Bangladesh J Microbiol, Volume 28, Number 1, June 2011, pp 7-11 Prevalence of Ciprofloxacin and Nalidixic Acid Resistant Salmonella entericaserovar Typhi in Bangladesh Shirin Afroj1, Mohammad Ilias1, Maksuda Islam2, and Samir K Saha2* 1Department of Microbiology, University of Dhaka, Dhaka-1000, Bangladesh. 2Department of Microbiology, Dhaka Shishu (Children) Hospital,Dhaka-1207, Bangladesh
Microsoft word - rnr-3-1-45.docxJournal of Renewable Natural Resources Bhutan ISSN: 1608-4330 The pattern of antibiotic-resistance of Gram-negative bacilli, isolated from
urine samples of Shafa Hospital in Kerman (Iran)
Hojjat Samareh Fekri*, Dr. Toorajreza Mirshekari, Maliheh Nejad Mahmoodabadi, Samaneh Koohkan, Kamal Fakhral-dini, Mahboobeh Pakravanan Kerman University of Medical Sciences, Kerman, Iran *Corresponding Author ABSTRACT
Background and aim: resistance to antibiotics among pathogenic bacteria is determined as a
worldwide problem of antibiotic resistance and is important to select the patterns of common
disease-causing bacteria and specific experience to guide empirical treatment against a
particular pathogen. Therefore, urine samples were examined to determine antibiotic resistance
in Gram-negative bacteria.
Materials and Methods: All samples were sent to the laboratory affiliated to Administrative
Shafa center Kerman University of Medical Sciences to be cultivated during the 12 months April
to March 2013, in agar mechanical media, blood agar and differential diagnostic media Gram-
negative bacteria were cultivated and then, Antibiogram pattern of the bacteria were studied by
disk diffusion method and believe Kirby- Inhibition zone in accordance with national standards
committee Clinical Laboratory (NCCLS).
Results: From 2830 urine samples cultivated by 549 positive cultures (19/40 percent) from the
total of 391 cases of gram-negative bacilli (71 /22 percent) being the most common mass of
E.coli with 58 /57 percent. Sensitivity to antibiotics in Gram-negative bacilli most sensitive to
chloramphenicol (70/33%) and least sensitive to amikacin (10/74 %), respectively.
Conclusion: Due to the difference of view in different geographical areas is required using
Antibiogram regional pattern of antibiotic resistance in experimental treatment for each patient.
Keywords: urinary tract infection, urinary tract infection, antibiotic pattern, gram-negative
The urinary tract infection (UTI) is one of the most common problems encountered in practice
with a wide clinical range.
Community-acquired urinary tract infections and uncomplicated in the majority of cases due to
E. coli and in other cases may be due to other Enterobacteriaceae, including strains of Proteus is
Klebsiella (1) in patients with complicated UTI, or who have a history of antibiotic therapy or
catheter urine ways, E. coli continues recognized to be the most common cause (40%). However,
in these patients, the incidence of other species increases for example, other members of
Enterobacteriaceae, Enterococcus, Pseudomonas, Pseudomonas and Candida family (2).
Resistance to antibiotics among pathogenic bacteria is what today is regarded as a worldwide
problem. Pattern of antibiotic resistance in common pathogenic bacteria is important to conduct
empirical treatment (experimental) and specificity against a particular pathogen.
Enterobacteriaceae bacteria family resistance to antimicrobial agents is highly variable due to
Bhu.J.RNR. Vol 3.1, 404-409: 2015 Hojjat Samareh Fekri et al
inherent or acquired resistance mechanisms. Acquired resistance occurs as a result of exposure to
antimicrobial agents and the family is the most important disease-causing bacteria are resistant to
antibiotics commonly used (3). Due to the unpredictable patterns of antimicrobial susceptibility
of Gram-negative bacilli, whereas Gram-negative bacilli antimicrobial therapy, antimicrobial
therapy should be considered if the antibiotic sensitivity test should be carried out (4).
On the other hand, however, the initial treatment of an infection often occurs based on
experience, but the availability of the results of tests to determine the sensitivity can help the
initial dose adjustment or modify existing treatments the following reasons: A) Microorganisms
causing infection are resistant to the medication being taken. B) A drug with the same effects and
lower prices can be replaced (5).
Due to the above reasons, and considering the importance of the determination of antibiotic
susceptibility pattern, these pathogens are in the correct use of antibiotics in the empiric
treatment of urinary tract infection (6) and also reduce the treatment costs due to the increase in
the resistance of pathogens to more accessible antibiotics (7) to determine the antibiotic
susceptibility of gram-negative bacteria in urine samples of Patient Education Center – Shafa
Therapy Kerman (Iran), we have 2013 years in addition to benefiting from these results
contribute to the proper treatment of patients.
Materials and Methods:
The cross - sectional study of all samples sent to the laboratory for cultivation were enrolled to
education center affiliated to Kerman University Hospital over a period of 12 months (April to
March 2013). Mid-stream urine sample method (mid-stream urine) were collected in a sterile
container using a calibrated loop (0/01 ml) of urine samples in sterile conditions on blood agar
and incubated mechanical environment, were incubated at 37 ° and were examined within 24-18
hours (8-9) (medium company was HIMEDIA). Examples of the number of colonies has grown
equal to or more than 100000 CFU / ml was positive for urinary tract infections (9) and
diagnostic tests to identify the bacteria on which they were made. Including Gram staining,
oxidase drive and differential medium:
Urease, Phenylalanine deaminase, SIM TSI, Methyl red, Citrate (simmons)،Lysine
Finally, after the final diagnosis in order to perform antimicrobial susceptibility testing disk
diffusion method was used on Agar Mueller Hinton. Inhibition was studied based on the
recommendations of the National Committee for Clinical Laboratory Standards (NCCLS) (3)
Antibiotics used include: ceftriaxone (30mcg), ciprofloxacin (30mcg), trimethoprim-
sulfamethoxazole (25mcg), amikacin (30mcg) nalidixic acid (30mcg), nitrofurantoin (30mcg),
Syfyksym (5mcg), chloramphenicol (30 mcg).
The results of this study were analyzed with spss.
In 2013, in the Hospital, of the number of urine samples submitted for cultivation in 2830, 549
positive cultivations (19/40 percent) were obtained, of which 391 samples (71/22%) and gram-
negative bacilli and the rest of the cases (28/78%) and gram-positive bacilli and fungi were
isolated. Strains of Gram-negative isolates, respectively, including Escherichia coli (58/57
percent), Enterobacter (15/08%), Klebsiella (13/82 percent)), Pseudomonas (5/63 percent)
Proteus (2/30%) and other gram negative bacilli (4/60%) and detailed results are given in Table
Bhu.J.RNR. Vol 3.1, 404-409: 2015 Hojjat Samareh Fekri et al Table 1: Percentage and Frequency of separation of Gram-negative bacteria isolated from
Pseudomonas Klebsiella Figure (1): separation frequency Gram-negative bacteria isolated from urine Of all cultures for gram-negative bacilli, 279 samples (71/36%) belonged to the female and 112 (28/64%) for male sex. The percentage of the isolated species total was higher in women than men. Table (2): The frequency and percentage of people who are sensitive to the separation of
Abbreviated Antibiotics sensitive individuals name Bhu.J.RNR. Vol 3.1, 404-409: 2015 Hojjat Samareh Fekri et al
Based on the findings of the most sensitive gram-negative bacilli in Table and Figure 2 is related
to chloramphenicol (70/33), ciprofloxacin (57/28), Nitrofurantoin (56/52) and the other low
sensitivity (maximum strength) gram-negative bacilli were related to amikacin (10/74), Nalidixic
acid (32/99), trimethoprim-sulfamethoxazole (37/34).
The results of identification of the bacteria isolated in this study show that Gram-negative
bacteria (71/22 percent) are the most common cause of urinary tract infections.
E.coli among Gram-negative bacteria Enterobacter with 58/57% and 15/08 percentage devoted
the most frequency. This result is similar to most studies have been achieved in Iran, countries in
the region (Turkey, Saudi Arabia, India) and European countries - the United States (15, 12, 11,
10, 8), which can be due to the presence of Enterobacteriaceae bacteria in the stool, the
possibility of contamination through the urinary tract. The study also shows the percentage of
gram-negative infections in women with higher levels of urinary tract infection (71/61% to
28/39%) which is probably due to the short urine and near its mouth of the vagina and the anus
outside. According to the results of the study compared to studies in previous years, it appears to
change the appearance of antibiotic-resistant infections in the urinary problem is improving so
that, in the study was conducted in 2008 by Farahani et al. (16) as well as by Kenani et al. in
2009 (17) these results somewhat were confirmed.
However, antibiotic sensitivity patterns somewhat are inconsistent with which can be considered
as the lack of use the same disc, genetic and geographic diversity of people, different customs,
safe and the difference is referred to the hospital. In a study conducted in Saudi Arabia antibiotic
resistance during the years 1999-2002 Klebsiella pneumoniae resistance to antibiotics as
amoxicillin was reported as 100 percent while the extent of resistance to antibiotics, includes
trimethoprim, and Chloramphenicol Cephalexin respectively 26 percentage of, 21 percentage of
and 12 percent (12). While in our study the most sensitive gram-negative bacilli was
Chloramphenicol (33/70%) and the lowest sensitivity is related to amikacin. According to the
study, although the increasing trend of resistance is similar but the percentage increased
resistance. It seems Period of two studies may partly explain the differences and unfortunately,
the alarm is sounded microbial resistance. Therefore, based on this study is expected to be used
as amikacin, Nalidixic acid, more empirical treatment of UTI mean Prem sulfamethoxazole place
chloramphenicol and ciprofloxacin are the best choice. Also, specific treatment for each species
and also in case of lack of response to best empirical therapy is using Antibiogram.
Thus, despite the fact that most antibiotic susceptibility of gram-negative bacteria compared to
ciprofloxacin have been approved in our study and similar studies, but the sensitivity varies in
different studies (13, 10), on the other hand the issue of ampicillin is different, so that, although
it has the lowest antibiotic susceptibility, but the rate has varied in different studies. (14, 12-10,
8, 7) the change of location is one of the most important causes of these differences (10) As well
as the proper use of antibiotics to avoid unnecessary prescription of antibiotics and prevents
Bhu.J.RNR. Vol 3.1, 404-409: 2015 Hojjat Samareh Fekri et al
occurring antibiotic-resistant strains (acquired resistance) in developing countries is one of the
causes of this difference (14).
The results of various studies show that:
1. Antibiotic resistance pattern in different geographical areas
2. High resistance to antibiotics that are commonly used. 3. The emergence of a degree of resistance to antibiotics that is the newest wake-up call. Therefore, it is suggested that periodic monitoring of resistance patterns and taking advantage of these models in specific experimental treatment performed by doctors.
The authors thank the microbiology laboratory personnel of Shafa hospital in Kerman as well as
researchers in the laboratory of Kerman University of Medical Sciences.
1. Mandell Gerald L, Bennet John E. Principles and practice of infectious disease. 6th Ed.
Philadelphia: Elsevier Inc.; 2005. P. 887-92.
2. Gobernado M, Valdes L, Alos J I, García-Rey C, Dal-Ré R, García de Lomas J. Antimicrobial
susceptibility of clinical Esherichia coli isolates from uncomplicated cystitis in women over a 1-
year period in Spain. Rev Esp Quimioterap Enero
3. Gangoue-Pieboji J, Koulla-Shiro S, Ngassam P, Adiogo D, Njine T, Ndumbe P. Antimicrobial
activity against gram negative bacilli from Yaounde Central Hospital, Cameroon. Afr Health
4. Henry JB. Clinical diagnosis and management by laboratory methods. 21st Ed. Philadelphia:
Saunders Elsevier; 2007.
5. Kazaei M. A survey on Incidence of broad spectrum antibiotics lactamase ESBL in
Enterobacteriaceae isolated from patients hospitalized in Mofid Children Hospital [dissertation].
Tehran: Shahid Beheshti University of Medical Sciences: 2006.
6. Ochoa Sangrador C, Eiros Bouza JM, Mendez CP, Inglada Galiana L.The etiology of urinary
tract infections and the antimicrobial susceptibility of urinary pathogens. Rev Esp Quimioter
7. Wu CY, Chiu PC, Hsieh KS, Chiu CL, Shih CH, Chiou YH. Childhood urinary tract infection:
a clinical analysis of 597 cases. Acta Paediatr Taiwan 2004 ; 45(6):313-4.
8. Guta V, Yadav A, Joshi RM. Antibiotic resistance pattern in uropathogens. Indian J Med
Microbiol 2002; 20(2):96-8
9. Forbes BA, Sahm DF. Weissfeld AS. Diagnostic microbiology.12th Ed. St Louis: Mosby;
2007. P. 849-51.
10. Grude N, Tveten Y, Jenkins A, Kristiansen BE. Uncomplicated urinary tract infections.
Scand J Prim Health Care 2005; 23:115-19.
11. Yuksel S, Ozturk B, Kavaz A, Ozcakar ZB, Acar B, Guriz H, et al. Antibiotic resistance of
urinary tract pathogens and evaluation of empirical treatment in Turkish children with urinary
tract infections. Int J Antimicrob Agents 2006; 28(5):413-6.
Bhu.J.RNR. Vol 3.1, 404-409: 2015 Hojjat Samareh Fekri et al 12. Kader AA, Kumar A, Dass SM. Antimicrobial Resistance Patterns of Gram-Negative Bacteria Isolated from Urine Cultures at a General Hospital. Saudi J Kidney Dis Transpl 2004- 15(2):135-9. 13. Farrell DJ, Morrissey I, De Rubeis D, Robbins M, Felmingham D. A UK multicentre study of the antimicrobial susceptibility of bacterial pathogens causing urinary tract infection. J Infect 46:94-100. 14. Hunjak B, Pristas I, Stevanovic R. Uropathologens and antimicrobial susceptibility in outpatients.Acta Med Croatica 2007;61(1):111-5. 15. McLoughlin TG Jr, Joseph MM. Antibiotic resistance patterns of uropathogens in pediatric emergency department patients. Acad Emerg Med 2003; 10(4):347-51. 16. Hamid-Farahani R; MD1, Tajik AR; MD2, Noorifard M; MD3, *Keshavarz A; MSc4, Taghipour N; MD5, Hossieni-Shokouh J; MD6.Antibiotic resistance pattern of E.coli isolated from urine culture in 660 Army clinical laboratory center in Tehran [Persion].2008:1(10):45-49 17. Dr. Malik Kenan 1, Seyed Hamid Madani 2, S. Khazaee 3, M. King. The pattern of antibiotic resistant Gram-negative bacilli isolated from urine samples Center Hospital Imam Reza (AS) Kermanshah[Persion].2009
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