Albanian j. agric. sci. 2013;12 (3): 441-444

Agricultural University of Tirana

(Open Access)

RESEARCH ARTICLE

The study of infectious agents of the urinary tract infections in Durrës, Albania AURORA BAKAJ (ÇIZMJA)1, ENTELA RUÇI (KULLA)2, MIRELA LIKA (ÇEKANI)3 1

University Colleges Medicom, Vlorë

2

Regional Department of Public Health, Durrës

3

Department of Biology, University of Tirana, Faculty of Natural Sciences, Boulevard Zog I, Albania

Abstract: Urinary tract infections (UTI) are characterized by the presence of infectious agents in the genital-urinary tract that cannot be explained by contamination. These agents have the potential to invade the tissues of the urinary tract and adjacent structures. Settings and Design: Prospective study was done in the Health Directory in Durrës. Methods and Material: The study included all the patients who were admitted or visited the outpatient departments in the Health Directory and had urinary tract infection confirmed by positive urine culture reports. Results: A total 3160 urine samples were analyzed for isolation and identification of bacterial isolates. Out of which 956 (30.25%) samples were found to have significant bacteriuria and remaining 2204 samples were found to have either non significant bacteriuria or very low bacterial count or sterile urine. In the present study, out of 223 isolated pathogens the most common isolate was Escherichia coli (25.89%), followed by Staphylococcus aureus (2.94%), Proteus vulgaris (1.04%) and Pseudomonas aeruginosa (0.38 %). Age group most affected by Escherichia coli is 61-75 years (38.8%). Conclusions: Women are more susceptible to urinary tract infections, especially against Escherichia coli, resulting positive in 52.4% of cases; while Proteus vulgaris have a female percentage of 57.7%. This percentage increased slightly among women infected with Staphylococcus saprophyticus in 58% and low in 61.5% infected with Pseudomonas aeruginosa. Keywords: Escherichia coli, Staphylococcus aureus, Proteus vulgaris, Pseudomonas aeruginosa

1. Introduction Urine is usually a sterile fluid, but when it is infected, it contains bacteria. Urinary tract infections (UTI) are one of the most common types of bacterial infections in humans occurring both in the community and the health care settings and ranks high amongst the most common reasons that compel an individual to seek medical attention [3,5,8,9]. UTIs are characterized by the presence of infectious agents in the genital-urinary tract that cannot be explained by contamination. These agents have the potential to invade the tissues of the urinary tract and adjacent structures. The microbiological profile is well known and pathogens such as Escherichia coli have been present in the vast majority of cases [2,6,10,13]. The infection may be limited to the growth of bacteria in the urine (which frequently don’t produce symptoms) or it can result in several syndromes associated with an inflammatory response to the bacterial invasion. Actually, the term UTI represent a wide variety of conditions, including asymptomatic forms of UTIs,

urethritis, cystitis, acute pyelonephritis and pyelonephritis with bacteremia or sepsis [1,7,12] . Urinary tract infections (UTI) are the second most common infectious disease, in which uropathogenic Escherichia coli (UPEC) causes approximately 80% of community-acquired infections and 40% of nosocomial infections [3,4,9,11,13]. The most common bacteria implicated as causative agents of UTI generally originate in the intestine and include but not limited to E. coli, Pseudomonas spp, Streptococcus spp, Proteus spp., Klebsiella spp., Staphylococcus spp, Neisseria gonorrhoea, Chlamydia trachomatis, Candida spp, Mycoplasma.

While UTIs can affect both men and women, they are far more prevalent in females. Approximately 50% of adult women report having had one or more UTIs, and some of these women will develop a history of repeated infections [3,7,8,11]. 2. Material and Methods Midstream urine specimens were collected from 3160 (1580 males and 1580 females) patients who

Correspondence: Aurora Bakaj, University Colleges Medicom, Vlorë, ; Email [email protected] (Accepted for publication 27 June 2013) ISSN: 2218-2020, © Agricultural University of Tirana

Bakaj et al

were admitteed or visited the outpatiennt departmennts in w thhe Health Directory, D D Durrës and had h urinary tract innfection connfirmed by positive p urinee culture repports. T urine samples were collected innto sterile boottles. The A the grounnd for plantiing urine is used blood agar, As e endo agar, McConkey, M ettc.. Plantingg of urine in the terrain is i done in suuch a w that we can count coolonies and based way b on theem to f find the num mber of bacteeria / ml uriine; therefore are b been developped quantitattive methodss of urine cuulture [6,11]. As the ground for planting p urinne is used blood b a agar, endo agar, a McCoonkey, etc.. For Proteuus, to a avoid increassing its pervvasive and allowing a sepparate p potential coloony growth to t be countedd, we preparre the g ground with the highestt percentage agar (4-5% %) by S Sonnenwirth [4,9, 11]. The colllection of samples s was carried ouut in D Durrës betw ween Januaryy, 2012 - December, D 2 2012. D Data analysiis was carrried out on the basis of a p preliminary plan using statistical package p EppiInfo v version 7.

Different types of genus Protteus, are also a con nsidered ass frequent agents of urinary trract inffections. Prooteus is innvading bacterium and is dirrectly relatedd to infectionns of the upper urinary traact. Am mong opporttunistic pathoogenic bacterria as the cauuse of UTI is and Pseuddomonas aerruginosa. This T baccterium muultiplies in environmen nts with trace org ganic substannces. 2 2000 1 1500 1 1000 500 0 Urine samples of Bacteria isolated  patients frrom urine  the p samples

Femalee

%

Male

Figure 1. Bacteria isolated fro om urine

3 Results an 3. nd Discussioon

samples Table 1. Type of infecction isolated from total

A total of 3160 urinne specimenns were colleected f from patientss suspected of o having UT TI, out of whhich a total numberr of 956 showed s signnificant bactterial g growth and were w includedd in the studyy. Of the sam mples a analysed, 9566 strains of various v bacteeria were isollated, c consisting of 447 (46.775%) from males and 509 ( (53.25%) from m females ass detailed in Figure. 1.

mples. urine sam Type of infection Esscherichia cooli Negative Prroteus vulgarris Pseudomonas P s aeruginosa Sttaphylococcu us aureus Total

The gram-neegative bacteria constittuted the larrgest T g group with a prevalence of 863 (90.27%) while w g gram-positiv ve bacteria constitutedd only som me 93 ( (9.73%) of the t total isoolates. The bacteria b isollated w were E. coli (25.89%)), S. aureeus (2.94%)), P. v vulgaris (1.004%) and P. P aeruginossa (0.38%). The h highest prooportion of isolates were E. coli ( (25.89%) annd S. aureuus (2.94 %)) accountingg for 9 95.2% of thhe total num mber of isoolates recovvered f from the urine u sampples. Otheer less-freqquent isolates in agggregate caaused 4.8% of infectionns.

Frequen ncy

Percentt

818 2204 33

25.89% % 69.75% % 1.04%

Cumulattive Percen nt 25.89% % 95.63% % 96.68% %

12

0.38%

97.06% %

93

2.94%

100.00% %

3160

100.00% %

100.00% %

Table 2.. 95% Confiddential limits for each type of infection isollated from to otal urine samples.

Viewingg Table 1, we w notice thatt people are more m a affected by Escherichiaa coli in a much higher p percentage t than the thrree other bacteria: b Prooteus v vulgaris, Stap aphylococcuss aureus annd Pseudom monas a aeruginosa. Pronounnced prevaleence of Esccherichia cooli in u urinary tract infections, compared c wiith other baccteria n normally preesent in the gut, g is indicaative of a unnique a ability of thiss bacterium to t invade, annd to be placced in thhe urinary trract.

Type of infeection

995% Confiden ntial limits

Escherichiaa coli

224.37%

27.46% 2

Negativve

668.11%

71.34% 7

Proteus vullgaris

0.73%

1.48%

Psseudomonas aeeruginosa

0.21%

0.68%

Staphylococcu S us aureus

22.39%

3.61%

Staphylococci are connsidered morre contaminaants of urine. In ouur results thhe most frequ uently betweeen aphylococci is i Staphylocooccus aureuss. Sta

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The study of infecctious agents of o the urinary tract infectionns in Durrës, A Albania

Sampless obtained from female subjects s (53.225%) y yielded moree bacteria thaan those obtaained from males m ( (46.75). The sex distributtion of patiennts in the present s study was connsistent withh that of otheer studies [7,12]. Several reports havve indicated that females are m more prone to t having UTIs U than maales, becausee the u urethra is shoorter in females than maales and is easily e m more readilyy transverse by micrroorganisms [7]. W Women’s proopensity to develop UT TIs has also been e explained onn the basis of o certain beehavioral facctors, inncluding dellays in icturaation, sexuall activity, thee use o diaphragm of ms and sppermicidal (both ( of which w p promote coloonization off the periurrethral area with b bacteria). Allso, the lenggth of the urethra, u the dried e environment surroundinng the meeatus, and the a antibacterial properties of prostatic flluid contribuute to a lower rate of o infection in i males. In Figurre 2 are preesented steriile, negativee and p positive cases with bacterria. We emphhasize that iff you u a good hygiene in urine then emerges stterile use c culture, that is i to say that we do not have any kinnd of b bacteria grow wing in the ground; g while negative cases c a them thatt have 2-3 colonies, are c whiich are not taken t innto account.

Urine is a very good gground for th he developm ment of bacteria, especially gram-negaative bacteria. Baakteriuria in clinical annalysis of urine u is alm most alw ways assocciated withh specific bacteria of baccteriologicall analysis. B Bacteria in the t urine were w fou und at a rate of about 69.75%. Table 3. Frequency a bbacteriologicaal analysis by age grroup in total Ag ge Group ≥ 76 1 - 15 16 1 - 30 31 3 - 45 46 4 - 60 61 6 - 75 Total

1200 1000 800 600 400 200 0 Positive

P Percent 13.29% 88.70% 10.32% 88.48% 20.41% 38.80% 1000.00%

Cum m. Percent 13.29% 1 21.99% 2 32.31% 3 40.79% 4 61.20% 6 100.00% 100.00%

Companioonship of bacterinuriaa of cliniical anaalysis with Pseudomona P as aeruginossa and Protteus vullgaris, are respectively r 100% and 93.94% thatt is alsso seen in thhe low numbber of cases with these two t typ pes of bacterria. While coompatibility for Eschericchia colli is in the order of 995.1% and Staphylococcus sap prophyticus is 91.4%. Itt explained that t not always thee first bacteriia seen in a m microscopy field f for cliniical anaalysis follow wed 100% of bacteriaa growing on sellective grounnds, and ofteen the reason n for not takking bettter the analyysis. The sam me reasoning g is and for the com mpanionshipp of leukocyttes with bacteria. Urinary leeukocyte com mpatibility with w Eschericchia colli is in the order of 995.1%. If we compare the baccteriuria withh leukocituriia, then we see s that we shhift sm mall and not significant. If you wantt to see if thhere aree correlationss between eaach of the 4 and a leukocituuria baccteria in urinne do the foollowing analysis: From the tab ble above, itt appears thhat we correelation betweeen leu ukocituri andd bacteria E.ccoli. This is very importtant in the evaluation of urinarry tract infecctions. Analyysis waas carried ouut by each bbacterium acccording to sex (m male / female)). On the basis b of the urine samp ples we se that t wo omen, support better growth of E. co oli comparedd to thee male urine samples. In our stud dy females are afffected with E. E coli by 522.4% comparred to men who w aree affected onnly 47.6%. These differrences betweeen thee sexes havee to do with the pH of th he urine andd its osm molarity andd this reinfforces the hypothesis h t that am mong other factors, urinnary tract in nfections occcur mo ore often in women. w Proteus vuulgaris havee a percentag ge of 57.6% for wo omen and 42.4% for menn. So again we w have a higgher perrcentage of women w than men.

1400

N Negative

Frrequency 420 275 326 268 645 1226 3160

Steril

Frequency F Figure 2. Positive, negative n and sterile s cases of urinee samples

Of courrse, we havee made an analysis by age. Ages which have A h provedd most affecteed have beenn 617 years (38..8%) and 46-60 years to (20.41%). Often 75 O thhe risk of urrinary tract infections i inccreases withh age, thherefore people often have conceerns and doo the a analysis in thhis age.. Bacterioological analyysis of urinee usually is made m a after clinical analysis in which the value v of baccteria a leukocytees emerged over and o the rate.

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We have made an analysis based on the seasons. Distribution is different; therefore E. coli roof is in the summer, while in three other seasons have almost similar values. P. vulgaris have two peaks in winter and in summer; while two others: P. aeruginosa and S.saprophyticus have the same distribution almost the entire year.

5. References 1. Alcomo IE: Bacterial reproduction and growth. Microbiology; 1987: 116-126 2. Andoni R, Ibro M: Infeksionet e traktit urinar. Bakterologjia Klinike; 2004: 84-89 3. Atlas MR: Urinary tract infections. Microbiology, Fondamentals and Applications; 1998: 614.

160 140

4. Balows A, Hansler J, Hermann K, Isenberg H, Shadomy J: Urinary tract pathogens. In: Manual of Clinical of Microbiology; 1991: 186.

120 100 80

5. Benson JH: Urinary tract pathogens. Microbiological aplications; 2001:262-267.

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6. Hysko M: Urokultura. Manual i mikrobiologjisë; 2007: 283

40 20

7. Kolawale AS, Kolawale OM, Kandaki-Olukemi YT, Babatunde SK, Durowade KA, Kplawale CF: Prevalence of urinary tract infections among patients attending Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State, Nigeria. Int. J. Med. Med. Sci. 2009, 1(5): 163-167

0 Winter

Spring

E. coli P. vulgaris

Summer

Autumn

S. aureus P. aeruginosa

8. Lika (Çekani) M: Sistemi urinar. Histologjia; 2007: 274-285

Figure 3. Distribution of cases according to the seasons

9. Lika (Çekani) M, Kullaj A, Nelaj E, Meçe O: Bacterial load in the human upper respiratory tract. Albanian Journal of Agricultural Sciences (AJAS), 2011. Vol.10, 1: 39-44

4. Conclusions This paper describes a study undertaken to evaluate the prevalence and susceptibility patterns of bacterial strains isolated from patients diagnosed with UTIs in a referral Health Directory in Durrës, Albania. Women are more susceptible to urinary tract infections, especially against Escherichia coli, resulting positive in 52.4% of cases; while Proteus vulgaris have a female percentage of 57.7%. This percentage increased slightly among women infected with Staphylococcus saprophyticus in 58% and low in 61.5% infected with Pseudomonas aeruginosa. Greater frequency of infections with Escherichia coli and Proteus vulgaris is found in the hot summer season, which also affects many factors that have not been analyzed in this study.

10. Neu HC: Urinary tract infections. Am. J. Med. 1992, 92:63–70. 11. Papajorgji M, Kero A: Diagnoza mikrobiologjike e infeksioneve të shkaktura nga E.coli dhe e infeksioneve të tjera. Manual bazë mbi metodat diagnostike mikrobiologjike e bakterologjike; 2002: 80-82, 104 12. Ronald A: The etiology of urinary tract infection: traditional and emerging pathogens. Dis. Mon. 2003, 49: 71–82. 13. Sheffield J S, Cunningham F G: Urinary tract infection in women. Obstet Gynecol; 2005: 106, 1085-1092.

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