Introduction
Urinary tract infection (UTI) is the foremost prevailing bacterial infection during pregnancy. The urinary tract infection in pregnancy may be symptomatic (cystitis, pyelonephritis) or asymptomatic (bacteriuria without symptoms). Based on the research evidence available, the prevalence of symptomatic and asymptomatic urinary tract infections in pregnant women has been 17.9% and 13% respectively.1, 2 The urethra's small length, lack of prostatic secretions, pregnancy, and the probability of urinary tract contamination by faecal bacteria make women more prone to UTIs than men.3 Asymptomatic bacteriuria can lead to maternal and neonatal complication like preterm labour, pre-eclamptia, IUGR, Preterm babies.4, 5 Enterobacteriaceae, which are frequently present in the gastrointestinal system, are the source of most infections; 80–90% of these instances are caused by Escherichia coli, or E. coli. Other bacteria, such as coagulase-negative Staphylococcus, Klebsiella pneumoniae, Group-B Streptococcus saprophyticus, Proteus mirabilis and, Staphylococcus aureus, are present in smaller amounts.6
The empirical antimicrobial therapy commenced prior to the laboratory antibiotic sensitivity tests outcomes of urine culture, may leads to increase in resistant among uropathogens.7 The prevalence of resistance among UTI patients is rising and varies according on the patient's geographic & regional area.8 Treatment recommendations are often determined by taking into account frequently occurring infections, susceptibility patterns, evidence, physician acceptance, antimicrobial stewardship norms, availability of formularies, and antimicrobial prices.
Choosing the appropriate antibiotic for each patient while considering the safety profile of both the mother and the newborn is crucial, and treatment recommendations for UTIs have been produced globally to help clinicians in this regard. The regular screening of antibacterial susceptibility of available therapeutic agents may help to prevent antibacterial resistance and, to furnish revised antibacterial guidelines for the rationale approach to UTI in pregnancy. So the study was conducted.
Materials and Methods
Cross-sectional study was conducted at antenatal care (ANC) in Fathima Institute of Medical Sciences Kadapa, from December 2022 to December 2023. Being pregnant and having an ANC follow up were involved in the study. The study excluded pregnant women who had taken antibiotics within the two weeks prior to their ANC follow-up and symptomatic UTI pregnant women. Competent nurses collected clinical and sociodemographic data using a structured questionnaire. A sterile container with a wide opening was used to collect 10 ml of clean catch midstream urine samples from every study participant. The urine sample that was obtained was labeled and transported to the hospital laboratory less than one to one and half hour.9 By calibrated wire loops (0.001 ml), urine samples were plated on blood agar, MacConkey, and Cystine Lactose Electrolyte-Deficient (CLED) media. After that, all plates were aerobically incubated at 37°C for 24 hours. The bacterial growth in all plates was examined under microscope and, if the count of colonies is more than 105 CFU, and is deemed to be a significant growth.
The species level identification was done by employing the conventional microbiological procedures, colony features, Gram-staining response, and pattern of biochemical profiles to all significant positive cultures. The KIA agar method, H2S generation, carbohydrate fermentation, urease test, indole production, motility test, citrate consumption and, oxidase test were used to identify the enterobacteriaceae. Catalase and coagulase tests were employed to identify the Gram positive bacteria. A tube with 4-5 mL of nutrient broth was filled with three to five pure colonies, gently mixed, and cultured for two to six hours at 35–37 °C. To standardize the size of the inoculum, the suspension's turbidity was evaluated using McFarland 0.5 tubes.7 Inoculate the whole Mueller-Hinton agar (MHA) (Oxide Ltd, Hampshire, UK) surface equally by dipping a sterile cotton swab into the solution. The inoculated plates were left at room temperature to dry for 3–15 min.6, 10 Following the organism inoculation and disc implantation, plates were incubated for twenty-four hours. The inhibitory zones were evaluated 24 hours later.
The antibiotics that were assessed in this study were: Nitrofurantoin (300 μg), Azithromycin (15 μg), Gentamicin (10 μg), Ciprofloxacin (5 μg), Norfloxacin (10 μg), Trimethoprim-Sulphamethoxazole (co-trimoxazole) (1.25-23.75μg), Ceftriaxone (30 μg) and Amoxycillin (10 μg), Amoxycillin-Clavulinic Acid, Tetracycline (30 μg), Meropenem (10 μg). In accordance with the Clinical Laboratory Standards Institute (CLSI) the data were evaluated.11 Before every patient's samples were collected, informed consent was sought both verbally and in writing. The research was initiated with the necessary institutional ethics committee permission. The American Type Culture Collection (ATCC) 25922, Staphylococcus aureus (ATCC 25923), Enterococcus fecalis (ATCC 29212), and, Pseudomonas aeruginosa (ATCC 27853) were utilized as standard strains for quality control. The antibiotic discs, quality control stains and, culture media were attained from HiMedia Laboratories, Mumbai, India.
Results
According to the sampling technique described in the methodology, 377 pregnant women participated in the present study. Among them 243 urban participants and 134 rural participants from Kadapa district. Out of the participants, 86, 151 and, 140 participants were <25 years, 25-30 and, >30 years old respectively. Among study participants, 73 were illiterates, 99 had primary education, 158 had secondary education, and 47 had higher education. According to family income, the participants were poor (76), middle class (110), upper middle class (168), and rich.12 Out all study participants, 96 were housewives, 125 were businesswomen, 151 were working professionals and 5 participants were students (Table 1).
Table 1
Sociodemographic characteristics of pregnant women
Table 2
Clinical characteristics of study participant
According to Table 2, second trimester (176), multigravida (291) participants were in majority number. Few participants recruited with history of Catheterization, diabetes mellitus, abortion, obstetric and gynecologic surgery, premature labor, previous UTI.
Table 3
Prevalence of uropathogen in pregnant women
The uropathogens isolated from the urine samples of the participants were tabulated and represented in the Table 3. In the current research 77 percentage (79) of microorganism isolates were gram negative and 23 (24) percentage was Gram positive among 103 microorganism isolates. Out of seventy-nine isolates 36, 26, 7, 6, 1 and, 3 were Escherichia coli, Klebsiella spp., Citrobacter spp., Pseudomonas spp., Proteus spp., and Enterobactor spp respectively. Out of 24 gram positive isolates 6, 12, and 6 isolates were enterococcus, Coagulase Negative Staphylococci (CONS), and Staphylococcus aures.
Table 4
Antibacterial susceptibility configuration of isolated uropathogens in the study
The antibacterial sensitive of 6 gram negative and 3 gram positive organisms were depicted in relation with Nitrofurantoin (300 μg), Azithromycin (15 μg) Gentamicin (10 μg) Ciprofloxacin (5 μg) Norfloxacin (10 μg) (co-trim) (1.25 23.75μg) Ceftriaxone (30 μg) Amoxycillin (10 μg) Amoxycillin-Clavulinic Acid Tetracycline (30 μg) Meropenem (10 μg) and the same was tabulated in Table 4.
The major uropathogenic bacteria in the present study were Escherichia coli (36), Klebsiella spp (26) and Coagulase Negitive Staphylococci (CONS) (12) belongs to gram negative and positive bacteria respectively.
Escherichia coli
The evaluated antibacterial sensitivity of Escherichia coli was grater with, Meropenem (10 μg), Nitrofurantoin (300 μg), Ceftriaxone (30 μg), co-trimoxazole (1.25 - 23.75μg), Norfloxacin (10 μg), Azithromycin (15 μg) Gentamicin (10 μg), Ciprofloxacin (5 μg). E coli showed resistance to Amoxycillin (10 μg), Tetracycline (30 μg) and the antibacterial sensitivity was moderate to Amoxycillin-Clavulinic Acid.
Klebsiella species
The strains in the Klebsiella species of this study were sensitive to co-trimoxazole (1.25 23.75μg), Azithromycin (15 μg), Norfloxacin (10 μg), Meropenem (10 μg), Ceftriaxone (30 μg), Gentamicin (10 μg), Ciprofloxacin (5 μg), Nitrofurantoin (300 μg). Klebsiella spices demonstrated intermediate antibacterial sensitivity to Amoxycillin-Clavulinic Acid, and were highly resistant to Tetracycline (30 μg), Amoxycillin (10 μg).
Coagulase Negative Staphylococci (CONS)
Coagulase Negative Staphylococci (CONS) is a major gram positive bacterium observed in the present study was sensitive to Nitrofurantoin (300 μg), Azithromycin (15 μg), co-trimoxazole, Ceftriaxone (30 μg), Meropenem (10 μg), Gentamicin (10 μg), Norfloxacin (10 μg), Ciprofloxacin (5 μg) and resistant to Amoxycillin (10 μg), Tetracycline (30 μg), Amoxycillin-Clavulinic Acid.
Discussion
The proper diagnosis and treatment are preferred to impede the risk of morbidity and fatal conditions due to uropathogens in pregnancy. There are better antibiotics available for treatment of UTIs in pregnancy, majority of them included in category B of the US-FDA guidelines sense that they have negligible evidences of untoward effects, some in category C have to be cautious in their usage.13 The availability of better antibiotics for UTI is always in the front line to discuss due to the resistance developed by the uropathogens. The prevalence of UTI and susceptibility of its causative agents vary with geographical distribution.14 In this context, resistance is an issue that is steadily becoming worse around the globe and has intriguing patterns.15 Irrational and prior usages of antibiotics are great risk factors. Resistance, irrational, miss use were driving forces to conduct the study in Kadapa region of Andhra Pradesh, India.
The current study results demonstrated that participants lived in urban area (64%) was affected. The results also suggest that 42% of participants who had secondary educations as highest level of education, 45% of participants belong to upper middle-class family and, 40% of working professionals in the study were affected. Due to limited participants, the association of obstetrics-clinical features such as diabetes mellitus, history of catheterization, obstetric and gynecologic surgery, abortion, premature labor, previous UTI was observed in fewer participants.
This study was supported by Matalka et al a retrospective study stated that E. coli and CoNS were the utmost acknowledged bacteria. The significant increase in antibacterial resistance in Enterobacter species was established.16 This pattern of isolates was supported by de Souza et al systematic review by includig 67 studies. Their review results suggested that major isolate bacterial species were Escherichia coli, Klebsiella spp. Staphylococcus sp., excluding Staphylococcus aureus, Proteus mirabilis and Enterobacter spp.17, 18
The Gram-staining response, colony features, and pattern of biochemical profiles, together with conventional microbiological procedures, were used to identify all significant positive cultures of bacteriuria (>105 CFU colonies) at the species level. In this study out of 103 isolates 79 isolates were gram negative & 24 were Gram positive. Out of seventy-nine gram negative isolates the major contribution was by Escherichia coli (36), Klebsiella spp. (26). Among 24 gram positive isolates, the major contribution was by Coagulase Negative Staphylococci (CONS) (12).
This study results were supported by Ali, A.H et al study demonstrated that “most of the gram negative were sensitive to meropenem (95.9%), ceftriaxone (79.6%), Norfloxacin (77.5%), gentamicin (75.5%), nitrofurantoin (75.5%) and ciprofoxacin (71.4%), and were resistance to tetracycline (71.4%), trimethoprim–sulfamethoxazole (57.1%), amoxicillin clavulanic acid (55.1%) and nalidixic acid (51%).19 Analogous research conducted in diverse geographical area like in Addis Ababa, Ethiopia that showed highly sensitive to meropenem (75.2%), nitrofurantoin (93.1%), gentamicin (85.2%), ceftriaxone (82.2%), cefuroxime (79.3%), and ciprofloxacin (75.2%).20
The evaluated sensitivity of Escherichia coli was grater with, Meropenem (10 μg), Nitrofurantoin (300 μg), Ceftriaxone (30 μg), co-trimoxazole (1.25 - 23.75μg), Norfloxacin (10 μg), Azithromycin (15 μg) Gentamicin (10 μg), Ciprofloxacin (5 μg). E coli showed resistance to Amoxycillin (10 μg), Tetracycline (30 μg) and the sensitivity was moderate to Amoxycillin-Clavulinic Acid. In contrast Belete MA et al study showed increased E. coli resistant to gentamicin, sulfamethoxazole, Trimethoprim, Nitrofurantoin, Norfloxacin, Ciprofloxacin, ampicillin, Ceftriaxone, amoxicillin, and nalidixicacid (20). This may be the usage of antibacterial at that particular geographical area.
The strains in the strains in the Klebsiella species of this study were sensitive to co-trimoxazole (1.25 23.75μg), Azithromycin (15 μg), Norfloxacin (10 μg), Meropenem (10 μg), Ceftriaxone (30 μg), Gentamicin (10 μg), Ciprofloxacin (5 μg), Nitrofurantoin (300 μg). Klebsiella spices demonstrated intermediate sensitivity to Amoxycillin-Clavulinic Acid, and were highly resistant to Tetracycline (30 μg), Amoxycillin (10 μg). This was supported with little variation by Johnson B et al. and, Moyo SJ et al. studies.21, 22 The findings of Derese et al. study stated that Klebsiella species were entirely (100%) resistant to amoxicillin, ampicillin, and nitrofurantoin, nevertheless 66.7% of bacteria were resistant to tetracycline, and chloramphenicol.12
According to current study among the Gram Positive bacteria Coagulase Negative Staphylococci (CONS) is a foremost bacterium perceived in the current research study was sensitive to Nitrofurantoin (300 μg), Azithromycin (15 μg), co-trimoxazole, Ceftriaxone (30 μg), Meropenem (10 μg), Gentamicin (10 μg), Norfloxacin (10 μg), Ciprofloxacin (5 μg) and resistant to Amoxycillin (10 μg), Tetracycline (30 μg), Amoxycillin-Clavulinic Acid. This study was supported by Aseffa, A et al by stating that CoNS was the foremost gram positive bacterium (55%) was found 63% to 81% sensitive to erythromycin, cefriaxone, cefoxitin, nitrofurantoin, ciprofloxacin, and gentamicin. However the study conducted in Ethiopia was shown Cons resistant to nitrofurantoin (26.7%).8, 23 According to Shaheen et al study, CoNS is exceedingly unaffected with ampicillin (81.8%), tetracycline (54.5%), and amoxicillin clavulanic acid (45.4%) but affected by cefoxitin (81.8%), erythromycin (81.8%), nitrofurantoin (72.7%), ceftriaxone (72.7%) and gentamicin (72.7%), ciprofloxacin (63.6%) and co-trimoxazole (54.5%).19
Conclusion
This study demonstrated and supported that the antibacterial susceptibility and resistant of uropathogens may be vary in different geographical areas based on the antibiotic usage, and also demonstrated the imperative prerequisite of periodic assessments to determine the susceptibility configurations of bacteria that are responsible for bacteriuria in pregnant women. Operative health policies have to be designed to reduce irrational use of antibiotics and to provide revised strategies on empiric management of UTIs in pregnant women. There should be practices to educate antibiotic usage in pregnant women and to prevent prior usage of antibiotics to its susceptibility test.
