Diversity of uropathogens and their antibiotic resistance among diabetic patients presented to MTI-Lady Reading Hospital, Peshawar

Objective: Our objective was to quantify the number of various bacteria that frequently cause UTI in diabetes patients as well as to gauge their susceptibility and resistance to antibiotics. Method: A cross-sectional study was conducted at the Internal Medicine Ward of Lady Reading Hospital, Peshawar, Pakistan from June 2021 to December 2021, Patients with confirmed diabetes were included in the study; however, participants receiving antimicrobial medications for a maximum of 14 days were excluded from the study. Resistance of Escherichia coli, Candida, Pseudomonas, E. faecalis, Klebsiella, P. mirabilis and Staphylococcus was asssessed using ciprofloxac, ceftazidime and meropenem. Results: The findings highlighted the the prevalence of Escherichia coli in 38.8% of patients, Candida in 19% of patients, Enterococcus faecalis in 11.8% of patients, Pseudomonas in 10%, Klebsiella in 9.5% patients, Proteus mirabilis 6.2% patients and Staphylococcus was found in 5.2% patients. According to the overall sensitivity and resistance of antibiotics in microorganisms, Meropenem showed 89.6% sensitivity and 10.4% resistance. Ciprofloxacin showed 38.9% sensitivity and 61.1% resistance and ceftazidime showed 22.7 sensitivity and 77.3% resistance. Conclusion: UTIs were very common in diabetes patients, and Escherichia coli was the most common uropathogen found. Compared to male patients, more female patients had infections. The uropathogens showed a significant degree of resistance to ceftizidime and ciprofloxacin.


INTRODUCTION
The most frequent bacterial infections are urinary tract infections, which account for almost seven the Tamm-Horsfall Protein (THP), granulocyte dysfunction, the presence of diabetic cystopathy, and microvascular disease in the kidneys. 6In addition, women (42.8%) are more likely than men (34.1%) to get a UTI among diabetic patients. 7,8he majority of unrestricted antibiotic usage leads to an increase in resistance among uropathogens in both community and healthcare settings, and treatment of UTI patients is frequently initiated empirically. 9,10For appropriate UTI therapeutic interventions, local data regarding the antibiotic resistance of uropathogens should be available.The study's objective was to assess the range of uropathogens and their profiles of antibiotic resistance in a group of patients with and without diabetes.

METHOD
In this cross-sectional investigation conducted from from June 2021 to December 2021.Two hundred eleven patients with confirmed diabetes were included.50% as the anticipated prevalence of UTIs was used to calculate the sample size.The formula n=z²*p (1-p)/ d² was used to determine the minimal sample size. 11here n is the necessary sample size, z is the normal deviation (= 1.96), which corresponds to the 95% confidence interval, p is the percentage of the target population with the desired features (0.5 = 50%) and d is degrees of freedom (= 0.05).Patients with confirmed diabetes were included in the study; however, participants receiving antimicrobial medications for a maximum of 14 days were excluded.A selfadministered questionnaire was utilized to gather data on demographic and socioeconomic characteristics after each patient gave their informed consent.Ethical Approval: The study was approved by ethics and scientific committee (Reference# 543/LRH/MTI; Date 27/07/2020).
Fasting blood glucose, random blood glucose, urine routine examination (dipstick and microscopy), urine culture and sensitivity on urine culture media (McConkey agar, cystine lactose electrolyte deficient medium) were performed.All the data were recorded on predesigned proforma for subsequent analysis.Data analyses were done by using IBM SPSS version 20.Microorganisms and resistance/sensitivity to different drugs were stratified according to different age groups, gender and presenting symptoms to see the role of effect modifiers.

DISCUSSION
Urinary tract infections (UTIs) are the most common bacterial infectious illness in community practice, with  12 Both the lower and higher urinary systems can be impacted by lower urinary tract infections.Cystitis, often known as a lower urinary tract infection (UTI), is characterized by symptoms such as suprapubic pain, frequency, and urgency.The likelihood of an upper UTI, which is typical in most UTI patients, is not excluded only because lower UTI symptoms are present. 13TI is more common in females than in males because the female urethra is physically less efficient at preventing bacterial invasion. 14The urothelial mucosa's attachment to the mucopolysaccharide lining and the vaginal tract's close proximity to the urethra could be the cause.Other significant risk factors for UTI in women include pregnancy and sexual activity. 15he normal increase in plasma volume and decrease in urine concentration in pregnant women (70%) results in glycosuria, which promotes bacterial growth in the urine. 16In a non-pregnant state, the uterus is similarly located above the bladder; however, in a pregnant state, the enlarged uterus has an impact on the urinary system.Because bacteria can enter the urethra during sexual activity and can be rubbed up the urethra and into the bladder after childbirth, female sexual activity increases the risk of urethra infection. 17ur study found that women were more likely than men to present with UTI (69.7% vs. 30.3%),which is in line with other studies that have found that women are more prone to get UTI. 18According to this study, Escherichia coli was found in 38.8% of urine samples with positive UTI findings and was the most prevalent gram-negative bacterium.This result is consistent with what previous research has shown. 19In this investigation, Candida (19%), Enterococcus faecalis (11.8%),Pseudomonas (10%), Klebsiella (9.5%), Proteus mirabilis (6.2%), and Staphylococcus (5.2%) were also identified bacteria from UTI patients.These results are consistent with research that found E coli prevalence to be 34.4%,candida prevalence to be 17.7%, enterococcus faecalis prevalence to be 10.9%, pseudomonas prevalence to be 10.4%, Klebsiella prevalence to be 8.8%, proteus mirabilis prevalence to be 7.3%, and staphylococcus prevalence to be 5.2%. 10. coli and Klebsiella were shown to be the most common uropathogens in UTIs in various parts of the world.The higher incidence of gramme-negative bacteria from the Enterobacteriaceae family causing UTI is due to a variety of reasons, including their adhesion to the uroepithelium.In addition, adhesins, pili, fimbriae, and the P-1 blood group phenotypic receptor allow them to infiltrate the urogenital mucosa. 20eropenem used in this study was found to be the most sensitive drug against all isolated uropathogens showing 89.6% overall sensitivity.Meropenem was found the most effective against all uropathogens, E. coli (88.9%),Candida (92.5%),Enterococcus faecalis (92%), Pseudomonas (95.2%),Klebsiella (80%), Proteus mirabilis (92.3%) and Staphylococcus (81.8%).The results of this study on antibiotic susceptibility match those of other research. 18Meropenem was found to be 95.8% sensitive against extended-spectrum lactamaseproducing E. coli in research.Meropenem was followed by amikacin (93.7%) and imipenem (91.71%). 21

Suggestions:
The results of this study suggest that future research should concentrate on the root causes of resistance to discover answers to this serious issue as well as the use of health education to discourage medication use.

CONCLUSION
The results of our investigation showed that UTIs were very common in diabetes patients, and Escherichia coli was the most common uropathogen found.Compared to male patients, more female patients had infections.The uropathogens showed a significant degree of resistance to ceftizidime and ciprofloxacin.

Table - I
: Frequency of microorganism.Table-II: Sensitivity and resistance of antibiotics.

Table -
III: Microorganisms and their sensitivity and resistance to antibiotics.