecology, Khyber Teaching Hospital, Peshawar. 2 Resident Officer, Department of Cardiology, Lady Reading Hospital, Peshawar. 3 Resident Officer, Department of Urology, Hayatabad Medical Complex, Peshawar. 4 Associate Professor, Department of Paediatrics, Gajju Khan Medical College, Swabi. 5 Final-year MBBS student, Khyber Girls Medical College, Peshawar. 6 Senior Registrar, Department of Gynaecology, Gomal University, Dera Ismail Khan, KPK. Author’s Contribution 2 Conception of study 1,3 Experimentation/Study conduction 1,3 Analysis/Interpretation/Discussion 5 Manuscript Writing 4 Critical Review 6 Facilitation and Material analysis Corresponding Author Dr. Romana Bibi, Resident Officer, Department of Gynaecology, Khyber Teaching Hospital, Peshawar. Email: romanawazir14@gmail.com Article Processing Received: 24/08/2021 Accepted: 08/12/2021 Cite this Article: Bibi, R., Ullah, R., Izhar, M., Rehman, S., Sheikh, K., Bhattani, K.E. Cathetar Related Antimicrobial Resistance Pattern in Intensive Care Unit Patients: A Single Centre Study. Journal of Rawalpindi Medical College. 31 Dec. 2021; 25(4): 531- 534. DOI: https://doi.org/10.37939/jrmc.v25i4.1764 Conflict of Interest: Nil Funding Source: Nil Access Online: Abstract Introduction: Urinary catheter is the most common cause of urinary tract infection (UTI) which has been associated with a three-fold increase in risk in mortality. The primary aim of the study is to know the strain of pathogens; its drugs sensitivity and resistance in intensive care unit (ICU) patients which help the physician in proper management and reduce the mortality and morbidity in urinary catheter-related complications. Materials and Methods: This study was conducted in Intensive care unit patients of Hayatabad medical complex Peshawar Pakistan over a period of 1 year from 1st January to 31st December 2019. Medical charts were reviewed and 100 patients were selected based on inclusion criteria and their urine culture and sensitivity reports were noted to know about the most common pathogens, its drugs sensitivity, and resistance in these patients. Clinical and Laboratory Standards Institute (CLSI) was used for uropathogen by culture and Disc diffusion method to determine antimicrobial susceptibility pattern. Results: The mean age (standard deviation) of patients was 51.60+26.59 years (Median age 58.50 years). Of the total, 64 were female and the remaining were male patients. It was found that the most common pathogens in urine samples were E. coli. Maximum pathogens were sensitive to intravenous meropenem (65%) and fosfomycin (55%). Chi-square test is used for correlation of sensitivity of meropenem and fosfomycin with the type of organism shows p-value=0.004 and 0.002. Conclusion: It is concluded that resistance patterns of uropathogens change which results in treatment failure. Further, based on clinical practice, meropenem, fosfomycin, and cefepime had high sensitivity profiles against catheter-related infection in ICU. Keywords: Antimicrobial resistance, catheters, urinary tract infections (UTIs). 532 Journal of Rawalpindi Medical College (JRMC); 2021; 25(4): 531-534 Introduction The common presenting symptoms of Urinary tract infections (UTIs) are fever, dysuria, and pain hypogastrium however some cases may be asymptomatic. Common predisposing factors are urinary catheters, instrumentation, urolithiasis, and anatomic anomalies. Urinary tract infections account for about 30 to 40% of all nosocomial infections. A high level of resistance was noted among the admitted patients for cephalosporins.1 Urinary catheter is the most common cause of UTI as 17.5% shown by the study done in 66 European hospitals suffered from catheter-related infection. Nosocomial UTIs have been associated with a three-fold increase in the risk of mortality.2 In a study conducted in Iran, 30.9% of intensive care patients with nosocomial infections developed urinary tract infections.3 Pattern of bacterial resistance changes with antibiotics use.4 As study showed 28 (9.2%) patients among 306 admitted patients at ICU were suffered from nosocomial UTI. Indiscriminate use of antibiotics is responsible for the development of drug-resistant strains of urinary tract bacteria.5 The present study focus for the first time on the strain of pathogens, its drugs sensitivity, and resistance in one of the largest public tertiary care set up from Peshawar. Materials and Methods This descriptive study was conducted in Intensive care unit patients of Hayatabad Medical Complex (HMC) Peshawar Pakistan over a period of 1 year from 1st January to 31st December 2019. 100 patients' urine samples were taken from urine bags in CS bottles of ICU patients having the urinary catheter is placed. Urine culture and sensitivity reports were traced to know about the most common pathogens, its drugs sensitivity, and their resistance. Only ICU patients were included with comorbid conditions like diabetes, cardiac disease, chronic renal disease, immunocompromised patients. Results A total of 100 samples were obtained from 100 intensive care patients with a urinary catheter. The mean ages (standard deviation) of patients were 51.60+26.59 years (Median age 58.50 years). Of the total, 64 were female and the remaining were male patients. . It was found that the most common pathogens in urine samples were E. coli (cephalosporinase producer 23%), followed by Klebsiella pneumonia Sp. (17.1%), Pseudomonas aeruginosa 14(6.83%), Enterococcus 12 (5.85%), candida species (1%). Most of the pathogens were sensitive to intravenous meropenem (65%) and oral Fosfomycin (55%). Chi-square test is used for correlation of sensitivity of meropenem and fosfomycin with the type of organism shows p- value=0.004 and 0.002. Data were analyzed using SPSS version 20. The frequency along with percentage was calculated for each organism isolated from culture and the pathogens sensitivity and resistance for Augmentin, Meropenem, and Fosfomycin as shown in the table below. Table 1: Age of patient Mean 51.60 Median 58.50 Std. Deviation 26.598 Table 2: Frequency Percent Proteus vulgaris (cephalosporinase producer) 2 2.0 E.coli(ESBL Producer) 12 12.0 Providencia alcalifaciens(cephalosporinase producers) 2 2.0 klebsiella pneumoniae( ESBL producers) 3 3.0 enterococcus species 7 7.0 E.Coli (cephalosporinase producer) 23 23.0 klebsiella pneumonae (cephalosporinase producer) 3 3.0 candida species 15 15.0 Klebsiella oxytoca (cephalosporinase producers) 8 8.0 pseudomonas aeruginosa 4 4.0 mixed skin organisms 12 12.0 Morganella morganii ( cephalosporinase producers) 1 1.0 proteus mirabillis 2 2.0 staphylococcus saprophyticus 1 1.0 providencia sturtaii ( cephalosporinase producer) 1 1.0 Serratia species (ESBL producer) 1 1.0 Actinobacter baumanni 1 1.0 E.coli 1 1.0 Enterobacter species (cephalosporinase producer) 1 1.0 Total 100 100.0 533 Journal of Rawalpindi Medical College (JRMC); 2021; 25(4): 531-534 Maximum pathogens were resistant to Augmentin. Table 3: Frequency Percent sensitive 5 5.0 resistant 63 63.0 not tested 32 32.0 Total 100 100.0 Least number of pathogens resistant to Meropenem (IV) Table 4: Frequency Percent sensitive 65 65.0 resistant 1 1.0 not tested 34 34.0 Total 100 100.0 Least number of pathogens was resistant to Fosfomycin Table 5: Frequency Percent sensitive 55 55.0 resistant 8 8.0 not tested 37 37.0 Total 100 100.0 Discussion The present study focused on ICU patients suffering from urinary tract infections having a urinary catheter is placed that were present in the ICU of HMC. This study showed the most common urinary pathogen is E. coli cephalosporinase producer) (23%), E. Coli (ESBL producer) (12%), Candida species (15%), mixed skin organism (12%).¹,² Out of these pathogen majorities were resistant to Co-amoxiclav (Augmentin) (63%). A maximum number of pathogens were sensitive to intravenous meropenem (65%) given in table 4 and oral foscin (55%).5,8 The spectrum of urinary tract pathogens isolated from urine samples in this study is similar to the findings of Nicolle LE et al.4 A study conducted in North India reported 76% resistance to ampicillin5. Such a high level of ampicillin resistance has been documented in different studies conducted in different parts of India. A study in northern India reported 76% resistance to ampicillin.5 The first international surveillance program to determine the susceptibility of major urinary tract pathogens in 16 countries in Europe and Canada was 2525. E.coli isolates were cultured from 4734 women.6 Another study conducted in West Bengal by Saha et al, (2008-2013) India, reported that Escherichia coli was the primary uropathogen (67.1%) isolated, followed by Klebsiella, (22%), and Pseudomonas spp (6%).7 While a study from Rajasthan reported 94.63%, 77.88%, and 74.75% resistance in E.coli to nalidixic acid, norfloxacin, and ciprofloxacin respectively.8 Urinary tract infection is considered the most common infectious disease because it has reached a global incidence of 18/1000 persons per year in the general population.9,10 It has been previously reported that in 80% of acute and recurrent urinary tract infections in women, E. coli is the primary organism, followed by S. saprophyticus (10–15%). Other less common urinary tract pathogens that can cause UTI include Klebsiella, Enterobacter, Serratia, Proteus, Pseudomonas, and Enterococcus.¹¹ Resistance to the antimicrobial agents occurs due to widespread use of antibiotics and the resistance pattern may change from time to time and even in the same region.12,13 Some antibiotics which are used for treating UTIs such as trimethoprim may cause acute kidney insult.14 So the antibiotics may be carefully selected and so as the emergence of antimicrobial resistance may be monitored which will help to administer the proper drug.15,16,17 However, extended-spectrum beta- lactamase-positive organisms are sensitive to drugs like imipenem, polymixin, and nitrofurantoin; therefore these can be the drug of choice for such highly resistant bacteria.18 Most bacteria colonize the indwelling catheter in the form of biofilm. Microbial agents which grow in the biofilm are resistant to antibiotics mostly which may lead to sepsis.19 Irrational use of drugs by practitioners has further worsened the situation, which in turn resulted in increased drug resistance.20 Further studies are suggested to find out more common urinary pathogens in ICU patients time by time due to higher resistance of pathogens to the drugs. The first worth limitation of this study is the small sample size and not taking the history of nephrolithiasis, bladder disorder, and other comorbid conditions. The second limitation includes the sampling technique and study design. Thirdly patients were not followed up. Fourthly urine C/s technique was not observed. 534 Journal of Rawalpindi Medical College (JRMC); 2021; 25(4): 531-534 Conclusion It is concluded that resistance patterns of uropathogens change which result in treatment failure. Furthermore, based on observations, carbapenem and cefepime are the drugs of choice for empirical antibiotic treatment of catheter-related infections in intensive care units. References 1. Talan, D.A., Stamm, W.E. and Hooton, T.M. 2000. Comparision of ciprofloxacin (7 days) and trimethoprime- sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial, J. American Med. Assoc. 283, 1583-1590. 2. Zarb P, Coignard B, Griskevicienne J, Muller A, Vankerckho ven Weist K, Goossens MM, Vaerenberg S, Hopkins S, Catry B, Monnet DL, Goosens H, Suetens C. The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use. Euro Surveill. 2012;17(46):pil=20316Moro 3. Tessema B, Kassu A, Mulu A, Yismaw G. Predominant isolates of urinary tract pathogens and their antimicrobial susceptibility patterns in Gondar University Teaching Hospital, northwest Ethiopia. Ethiop Med J. 2007;45:61–7. - DOI: 10.22088/cjim.8.2.76 4. Nicolle LE. Epidemiology of urinary tract infections. Infect Med. 2001;18:153–62. 5. Gupta N, Kundra S, Sharma A, Gautam V, Arora DR. Antimicrobial susceptibility of uropathogens in India. J Infect Dis Antimicrob Agents. 2007;24:13–8. 6. Kahlmeter G. Prevalence and antimicrobial susceptibility of pathogens in uncomplicated cystitis Europe. The ECO. SENS study. Int J Antimicrob Agents. 2003; 22: 49–52. 7. Saha S, Nayak S, Bhattacharyya I, Saha S, Mandal AK, Chakraborty S, et al. Understanding the patterns of antibiotic susceptibility of bacteria causing urinary tract infection in West Bengal, India. Front. Microbiol., 2015; 5: 463.- DOI: 10.3389/fmicb.2014.00463 8. Sood S and Gupta R. Antibiotic Resistance Pattern of Community Acquired Uropathogens at a Tertiary Care Hospital in Jaipur, Rajasthan. Indian J Community Med. 2012; 37(1): 39– 441.- DOI: 10.4103/0970-0218.94023 9. Bader MS, Hawboldt J, Brooks A. Management of complicated urinary tract infections in the era of antimicrobial resistance. Postgrad Med. 2010;122(6):7–15. doi:10.3810/pgm.2010.11.2217. 10. Mittal R, Aggarwal S, Sharma S, Chhibber S, Harjai K. Urinary tract infections caused by Pseudomonas aeruginosa: a minireview. J Infect Public Health. 2009;2(3):101–11. DOI: 10.1016/j.jiph.2009.08.003.- doi.org/10.1016/j.jiph.2009.08.003 11. Ronald A. The etiology of urinary tract infection: traditional and emerging pathogens. Dis Mon. 2003;49(2):71–82. DOI: 10.1067/mda.2003.8.- doi.org/10.1016/S0002- 9343(02)01055-0 12. Manjunath GN, Prakash R, Annam V, Shetty K. Changing trends in the spectrum of antimicrobial drug resistance pattern of uropathogens isolated from hospitals and community patients with urinary tract infections in Tumkur and Bangalore. Int J Biol Med Res. 2011;2:504–7. 13. Murugan K, Savitha T, Vasanth S. Retrospective study of antibiotic resistance among uropathogens from rural teaching hospital, Tamilnadu, India. Asian Pac J Trop Dis. 2012;2:375– 80.- doi.org/10.1016/S2222-1808(12)60082-6 14. Crellin E, Mansfield KE, Leyrat C, et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ2018;360:k341.- DOI: https://doi.org/10.1136/bmj.k341 15. Baral R, Timilsina S, Jha P, Bhattarai NR, Poudyal N, Gurung R, et al. Study of antimicrobial susceptibility pattern of Gram positive organisms causing UTI in a tertiary care hospital in eastern region of Nepal. Health Renaiss. 2013;11(2):119–124. DOI: https://doi.org/10.3126/hren.v11i2.8218 16. Bano K, Khan J, Begum RH, Munir S, Akbar N, Ansari JA, et al. Patterns of antibiotic sensitivity of bacterial pathogens among urinary tract infections (UTI) patients in a Pakistani population. Afr J Microbiol Res. 2012;6(2):414–20.- doi.org/10.5897/AJMR11.1171 17. Gupta K, Hooton TM, Stamm WE. Increasing antimicrobial resistance and the management of uncomplicated community- acquired urinary tract infections. Ann Intern Med. 2001;135(1):41–50.- doi.org/10.7326/0003-4819-135-1- 200107030-00012 18. Kausar A, Akram M, Shoaib M, Mehmood RT, Abbasi MN, Adnan M, Aziz H, Asad MJ. Isolation and identification of UTI causing agents and frequency of ESBL (extended spectrum beta lactamase) in Pakistan. Amer JPhytomed Clin Ther. 2014;2:963- 75. 19. Stickler DJ: Bacterial biofilms in patients with indwelling urinary catheters. Nat Clin Pract Urol. 2008, 5 (11): 598-608. 20. Hussain A, Sohail M, Abbas Z. Prevalence of Enterococcus faecalis mediated UTI and its current antimicrobial susceptibility pattern in Lahore, Pakistan. JPMA. The Journal of the Pakistan Medical Association. 2016 Oct 1;66(10):1232.