Susceptibility pattern of uropathogens to ciprofloxacin at the Ghana police hospital

Introduction Reports of increasing resistance of uropathogens to antimicrobials is of global concern. Culture and drug susceptibility tests remain a vital guide to effective therapy. The aim of this study was to determine the susceptibility pattern of isolated uropathogens to ciprofloxacin at the Ghana Police Hospital. Methods A total of 705 mid-stream urine samples were collected from patients suspected of having urinary tract infection, and visited the Ghana Police Hospital's laboratory from December 2013 to March 2014. Samples were cultured and isolates identified by standard methods, after which isolates susceptibility to ciprofloxacin was determined. Results Prevalence of urinary tract infection among patients’ whose samples were analyzed was 15.9%. Predominant uropathogens isolated were E. coli (46.4%), Coliform (41.1%) and Coliform spp. with Candida (6.2%). Other isolates were Pseudomonas spp. (2.7%), Salmonella spp. (1.8%), Candida spp. (0.9%) and Klebsiella spp (0.9%). The overall resistance among the top three isolated uropathogens to ciprofloxacin was 35.9%. Resistance pattern demonstrated by respective isolates to ciprofloxacin were: E. coli (38.5%), Coliform (54.3%), and Coliform spp. with Candida (15%). The other isolates showed 100% sensitivity. Conclusion This study revealed a relatively high ciprofloxacin resistance among isolated uropathogens, hence, the need for prudent prescribing and use of ciprofloxacin in urinary tract infection management.


Introduction
Urinary tract infections (UTIs) are common among inpatients and outpatients, ranking second only to respiratory infections [1].
Increasing microbial resistance to conventional antibiotics like betalactams, aminoglcosides, sulfonamides and cephalosporins used in UTI management necessitated the use of other agents such as macrolides and fluoroquinolones.
Since their introduction, fluoroquinolones have become a mainstay in the treatment of bacterial infections [6,7]. Fluoroquinolones are often preferred as first line agents in the management of UTIs, especially when antimicrobial resistance is of concern [8,9]. They are also recommended where conventional agents are less desirable due to toxicity or hypersensitivity concerns [10]. Ciprofloxacin is the most frequently prescribed fluoroquinolone for UTIs because of its availability in oral and intravenous formulations, favorable bioavailability, and pharmacokinetics which allows twice-daily administration [11,12]. Resistance to fluoroquinolones has increased markedly since their introduction for treatment of UTI.
Rattanaumpawan et al, documented fluoroquinolone resistance of 15.8% and 57.4% among E. coli and A. baumannii respectively [13]. In Africa, substandard drugs, indiscriminate use of antibiotics and erratic prescription by unqualified drug sellers have been identified as contributing to emergence of resistance [14]. Evidence of increasing resistance to ciprofloxacin in some communities is also documented [15,16]

Study population
This was a cross-sectional study that involved analyzing 705 urine samples of suspected UTI patients, who visited the Ghana Police Hospital's laboratory from December 2013 to March 2014. The population consisted of both in-and out-patients.

Sample collection and processing
Midstream urine samples were collected in sterile urine containers.
With a calibrated wire, a loop-full (0.01 ml) of urine was inoculated onto a quarter-plate of Cysteine Lactose Electrolyte-Deficient agar (CLED) (Biotic Laboratories Ltd, U.K) and incubated at 37°C for 24 hours in Nodermann GMBH incubator (Germany). After incubation period, colonies were enumerated and those with significant growth identified. Significant microbial growth was categorized by microbial count greater than 1x10 5 cfu/ml. Microbial colonies were identified biochemically and serologically according to standard methods [19].
Isolates were speciated by routine procedures which included colonial characteristics, gram-staining, coagulase test and API 20 system. Each colony, representing an isolate was emulsified in 2 ml sterile peptone water, and then transferred into sensitivity agar plates (Biotec laboratories, UK).

Susceptibility Testing
Susceptibility test was with the Kirby-Bauer disc diffusion method using sensitivity agar (Oxoid, UK) and pertinent antibiotics emphasizing ciprofloxacin with a break point of 5 μg. Inhibition zone diameters pertaining to ciprofloxacin were measured using calipers and compared with standard interpretation charts [20] and scored as sensitive or resistant.

Data analysis
Data were checked for completeness, entered, and analyzed using SPSS version 20 (Armonk, NY: IBM Corp). Chi-square (χ ² ) was used to test for association and a p value less than 0.05 was considered statistically significant.

Ethical issues
Protocol for this study was approved by the Ghana Police Hospital Administration.

Discussion
This study showed UTI prevalence rate of 15.9%, and its incidence was significantly higher in female than in males. Prevalence rate in this study was lower than findings of 31.6% from a study at the Ghana Police hospital in 2011 [17], and from a similar study in Ghana that reported 56.5% [4]. Multiple predisposing factors have been identified to contribute to higher prevalence among females. A major factor being anatomical differences in the urogenital organs between the two sexes; shorter urethra in females allows quicker access of bacteria to the urinary system [21]. Furthermore, poor personal hygiene coupled with certain cultural practices [22], may account for a higher incidence in women. On the other hand, the antibacterial activity of prostatic fluid in males makes them less susceptible to UTI [23]. compared with other studies [5,12,33,34]. Although the causative microorganisms of UTI keeps changing over the years, E. coli and Enterobacteriaceae remain the most common uropathogens, accounting for about 75-90% of laboratory culture isolates [2]. E.
coli resistance to ciprofloxacin (38.5%) observed in this study, was lower than the 46.7% observed in a similar study in Ethiopia [37].
However, E. coli resistance to ciprofloxacin in this study was higher than similar studies; 32 % in Kumasi, Ghana [38], 11% from nine out of ten regions in Ghana [24], 33% in Ethiopia [39], and 22% in Switzerland [40]. coliisolates in these studies are fewer than that of isolated from urine, ciprofloxacin resistance among urine E. coli appears to be lower than those observed in fecal isolates. Since E. coli has been found to be the causative microorganism in over 70% of UTIs worldwide, its resistance to ciprofloxacin observed in this study, and other similar studies in Ghana should be of concern to medical practitioners and drug policy makers. Studies have shown that, pressure on drugs used in therapy can influence resistance pattern of causative organisms than intrinsic bacterial protective mechanisms [42]. In Ghana, the broad therapeutic indications of ciprofloxacin; typhoid fever, infectious diarrhoea, lower respiratorytract infections, gastro-enteritis, cholera, gonorrhea among others [43], exerts pressure on its use, and increases its risk of misuse.
Additionally, although a prescription drug, ciprofloxacin can be obtained over the counter in a number of pharmacies in Ghana, and this further contributes to its misuse.

Conclusion
The relatively high ciprofloxacin resistance demonstrated by the most predominant isolates, Coliform spp. and E. coli, in this study should be of great concern to medical practitioners, drug regulatory agencies and policy makers. This emphasizes the need for continuous evaluation of the quality of common antibiotics, prudent drug prescription and judicious use of ciprofloxacin in UTI management.

Competing interests
The authors declare no competings interest.

Acknowledgments
The authors are grateful to the Ghana Police Hospital for technical support given this project. Table 1: Level of microbial growth among UTI patients (n = 705)   Pseudomonas spp.