Bacterial Urinary Tract infection in adults , Hit District Anbar Governorate , west of Iraq

Background: Urinary tract infection (UTI) is one of the health problems in the community in all ages and both sexes. Many organisms are involved particularly enteric bacteria in females. Antimicrobial resistance of bacterial pathogen are complaining treatment and recovery of infected individuals. So UTI become more complicated and recurrent trouble maker infection for community. Aims of the study This study was devoted to focus on the main bacterial pathogens causing UTI in adult patients from both sexes in Hit District as well as to show the Antibiogram of the predominant bacterial isolate from patients. Patients and methods Midstream urine specimens were collected from adult males and females, each specimen was cultivated on blood agar and Mac Conkey agar and incubated at 37C aerobically for 24 hours. Bacterial isolates were identified with Gram stain and biochemical tests. Predominant bacterial isolate, E. coli was tested for antimicrobial sensitivity test by disk diffusion test (Kerby-Bauer Technique). Results Adults females were showing higher rate of UTI than adult males (77.8 %), (263) and (59.6%), (37) respectively. E. coli took first rank of isolation in both sexes, 26.5 % in males and 40.8% in females. Staphylococcus became next (73), (25.26%) while proteus mirabilis was showing third rank of isolation in both sexes. Regarding Antibiogram, E coli showed high sensitivity for imipenium (95.5%) followed by Amikacin (90.2%) while studied E coli isolate showed high tare of resistance to Ampicillin and Cotrimasol-Methprim. Conclusion: We can conclude from this study that UTI is an important infection in community and enteric bacteria particularly E. coli is an important causative agent. So precautions must be taken by people to prevent infection. Community education in self hygiene and social status must be done. Physicians must care of multi drug resistant E. coli during manipulation UTI


INTRODUCTION
Urinary tract infection (UTI) is defined as an inflammatory response of the urothelium to bacterial invasion (Stam andNorrby 2001 Tomas 2003).1 It occurs far more commonly in women than in men, except at the extremes of age, After 50 years of age, the incidence of UTI is almost as high in men as in women, presumably because of obstruction from prostatic hypertrophy.In persons between 1 and about 50 years of age, UTI is predominantly a disease of females.(Tomas, 2003, Kalpana andWalter, 2005).
Different classification was devoted for UTI to help treatment ,like upper and lower UTI, (Schaeffer, 2003).An increased rate of antimicrobial resistance was found to different antimicrobial agents due to abuse of antibiotics (Shafaq et al. 2011) and the emergence of resistance factors in bacteria trough different mechanisms of resistance ( 6 Nasreen et al. 2009Shafaq et al. 2011).This study was done to show the rate of UTI and the type of bacteria imposed in this infection in adults in Hit District, West of Ramadi, Anbar Governorate, IRAQ Patients and methods: Midstream urine specimens were collected from (400) adult patients from both sexes using clean catch method recommended by (Vandepitte et al. 2003).Patients were attending private Clinics of Urologists and senior physicians in Hit District, Anbar Governorate, West of IRAQ.
Urine specimens were processed as soon as possible (within 30 minutes) in Hit Central Private Lab licensed by Iraqi Ministry of Health.
Urine samples were tested using direct and direct bacteriological investigations, direct smear stained with gram stain was employed to each specimen.Urine were cultivated on sterile culture media using blood agar and MacConkey agar and incubated aerobically under 37C for 24 hrs.Results of urine cultures were Interpretated quantitatively and qualitatively following (Vandepitte et al. 2003).Bacterial isolates were identified and diagnosed using morphological and cultural criteria.Necessary confirmative tests were done to reach final diagnosis for each bacterial isolate following (Vandepitte et al. 2003, Forbes et al. 2011).Bacterial isolates were kept frozen in Brain Heart infusion broth containing 10 % Glycerol.
Antimicrobial sensitivity test was done for the predominant bacterial isolate using Kirby-Bauer disc diffusion technique (Vandepitte et al. 2003).Standard E. coli strain employed as control, results were reported and analyzed using SPSS .

RESULTS
Adult females were showing higher rate of urinary tract infection than adult males, 263 (77.8%) and 37 (59.6)respectively (P< 0.05) Table1.Proteus mirabilis was the third bacterium among isolated bacteria, 35 (12.2%) and all bacterial isolates were showing higher rate of isolation in females than males (P< 0.05) Table 2.
Regarding mixed bacterial isolation, it was found that eleven (11) patients were showing positive urine cultures with mixed growth of more than one organism and majority of them were in females also (Table 3).The Antibiogram for the dominant isolated bacterial type (E.coli), it was found that 95.5 % of E coli isolates were sensitive to Imepimen and majority of them were from females (104) and the rest number (9) were from males.Amikacin became next (90.2%) followed by Ciprofloxacin.E coli isolates were showing high resistance to Ampicillin and Methiprim (Table 4).

DISCUSSION
Increased rate of urinary tract infection (UTI) in females was in accordance with the findings of ( Nasreen et al. 2009., Manges, R.A et al. 2008, Khaled et al. 2010) The higher rate of urinary tract infection in females was ought to the feature of female urogenetal tract (short female urethra) which makes it easy to be contaminated with fecal flora ( 11 Naber 2000).
Aged males (particularly above 50 years old) tend to show an increased urinary tract infection (UTI), This was predisposed by the prostate infection and hypertrophy which leads to incomplete evacuation of urinary bladder due to urethral stenosis there leading to a residual volume of urine in the urinary bladder and this residual urine acts a good medium for bacterial growth in males ( Stamm andHooton 1993, Kalpana et al. 2005).Enteric bacteria particularly E. coli showed the first rank of isolation in females and this was in accordance with the findings of ( Nasreen et al. 2009, Shafaq et al. 2011  9 Manges, R.A et al. 2008), this was due to the above mentioned explanation for the feature of female urogenetal tract exposed to sepses with fecal contents in which E. coli showed high count, 1x10 5 cell /gr.Of stool (Brooks et al. 2007).E coli is an important pathogen in for the urinary tract, particularly uropathogenic strains through possessing adhesion pili and other adhessins that predispose bacterial binding to the uroethelium ( Jasmina et al. 2005,  16 SOdernm 2011, Jacobson et al. 1985).In addition to that E. coli possess many other tools make it potent pathogen to urinary tract and other sites of the body (Jacobson et al. 1989Brooks et al. 2007).So for the above mentioned criteria E. coli took the first rank of isolation from urinary tract infection in this study.
Staphylococcus, particularly Staphylococcus saprophyticus was showing a high rate of isolation in females and this was in agreement with the findings of (Anderson 2010, Wallmark et al. 1978, Roland A., 2002.This was attributed to the ability of Staphylococcus saprophyticus to reside urinary tract of virgin females and so imposed in the UTI among them (Mark et al. 1992, Brooks et al. 2007).
Staphylococcus aureus is an actual pathogen because it possesses virulence factors like protein A. and microcapsule in some strains which enable its binding on host tissue (Brook et al. 2007).
E. coli showed more mixed growth with other bacteria Staphylococcus species, this was due to the compatibility of such organisms to grow due to their physiological and growth features (Brook et al. 2007).

Antibiogram of bacterial isolates:
Regarding the Antibiogram results of E. coli studied isolates showed Imipenem, up on my knowledge this was ought to the reason that imipenem is newly used in Iraq as treating antibiotic so the local isolates still are not showing resistance to it , in addition to that imipenem is a carbapenem antibiotics which is highly active against Enteric bacteria producing ESBL ( Ko et al. 2007).Our findings were in accordance with the findings of Nasreen et al. 2009Shafaq et al. 2011).
Amikacin became next to imipenem, it showed high efficiency against E. coli isolates though it is available in Iraq before imipenem Many years ago, this was might be due to low resistance rate of bacterial isolates to Amikacin.
High rate of resistance of E. coli to cotrimasol-methprim and ampicillin in this study and this was in agreement with the findings of Shafaq et al. 2011, Nasreen et al. 2009) the ampicillin and Cotrimasolmethprim resistance is probably due to continuous use of it fro many years her, so the long exposure of bacteria to these antimicrobial agents trough use and the E. coli found the tool of resistance like beta lactame enzymes for ampicillin (Shafaq et al. 2011, Nasreen et al. 2009)  In the other hand majority of clinicians prescribe antibiotics without laboratory guidance (Wright et al. 2000).
We can conclude from this study that UTI is an important infection in community and enteric bacteria particularly E. coli is an important causative agent.So precautions must be taken by people to prevent infection.Community education in self hygiene and social status must be done.Majority of E. coli isolates were sensitive to imipenem and amikacin while they were showing high resistance to ampicillin and cotrimasol.So physicians must care of multi drug resistant E. coli during manipulation UTI, which showed the highest rate in UTI in HIT District .Restrictions must be taken against abuse of antibiotics trough buying drugs without doctor's prescription from pharmacy and following laboratory guidance during antibiotic therapy by physicians.

Table 1 : Rate of UTI in both sexes
Bacterial Urinary

Tract infection in adults Hit District Anbar Governorate, west of Iraq 23Table 2 :
Bacterial types, single isolated.

Table 4 :
Antibiogram of E. coli isolated from UTI.