On-line version ISSN 1678-2674
Acta Cir. Bras. vol.18 suppl.5 São Paulo 2003
Prevalence and bacterial susceptibility of hospital acquired urinary tract infection1
Prevalência e susceptibilidade bacteriana da infecção urinária hospitalar
José Anastácio Dias NetoI; Leonardo Dias Magalhães da SilvaI; Antonio Carlos Pereira MartinsII; Ricardo Brianezi TiraboschiI; André Luis Alonso DomingosI; Haylton Jorge SuaidII; Silvio Tucci JrII; Adauto José ColognaII
IMedical resident of Hospital das Clínicas FMRP-USP
IIProfessor and Assistants of FMRP-USP
PURPOSE: Urinary tract infection is the most common nosocomially acquired infection. It is important to know the etiology and antibiotic susceptibility infectious agents to guide the initial empirical treatment.
OBJECTIVE: To determine the prevalence of bacterial strains and their antibiotic susceptibility in nosocomially acquired urinary tract infection in a university hospital between January and June 2003.
METHODS: We analyzed the data of 188 patients with positive urine culture (= 105 colony-forming units/mL) following a period of 48 hours after admission.
RESULTS: Half of patients were male. Mean age was 50.26 ± 22.7 (SD), range 3 months to 88 years. Gram-negative bacteria were the agent in approximately 80% of cases. The most common pathogens were E. coli (26%), Klebsiella sp. (15%), P. aeruginosa (15%) and Enterococcus sp. (11%). The overall bacteria susceptibility showed that the pathogens were more sensible to imipenem (83%), second or third generation cephalosporin and aminoglycosides; and were highly resistant to ampicillin (27%) and cefalothin (30%). It is important to note the low susceptibility to ciprofloxacin (42%) and norfloxacin (43%).
CONCLUSION: This study suggests that if one can not wait the results of urine culture, the best choices to begin empiric treatment are imipenem, second or third generation cephalosporin and aminoglycosides. Cefalothin and ampicillin are quite ineffective to treat these infections.
Key Words: Urinary tract infection. Etiology, susceptibility. Nosocomial infection. Microbiology.
INTRODUÇÃO: A infecção urinária é a mais comum das infecções hospitalares. O conhecimento da prevalência das cepas bacterianas e do antibiograma é importante para orientar a escolha inicial do antibiótico.
OBJETIVO: Determinar a prevalência bacteriana e a sensibilidade aos antibióticos na infecção urinária hospitalar, em um hospital universitário, período janeiro-junho de 2003.
MÉTODOS: Foram analisados os prontuários de 188 pacientes com urocultura positiva (³ 105 colônias/ml), depois de decorrido um período de pelo menos 48h da internação.
RESULTADOS: Metade dos pacientes era homens. A idade média da amostra foi 50,2±22.7 anos com variação de 3 meses a 88 anos. Em 80% dos casos a bactéria identificada era Gram-negativa. Os micróbios mais comuns foram E. coli (26%), Klebsiella sp (15%), P. aeruginosa (15%) e Enterococcus sp (11%). O antibiograma mostrou maior sensibilidade bacteriana ao imipenem (83%), cefalosporinas de segunda e terceira geração e aminoglicosídeos e grande resistência à ampicilina e cefalotina. A sensibilidade foi baixa também para ciprofloxacina (42%) e norfloxacina (43%).
CONCLUSÃO: Este estudo sugere que se não for possível aguardar os resultados da cultura e antibiograma a melhor escolha para início do tratamento seria o imipenem, cefalosporinas de segunda e terceira geração e aminoglicosídeos. A cefalotina e a ampicilina não constituem boa opção para o tratamento empírico inicial.
Descritores: Infecção urinária. Etiologia, antibiograma. Infecção hospitalar. Microbiologia, sensibilidade.
Hospitalized patients are predisposed to a variety of nosocomial infections, especially with multidrug-resistant organisms1. Urinary tract infection (UTI) is the most frequent nosocomial infection and has been suffering a shift in the etiology and antimicrobial susceptibility, as common as other infections detected in the last decade2-5. Since most of treatments began empirically, prior knowledge of the bacterial prevalence as well as the resistance patterns in a particular setting is essential.
Informations on the etiology and bacterial susceptibility of nosocomially acquired UTI in Brazil are scarce which makes the decisions on antibiotic choice almost entirely dependent of international data6. As both geographic and temporal factors can influence these data, they need to be constantly and locally re-evaluated.
The aim of this study was to determine the local prevalence of bacterial strains and the antibiotic susceptibility of the nosocomially acquired UTI in our institution to guide antibiotic choice and to achieve a maximal clinical response in empiric treatment while the antibiotic susceptibility of the pathogen is still unknown.
All urinary specimens with significant bacteriuria, defined by Kass8 as being urine culture with more than 105 colony forming units/mL, processed in the laboratory of the Hospital das Clínicas of the School of Medicine of Ribeirão PretoUniversity of São Paulo, between January and June of 2003, were included in this study. Nosocomial episode was defined as any UTI beginning 48 hours after admission.
We analyzed patient data and bacterial etiology as well as antimicrobial susceptibility to commonly used antibiotics.
We obtained clinical information of 188 patients that had nosocomially acquired UTI. Half of them were male (99 patients). Mean age was 50.26 ± 22.7 (SD) (range 3 months to 88 years).
The prevalence increased after the 5th decade in males and 4th decade in the females (Table 1).
There were a great variety of isolated pathogens and their frequency is listed on Table 2. E. coli was the most frequent bacteria (26%), followed by Klebsiella sp. (15%), Pseudomonas aeruginosa (15%), and Enterococcus sp (11%).
Table 3 shows the antibiotic susceptibility of the four most frequent pathogens and the overall sensibility to antibiotics.
E. coli was very susceptible to imipenem, second or third generation cephalosporin, aminoglycosides, ciprofloxacin and nitrofurantoin, and showed a great resistance to ampicillin, trimethoprim-sulfamethoxazole (TMP-SMX) and norfloxacin.
Klebsiella sp were sensible to imipenem, second or third generation cephalosporin and fluoroquinolones, and highly resistant to ampicillin. P. aeruginosa had high levels of resistance, and was more sensible to ceftazidime, imipenem and specially to cefepime (100%), a forth generation cephalosporin that is not commonly tested, only in special situations of multidrug-resistant organism.
Enterococcus sp. was the only Gram-positive bacteria with a high incidence and was very sensible to ampicillin (89%) different from the Gram-negative organisms described above. It was more sensible to specific antibiotics not presented in Table 3, like penicillin G (83%) and vancomycin (100%).
The overall antibiotic susceptibility is highly influenced by the Gram-negative bacteria, which were involved in approximately 80% of nosocomially acquired urinary tract infections. The pathogens were more sensible to imipenem, second or third generation cephalosporin and aminoglycosides; and were highly resistant to ampicillin and cefalothin. It is important to note the low susceptibility to ciprofloxacin and norfloxacin.
The high mean age of our patients reflect the hospital population. The increase of prevalence of nosocomially acquired UTI in the male group after fifty years might be caused by the higher incidence of urinary tract pathologies like prostate diseases. The female group has a more uniform distribution, and the elevated incidence in the twenties and forties might be caused by the obstetric and gynecologic causes, respectively.
We found that E. coli is the predominant bacterium in urine samples, followed by P. aeruginosa and Klebsiella sp, reflecting the predominance of Gram-negative bacteria. This is in accordance to previous studies in other countries9-11. There is a high prevalence of Gram-positive bacteria, corresponding to 22% of total, mainly due to Enterococci and Staphylococci, which correlates with previous data from other studies that report an increase in the number of Gram-positive bacteria and yeasts as nosocomial UTI pathogens4,9.
In this study, E. coli and Klebsiella sp. showed a higher resistance to ampicillin, TMP-SMX and cephalothin than described in the literature11,12. Nevertheless, the susceptibility to aminoglycosides, fluoroquinolones, second and third generation cephalosporins, nitrofurantoin and imipenem were equivalent to previous reports that have been showing an increasing resistance to antibiotics13-15.
P. aeruginosa showed resistance rates of over 50% for quinolones, aminoglycosides and some third generation cephalosporin, thereby posing a major problem in the management of nosocomial UTI. The same pattern was described in several European hospitals12.
This study suggests that if one could not wait the results of urine culture, the best choices to begin empiric treatment of nosocomial UTI are imipenem, second or third generation cephalosporin and aminoglycosides. Cefalothin and ampicilin are quite ineffective to treat these infections.
1. Dieckhaus KD, Cooper BW. Infection control concepts in critical care. Crit Care Clin 1998; 14: 55-70. [ Links ]
2. Arosio A, Ferrari S, et al. Urinary tract infections in a general medicine department. Comments on cases collected over 3 years. Minerva Med 1986; 77(28-29): 1339-46. [ Links ]
3. Papapetropooulou M, Pagonopoulou O, Kouskouni E. Prevalence and sensitivity to antibiotics of Enterobacteriaceae isolated from urinary cultures in some microbiology laboratories of a city in west Greece. Pathol Biol (Paris) 1997:45(9): 716-20. [ Links ]
4. Bronsema DA, Adams JR, Pallares R, Wenzel Rp. Secular trends in rates and etiology of nosocomial urinary tract infections at a University hospital. J Urol 1993; 150(2Part 1): 414-6. [ Links ]
5. Meares EM Jr. Nosocomial infection of urinary tract: changing pathogens, changing patterns. Urology 1985; 26(Suppl. 1): 2-4. [ Links ]
6. Rubinstein I, Rubinstein M. Infecção do trato urinário-aspectos gerais. In: Wroclawski ER, Bendhack DA, Damião R, Ortiz W, editors. Guia Prático de Urologia. São Paulo: Editora Segmento; Rio de Janeiro: SBU-Sociedade Brasileira de Urologia, 2003: 3-6. [ Links ]
7. Prais D, Strussberg R. Bacterial susceptibility to oral antibiotics in community acquired urinary tract infection. Arch Dis Child 2003; 88: 215-8. [ Links ]
8. Kass EHFM. Assymptomatic infections of the urinary tract. Trans Assoc Am Physicians 1956; 69: 56-64. [ Links ]
9. Jones RN, Kugler KC, Pfaller MA, Winokur PL. The SENTRY Surveillance Group North America. Characteristic of pathogens causing urinary tract infections in hospitals in North-America: results from SENTRY Antimicrobial Surveillance Program, 1997. Diagn Microbiol Infect Dis 1999; 35: 55-63. [ Links ]
10. Vromen M, van der Ven AJ. Antimicrobial resistance patterns in urinary isolates from nursing home residents. Fifteen years of data reviewed. J Antimicrob Chemother 1999; 44: 113-6. [ Links ]
11. Jones RN. Impact of changing pathogens and antimicrobial susceptibility patterns in the treatment of serious infections in hospitalized patients. Am J Med 1996; 100(6A): 3S-12S. [ Links ]
12. Dornbusch K, King A, LegalisN. Incidence of antibiotic resistance in blood and urine isolates from hospitalized patients. Report from a European collaborative study. European Study Group on Antibiotic Resistance (ESGAR). Scand J Infect Dis 1998; 30(3): 281-8. [ Links ]
13. Burven DR, Banerjee SN, Gaynes RP and the National Nosocomial Infections Surveillance System. Ceftazidime resistance among selected nosocomial gram-negative bacilli in the United States. J Infect Dis 1994; 170:1622-5. [ Links ]
14. Rice LB, Eckstein EC. Ceftazidima-resistant Klebsilla pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical center. Clin Infect Dis 1996; 23:118-24. [ Links ]
15. Schiappa DA, Hayden MK. Ceftazidima-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection: A case-control and molecular epidemiologic investigation. J Infect Dis 1996; 174:529-36. [ Links ]
1. This research was developed at Hospital das Clínicas FMRP-USP