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Microbial Spectrum and Antibiotics Susceptibility Profile of Nosocomial Urinary Tract Infections in Mansoura Oncology Center

Nowadays, Hospital acquired infections (HAIs) are the major worldwide safety concern for both patients and health-care workers (Scherbaum et al., 2014). HAIs monitored closely by agencies such as CDC to minimize their occurrence and improve patient safety (Monegro and Regunath, 2018). Hospital acquired infections occurs within 48 and 72 hours of patient’s hospital admission (Rose et al., 2019). UTIs are estimated to be 25-40% of HAIs so they represent the most common nosocomial infections (Pragash et al., 2017). Catheter associated urinary tract infection (CAUTI) represent one of the highest rates of occurrence among hospitalized patients, comprising about 36% of HAIs (Aly et al., 2016). Hence, urinary tract instrumentation and prolonged hospital stay are predisposing factors for developing nosocomial UTIs (Gharaghani et al., 2018). The predominant causative agents are Escherichia coli, Klebsiella spp., Proteus International Journal of Current Microbiology and Applied Sciences ISSN: 2319-7706 Volume 9 Number 12 (2020) Journal homepage: http://www.ijcmas.com


Introduction
Nowadays, Hospital acquired infections (HAIs) are the major worldwide safety concern for both patients and health-care workers (Scherbaum et al., 2014). HAIs monitored closely by agencies such as CDC to minimize their occurrence and improve patient safety (Monegro and Regunath, 2018). Hospital acquired infections occurs within 48 and 72 hours of patient's hospital admission (Rose et al., 2019). UTIs are estimated to be 25-40% of HAIs so they represent the most common nosocomial infections (Pragash et al., 2017). Catheter associated urinary tract infection (CAUTI) represent one of the highest rates of occurrence among hospitalized patients, comprising about 36% of HAIs (Aly et al., 2016). Hence, urinary tract instrumentation and prolonged hospital stay are predisposing factors for developing nosocomial UTIs (Gharaghani et al., 2018 Hospital acquired infections (HAIs) are the commonest untoward incident in healthcare delivery worldwide that not only bring additional medical cost but also, extend hospital stay and affect patient's morbidity and mortality. Urinary tract infections (UTIs) account for majority of these infections. The objective is to estimate hospital acquired UTIs prevalence and antibiogram among the admitted cancer patients. Also, to evaluate the performance of chromogenic Uriselect 4 agar medium in isolation and presumptive identification of nosocomial UTIs. Among 10414 patients stayed in hospital > 48 h., 1080patients were suspected to have nosocomial UTIs. 698 (64.6 %) were catheterized and 382 (35.4%) were not. (4.49%) patients confirmed to have nosocomial UTIs. 468 (43.3%) yielded aerobic growth on CLED agar, versus 624(57.8%) on the chromogenic Uriselect4 media. On CLED, 408 isolates were identified by automated Vitek 2 system versus 348 (33.3%) were identified by manual biochemical reactions while 10% and 1.7% of the isolates were not identified by manual biochemical tests and automated Vitek2 system respectively. E.coli was the most frequent isolated uropathogen in cancer patients identified by manual biochemical reactions, automated Vitek 2 system and chromogenic Uriselect 4 medium(11.1%, 23.1% and 17.8% respectively).Catheterization had been the main risk factor for nosocomial infection in our patients.

mirabilis,
Enterococcus spp. and Staphylococcus (Xiaoyan et al., 2017). Identification of causative organism is crucial to plan for treatment protocol and decrease the risk of nosocomial infection. Our objective is to estimate the prevalence and antibiogram of nosocomial UTIs in the admitted cancer patients. Also, the performance of chromogenic Uriselect 4 agar medium which was compared with cysteine lactose electrolyte deficient medium (CLED) in isolation and presumptive identification of nosocomial UTIs.

Materials and Methods
This study was conducted on 1080 specimens that obtained from patients suspected to have nosocomial UTIs (64.6 % were catheterized, 35.4% were non-catheterized) from a total of 2304 urine samples received in OCMU laboratory from 10414 patients stayed more than 48h from a total number of 49585 patients admitted to OCMU during the period from January 2019 to December 2019.
Pd (patient days): total patient's days number in hospital within this period =24414. Dd (Device days): total number of exposure to the devices for all patients during this period=22757 Symptomatic nosocomial UTIs were diagnosed based on the National Health Safety Network guidelines (NHSN, 2015). They include at least one of these signs or symptoms that affect patients without any recognized cause: fever more than 38° C, urgency, frequency, or suprapubic tenderness and positive urine culture more than10 5 cfu/ml. Early morning midstream voided urine or catheter-catch urine samples were aseptically collected in sterilized cap. Samples were then transported to microbiological laboratory within 2 hours.
Allurine specimens were cultured on both CLED agar and chromogenic Uriselect 4 media simultaneously then incubated at 37°C. Significant growth on both plates was identified.
Presumptive bacterial growth identification was done on chromogenic Uriselect 4 medium according to their colour and colony morphology as shown by manufacture supplement catalogue (as shown in Photos A to K). Colonies on CLED agar were identified by gram stain, manual biochemical reactions such as; coagulase, catalase, citirate utilization, ureas, TSI and oxidase and confirmed by by automated Vitek 2 System. Tests for antimicrobial susceptibility were done on Mueller-Hinton agar according to Amoxicillin-Clavulanic, Norfloxacin and Cefotaxime were antimicrobial agents used.

Results and Discussion
Patients included in this study were 444males and 636 females, with range of age from 31 to 66 years.
Another study reported that the incidence rate for device associated infections (DAI) was 19.55% (113/578). This is much lower than our findings. Nevertheless, the device utilization was very high in case of urinary catheter (0.838) in the same study which agrees with our results. DAI rate/100 cases was 6.23 while DAI/1000 cases was 4.25 (Jana et al., 2015). Sawsan et al., 2020 reported the incidence rate of CAUTI was 29.5%. The difference from the result could be due to the fact that this study included only cancer cases who were more liable to nosocomial UTI due to immunodeficiency. Moreover, patient days were much longer in the current study compared to others in the existing literature.
In this study, CLED agar culture revealed bacterial growth in 468 samples (43.3%), gram negative bacilli were detected in 348 cases (74.4%), whereas gram positive organisms were encountered in 120 cases (25.6%).This findings were similar to the study conducted by Akter et al., 2014 which resulted in (42.67%) bacterial growths and (57.33%) showed no growth. Bitew et al., (2017) revealed that 256 of bacterial isolates were recovered, 68.4% of the isolates were Gram-negative and 31.6% isolates were Gram-positive bacteria. Furthermore, another study reported that gram negative bacteria accounted for 73.2% of cases with UTI, while the remaining cases were due to gram positive organisms (Yerega Belete et al., 2019). (Table 2) represent the growth on chromogenic Uriselect 4 medium that yielded 792 isolates. The most frequent isolated organism among the gram-negative bacilli was E-coli 192(17.8%), followed by Citrobacter 120 (11.1%). Regarding gram positive organisms Enterococci 216 (20%) were the most frequent.
In this study, (Table 3) shows the identification of organism growth was 43.3% and 57.8% in CLED agar and chromogenic Uriselect4 medium respectively. In addition, CLED agar yielded single organism in all specimens, while Uriselect4 detected mixed organisms in 19.2% of specimens. On comparing CLED agar with chromogenic Uriselect4 media, there was a significant difference between the two media in organism identification (p < 0.001), this means that chromogenic Uriselect 4 media was superior to CLED agar in isolation and identification of UTI organisms.
There was good agreement between the two techniques. Uriselect4 media had sensitivity and specificity of 100 and 74.5% respectively, with a diagnostic accuracy of 85.6%. Perry et al., (2003) showed that chromogenic Uriselect4 medium lead to the recovery of 98.3% of strains, while it was 90.9% for CLED agar. This study agree with our findings that chromogenic Uriselect4 media were more effective in identification of uropathogens.
( Table 4), shows that 10% and 1.7% of the isolated organisms were not identified by manual biochemical tests and automated Vitek2 system respectively. The result indicated that E. coli was the most commonly isolated gram-negative bacteria (11.1%) by manual biochemical test and (23.1%) by vitek. This is due to the fact that, the commonest gastrointestinal tract and bowel flora is E. coli which ascends to urinary tract (Yerega Belete et al., 2019).  Table.2 Phenotypic identification of the isolated organisms on chromogenic Uriselect 4 medium Table.3 Urine culture on CLED agar versus chromogenic Uriselect 4 medium  By using automated Vitek2 system in this study, 408 isolates were identified E.coli, Citrobacter, and Klebsiella species were identified in 23.1%, 20.5%, and 5.1% respectively. Enterococci, Staphylococcus, Enterobacter, and Candida were detected in 15.4%, 12.8%, 7.7% and 2.6% respectively, while 1.7% weren't identified by Vitek2 system. Bitew et al., (2017) showed that Staphylococci were the commonest grampositive organism identified by automated Vitek2 system 21.4%, followed by Enterococci 5.9%, Streptococci 3.5% and kocuria 0.8%. Regarding gram-negative species, E. coli 52.7% and K.pneumoniae 7%. (