Bacterial infections and antimicrobial resistance patterns: a comprehensive analysis of health dynamics across regions in Pakistan (2013-2023)Abstract
Antimicrobial resistance (AMR) is a significant public health concern globally, and Pakistan is no exception. The misuse and overuse of antibiotics, inadequate regulation of their sale, and a lack of awareness contribute to the rising levels of AMR in the country. study presents a detailed analysis of blood and urine samples collected in Pakistan over various periods, focusing on pathogen prevalence, gender distribution, and age-wise patterns. From January 2013 to 2017, the North region exclusively contributed to the blood sample dataset, with Salmonella emerging as the primary pathogen, particularly affecting infants and neonates. Subsequently, from January 2017 to December 2020, a significant dataset emerged from the North and Punjab regions, with Salmonella and E.coli prevalent across all age groups, notably impacting adults and infants. In the period from January 2021 to the present, blood samples predominantly originated from the North and Punjab regions, with Salmonella and E.coli remaining significant pathogens, affecting adults and the elderly. Regarding urine samples, from January 2013 to December 2017, E.coli was the dominant pathogen, with females showing a higher susceptibility to urinary tract infections (UTIs), particularly among the elderly. Similarly, from January 2017 to December 2020, E.coli remained predominant, with UTIs more prevalent in females and the elderly. In the most recent period, the North region significantly contributed to UTI cases, with E.coli remaining predominant and females exhibiting a higher susceptibility, especially among the elderly. This comprehensive analysis provides crucial insights into the epidemiology of blood and urinary tract infections in Pakistan, informing public health strategies and interventions aimed at addressing these health challenges.
Keywords:
antimicrobial resistance; AMR; XDR; urinary tract infections; blood infections; Pakistan
Resumo
A resistência antimicrobiana (RAM) é uma preocupação significativa de saúde pública em todo o mundo, e o Paquistão não é uma exceção. O uso inadequado e excessivo de antibióticos, a regulamentação deficiente da sua comercialização e a falta de conscientização contribuem para o aumento alarmante da RAM no país. Este estudo apresenta uma análise detalhada de amostras de sangue e urina coletadas no Paquistão ao longo de diferentes períodos, com foco na prevalência de patógenos, distribuição por gênero e padrões etários. De janeiro de 2013 a 2017, apenas a região Norte contribuiu com dados de amostras de sangue, sendo a Salmonella o principal patógeno identificado, com destaque para infecções em lactentes e neonatos. Posteriormente, entre janeiro de 2017 e dezembro de 2020, um conjunto expressivo de dados foi coletado nas regiões Norte e Punjab, com Salmonella e E.coli prevalecendo em todas as faixas etárias, afetando especialmente adultos e lactentes. No período de janeiro de 2021 até o presente, as amostras de sangue continuaram a vir predominantemente das regiões Norte e Punjab, com Salmonella e E.coli mantendo-se como patógenos relevantes, afetando principalmente adultos e idosos. Em relação às amostras de urina, de janeiro de 2013 a dezembro de 2017, E.coli foi o patógeno dominante, com maior suscetibilidade observada entre as mulheres, especialmente idosas, às infecções do trato urinário (ITUs). De forma semelhante, entre janeiro de 2017 e dezembro de 2020, E.coli permaneceu como o principal patógeno, com maior prevalência de ITUs em mulheres e idosos. No período mais recente, a região Norte teve contribuição significativa para os casos de ITUs, com E.coli permanecendo como o patógeno predominante, e com as mulheres, particularmente as idosas, demonstrando maior suscetibilidade. Esta análise abrangente oferece insights cruciais sobre a epidemiologia das infecções sanguíneas e do trato urinário no Paquistão, servindo como base para estratégias e intervenções de saúde pública voltadas ao enfrentamento desses desafios emergentes.
Palavras-chave:
resistência antimicrobiana; RAM; XDR; infecções do trato urinário; infecções sanguíneas; Paquistão
1. Introduction
Antimicrobial resistance (AMR) represents a critical global health challenge that jeopardizes the effectiveness of antibiotics and other antimicrobial drugs in treating bacterial infections (Saeed et al., 2023). This phenomenon occurs when bacteria evolve and develop resistance to medications designed to eliminate or slow down their growth, leading to increased complexity in managing infections and a higher likelihood of severe outcomes, such as organ failure and sepsis (Buchy et al., 2020).
The widespread misuse and overuse of antibiotics have fueled the emergence and dissemination of drug-resistant bacteria, making AMR a significant worldwide public health concern. According to the World Health Organization (WHO), AMR is among the most pressing global health hazards, causing approximately 700,000 deaths annually due to related illnesses (Higgins et al., 2022). AMR's consequences extend beyond individual health, impacting economies and societies. It leads to prolonged hospitalizations, heightened medical expenses, and reduced productivity, with vulnerable populations such as children, the elderly, and immunocompromised individuals facing severe consequences. Addressing the threat of AMR requires a coordinated global effort, including optimizing antibiotic use, advancing research into new antimicrobial drugs, enhancing surveillance and monitoring methods, and promoting worldwide collaboration and alliances for research, innovation, and improved antimicrobial management (Klein et al., 2018).
While AMR can manifest in various pathogens, bacteria are the primary culprits, with notable examples including Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. These bacteria, particularly in multidrug-resistant forms, pose significant challenges in treating infections, leading to prolonged illnesses and increased mortality rates (Asokan et al., 2019; Hwengwere et al., 2022).
The rise of AMR has reignited interest in alternative treatments, such as bacteriophage therapy. Bacteriophages are viruses that can target and eliminate bacteria with precision. This approach offers a promising substitute for antibiotics, especially in the face of increasing antimicrobial resistance (Pandey et al., 2022). Bacteriophages can be customized to target specific bacterial strains, providing a potential solution for infections caused by antibiotic-resistant bacteria. However, challenges such as regulatory requirements, consistent production, and clinical testing must be addressed for widespread acceptance and integration of bacteriophage therapy (Kline and Lewis, 2016).
Multidrug-resistant (MDR) bacterial pathogens, resistant to various types of antibiotics, further exacerbate the challenge of AMR. Examples include MRSA, ESBL-producing bacteria, Acinetobacter baumannii, Pseudomonas aeruginosa, and Mycobacterium tuberculosis, posing serious threats to public health globally. The prevalence of AMR is observed across all continents, with North America facing significant challenges (Ibrahim et al., 2021). In the United States, the Centers for Disease Control and Prevention (CDC) estimate millions of annual infections caused by antibiotic-resistant bacteria, resulting in thousands of deaths. MRSA, carbapenem-resistant Enterobacteriaceae (CRE), and vancomycin-resistant Enterococci (VRE) are prevalent in the United States. In Canada, rising rates of AMR are reported, affecting bacterial strains like MRSA, Escherichia coli, and Klebsiella pneumonia (Khan et al., 2020; Mayorga-Ramos et al., 2023).
The global nature of AMR necessitates a united effort from diverse sectors to combat this complex and evolving public health threat. Effective strategies include optimizing antibiotic use, advancing research, enhancing surveillance, and promoting international collaboration to ensure the availability and accessibility of potent antimicrobial remedies worldwide (Abrar et al., 2018).
2. Materials and Methods
Aseptic venipuncture techniques were utilized to collect blood samples employing sterile needles and vacutainer tubes. These samples were drawn into blood culture bottles containing specialized culture media to support microbial growth. Clean-catch midstream urine samples were collected in sterile containers to prevent contamination. Samples were promptly transported to the microbiology laboratory under controlled conditions to maintain sample integrity. Blood culture bottles were incubated in automated blood culture systems to facilitate the detection of microbial growth. Positive blood cultures were then sub-cultured onto appropriate agar plates for subsequent identification. Urine samples underwent quantitative culture on selective media to determine the bacterial load present.
2.1. Microbial identification
Colonies obtained from sub-culturing were identified using standard microbiological techniques including Gram staining and biochemical tests. Additionally, automated microbial identification systems were employed for rapid and accurate identification when necessary.
2.2. Antibiotic sensitivity testing
The identified bacterial isolates underwent antibiotic sensitivity testing using either the Kirby-Bauer disc diffusion method or automated systems. A panel of antibiotics representing different classes was employed to assess the sensitivity or resistance of the isolates. Zone sizes around antibiotic discs were measured, and results were interpreted based on established Clinical and Laboratory Standards Institute (CLSI) guidelines. The susceptibility or resistance profile of bacterial isolates was reported accordingly.
2.3. Quality control
Quality control strains were routinely employed to validate the performance of culture media, reagents, and antibiotic discs. Standard operating procedures were strictly adhered to, ensuring the accuracy and reliability of results. Microbial culture and sensitivity analysis were reported in a clear and standardized format, inclusive of identified pathogens, quantitative bacterial counts (for urine samples), and antibiotic susceptibility profiles. Patient information and results were handled with strict confidentiality and stored securely in compliance with national and international regulations governing clinical laboratory practices. Regular audits and assessments were conducted to ensure adherence to established standards. Clear communication channels were established to promptly convey results to healthcare providers. Consultation services were readily available for interpreting complex results or guiding appropriate therapeutic interventions. Continuous training and education programs for laboratory staff were conducted to keep them updated on emerging microbial trends and new methodologies. Through the rigorous adherence to these methods and quality assurance measures, the microbiology laboratory at Islamabad Diagnostic Center provided accurate and clinically relevant information for the effective management of bacterial infections.
3. Results
3.1. Blood samples analysis: January 2013-2017
During the period from January 2013 to 2017, as shown in Table 1, the North region exclusively contributed to the blood sample dataset, comprising 577 cases. This regionally focused collection provides a unique insight into the health dynamics within the North.
3.1.1. Gender distribution
The gender distribution revealed a slight male predominance, with 55.8% (322) males and 44.2% (255) females. This gender breakdown sets the context for understanding potential gender-specific health patterns.
3.2. Dominant pathogen - Salmonella
Salmonella emerged as the primary pathogen, commanding a significant presence in 33.10% of the cases, with a total count of 191. This suggests a noteworthy prevalence of Salmonella-related infections in the blood samples during this timeframe.
3.2.2. Variety of pathogens
Beyond Salmonella, the dataset exhibited a diverse array of pathogens. Notable organisms included E.coli (2.25%), Klebsiella (1.73%), Pseudomonas (1.21%), MRSA (2.08%), and a spectrum of other bacteria and fungi. This diversity underscores the complexity of infections present in the blood samples.
3.3. Age-wise patterns
Infants/Neonates (13.00%): The dataset indicated a substantial representation of cases in infants and neonates, constituting 13.00% with a total count of 75.
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Pediatrics (20.45%): The pediatric age group contributed significantly, comprising 20.45% with a total count of 118 cases.
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Adults (48.01%): The majority of cases were observed in the adult population, representing 48.01% with a count of 277.
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Elderly (18.54%): The elderly age group accounted for 18.54% of the cases, with a total count of 107. This highlights the prevalence of blood-related infections in the older demographic.
3.4. Detailed organism-specific breakdown
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Salmonella (33.10%): Salmonella infections were not only prevalent across all age groups but were particularly notable in infants and neonates, constituting 13.00% of the total cases.
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E.coli (2.25%): E.coli cases were distributed across all age groups, with the highest count observed in the adult population (48.01%).
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Other Organisms (48.35%): Skin flora emerged as the most prevalent among other organisms, representing 48.35% of cases. This indicates a diverse range of bacterial and fungal flora present in the blood samples.
This comprehensive analysis of blood samples from January 2013 to 2017 in the North region provides valuable insights into the prevalence of various pathogens, gender distribution, and age-wise patterns, shedding light on the health dynamics within the region.
3.5. Blood samples analysis: January 2017-December 2020
In the period spanning from January 2017 to December 2020, as shown in Table 2, an extensive dataset of blood samples emerged, primarily sourced from the North (81.19%) and Punjab (18.81%) regions. The North region particularly stands out, constituting a significant proportion of the dataset, indicating a substantial representation of health data within this area.
3.5.1. Gender distribution
The gender distribution within the dataset indicates a balanced representation, with 56.97% (1030) males and 43.03% (778) females contributing. This equilibrium in gender distribution lays the groundwork for exploring potential gender-specific health patterns.
3.5.2. Dominant pathogen – Salmonella
Salmonella maintains a robust presence, comprising 39.44% of the cases with a total count of 713. This suggests a sustained prevalence of Salmonella-related infections throughout the analyzed timeframe.
3.5.3. Variety of pathogens
The dataset showcases a diverse array of pathogens beyond Salmonella. Noteworthy organisms include Klebsiella (2.27%), E.coli (6.69%), Pseudomonas (2.65%), MRSA (1.60%), and a spectrum of other bacteria and fungi. This diversity underscores the complexity of blood-related infections during this period.
3.6. Age-wise patterns
Infants/Neonates (16.76%): Infants and neonates contribute significantly, comprising 16.76% with a total count of 303 cases. This emphasizes the vulnerability of this age group to blood-related infections.
Pediatrics (29.76%): The pediatric age group is prominently affected, contributing 29.76% with a total count of 538 cases, highlighting the impact on children's health during this period.
Adults (38.50%): The majority of cases are observed in the adult population, representing 38.50% with a count of 696, indicating the prevalence of blood-related infections in adults.
Elderly (14.99%): The elderly age group accounts for 14.99% of the cases, with a total count of 271, indicating a notable impact on the older demographic.
3.7. Detailed organism-specific breakdown
Salmonella (39.44%): Salmonella infections were consistently prevalent across all age groups, with a noteworthy impact on infants/neonates (16.76%).
E.coli (6.69%): E.coli cases are distributed across all age groups, with the highest count observed in the adult population (38.50%).
Other Organisms (29.48%): Normal flora emerges as the most prevalent among other organisms, representing 29.48% of cases, suggesting the presence of diverse bacterial and fungal flora in the blood samples.
This comprehensive analysis of blood samples from January 2017 to December 2020 elucidates the prevalence of various pathogens, gender distribution, and age-wise patterns, providing valuable insights into the health landscape within the North and Punjab regions.
3.8. Blood samples analysis: January 2021 to present
The analysis of blood samples from January 2021 to the present, as shown in Table 3, period highlights a significant dataset primarily sourced from the North (62.9%) and Punjab (36.5%) regions, providing insight into the geographical prevalence of blood-related infections during this timeframe. Gender distribution reveals a slightly higher representation of males, constituting 55.03% (1329) of the cases, while females contribute 44.97% (1086), establishing a balanced gender distribution essential for understanding potential gender-specific patterns in blood-related infections.
3.8.1. Dominant pathogen - Salmonella
Salmonella continues to be a prominent pathogen, comprising 38.39% of the cases with a substantial total count of 927, indicating the sustained prevalence of Salmonella-related infections during this period.
3.8.2. Variety of pathogens
The dataset exhibits a diverse array of pathogens beyond Salmonella. Key organisms include Klebsiella (4.47%), E.coli (8.53%), Enterococcus (3.31%), and a spectrum of other bacteria and fungi, highlighting the complexity of blood-related infections during this timeframe.
3.9. Age-wise patterns
Infants/Neonates (13.21%): Infants and neonates contribute significantly, constituting 13.21% with a total count of 319 cases, emphasizing the vulnerability of this age group to blood-related infections.
Pediatrics (23.44%): The pediatric age group is notably affected, contributing 23.44% with a total count of 566 cases, highlighting the impact on children's health during this period.
Adults (42.86%): The majority of cases are observed in the adult population, representing 42.86% with a count of 1035, emphasizing the prevalence of blood-related infections in adults.
Elderly (20.49%): The elderly age group accounts for 20.49% of the cases, with a total count of 495, indicating a significant impact on the older demographic.
3.10. Detailed organism-specific breakdown
Salmonella (38.39%): Salmonella infections are prevalent across all age groups, with a significant impact on infants/neonates (13.21%).
E.coli (8.53%): E.coli cases are distributed across all age groups, with the highest count observed in the adult population (42.86%).
Other Organisms (13.83%): Normal flora emerges as the most prevalent among other organisms, representing 13.83% of cases, suggesting the presence of diverse bacterial and fungal flora in the blood samples.
This detailed analysis provides a comprehensive understanding of the characteristics of blood samples during the specified period, emphasizing the sustained dominance of Salmonella, the diversity of pathogens, and age-specific patterns in infection prevalence. This table provides a breakdown of the blood sample analysis from January 2021 to the present, detailing regional distribution, gender representation, prevalent organisms, and age-specific patterns.
3.11. Urine samples analysis: January 2013 to December 2017
The analysis of urine samples from January 2013 to December 2017, as shown in Table 4, reveals a substantial dataset primarily sourced from the North region, constituting 100% of the cases. The prevalence of urine-related infections in this region is evident, laying the groundwork for further detailed insights.
3.11.1. Gender distribution
Male individuals contribute 24.86% to the total urine-related infection cases, with a count of 1746, highlighting a relatively lower prevalence in males during the specified period. Conversely, female individuals significantly dominate the dataset, representing 75.14% of the cases with a total count of 5276, indicating a higher susceptibility or reporting of urine-related infections among females.
3.11.2. Dominant pathogen - E.coli
E.coli emerges as the predominant pathogen in urine samples, constituting a substantial 61.34% of the cases. This underscores the significance of E.coli in urinary tract infections during the specified period.
3.11.3. Variety of pathogens
The dataset exhibits a diverse range of pathogens beyond E.coli, including Klebsiella (10.52%), Pseudomonas (3.90%), Proteus (1.84%), and several others. This diversity highlights the complexity of urinary tract infections, with multiple organisms contributing to the overall prevalence.
3.12. Age-wise patterns
Infants/Neonates (2.78%): The dataset includes a small percentage of cases from infants/neonates, constituting 2.78% with a total count of 195, suggesting that urinary tract infections are relatively uncommon in this age group.
Pediatrics (10.00%): The pediatric age group contributes 10.00% to the total cases, with a count of 702, indicating a noticeable presence of urinary tract infections in children.
Adults (23.57%): The majority of cases are observed in the adult population, representing 23.57% with a count of 1655, emphasizing the prevalence of urinary tract infections in adults.
Elderly (63.66%): The elderly age group significantly dominates the dataset, constituting 63.66% of the cases with a total count of 4470, highlighting the substantial impact of urinary tract infections on the older demographic.
3.13. Detailed organism-specific breakdown
E.coli (61.34%): E.coli infections are widespread across all age groups, with a substantial impact on adults (23.57%) and the elderly (63.66%).
Klebsiella (10.52%): Klebsiella is a notable contributor, with a prevalence of 10.52%, affecting individuals across different age groups.
Other Organisms (5.16%): Candida emerges as a significant organism beyond bacteria, constituting 5.16% of the cases, highlighting the presence of fungal infections in urine samples.
This table provides a detailed breakdown of urine sample analysis from January 2013 to December 2017, covering regional distribution, gender representation, prevalent organisms, and age-specific patterns.
3.14. Urine samples analysis: January 2017 to December 2020
The urine samples collected from January 2017 to December 2020, as shown in Table 5, provide valuable insights into the prevalence of urinary tract infections across different regions. The North region dominates the dataset with 90.56% of the cases, indicating a higher incidence of urinary tract infections in this area, while Punjab contributes to 9.44% of the cases, providing a significant portion of the dataset.
3.14.1. Gender distribution
Male individuals account for 29.91% of the cases, with a total count of 2733, suggesting a higher prevalence of urinary tract infections in females during the specified period. Female individuals significantly dominate the dataset, representing 70.09% of the cases with a total count of 6403, highlighting a higher susceptibility or reporting of urinary tract infections among females.
3.14.2. Dominant pathogen - E.coli
E.coli emerges as the predominant pathogen in urine samples, constituting a substantial 62.97% of the cases, underscoring the continued significance of E.coli in urinary tract infections during the specified period.
3.14.3. Variety of pathogens
The dataset exhibits a diverse range of pathogens beyond E.coli, including Klebsiella (13.29%), Proteus (1.89%), Pseudomonas (4.57%), and several others. This diversity emphasizes the complexity of urinary tract infections, with multiple organisms contributing to the overall prevalence.
3.15. Age-wise patterns
Infants/Neonates (0.96%): The dataset includes a small percentage of cases from infants/neonates, constituting 0.96% with a total count of 88, suggesting that urinary tract infections are relatively uncommon in this age group.
Pediatrics (7.95%): The pediatric age group contributes 7.95% to the total cases, with a count of 726, indicating a noticeable presence of urinary tract infections in children.
Adults (45.88%): The majority of cases are observed in the adult population, representing 45.88% with a total count of 4192, emphasizing the prevalence of urinary tract infections in adults.
Elderly (45.21%): The elderly age group significantly dominates the dataset, constituting 45.21% of the cases with a total count of 4130, highlighting the substantial impact of urinary tract infections on the older demographic.
3.15.1. Detailed organism-specific breakdown
The dataset includes cases where patients have double organism infections, resulting in an organism count higher than the total count.
This table provides a comprehensive breakdown of urine sample analysis from January 2017 to December 2020, covering regional distribution, gender representation, prevalent organisms, and age-specific patterns.
3.16. Urine samples analysis: January 2021 to date
The data collected from January 2021 to the present, as shown in Table 6, date offers valuable insights into the prevalence of urinary tract infections (UTIs) across different regions. The North region emerges as the primary contributor, representing 77.56% of the cases, indicating a higher incidence of UTIs in this area. Punjab contributes significantly with 22.19% of the cases, while Sindh, Balochistan, and Azad Kashmir collectively contribute only a minimal percentage to the dataset.
3.16.1. Gender distribution
Male individuals account for 29.89% of the cases, totaling 5399, suggesting a higher prevalence of UTIs in females during the specified period. Female individuals significantly dominate the dataset, representing 70.11% of the cases with a total count of 12664, emphasizing a higher susceptibility or reporting of UTIs among females.
3.16.2. Dominant pathogen - E.coli
E.coli emerges as the predominant pathogen in urine samples, constituting a substantial 57.81% of the cases, highlighting its continued significance in UTIs during the specified period.
3.16.3. Variety of pathogens
Beyond E.coli, the dataset exhibits a diverse range of pathogens, including Klebsiella (12.71%), Proteus (1.25%), Pseudomonas (5.35%), and numerous others. This diversity underscores the complexity of UTIs, with multiple organisms contributing to the overall prevalence.
3.17. Age-wise patterns
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Infants/Neonates (2.33%): The dataset includes cases from infants/neonates, constituting 2.33% with a total count of 421, indicating a relatively low but existent occurrence of UTIs in this age group.
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Pediatrics (8.14%): The pediatric age group contributes 8.14% to the total cases, with a count of 1471, signifying a noticeable presence of UTIs in children.
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Adults (43.66%): The majority of cases are observed in the adult population, representing 43.66% with a total count of 7886, emphasizing the prevalence of UTIs in adults.
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Elderly (45.87%): The elderly age group significantly dominates the dataset, constituting 45.87% of the cases with a total count of 8285, highlighting the substantial impact of UTIs on the older demographic.
This table provides a comprehensive breakdown of urine sample analysis from January 2021 to the present date, covering regional distribution, gender representation, prevalent organisms, and age-specific patterns.
In the analysis of blood samples spanning January 2013 to 2017, the North region exclusively contributed to the dataset, totaling 577 cases. The gender distribution showed a slight male predominance (55.8%), and Salmonella emerged as the dominant pathogen, present in 33.10% of cases. Noteworthy age-wise patterns revealed a substantial representation in infants/neonates (13.00%), pediatrics (20.45%), adults (48.01%), and the elderly (18.54%). Salmonella infections were prevalent across all age groups, particularly impacting infants/neonates (13.00%). E.coli cases were distributed across all age groups, with the highest count in adults (48.01%). Skin flora emerged as the most prevalent among other organisms (48.35%). Moving on to the blood samples analysis from January 2017 to December 2020, the dataset was primarily sourced from the North (81.19%) and Punjab (18.81%) regions. Gender distribution was balanced (56.97% males, 43.03% females), and Salmonella remained a robust pathogen, constituting 39.44% of cases. The age-wise breakdown showed significant contributions from infants/neonates (16.76%), pediatrics (29.76%), adults (38.50%), and the elderly (14.99%). Salmonella infections persisted across all age groups, notably impacting infants/neonates (16.76%), while E.coli cases were distributed, with the highest count in adults (38.50%). Normal flora emerged as the most prevalent among other organisms (29.48%). In the most recent analysis from January 2021 to the present, the North region contributed the majority (62.9%), followed by Punjab (36.5%). Gender distribution indicated a slightly higher representation of males (55.03%), and Salmonella remained a prominent pathogen, constituting 38.39% of cases. The age-wise patterns showcased significant contributions from infants/neonates (13.21%), pediatrics (23.44%), adults (42.86%), and the elderly (20.49%). Salmonella infections were prevalent across all age groups, particularly impacting infants/neonates (13.21%), while E.coli cases were distributed, with the highest count in adults (42.86%). Normal flora emerged as the most prevalent among other organisms (13.83%).
Shifting to the analysis of urine samples from January 2013 to December 2017, the dataset was entirely from the North region (100%). Gender distribution revealed 24.86% male cases and 75.14% female cases. E.coli was the dominant pathogen, constituting 61.34% of cases. Age-wise patterns showed contributions from infants/neonates (2.78%), pediatrics (10.00%), adults (23.57%), and the elderly (63.66%). Notable organisms beyond E.coli included Klebsiella (10.52%) and Pseudomonas (3.90%). Candida emerged as a significant organism (5.16%). For the urine samples from January 2017 to December 2020, the North region dominated (90.56%), with Punjab contributing 9.44%. Gender distribution indicated a higher prevalence in females (70.09%). E.coli remained the dominant pathogen (62.97%), and age-wise patterns highlighted contributions from infants/neonates (0.96%), pediatrics (7.95%), adults (45.88%), and the elderly (45.21%). The dataset included cases with double organism infections. In the most recent urine samples analysis from January 2021 to date, the North region was the primary contributor (77.56%), followed by Punjab (22.19%). Gender distribution showed a higher prevalence in females (70.11%). E.coli remained the predominant pathogen (57.81%), with notable contributions from Klebsiella (12.71%) and Proteus (1.25%). Age-wise patterns demonstrated contributions from infants/neonates (2.33%), pediatrics (8.14%), adults (43.66%), and the elderly (45.87%). The dataset included cases with double organism infections. Comparatively, across the years, Salmonella consistently emerged as a significant pathogen in blood samples, while E.coli dominated urine samples. The prevalence of these pathogens varied across different regions and age groups, emphasizing the dynamic nature of infectious patterns in blood and urine samples over time. The gender distribution remained relatively balanced, and normal flora consistently appeared as a prevalent organism among blood samples, while Candida was notable in urine samples. These detailed analyses provide valuable insights into the evolving landscape of infections in the studied regions and timeframes.
The analysis of percentage resistance trends for various oral antibiotics, as shown in Table 7, in urine and other samples over three distinct periods, 2013-2017, 2017-2020, and 2021 onwards, provides valuable insights into antibiotic effectiveness. Amoxycillin demonstrated a consistent downward trend in resistance in urine samples, declining from 78.9% in 2013-2017 to 67.9% in 2021 onwards, indicating improved efficacy against urinary infections. Ampicillin also showed a decline in resistance in both urine and other samples, from 81.7% to 75.5% and from 61.1% to 72.2%, respectively. Azactam exhibited a significant decrease in resistance over time, reaching 0.8% in urine samples and 1.3% in other samples in 2021 onwards, suggesting improved susceptibility of pathogens. Carbencillin, Cefaclor, Cefadroxil, Cefexime, Cefotaxime, and other antibiotics showcased reductions in resistance, indicating enhanced effectiveness against urinary and other infections. Conversely, antibiotics like Cephalexin and Cephradine displayed increased resistance in other samples, potentially posing challenges in treating other infections. The comprehensive analysis offers a nuanced understanding of antibiotic efficacy dynamics, guiding clinical decisions for the treatment of urinary and other infections.
4. Discussion
The analysis of blood and urine samples spanning multiple years in Pakistan offers valuable insights into the prevalence of pathogens, antimicrobial resistance (AMR) trends, and demographic patterns of infection (Hannan et al., 2013). The findings reveal notable shifts in pathogen prevalence, gender distribution, and age-specific susceptibility, underscoring the dynamic nature of infectious diseases in the region. Firstly, the prevalence of Salmonella as a significant pathogen in blood samples across different periods highlights persistent health challenges (Ouedraogo et al., 2017). Despite variations in the distribution of other pathogens, Salmonella remains a consistent concern, particularly affecting infants and neonates. This underscores the importance of targeted interventions to address Salmonella-related infections, especially in vulnerable populations. In urine samples, Escherichia coli (E. coli) emerges as the predominant pathogen, aligning with global trends in urinary tract infections. The prevalence of E. coli across age groups underscores the need for effective management strategies, including appropriate antibiotic prescribing practices and hygiene measures to prevent transmission. Regional disparities in pathogen prevalence emphasize the importance of localized interventions. The North region consistently contributes a significant portion of the dataset, indicating specific challenges in this area. Understanding regional variations in pathogen prevalence can inform targeted public health efforts and resource allocation to address local needs effectively (Tacconelli and Pezzani, 2019). Gender and age disparities in infection susceptibility further highlight the complex interplay between biological, behavioral, and socio-economic factors. Tailoring interventions to address gender-specific and age-specific vulnerabilities can enhance the effectiveness of public health initiatives and reduce the burden of infectious diseases in different demographic groups. The analysis of antibiotic resistance trends reveals both promising improvements and concerning trends. While some antibiotics demonstrate decreasing resistance rates, others show signs of increasing resistance, posing challenges for treatment. The findings underscore the importance of antibiotic stewardship programs and the development of alternative treatment modalities to combat multidrug-resistant infections effectively. Overall, the comprehensive analysis provides critical insights into the epidemiology of infectious diseases and antimicrobial resistance in Pakistan. The findings underscore the need for coordinated efforts across healthcare, research, and policy sectors to address the complex challenges posed by infectious diseases and ensure the effective management of antimicrobial resistance in the region (Teklu et al., 2019; Asif et al., 2025; Nawaz et al., 2025a, b; Khan et al., 2025; Uppal et al., 2025).
5. Conclusion
The detailed analysis of blood and urine samples from multiple years in Pakistan offers valuable insights into the prevalence of pathogens, antimicrobial resistance trends, and demographic patterns of infection. The study highlights the persistent challenges posed by pathogens like Salmonella and Escherichia coli, especially among vulnerable populations such as infants and neonates. Regional disparities, gender-specific vulnerabilities, and age-specific susceptibility underscore the need for tailored interventions to address localized needs effectively. Moreover, the findings emphasize the importance of antibiotic stewardship programs and the development of alternative treatment modalities to combat emerging antimicrobial resistance. Overall, this study provides a comprehensive understanding of the epidemiology of infectious diseases in Pakistan, laying the foundation for targeted public health efforts and policy interventions to mitigate the burden of infectious diseases and antimicrobial resistance in the region.
Data Availability Statement
All data supporting the findings of this study are available within the article. Additional data analyzed during the current study are available from the corresponding author upon request.
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Edited by
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Editor:
Takako Matsumura Tundisi
