Isolation and Diagnosis of Resistant Bacteria from Pregnant Women with Urinary Tract Infections in Karbala

ABSTRACT


Introduction
In hospitals as well as the general population, urinary tract infections are among the most prevalent bacterial infections, coming in second only to respiratory infections (1).Around 150 million people worldwide are thought to have urinary tract infections (UTIs) (2).Women are more prone to UTI than men are, and this is partly because of a shorter urethra, the lack of prostatic secretion, pregnancy, and the ease with which fecal microbes can enter the urinary tract (3).Around 50% of women will get at least one urinary tract infection (UTI), including while pregnant.Pregnant women can develop UTIs from a variety of pathogenic microbes, including bacteria, fungus, protozoa, and viruses.E. coli and other Enterobacteriaceae make up around 75% of the isolates and are the most common bacterial infections (4).
The use of antibiotics as a treatment for UTIs is among the most widespread around the globe, and its significance for world health cannot be overstated.Notwithstanding how important they are, the emergence of resistance threatens the long-term efficacy of antibiotics.The primary cause of antibiotic resistance has been the excessive and unneeded use of antibiotics (5).Antimicrobial resistance (AMR), which is thought to be responsible for more than 700,000 deaths annually worldwide, is a problem that is becoming more and more of a worry on a global scale (6).A general term used to describe resistance to all antimicrobial substances is "antimicrobial resistance."Due to antimicrobial resistance, traditional treatments are less effective and take longer to complete, which increases the risk of diseases spreading (7).The public's misuse of antibiotics is one of the major causes of antibiotic resistance (8), and some research has revealed that some pregnant women are unaware of how to treat common infections, which contributes to AMR (9).

Methods
In November 2022, certain private laboratories in the province of Karbala collected samples.50 pregnant individuals with urinary tract infections provided urine samples.Following general urine examination (G.U.E.) and urine cultivation for bacterial isolation, patients were deemed to have a positive UTI.
Patients with symptomatic UTIs had approximately 10 ml of clean-catch mid-stream or transurethral catheterization urine specimens taken in sterile containers.Each urine sample was divided into two portions in the medical laboratory: the first portion was centrifuged and stored at -80 ºC, and the second portion was directly inoculated on standard culture media (MacConkey and Blood agar) and incubated aerobically at 37 ºC for 24-48 hours using conventional methods.To prepare urine fragments for direct microscopic analysis, the remaining pee was centrifuged (1500 rpm for 5 minutes).
Before using a completely automated VITEK-2 compact system to identify the bacterial species, manual biochemical tests for bacterial isolates were performed to determine the species.Bacterial identification was done using cards that were grampositive and gram-negative.If the test organisms were isolated as pure isolates from MacConkey or Blood agar, 3 ml of 0.45% sterile saline was added to the polystyrene tube, and the organism was then homogeneously suspended in the saline.Gramnegative and gram-positive bacteria had densities of 0.5 to 0.63 in the bacterial solution.A microorganism suspension is inoculated on the identification cards.The identification card is inserted into the adjacent slot while the transfer tube is inserted into the appropriate suspension tube in a special rack (Cassette) holding a test tube containing a suspension of microorganisms.

Results
Of the 50 bacterial isolates obtained from pregnant women with UTIs, 42 were gram-negative (84%) and eight were gram-positive (16%).The results of the laboratory diagnosis using the VITEC-2 system, which are shown in Figure 1, showed the appearance of five bacterial species and six species belonging to these species.The results also show that the number of bacterial isolates isolated from pregnant women suffering from urinary tract infection was 50 bacterial isolates, distributed according to bacterial species, where E. coli was diagnosed in 60% of the diagnosed isolates, followed by Proteus mirabilis by 12%, while the percentage of Pseudomonas aeruginosa, Staphylococcus aureus and Staphylococcus hominis bacteria was 8% each, and Klebsiella pneumonia bacteria were the least visible bacterial species with a rate of 4%.Table 1 shows antibiotics and their abbreviations in the international system of abbreviations that were used in this study to determine bacterial resistance to them.When examining the sensitivity of 30 E. coli bacterial isolates towards antibiotics, the results are shown in Figure 2. All isolates were resistant (100%) to the AMOX antibiotic, and the isolates showed high resistance (87%) to CFR, CN, CZ, CXM, CAE, CPD, CRO NA and SXT antibiotics, while the isolates were highly sensitive (93 %) to CAZ-AVI, EPT, IM, ME, AK and FOS antibiotics.
The results of Figure 6 indicated that Staphylococcus aureus was resistant (100%) to BENPEN, OXA, ERY, CLIN, TEC, VAN, TET, FUS, RIM and SXT antibiotics, while it was fully sensitive (100%) to GEN, TOB, LEV, TIG and NIT antibiotics, it was only moderately sensitive to MOX.

Discussion
In contrast to the findings of the current study, the outcomes differed among studies and nations.Staph.Bacteria were the most common among the other species in the Cameroon study by Ndamasson et al., they found that the rate of UTI in pregnant women was 45 % (10).The findings of a local study on pregnant women with urinary tract infections conducted in Baghdad, Iraq, did not match those of the current study, with the findings of that study being as follows: The most common bacteria were Escherichia coli (34%) and Staphylococcus aureus (22.2%),Klebsiella spp.(14.6%), non-coagulase Staphylococcus (11.5%),Proteus spp.(4.5%), Pseudomonas spp.(3.7%), Acinetobacter spp.(2.8%), Citrobacter (2.8%), Enterococcus (11).We find agreement between the findings of the current study and those of Yata and his team in 2021 in Zambia.The researchers came to the conclusion that the majority of the bacterial isolates that were isolated from pregnant women with urinary tract infections were E. coli bacteria, with a rate of 59% (12).The study carried out in Uganda by Johnson and his team in 2021 had different findings from the present study, with Klebsiella pneumoniae coming in at 37.41%, Escherichia coli at 28.78%, Pseudomonas aeruginosa and Proteus mirabilis at 5.04% apiece, and Citrobacter freundii at 1% and Staphylococcus aureus at 23.57%.(13).
As is evident from the results of Figures 2, 3, 4 and 5 related to the resistance of gram-negative bacterial species towards the studied antibiotics, some species showed complete resistance to some antibiotics, including AMOX, and some species showed complete sensitivity to some antibiotics.These results come in light of the resistance mutations that occur in the bacterial species, which give them the characteristic of complete, high or medium resistance.The results of the current study were somewhat consistent with the findings of some researchers in the countries around the world and in Iraq, including the study conducted in Iraq, high resistance to ampicillin (85.6%), cotrimoxazole (72.2%), and tetracycline (71.3%) was found as a result.A moderate resistance to Ceftazidime, Ciprofloxacin, Amoxicillin-clavulanic acid, and Ceftriaxone was also discovered (11).We found that most gram negative isolates from UTI patients showed great susceptibility to aminoglycosides and nitrofurantoin in a study conducted in Addis Abeba (14).Antibiotic resistance among pathogenic bacteria is a serious health issue in developing nations and has an impact on the entire world because there aren't enough surveys for antimicrobial resistance and there aren't any laws in place to restrict prescribing.There is a greater risk to the mother and fetus due to the growing multidrugresistant bacteria (MDR), which reduces the likelihood of giving a safe antibiotic and makes infection elimination and treatment success challenging (15, 16).Due to the lack of effective medicines and the higher incidence of pyelonephritis in pregnant women, UTIs are complex diseases.Due to the high prevalence of amoxicillin-and cephalosporin-resistant isolates in our local strains, it is not recommended to use these antibiotics during pregnancy.Instead, safer alternatives were used, such as amoxicillin/clavulanate and nitrofurantoin for cystitis and fourth-generation cephalosporins for pyelonephritis (17, 18).
According to the findings of a different study, nalidixic acid (88.3%), ampicillin (77.8%), and norfloxacin (58.5%) were the medications with the highest antimicrobial resistance, while chloramphenicol (20%) had the lowest resistance (12).The incidence of drug resistance to various substances was assessed, and results showed rather significant levels of resistance to widely prescribed medications, including ciprofloxacin and chloramphenicol.These have likely been on the market for a long time, giving bacteria time to develop resistance mechanisms to the antibiotics, which may account for the high level of resistance that has been documented (19-21).Moreover, the availability nless no other options are available (22).Both pregnant and non-pregnant women were found in one study.In pregnant and non-pregnant women, Staphylococ of inexpensive over-the-counter antibiotics in underdeveloped nations like Zambia may be a contributing factor in this level of resistance (19).In addition, the initial use of antibiotics prior to the appearance of antimicrobial susceptibility data in the laboratory may contribute to the high levels of resistance.Therefore, the importance of creating and enforcing antibiotic laws as well as good antibiotic stewardship in poor nations cannot be overstated.
The regular exposure to antibiotics in the area may be the cause of the resistance to commonly given antibiotics that was seen in our investigation.Cephalosporins (CEP) are generally safer to administer during pregnancy than quinolones (CIP, NOR, etc.), which are contraindicated u cus sp.displayed resistance to amoxicillin (AMO; 55.56%) and chloramphenicol (CHL; 100%), respectively (10).
Pregnant and non-pregnant women with UT infection had uro-pathogenic isolates that had high levels of multiple antibiotic resistance to medications that were often administered.Pregnant women had considerably greater rates of multidrug resistance to quinolones (NOR, CIP) than non-pregnant women (P=0.018).Pregnant women had considerably more multidrug-resistant Escherichia coli isolates than nonpregnant women (P = 0.018) (10).

Conclusion
From the results of the current study, we can conclude that gram-negative bacteria are more common than gram-positive bacteria in pregnant women with urinary tract infections.Also, E. coli is the most common and most resistant bacteria of type XRD, and gram-positive bacteria, staph bacteria, also showed resistance to type XRD.In addition, gramnegative bacteria showed high resistance to many antibiotics, including AMOX, CFR, CN, CZ, CXM, and CAE.Gram-positive bacteria showed complete resistance against BENPEN, OXA, CLIN, TEC, VAN, TET, FUS and VAN antibiotics.

Figure 1 .
Figure 1. Isolation rate of UTI bacterial species in pregnant women.

Volume 8 ,
November -December 2023 Journal of Obstetrics, Gynecology and Cancer Research

Figure 2 .
Figure 2. Antibiotic Susceptibility profile for 30 isolates of Escherichia coli by Vitek 2 system.

Volume 8 ,
November -December 2023 Journal of Obstetrics, Gynecology and Cancer Research

Figure 6 .
Figure 6.Antibiotic Susceptibility profile for 4 isolates of Staphylococcus aureus by Vitek 2 system.

Figure 7 .
Figure 7. Antibiotic Susceptibility profile for 4 isolates of Staphylococcus hominis by Vitek 2 system.