Antibacterial Resistance Trend in Urinary Tract Infections and their Control at a Tertiary Care Hospital in the Saurashtra Region of Gujarat, India

1Department of Microbiology, M. V. M. Science and Home Science College, Rajkot, Gujarat, India. 2Department of Microbiology, PDU Government Medical College, Rajkot, Gujarat, India. 3Department of Bioinformatics, Christ College, Rajkot, India. 4Department of Biotechnology, Shree M. and N. Virani Science College, Rajkot, Gujarat, India. 5Department of Microbiology, PSGVPM’S Arts, Science and Commerce College, Shahada, 425409 Maharashtra, India.

Urinary tract infections (UTIs) are very common and diagnosed with the help of urine culture technique 1,2 . It is always advisable to correlate clinical symptoms with the results of the test. Organisms like Escherichia coli are the most frequently isolated organism in uncomplicated and complicated UTIs. However, it creates ambiguity towards choosing correct empirical treatment 3 . Antimicrobial resistance in nosocomial UTIs, especially catheter-associated urinary tract infections poses grave concerns for antimicrobial effectiveness in treating 4,5 . It is necessary to measure and compare the antimicrobial resistance in hospitals regularly because the effects of antimicrobial resistance are mainly felt in healthcare facilities 6 .
Urinary catheters are used in critical patients, especially those who are unable to move from their bed or unable to empty the bladder naturally due to some clinical conditions. The catheter remains attached for a long period, which leads to catheter-associated urinary tract infection (CAUTI) because of the catheter act as a reservoir for multidrug-resistant organisms and responsible for hospital-acquired infections. Such infections are prevented by implementing a bundle of care 7,8 . CAUTI bundle care is an evidence-based guideline to assess the need, proper handling, and earliest removal of catheters to alleviate the risk in the patient 9 .
The study aimed to summarize the most common pathogens of UTIs and their antimicrobial susceptibility patterns, so this may be helpful while preparing the local empirical treatment regimens. The study also aims to evaluate the effectiveness of CAUTI bundle care as it checks whether it succors to reduce CAUTI by minimizing the number of days of catheterization or not.

Urine culture and antibiotic sensitivity
Urine samples received from the inpatient department as well as the outpatient department were processed as per the standard operating procedure followed by the hospital 10 . Samples were streaked on sheep blood agar and MacConkey's agar with a calibrated nichrome wire loop and incubated for 24 h at 35 o C. After 24 h, if any microbial growth found, it was carried for identification procedure. If no growth observed, then re-incubated and observed for microbial growth after a total of 48 h from the first incubation. Identification of organism and antibiogram was carried out by using automated system MicroScanautoSCAN (Siemens, Germany; Beckman Coulter, U.S.A.).

Bundle care compliance
Infection control program surveillance regarding urinary tract infections was carried out with the help of a trained infection control nurse.
Bundle care assessment and data about that were collected from the daily registers. Starting year (2013) and end year (2017) survey was taken in the account for CAUTI bundle care compliance to observe the difference.
Mostly two events were observed in bundle care: 1) Insertion of the catheter, and 2) Maintenance of catheter. Insertion care included the following points: hand hygiene must be performed before starting the insertion procedure, gloves must be worn before handling the catheter, the catheter must be secured in a comfortable position. Maintenance care included following points: catheter care or perineal care must be carried out in each shift, bladder wash must be given as per the treating doctor's recommendations, urobag must be emptied when it gets 2/3 rd full, or 8 h and also before transporting the patient, all junctions and connections in the tubing must be kept closed or not, urobag musts kept below the level of the urinary bladder, drainage bag, and tubing must not touch the floor, before collection of the urine sample, collection site must be disinfected with 70% alcohol swab, the patient must be educated regarding the care of catheter.

data analysis
Software WHONET-2019 (developed by WHO Collaborating Centre for the surveillance of antimicrobial resistance), EpiInfo (version 7.2.3.1), and SPSS were used for antibiotic resistance trends and statistical analysis, respectively.

Urinary isolates and their antibiogram
In this study, 2352 urine samples were tested for culture and sensitivity, out of which 46.3% of urine samples showed significant bacteriuria (colony-forming unit > 100000 per mL). Distribution according to gender shows 3.6% more significant bacteriuria in the case of females than male, statistically, fisher exact one-tailed p-value is < 0.05 which states that the rise is significant (Table 1).

Bundle care compliance
Catheterised patients during the starting and end year survey were 4686 and 3859 respectively. An unpaired t-test shows a significant difference in the number of catheterized patients in starting and in end-year conditions; t=5.821, p =0.0001. Catheter-associated urinary tract infections were 37 and 19 for starting and end year respectively. An unpaired t-test shows a significant reduction in CAUTI patients in end year as compared to the starting year where t=2.092, p = 0.0482. Urinary catheter days were 18744 and 16107 for starting and end year respectively. An unpaired t-test shows a significant reduction in the urinary catheter days in the end year as compared to the starting year, where t=3.890, p = 0.0008. CAUTI rate per 1000 catheter days were 2.0 and 1.1 for starting and end year respectively. An unpaired t-test showed no significant difference where t=1.846, p = 0.0783. CAUTI bundle care compliance was 92.6% and 93.0% for starting and end year respectively. CAUTI bundle compliance showed no significant rise in end-year which was demonstrated by an unpaired t-test where t=0.1946, p = 0.8475.
Emphasis on the reduction of usage of higher antibiotics like colistin, nitrofurantoin, and vancomycin showed a reduction in resistance during the end line. Table 2 shows the difference between the starting year and end year survey upon such antibiotics.

discUssion
This study proffers the details about the bacterial and fungal isolates responsible for UTIs as well as also gives antibiotic resistance patterns for bacterial isolates. It also proffers the cognizance about the importance of the selection of antibiotics in the UTI treatment. Effectiveness of the infection control program with the aspect of bundle care compliance can be well understood.
The current study shows the highest culture positivity i.e. 46.3%; whereas Pondei et al 11 showed 37.38% and Aboderin et al 12 showed 35.8%. This study complies with Patel et al. 13 and Demir et al 14 study that showed the prevalence of UTI is more in females than males. E. coli remains the most common organism which was upheld by other studies too 13,15-22 , whereas Aboderin et al 12 found Klebsiella spp. as a major isolate. The distribution of bacteria is different in different parts of the world and studying the influencing factors that cause this infection in unassociated geographical regions, indicates their dissipation 23 .
The present study shows that E. coli was less resistant to nitrofurantoin, amoxicillin/ clavulanic acid, tetracycline, gentamicin except for ciprofloxacin as compared to the study of Aboderin et al 12 . This shows the importance of local analysis of antibiotics. E. coli showed resistance to ampicillin, ampicillin/sulbactam, cefuroxime, levofloxacin, meropenem, nitrofurantoin, tobramycin, cefazolin in Patel et al study 13 which is quite lower than the current study except for Nitrofurantoin. Similar results were seen in K. pneumoniae and Ps. aeruginosa except for nitrofurantoin for K. pneumoniae, where resistant pattern remains similar. Antibiotics advised under empirical treatment by a government body are also showing a certain level of resistance in different studies 24 . Misuse of antibiotics leads to increasing resistance which becomes a matter of attention. General practitioners should consider about the microbiological profile and the antibiotic sensitivity pattern during management to avoid misuse of antibiotics 25 .
It has been estimated that due to symptomatic urinary tract infections, 7 million people take treatment at emergency units and 100,000 people seek for hospitalizations yearly. UTI has become the most frequent hospital-acquired infection, and responsible for as many as 35% of hospital-acquired infections. It is the second most common cause responsible for bacteremia in hospitalized patients 20  CAUTI bundle care compliance was 92.6% and 93.0% for starting and end year respectively (p =0.8475) which suggests that difference was statistically insignificant. Upon implementation of CAUTI bundle care in the hospital, a decline in nosocomial infection was observed in many of the studies. Effective bundle implementation requires the dedication of nursing staff and with continuous monitoring [29][30][31][32] .
conclUsion Urinary tract infections are the most common and some times life-threatening infections. Catheter-associated UTIs are also emerging and most of them are hospital-acquired. It was observed that antibiotic resistance has been reported for all known antibiotics and to confine prevention of infection is the convenient way. Effective implementation of bundled care approach can alleviate the burden of CA-UTI in the hospitals and implementation of antibiotic policy can save higher antibiotics as an option for an emergency. The invivo and in-vitro difference in antibiotic resistance should be studied. Continuous monitoring of resistance patterns and monitoring of the infection control program is inevitable.

acknowledgMents
The authors acknowledge the authorities of the participating colleges for providing all the necessary facilities required for the present research.