Volume 8, Issue 3 (Summer 2019)                   J Occup Health Epidemiol 2019, 8(3): 118-122 | Back to browse issues page

‎ 10.29252/johe.8.3.118
‎ 20.1001.1.22518096.2019.8.3.6.5

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Meskini M, Farhadi S, Esmaeili D. Antibiotic resistance in patients referred to Ali-ebn Abi-Taleb Hospital, Qom, Iran (2014-2015). J Occup Health Epidemiol 2019; 8 (3) :118-122
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Original Article
Antibiotic resistance in patients referred to Ali-ebn Abi-Taleb Hospital, Qom, Iran (2014-2015)
Maryam Meskini1 , Sohrab Farhadi2 , Davoud Esmaeili * 3
1- PhD Student, Department of Microbiology and Microbiology Research Center, Pasteur Institute, Tehran, Iran; Student Research Committee, Pasteur Institute of Iran, Tehran, Iran.
2- BSc Student, Department of Microbiology and Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran.
3- Associate Prof., Department of Microbiology and Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran; Applied Virology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. , esm114@gmail.com
Article history
Received: 2019/07/13
Accepted: 2019/10/13
ePublished: 2020/01/23
Subject: Epidemiology
Keywords: Antibiotic Resistance [MeSH], E. coli [MeSH], Drug Resistance [MeSH]
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Antibiotic resistance in patients referred to Ali-ebn Abi-Taleb Hospital, Qom, Iran (2014-2015)


Maryam Meskini1,2, Sohrab Farhadi3,5, Davoud Esmaeili4,5

1- PhD Student, Department of Microbiology and Microbiology Research Center, Pasteur Institute, Tehran, Iran.
2- Student Research Committee, Pasteur Institute of Iran, Tehran, Iran.
3- BSc Student, Department of Microbiology and Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran.
4- Associate Prof., Department of Microbiology and Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran.
5- Applied Virology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.

* Corresponding author:  Davoud Esmaeili, E-mail: esmaeili14@yahoo.com


Abstract
Background: In recent years, the risk of acquiring antibiotic resistance has been increasing due to the widespread use of antibiotics. This study aims to evaluate the antibiotic resistance pattern in patients referred to Ali-ebn Abi-Taleb hospital.
Materials and Methods: In a descriptive study, samples of urine, blood, cerebrospinal fluid, and body fluid were collected from patients referred to Ali-ebn Abi-Taleb Hospital from September 2014 to February 2015. Of these, 687 isolates identified as E. coli were tested for antibiotic susceptibility against 15 antibiotics by the Kirby- Bauer method based on CLSI 2015. The relevant prevalence, percentage, and mean were reported using SPSS (version 16).
Results: A total of 10824 samples were collected. A total of 866 isolates were grown on an agar medium, and 80.3% of the samples were isolated from women. The highest rate of antibiotic resistance was reported to be for Amoxicillin (82.2%). The lowestrate of antibiotic resistance was reported against Nitrofurantoin (14%).
Conclusions: We concluded there is an increasing rate of antibiotic resistance among E. coli isolates. Therefore, the necessity of identifying drug resistance is apparent using precise and straightforward methods to prevent the extensive distribution of antibiotic resistantagents.
 
Keywords: Antibiotic Resistance, E.coli, Drug Resistance
 
Introduction
Gram-negative and Gram-positive bacteria can cause urinary tract infections (UTIs), such as Escherichia coli, Staphylococcus aureus, Staphylococcus saprophyticus, Pseudomonas aeruginosa, Klebsiella spp., Enterobacter spp., Proteus spp., Haemophilus spp., and Coagulase-Negative Staphylococci (CoNS). These organisms colonize anal and perineal sections. Furthermore,  resistance to antibiotics is increasing and can create multidrug-resistant (MDR) as well as extensively drug-resistant (XDR) strains [1, 2].
E. coli are gram-negative and opportunistic bacteria most common in nosocomial infections, such as meningitis, sepsis, gastroenteritis, and UTI. In addition, they are the first pathogens causing nosocomial infections and the most common bacteria inducing community-acquired genital tract infections (UTIs) [3, 4]. Among antibiotic candidates for treating infections caused by E. coli are beta-lactam antibiotics, including cephalosporins and carbapenems, which can destroy bacterial cell walls [5, 6].
The treatment of E. coli in nosocomial infections is a global concern [7, 8]. Due to the presence of MDR and XDR E. coli in UTI patients, the costs of treatment, morbidity, and mortality are increasing, especially in developing countries, such as Iran [9, 10].
The extensive use of antimicrobial agents in the fields of human medicine, aquaculture, veterinary medicine, and horticulture has turned them into the sources of antibiotic-resistant bacteria [11]. As the risk of antibiotic resistance is high [12], the emergence of antibiotic resistance in nosocomial pathogens capable of causing nosocomial infections is a global concern .
This study was conducted to evaluate the antibiotic resistance pattern in patients referred to Ali-ebn Abi-Taleb Hospital from September 2014 to February 2015.
 
Materials and Methods
In a cross-sectional study, samples of urine, blood, cerebrospinal fluid, and body fluid were collected from patients referred to Ali-ebnAbi-Taleb Hospital (Qom) from September 2014 to February 2015.
At the first stage, the identification task was conducted based on biochemical and bacteriological standard tests, in which the samples were cultured on EMB agar, Blood agar, and Mac Conkey agar (13). At the next stage, the isolates were cultured in different media, including Triple Sugar Iron (TSI), Sulphide Indole Motility (SIM) (Merck-Germany), Methyl Red VogesProskauer (MR/VP) (Merck-Germany), and the Simmon Citrate medium (Merck-Germany), and they were then incubated at 37 °C for 18-24 hours [13].
Antimicrobial resistance rates were determined by the disc diffusion method, according to CLSI 2015. E. coli ATCC 25922 was used as a control for all testes. Next, antibiogram evaluations were carried out in Muller Hinton Agar (MHA), according to the CLSI protocol with PATANTEB (PatanTeb-Iran) antibiotic discs, including Ceftazidime (30 µg), Cefotaxime (30 µg), Ceftriaxone (30 µg), Imipenem (10 µg), Gentamicin (10 µg), Ciprofloxacin (5 µg), Amikacin (30 µg), Nalidixic acid (30 µg), Nitrofurantoin (300 µg), Cefixime (5 µg), Ceftizoxime (30 µg), Cotrimoxazole (25 µg), Amoxicillin (25 µg), and Azithromycin (15 µg). The plates were then incubated at 37 °C for 18-24 hours. The diameter of the inhibitory growth zone was measured and the resistance rates were determined based on CLSI 2015 [14]. The relevant prevalence, percentage, and mean were reported by SPSS Statistics 16.
 
Results
In this study, a total of 10,824 samples of urine, blood, cerebrospinal fluid, and body fluid were collected from patients referred to Ali-ebnAbi-Taleb Hospital (Qom) in a 6-month period. The patients’ ages ranged from one-month infants to 92-year old people. The 866 isolates were grown on an agar medium. There were 687 isolates identified as E. coli, among which, 552 (80.3%) isolates belonged to women. These isolates were tested for antibiotic susceptibility to 15 antibiotics by the Kirby- Bauer method, based on CLSI 2015. There were 495 (72%) samples taken from outpatients and 192 (18%) samples taken from the admission part. Approximately 99.5% of the E. coli bacteria were isolated from urine samples. Table 1 shows the characteristics of the clinical specimens.
 
Table 1:Characteristics of a total of 687 samples collected from outpatients and those at the admission part
Variables Sex Patients
Women Men Outpatients Admission
E. coli isolates 552 135 495 192
Percentage (%) 80.3 19.7 72 18
 
 
 
 Table2:The pattern of resistance to 15 antibiotics in UTI
Percentage of Resistance Resistance (mm) Intermediate (mm) Sensitive (mm) Antibiotic
82.2 % ≥13 14-17 ≤18 Amoxicillin (25 µg)
41.6 % ≥13 14-17 ≤18 Azithromycin (15 µg)
58.6 % ≥10 11-15 ≤16 Co-trimoxazole (25 µg)
14 % ≥14 15-16 ≤17 Nitrofurantoin (300 µg)
23.4 % ≥12 13-14 ≤15 Gentamicin (10 µg)
9.2 % ≥14 15-16 ≤17 Amikacin (30 µg)
50 % ≥13 14-18 ≤19 Nalidixic acid (30 µg)
23.5 % ≥15 16-20 ≤21 Ciprofloxacin (5 µg)
36.8 % ≥22 23-25 ≤26 Cefotaxime (30 µg)
39.1 % ≥17 18-20 ≤21 Ceftazidime (30 µg)
37 % ≥21 22-24 ≤25 Ceftizoxime (30 µg)
37.5 % ≥19 20-22 ≤23 Cefazolin (30 µg)
34.5 % ≥15 16-18 ≤19 Cefixime (5 µg)
34.6 % ≥19 20-22 ≤23 Ceftriaxone (30 µg)
30.7 % ≥19 20-22 ≤23 Imipenem (10 µg)
 
 



Figure1: Antibiotic resistance rates for isolates collected from patients referred to Ali-ebnAbi-Taleb Hospital (Qom) from September 2014 to February 2015.


Discussion
Antibiotic resistance in bacteria is usually caused by mechanisms, such as the production of drug-degrading enzymes, changes in membrane permeability, variations in drug side effects, and efflux pumps. E. coli are among the most prevalent bacteria detected in soil, water, etc. Correspondingly, E. coli are among the most opportunistic bacteria in nosocomial infections, especially in UTI patients. In fact, the antibiotic resistance of E. coli is important, particularly in outpatients and UTI patients. E. coli have a plasmid that could transferBeta-lactamase genes. Hence, the diagnosis and treatment of UTI are global concerns.
In this study, a total of 10,824 samples of urine, blood, cerebrospinal fluid, and body fluid were collected from patients referred to Ali-ebnAbi-Taleb Hospital (Qom) from September 2014 to February 2015. The patients’ ages ranged from one-month infants to 92-year old people. The 866 specimens were grown on a common bacteriological medium, among which 687 isolates were identified as E. coli, based on the common microbial culture and the biochemical test. Pourmand et al [15] studied UTIs in renal transplant patients at Sina University Hospital and reported that E. coli were the first cause of infections in UTI patients. Asadimanesh et al [16] explained that E. coli were the most prevalent bacterial factor in primary and recurrent UTIs. In addition, according to them, E. coli were the most prevalent bacteria in UTIs, which confirms the results of the present study. 
Women are more likely to develop UTIs than men. Chuang et al [17] reported that the prevalence of UTIs was more in women (68%) than in men (30%). Besides, in the study of Asadimanesh et al [16], 60.68% of the samples were women, and 39.31% of them were men. According to these results, UTIs are more prevalent in women than in men, yet the results of other studies showed that there were no differences between women and men in terms of developing UTIs [18]. According to the results of the present study, UTIs are more prevalent in women (80%) than in men. One of the reasons of the increase in UTIs in women compared to men could be the shortness of the urinary tract in women compared to men.
Manouchehriet al [19] reported that E. coli had the highest rate of resistance to Ceftazidime and Cefotaxime; however, in the other study, the isolates had the highest rate of resistance to Amoxicillin and Ampicillin [20]. According to the results of the present study, E. coli show the highest rate of resistance to Amoxicillin and Cotrimoxazole. Asadu Khan et al [21] reported that E. coli isolated from UTIs had the highest rate of resistance to Ampicillin and the lowest rate of resistance to kanamycin, yet our results showed that E. coli had the highest rate of resistance to Amoxicillin and Cotrimoxazole,but the lowest rate of resistance to Amikacin and Nitrofurantoin. These differences could be attributed to the different sources of the samples. In addition, in our study, resistance to antibiotics (the Cephalosporin group) was not significant in men and women. Karlowskyet al [22] reported that E. coli isolated from female outpatients in the United States showed the lowest rate of resistance to Nitrofurantoin, with this result having been consistent with the results of the present paper. To produce an antibiotic resistance pattern, the use of accurate methods, such as Minimum Inhibitory Concentration (MIC) is recommended.
 
Conclusion
Due to the high rate of antibiotic resistance in E. coli, the results of similar studies in recent years have shown that antibiotic resistance has been on the rise so rapidly in developing countries. Given the antibiotic use pattern in developing countries in treating various infections, especially urinary tract infections (UTIs), mortality rates and economic damage have been increasing year after year. In addition, it is recommended that more accurate methods, such as Minimum Inhibitory Concentration (MIC), be used to evaluate the antibiotic resistance pattern. The results obtained from this study and similar ones could be used by physicians in selecting appropriate antibiotics for experimental treatments.
 
Acknowledgement
We would like to express our special gratitude to Ali-ebnAbi-Taleb Hospital for sharing available samples with us during the course of this research; in addition, we would like to thank Pasteur Institute of Iran and Baqiyatallah University of Medical sciences for their financial support of the present research.
 
Conflict of interest: None declared.
 
References
  1. Issakhanian L, Behzadi P. Antimicrobial Agents and Urinary Tract Infections. Curr Pharm Des 2019; 25(12):1409-23.
  2. Basak S, Singh P, Rajurkar M. Multidrug Resistant and Extensively Drug Resistant Bacteria: A Study. J Pathog 2016; 2016:4065603.
  3. Ramos NL, Saayman ML, Chapman TA, Tucker JR, Smith HV, Faoagali J, et al. Genetic relatedness and virulence gene profiles of Escherichia coli strains isolated from septicaemic and uroseptic patients. Eur J Clin Microbiol Infect Dis 2010; 29(1):15-23.
  4. Shrestha LB, Baral R, Poudel P, Khanal B. Clinical, etiological and antimicrobial susceptibility profile of pediatric urinary tract infections in a tertiary care hospital of Nepal. BMC Pediatr 2019; 19(1):36.
  5. Uppala A, King EA, Patel D. Cefazolin versus fluoroquinolones for the treatment of community-acquired urinary tract infections in hospitalized patients. Eur J Clin Microbiol Infect Dis 2019; 38(8):1533-8.
  6. Falciglia G, HagemanJR, Schreiber M, Alexander K. Antibiotic Therapy and Early Onset Sepsis. Neoreviews 2012; 13(2):e86-93.
  7. Abdel-Raouf M, Aldeweik HM, Albannan MS, Zaki MM, Abdelkader AE, Moemen D. Influence of Different Families of Commercial Antibiotics on Controlling Nosocomial Infections. South Asian Journal of Research in Microbiology 2019; 4(2):1-8.
  8. Midturi JK, Ranganath S. Prevention and Treatment of Multidrug-Resistant Organisms in End-Stage Renal Disease. Adv Chronic Kidney Dis 2019; 26(1):51-60.
  9. Niranjan V, Malini A. Antimicrobial resistance pattern in Escherichia coli causing urinary tract infection among inpatients. Indian J Med Res 2014; 139(6):945-8.
  10. Kakian F, Shahini Shams Abadi M, Gholipour A, Fadaie M, Zamanzad B, Khairi S, et al. Evaluating the prevalence of virulence genes of Escherichia coli in patients affected by urinary tract infection. Gene Rep 2019; 16:100433.
  11. Paulshus E, Thorell K, Guzman-Otazo J, Joffre E, Colque P, Kühn I, et al. Repeated Isolation of Extended-Spectrum-β-Lactamase-Positive Escherichia coli Sequence Types 648 and 131 from Community Wastewater Indicates that Sewage Systems are Important Sources of Emerging Clones of Antibiotic-Resistant Bacteria. Antimicrob Agents Chemother 2019; 63(9).
  12. Sib E, Voigt AM, Wilbring G, Schreiber C, Faerber HA, Skutlarek D, et al. Antibiotic resistant bacteria and resistance genes in biofilms in clinical wastewater networks. Int J Hyg Environ Health 2019; 222(4):655-62.
  13. Tille P. Bailey & Scott's Diagnostic Microbiology - E - Book. 14th ed. Maryland Heights, Missouri, United States: Mosby; 2015.
  14. Balouiri M, Sadiki M, Ibnsouda SK. Methods forin vitro evaluating antimicrobial activity: A review. J Pharm Anal 2016; 6(2):71-9.
  15. Pourmand MR, Keshtvarz M, Soltan Dallal MM, Talebi M, Bakhtiari R, Pourmand Gh. Urinary tract infection in renal transplant patients in Sina University Hospital. Tehran University Medical Journal 2013; 71(2):114-21.
  16. Asadi Manesh F, Sharifi A, Mohammad Hosini Z, Nasrolahi H, Hosseini N, Kalantari A, et al. Antibiotic Resistance of Urinary Tract Infection of Children Under 14Years Admitted To The Pediatric Clinic of Imam Sajjad Hospital, 2012. Armaghan-e-Danesh 2014; 19(5):411-20.
  17. Chuang P, Parikh CR, Langone A. Urinary tract infections after renal transplantation: a retrospective review at two US transplant centers. Cli Transplant 2005; 19(2):230-5.
  1. Pourmand G, Salem S, Mehrsai A, Taherimahmoudi M, Ebrahimi R, Pourmand MR. Infectious complications after kidney transplantation: a single‐center experience. Transpl Infect Dis 2007; 9(4):302-9.
  2. Manouchehri M, Ahanjan M. Detection of CTX beta-lactamase Gene in Escherichia Coli Isolated from Urinary Tract Infection Using Polymeras Chain Reaction. Journal of Mazandaran University of Medical Sciences 2015; 25(129):36-45.
  3. Oteo J, Navarro C, Cercenado E, Delgado-Iribarren A, Wilhelmi I, Orden B, et al. Spread of Escherichia coli strains with high-level cefotaxime and ceftazidime resistance between the community, long-term care facilities, and hospital institutions. J Clin Microbiol 2006; 44(7):2359-66.
  4. Khan AU, Zaman MS. Multiple drug resistancepattern in Urinary Tract Infection patients in Aligarh. Biomed Res (Aligarh) 2006; 17(3):179-81.
  5. Karlowsky JA, Kelly LJ, Thornsberry C, Jones ME, Sahm DF. Trends in antimicrobial resistance among urinary tract infection isolates of Escherichia coli from female outpatients in the United States. Antimicrob Agents Chemother 2002; 46(8):2540-5.

 
References
1. Issakhanian L, Behzadi P. Antimicrobial Agents and Urinary Tract Infections. Curr Pharm Des 2019; 25(12):1409-23. [DOI] [PMID]
2. Basak S, Singh P, Rajurkar M. Multidrug Resistant and Extensively Drug Resistant Bacteria: A Study. J Pathog 2016; 2016:4065603. [DOI] [PMID] [PMCID]
3. Ramos NL, Saayman ML, Chapman TA, Tucker JR, Smith HV, Faoagali J, et al. Genetic relatedness and virulence gene profiles of Escherichia coli strains isolated from septicaemic and uroseptic patients. Eur J Clin Microbiol Infect Dis 2010; 29(1):15-23. [DOI] [PMID]
4. Shrestha LB, Baral R, Poudel P, Khanal B. Clinical, etiological and antimicrobial susceptibility profile of pediatric urinary tract infections in a tertiary care hospital of Nepal. BMC Pediatr 2019; 19(1):36. [DOI] [PMID] [PMCID]
5. Uppala A, King EA, Patel D. Cefazolin versus fluoroquinolones for the treatment of community-acquired urinary tract infections in hospitalized patients. Eur J Clin Microbiol Infect Dis 2019; 38(8):1533-8. [DOI] [PMID]
6. Falciglia G, Hageman JR, Schreiber M, Alexander K. Antibiotic Therapy and Early Onset Sepsis. Neoreviews 2012; 13(2):e86-93. [DOI]
7. Abdel-Raouf M, Aldeweik HM, Albannan MS, Zaki MM, Abdelkader AE, Moemen D. Influence of Different Families of Commercial Antibiotics on Controlling Nosocomial Infections. South Asian Journal of Research in Microbiology 2019; 4(2):1-8. [Article] [DOI]
8. Midturi JK, Ranganath S. Prevention and Treatment of Multidrug-Resistant Organisms in End-Stage Renal Disease. Adv Chronic Kidney Dis 2019; 26(1):51-60. [DOI] [PMID]
9. Niranjan V, Malini A. Antimicrobial resistance pattern in Escherichia coli causing urinary tract infection among inpatients. Indian J Med Res 2014; 139(6):945-8. [PMID] [PMCID]
10. Kakian F, Shahini Shams Abadi M, Gholipour A, Fadaie M, Zamanzad B, Khairi S, et al. Evaluating the prevalence of virulence genes of Escherichia coli in patients affected by urinary tract infection. Gene Rep 2019; 16:100433. [Article] [DOI]
11. Paulshus E, Thorell K, Guzman-Otazo J, Joffre E, Colque P, Kühn I, et al. Repeated Isolation of Extended-Spectrum-β-Lactamase-Positive Escherichia coli Sequence Types 648 and 131 from Community Wastewater Indicates that Sewage Systems are Important Sources of Emerging Clones of Antibiotic-Resistant Bacteria. Antimicrob Agents Chemother 2019; 63(9). [DOI] [PMID] [PMCID]
12. Sib E, Voigt AM, Wilbring G, Schreiber C, Faerber HA, Skutlarek D, et al. Antibiotic resistant bacteria and resistance genes in biofilms in clinical wastewater networks. Int J Hyg Environ Health 2019; 222(4):655-62. [DOI] [PMID]
13. Tille P. Bailey & Scott's Diagnostic Microbiology - E - Book. 14th ed. Maryland Heights, Missouri, United States: Mosby; 2015.
14. Balouiri M, Sadiki M, Ibnsouda SK. Methods for in vitro evaluating antimicrobial activity: A review. J Pharm Anal 2016; 6(2):71-9. [DOI] [PMID] [PMCID]
15. Pourmand MR, Keshtvarz M, Soltan Dallal MM, Talebi M, Bakhtiari R, Pourmand Gh. Urinary tract infection in renal transplant patients in Sina University Hospital. Tehran University Medical Journal 2013; 71(2):114-21. [Article]
16. Asadi Manesh F, Sharifi A, Mohammad Hosini Z, Nasrolahi H, Hosseini N, Kalantari A, et al. Antibiotic Resistance of Urinary Tract Infection of Children Under 14 Years Admitted To The Pediatric Clinic of Imam Sajjad Hospital, 2012. Armaghan-e-Danesh 2014; 19(5):411-20. [Article]
17. Chuang P, Parikh CR, Langone A. Urinary tract infections after renal transplantation: a retrospective review at two US transplant centers. Cli Transplant 2005; 19(2):230-5. [DOI] [PMID]
18. Pourmand G, Salem S, Mehrsai A, Taherimahmoudi M, Ebrahimi R, Pourmand MR. Infectious complications after kidney transplantation: a single‐center experience. Transpl Infect Dis 2007; 9(4):302-9. [DOI] [PMID]
19. Manouchehri M, Ahanjan M. Detection of CTX beta-lactamase Gene in Escherichia Coli Isolated from Urinary Tract Infection Using Polymeras Chain Reaction. Journal of Mazandaran University of Medical Sciences 2015; 25(129):36-45. [Article]
20. Oteo J, Navarro C, Cercenado E, Delgado-Iribarren A, Wilhelmi I, Orden B, et al. Spread of Escherichia coli strains with high-level cefotaxime and ceftazidime resistance between the community, long-term care facilities, and hospital institutions. J Clin Microbiol 2006; 44(7):2359-66 [DOI] [PMID] [PMCID]
21. Khan AU, Zaman MS. Multiple drug resistance pattern in Urinary Tract Infection patients in Aligarh. Biomed Res (Aligarh) 2006; 17(3):179-81. [Article]
22. Karlowsky JA, Kelly LJ, Thornsberry C, Jones ME, Sahm DF. Trends in antimicrobial resistance among urinary tract infection isolates of Escherichia coli from female outpatients in the United States. Antimicrob Agents Chemother 2002; 46(8):2540-5. [DOI] [PMID] [PMCID]
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