CENTRAL ASIAN JOURNAL OF MEDICAL AND NATURAL SCIENCES

Volume: 04 Issue: 02 | Mar-Apr 2023 ISSN: 2660-4159

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Etiological Spectrum and Antimicrobial Resistance among

Bacterial Pathogen Association with Urinary Tract Infection in
Wasit Governorate/ Iraq
1. Ban H. Qaddoori Abstract: Objectives: This study aimed to determine
the prevalence of uropathogens that cause urinary tract
infections (UTIs) in Wasit Governorate, Iraq, and
Received 2nd Jan 2023,
evaluate their patterns of antimicrobial resistance.
Accepted 3rd Feb 2023,
Online 27th Mar 2023
Methods: The study involved the examination of 840
urine samples taken from patients visiting the Al-
Karama and Al-Zahraa Teaching Hospitals in Wassit
1
Department of Microbiology, College of province. The samples were collected from February
Medicine, Wasit University, Iraq 2022 to March 2023. Using a VITEK 2 compact system,
we identified and tested the microorganisms responsible
for the infections.
Results: Of the 840 urine samples of symptomatic
patients with UTI, 669 (79.6%) were found to show
significant growth of UTI, among whom the females
were 470 (70.2%) episodes.
E. coli was the most frequently isolated uropathogen in
both sex groups (42.2%, n=284), followed by S. aureus
(21.2%, n=131), E. faecalis (12.5%, n=284), other
staphylococci (5.8%, n=39), Proteus (4.7%, n=32),
Group B Streptococcus (3.8%, n=26), Enterobacter
(2.8%, n=19), and Pseudomonas (0.7%, n=5).
Based on Gram-negative isolates (n=389), resistance
rates decreased in the following order: Ampicillin 68%<
Piperacillin/tazobactam 49% < Cefoxitin 47% <
Ceftriaxone 32% <Trimethoprim/Sulfamethoxazole and
Ceftazidime 28% <Cefepime 27% <Ciprofloxacin
25%<Nitrofurantoin 23% Levofloxacin
22%<Gentamicin 21%<Amikacin 19% <Imepenem 2%
on the other hand,
In the group of Gram-positive isolates (n=280) in
decreasing order were Oxacillin 33% <Tetracycline
38% <Levofloxacin 24% <Clindamycin 21%<

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CAJMNS Volume: 04 Issue: 02 | Mar-Apr 2023
Nitrofurantoin and Trimethoprim/sulfamet hoxazole
19%< Rifampicin 13%< Tobramycin 11%< Gentamicin
10% <Teicoplanin and Vancomycin 8%.
Conclusion: In Wassit Governorate, Iraq, the primary
cause of UTIs was E. coli, with S. aureus being the
second most common. Among Gram-negative
uropathogens, high resistance rates were found for
ampicillin, second and third-generation cephalosporins,
trimethoprim/sulfamethoxazole, and quinolones.
However, aminoglycosides exhibited comparatively
lower resistance rates. Imipenem (for Gram-negative
bacteria) and vancomycin and teicoplanin (for Gram-
positive bacteria) maintained strong activity, making
them suitable choices for antimicrobial treatment of
complicated UTIs when other options are unavailable.
Keywords: urinary tract infection, etiology,
antimicrobial resistance, VITEK system, Iraq.

Introduction
The most common infection in clinical settings is urinary tract infection (UTI). Around the world,
empirical therapy is frequently employed for both complex and simple UTIs, since postponing
treatment can lead to higher rates of illness and death [1,2,3].
The prevalence of infection is higher in females owing to specific anatomical differences. Factors that
increase the risk of infection include frequent sexual intercourse, infancy, old age, urinary tract
abnormalities, low socio-economic status, pregnancy, diabetes, and spinal cord injuries. [4].
UTIs are often caused by bacteria. Gram-negative bacteria like Escherichia coli, Proteus species,
Pseudomonas aeruginosa, Acinetobacter species, Klebsiella species, Enterobacter species, and
Citrobacter species are the most common. Staphylococcus saprophyticus, Enterococcus species, and
coagulase-negative Staphylococcus are also responsible for UTIs. [5,6].
Broad-spectrum antibiotics are used to treat UTIs, and treatment starts empirically without culture and
sensitivity. Depending on the local uropathogen resistance rate, first-line agents can be good for
empirical UTI treatment. In this context, some guidelines recommend that antibiotics shouldn't be used
as first-line empirical treatments for urinary tract infections if resistance is over 10% in the most likely
infected strains within a community. [1].
Antibiotic resistance rates vary across geographical areas due to the presence of distinct strains in
different regions worldwide and differences in antibiotic usage [7]. Pathogens' resistance patterns to
antibiotics are constantly evolving [8,9]. Antibiotic resistance is a critical medical issue and a priority
for the World Health Organization (WHO) as there is a growing global trend of antibiotic resistance,
which makes it more difficult to eradicate from the urinary tract, resulting in extended illnesses and
increased mortality rates [10,11]. Antimicrobial resistance also imposes a financial burden due to
additional laboratory tests and the need for more expensive drugs to treat resistant strains [12].
The best way to guide empirical antimicrobial choices is to monitor uropathogen resistance and
reevaluate recommended empirical antimicrobial regimens [1,13]. For tracking community-acquired
uropathogens, Iraq doesn't have an antimicrobial resistance surveillance system. Because of this,

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CAJMNS Volume: 04 Issue: 02 | Mar-Apr 2023
regional protocols for effectively managing community-acquired UTIs within the country aren't in
place.
The primary purpose of this study was to identify the prevalence of UTI-causing pathogens and their
susceptibility patterns, creating a reference database. Given the current situation, there is a concerning
lack of local research on this specific topic.
Antimicrobial resistance patterns are changing at an alarming rate, with the frequent emergence of new
multi-drug resistant (MDR) bacteria, leading to increased morbidity and mortality. This study aims to
emphasize the importance of using appropriate antibiotics for treating UTIs. Moreover, our findings
will help authorities develop antibiotic prescription policies and design antibiotic formulary guidelines
in line with the Iraq Action Plan of Antimicrobial Resistance (2018-2022). Raising awareness and
annually reporting these results will contribute to preventing the spread of emerging strains within the
community.
METHODS
Sample collection
A total of 840 Mid-stream urine samples were collected from people admitted to Al-Karama and Al-
Zahraa Teaching Hospitals of Wassit governorate from Febraury 2022 – March 2023. Samples were
collected from symptomatic patients of both genders. Samples were transported to the laboratory
within 30 minutes to one hour and then characterized using different conventional bacteriological and
biochemical methods.
Individuals who sought medical attention at outpatient clinics for UTI diagnosis were consecutively
enrolled if their urine samples showed significant bacteriuria, while those with non-significant
bacteriuria were excluded.
A single organism with quantitative counts ≥102 CFU/mL isolated from a clean-catch voided urine
specimen in symptomatic patients defined significant bacteriuria [14]. A checklist was used to
prospectively record age, sex, past medical history, and antibiotic exposure within the past 3 months.
To perform the routine culture, a standard loop was used to inoculate ten μl of each mid-stream urine
sample onto culture media such as blood agar and MacConkey agar. Bacterial growth was observed by
examining the cultures after they were incubated overnight at 35°C.
The VITEK 2 Compact System was utilized to identify and test the antimicrobial susceptibility of
bacteria isolated from urine samples. Bacterial colonies with notable growth on culture plates were
used to prepare a standardized saline inoculum, as suggested for VITEK identification. Specific ID
cards for Gram-negative and Gram-positive bacteria were used in the VITEK system to identify the
bacteria.
Antimicrobial susceptibility testing (AST) and determination of minimum inhibitory concentrations
were conducted using specialized AST cards. The interpretation of AST results was performed
following the guidelines of the Clinical and Laboratory Standards Institute, in accordance with the
instructions provided by the manufacturer (BioMérieux, France), and utilizing the Advanced Expert
System..
Ethics. The ethics committee of the College of Medicine, University of Wasit, approved the study
protocol.
Results
At the Microbiology Laboratory of the College of Medicine/Wasit University, 840 urine samples were
received for analysis and culture, out of which 669 (79.6%) displayed significant growth, indicating

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CAJMNS Volume: 04 Issue: 02 | Mar-Apr 2023
the presence of UTIs. Out of the significant growth samples, 470 (70.2%) cases were diagnosed in
females.
The average age (±SD) was 37±15 years. The frequency of gender distribution for UTI cases can be
seen in Table 1.
Table 1: The distribution of UTI cases by gender among patients admitted to Al-Karama and
Al-Zahraa Teaching Hospitals .
Variables Frequency (%)
Male 470 (70.2)
female 199 (29.8)
Total 669 (100)
In the study, 59% (n=395) of the cases involved Gram-negative bacteria, while 41% (n=274) were
Gram-positive. E. coli was the most common species linked to UTIs in the patient group, accounting
for 71.89% (n=284) of cases (Figure 1). This was followed by Klebsiella species at 12.4% (49),
Proteus at 8.1% (32), Enterobacter at 4.8% (19), P. aeruginosa at 1.2% (5), and other Gram-negative
bacteria at 1.5% (6).
Conversely, Gram-positive bacteria made up 40% (n=280) of the cases, with Staphylococcus aureus as
the primary pathogen in this group (48.9%, n=143). It was followed by Enterococcus faecalis at 30.6%
(134), while other Staphylococcus species and Streptococcus species were identified in 10.9% (n=30)
and 9.6% (n=26) of cases, respectively (Figure 2).

Figure 1. Species distribution of Gram-negative isolates, associated with UTIs

Figure 2. Distribution of Gram-positive species related to UTIs

According to Table 2, the majority of Gram-negative urinary pathogens exhibit resistance (R) to
antimicrobial agents.

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Overall, the rate of antibiotic resistance in Gram-negative urinary pathogens was highest for ampicillin
(68%), Piperacillin/tazobactam (49%), Cefoxitin (47%)and Ceftriaxone (32%)while the lowest
resistance rate was toward Imepenem (2%) and Amikacin (19%)m on the other hand , the rate of
antibiotic resistance in Gram-negative urinary pathogens was highest for Tetracycline (38%) and
Oxacillin (33%) and the lowest rate of resistance was against Teicoplanin (8%) and Vancomycin (8%)
. moreover E. coli and S.aureus had a 88% and 82% antimicrobial resistance rate, respectively.
Table 4: Distribution of microorganisms found in UTI patient samples
Organism isolated (n=672) Frequency (%)
E.coli 284 (42.2)
S. aureus 131(21.2)
E. faecalis 84 (12.5)
Klebsiella 49 (7.2)
Other staphylococci 39 (5.8)
Proteus 32 (4.7)
Streptococcus group B 26 (3.8)
Enterobacter 19 (2.8)
Pseudomonas 5 (.07)
Total 669 (100)

Table 2. Antimicrobial resistance in Gram-negative urinary pathogens

Tested antibiotics Overall E.coli Klebsiella Proteus Enterobacter Pseudomonas
(n= 389) (n=284) (n= 49) (n=32) (n= 19) (n= 5)
Ampicillin 248(68) 188(66) 36 (73) 24(75) - -
Piperacillin/tazobactam 190(49) 129 (52) 32 (66) 9 (28) 15 (80) 5 (100)
Ceftazidime 110(28) 79 (28) 13 (27) 10 (31) 3 (15) 5(100)
Cefoxitin 172(47) 139 (49) 25(51) 9(28) - -
Ceftriaxone 123(32) 88 (31) 20 (41) 12 (37) 3 (15) -
Cefepime 106(27) 77 (27) 13 (27) 9 (28) 3 (15) 4 (80)
Imepenem 6 (2) 5 (2) 1 (2) 0(0) 0(0) 0(0)
Amikacin 74 (19) 45 (16) 16 (33) 9 (28) 0(0) 4(80)
Gentamicin 83(21) 57 (20) 18 (37) 4 (13) 0(0) 4 (80)
Ciprofloxacin 97 (25) 70 (25) 17 (35) 0 (0) 6 (32) 4 (80)
Levofoxacine 87(22) 62 (22) 15 (31) 0(0) 6 (32) 4 (80)
Nitrofurantoin 82(23) 59 (21) 20 (41) - 3 (15) -
Trimethoprim/ 108(28) 70 (25) 18 (37) 13 (41) 7 (37) -
Sulfamethoxazole
Data presented as number (percentage of resistance) - not tested
Table3. Frequency and percentage of prevalent Gram-negative urinary pathogens resistant (R)
to antimicrobial substances
Tested antibiotics Overall S. E. Other Streptococcus
(n= 280 ) aureus faecalis staphylococci group B (n= 26)
(n=131) (n=84) (n=39)
Oxacillin 57 (33) 47 (35) - 10 (26) -
Gentamicin 19 (10) 15 (11) - 3 (8) 1 (4)
Tobramycin 19 (11) 13 (10) - 6(16) -
Levofloxacin 69 (24) 20(15) 33 (39) 8(20) 8(30)
Clindamycin 42 (21) 20(15) - 8(20) 14 (55)

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Teicoplanin 21 (8) 8 (6) 11 (13) 2(5) -
Vancomycin 21 (8) 8 (6) 11 (13) 2(5) -
Nitrofurantion 48 (19) 8 (6) 36 (43) 4(10) -
Rifampicin 23 (13) 17 (13) - 6 (15) -
Chloramphenicol - - - - 4(15)
Tetracycline 108(38) 27 (20) 40 (48) 27(69) 14(55)
Trimethoprim/sulfamet 38 (19) 12(9) - 16 (61) 10(40)
hoxazole
Data presented as number (percentage) - not tested
Discussion
Globally, UTIs pose a significant health threat because they can lead to urosepsis, renal scarring, or
progressive kidney disease. Antibiotics are used to treat UTIs, and empirical treatment with suitable
antimicrobial agents plays a crucial role in disease prognosis [17]. Antimicrobial resistance exhibits
geographical variation [18, 19], making it essential to periodically monitor local antibiotic sensitivity
patterns for urinary pathogens through studies like this one [20]. The primary objective of this study
was to examine the etiology of UTIs and to illustrate the trends in antimicrobial resistance among the
predominant uropathogens, which are commonly targeted in empirical treatment.
This study reveals a higher prevalence of UTIs in females (69.8%) compared to males (29.2%), which
aligns with other studies indicating that UTIs are more frequent in women than men [8,10,15]. UTIs
occur when bacteria in the urine have the capacity to affect tissues in the urinary tract and nearby
structures. Females are more susceptible to UTIs due to anatomical factors, such as a shorter and
straighter urethra and the proximity of the urethra to the anus, which facilitate the colonization of the
pre-urethral region by enteric bacteria. Additionally, UTIs can occur following sexual intercourse
when bacteria may unintentionally be introduced into the urethra [16]. In this study, Gram-negative
bacteria were identified in 59% (n=395) of cases, while Gram-positive bacteria were found in 41%
(n=274).
The current study's results are consistent with those reported by Mahde et al. [28], demonstrating that
Gram-negative bacteria had a prevalence of 52.48% while Gram-positive bacteria had a prevalence of
47.51% in UTI patients. A similar predominance of Gram-negative bacteria was also found in Duhok
governorate, as reported by Hadi et al. [29]. They observed that 81.3% of UTI cases were caused by
Gram-negative bacteria, while only 18.7% of cases in Basra governorate were attributed to Gram-
positive bacteria.
The results obtained in this study are consistent with those reported by Alshabi et al. [26], who found a
higher incidence of Gram-negative isolates compared to Gram-positive isolates, with E. coli being the
most commonly identified microorganism (73.68%). However, our findings differ from those of
another study [27], which reported that 90% of UTI cases were caused by Gram-negative bacteria,
while only 10% were caused by Gram-positive bacteria. Additionally, different results were obtained
by yet another study [25], which showed that the prevalence of staphylococci in UTIs was higher for
S. epidermidis (55.5%; 10 out of 18) than for S. aureus (26.6%; 8 out of 30).
These variations may be attributed to geographical differences, antibiotic misuse leading to more
virulent and invasive bacterial isolates, and varying levels of awareness across societies.
Table 4 demonstrates that the most frequently isolated pathogens were E. coli (42.2%), followed by S.
aureus (28.33%), E. faecalis (12.5%), and Klebsiella (7.2%). Other bacterial pathogens included
coagulase-negative staphylococcus (5.8%), Proteus (7.4%), Streptococcus group B (3.8%),
Enterobacter (2.8%), and Pseudomonas (0.7%).

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Comparable findings were reported by Martin et al. [22], who identified E. coli (41.9%) as the most
common bacterial uropathogen, followed by S. aureus (31.4%). Additionally, the current study's
results align with Alhamdany [23], who observed that the predominant isolate in UTIs was E. coli,
accounting for 55% of cases.
According to the Surveillance of antimicrobial resistance in Bulgaria [21], E. coli is the most
commonly isolated etiological agent UTIs, representing more than 50% of the urine isolates,
Klebsiella pneumoniae and Proteus spp.occupy the second and third place, respectively. These results
were partially agreed with the current study in regarding the predominance E.coli as the main
causative agent of UTI. The prevalence of E. coli can be attributed to several identified virulence
factors, including endotoxins found in all strains, and adhesin (pili) and capsules present in some
strains. These factors are associated with UTIs and colonization [24].
The overuse and improper use of antibiotics, combined with the frequent prescription of broad-
spectrum antibiotics and patients' insufficient compliance with antibiotic regimens, all contribute to
bacterial genetic mutations and the subsequent emergence of antibiotic resistance [30]. Globally,
antibiotic resistance is a big problem, especially since so many UTIs are treated without
bacteriological testing. Gaining insight into the susceptibility patterns of the microorganisms
responsible for UTIs can improve the choice of empirical treatments for these infections.
We found 66% resistance to ampicillin among E. coli isolates, considerably higher than the 30%
reported in Canada [31] and 49% in the United Kingdom [32]. Furthermore, our results demonstrated a
significantly higher resistance to trimethoprim/sulfamethoxazole compared to previous studies (11%
in Canada and 16-18% in the United States) [31]. This difference may stem from the easier availability
of these antibiotics in our country's drug market, as opposed to stricter regulations in other nations.
The increased resistance to ampicillin and trimethoprim/sulfamethoxazole found in our study indicates
that these antibiotics may no longer be suitable for empirical UTI treatment.
Fluoroquinolones have been proposed as potential empirical treatments for UTIs [33]. Our study
disclosed resistance rates of 25% for ciprofloxacin and 22% for levofloxacin, making them moderately
viable options compared to other antibiotics Although fluoroquinolones have been found to be
effective in treating uncomplicated UTIs, their increased use has raised concerns about the potential
development of resistance patterns in the future. In light of this, recent international clinical practice
guidelines suggest using fluoroquinolones as alternative agents rather than as the primary therapy for
treating uncomplicated UTIs [34]. This recommendation is in line with a recent directive by the US
Food and Drug Administration, which requires fluoroquinolone package inserts to include a warning
that these antimicrobial agents should not be used for routine respiratory tract infections or
uncomplicated UTIs unless no other suitable alternative is available [35].
E. coli strains isolated in our study showed the highest susceptibility to imipenem (2%). The
seemingly low resistance to this antibiotic might be due to its limited accessibility in our region and its
expensive price.
A concerning discovery from this study revealed a high level of drug resistance among G-
uropathogens to piperacillin/tazobactam (49%), Cefoxitin (47%) , Ceftriaxone (32%) , Ceftazidime
(28%) and Cefepime (27%). high rate of resistance for nitrofurantoin (23%) and
trimethoprim/sulfamethoxazole (28%) was also recorded in this study which is closerelated to the resut
of Gupta et al; [36]. The observed resistance is likely a result of the extensive use of third-generation
cephalosporins and fluoroquinolone antibiotics in patients with UTIs.
A favorable finding from this study is the relatively low resistance levels to gentamicin and amikacin
(21% and 19% respectively). This outcome is supported by Barlam et al. [39], who stated that

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aminoglycosides, such as gentamicin and amikacin, are preferred antimicrobials for parenteral
andcombined therapy in severe or complicated UTIs, or infections with limited alternative treatments.
UTI bacteria and their susceptibility to antimicrobial agents keep changing over time and vary by
country [37,38].
Limitations
The scope of this study was limited to a single location. Examining a wider patient population from
different geographical regions and various health conditions, as well as exploring the mechanisms
behind bacterial resistance development, could provide more comprehensive and valuable insights.
CONCLUSION
In Wassit governorate, Iraq, UTIs were mainly caused by E. coli, followed by S. aureus. For Gram-
negative uropathogens, there were high resistance rates to ampicillin, second and third-generation
cephalosporins, trimethoprim/sulfamethoxazole, and quinolones. Conversely, aminoglycosides
exhibited a relatively low resistance rate.
Imipenem (in the Gram-negative group), vancomycin, and teicoplanin (in the Gram-positive group)
exhibited strong activity and are suitable choices for antimicrobial treatment of complicated UTIs
when other options are unavailable.
The research emphasizes the significance of regularly monitoring resistance rates of commonly used
antimicrobial agents at the local level to provide guidance for empirical treatment recommendations.
For optimal medical practice, it is crucial to conduct microbiological analysis of urine samples in
patients suspected of having UTIs in order to determine the responsible pathogen and evaluate its
susceptibility to antimicrobial treatments. Antimicrobial resistance needs to be stopped urgently.
Additionally, more studies should be carried out to further evaluate the local resistance of frequently
prescribed antibiotics, allowing for better empirical treatment of UTIs.
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