S116 Asian Pac J Trop Med 2014; 7(Suppl 1): S116-S120

Contents lists available at ScienceDirect

Asian Pacific Journal of Tropical Medicine

journal homepage:www.elsevier.com/locate/apjtm

Document heading doi: 10.1016/S1995-7645(14)60216-9

Antibiotic sensitivity pattern from pregnant women with urinary tract

infection in Bangalore, India
Sibi G , Pinki Kumari, Kabungulundabungi Neema
*

Department of Biotechnology, Indian Academy Degree College, Centre for Research and Post Graduate Studies, Bangalore, India

ARTICLE INFO ABSTRACT

Article history: Objective: To determine the antibacterial profile of pregnant women with urinaty tract infections
Received 23 Jun 2014 and analyze the antibiotic sensitivity pattern for the effective treatment.
Received in revised form 10 Sep 2014 Methods: A total of 395 urine samples from pregnant women with different gestational age were
Accepted 15 Sep 2014 processed for the isolation of uropathogens and tested against eight groups of antibiotics namely
Available online 19 Sep 2014 penicillins, cephalosporins, fluoroquinolones, aminoglycosides, macrolides, lincosamides,
glycopeptides and sulfonamides.
Results: A positive culture percentage of 46.6% was obtained with the highest urinary tract
Keywords:
infection in third trimester gestational age. Among the uropathogens isolated, 85.6% were Gram
Urinary tract infection
negative and 14.4% were Gram positive with Escherichia coli as the predominant bacteria (43.9%)
Pregnancy
followed by Klebsiella oxytoca (19.4%) and Klebsiella pneumoniae (13.3%). Antibiotic sensitivity
Uropathogens
assay revealed that amikacin had the highest overall sensitivity (n=136; 76.7%) and the subsequent
Amikacin
highest sensitivity was observed with ciprofloxacin (n=132; 73.3%), clindamycin (n=124; 68.9%),
cefotaxime (n=117; 65%) and nalidixic acid (n=115; 63.9%).
Conclusions: The findings revealed that uropathogens were more resistant to penicillins,
macrolides and glycopeptides which restrict their use in treating urinaty tract infections during
pregnancy. In conclusion, common causative bacteria and their antibiotic sensitivity pattern are
to be determined along with their safety to mother and fetus for the effective treatment of urinary
tract infections during pregnancy.

1. Introduction bacterial growth[5]. UTIs in pregnancy left untreated leads to

Urinary tract infection (UTI) in women are more prevalent
due to their short urethra and its anatomical proximity
to the anal orifice[1,2]. UTIs are most common bacterial
infection which complicates pregnancy[3]. Pregnancy causes
numerous hormonal and mechanical changes in the body.
Beginning in the sixth week, with peak incidence during
22nd to 24th weeks, 90% of the pregnant females develop
urethral dialatation increasing the risk of urinary stasis and
vesicouretral reflux[4]. Further, glycosuria and aminoaciduria
during pregnancy are additional factors to facilitate
*Corresponding author: Sibi G, Department of Biotechnology, Indian Academy Degree
College, Centre for Research and Post Graduate Studies, Bangalore, India.
E-mail: gsibii@gmail.com
maternal and perinatal morbidity and mortality[6]. Untreated
bacteriruia during pregnancy is associated with low birth-
weight and premature delivery[7].
Resistance development to previously effective antibiotics
by the uropathogens has been reported globally in recent
years[8,9], and their susceptibility vary from place and
time[10]. There are two major challenges while treating
UTI s in pregnancy; protection of fetus and resistance
development of uropathogens. Physicians must consider
possible side effects from drugs to protect maternal and
fetal safety while prescribing antibiotics[11,12]. At the same
time the chosen antibiotic should have efficacy and low
resistance rates in a given population[13,14].
I solation of pathogens associated with UTI s and
determining their antibiotic sensitive pattern will
 Sibi G, Pinki Kumari and Kabungulundabungi Neema /Asian Pac J Trop Med 2014; 7(Suppl 1): S116-S120
potentially reduce the inappropriate prescription of
antibiotics and resistance development. Further, detection
of changing susceptibility pattern by the uropathogens
against commonly used antibiotics is one effective strategy
for empirical treatment. This study evaluates the antibiotic
susceptibility pattern of uropathogens from pregnancy.
2. Materials and methods
2.1. Study population
A total of 395 urine samples from pregnant women with
or without having symptoms of UTI were collected during
October 2012 to January 2014. The age of people included in
the study ranged from 25-40 years. Verbal informed consent
from target population and approval from institutional
research ethical committee were obtained before starting the
experiment.
2.2. Inclusion and exclusion criteria
F emale patients aged between 25 - 40 years with
uncomplicated UTI symptoms like frequency, urgency and
dysuria were included in the study. Pregnant women on
antibiotics within the last 2 weeks and those who could not
give consent to participate in the study were excluded.
2.3. Sample collection and processing
Clean catch midstream urine samples were collected
into a sterile screw capped universal container by standard
method. The samples were labeled and 0.2 mg of boric acid
was added to prevent the bacterial growth in urine samples.
The samples were cultured on cysteine-lactose electrolyte
deficient agar and blood agar using a sterile 4 mm platinum
wired calibrated loop for the isolation of microorganisms.
The plates were incubated for overnight at 37 °C and the
samples were considered positive when an organism
was cultured at a concentration of 104 CFU/mL which was
estimated through multiplying the isolated colonies by
1 000. The isolates were identified up to the species level by
standard biochemical tests[15].
2.4. Antibiotic sensitivity assay
A ntibiotic sensitivity testing was performed by
S117
the modified disc diffusion method as per the
recommendations[16]. Inoculums adjusted to 0.5 McFarland
standard was swabbed on Mueller Hinton agar plates for
antibiotic sensitivity assay. Eight groups of antimicrobials
such as penicillins, cephalosporins, fluoroquinolones,
aminoglycosides, macrolides, lincosamides, glycopeptides
and sulfonamides were selected based on frequent
prescription and used in this study. Among the group, the
antibiotics tested were amoxicillin (10 µg), oxacillin (10 µg),
cloxacillin (5 µg), cefotaxime (10 µg), ceftriaxone (30 µg),
nalidixic acid (30 µg), ciprofloxacin (5 µg), norfloxacin (10 µg),
amikacin (30 µg), gentamycin (10 µg), erythromycin (10 µg),
clindamycin (2 µg), vancomycin (30 µg) and co-trimoxazole
(30 µg). Statistical analysis was done using Chi-square test
and student’s t-test.
3. Results
Among the 395 samples collected, 180 were laboratory
confirmed cases of UTI with a positive culture percentage of
46.6% (Table 1). The age of the pregnant women ranged from
25-40 years. Majority (50.6%) of the study participants were in
the age group of 30-34 years. The highest UTI were observed
at third trimester gestational age (n=103; 57.2%).
Table 1
Characteristics of UTI in pregnant women.
Variables Numbers (n=180) Percentage
Age 25-29 years 87 48.3
30-34 years 91 50.6
≥35 years 2 1.1
Gestational period First trimester 21 11.7
Second trimester 31.1
56
Third trimester 103 57.2
From the 180 isolates, 154 were Gram negative while 26
were Gram positive bacteria (Figure 1). Escherichia coli (E.
coli) was the most common organism isolated accounting for
79 (43.9%) and the second highest organism was Klebsiella
oxytoca (K. oxytoca) (n=35; 19.4%) followed by Klebiella
pneumoniae ( K. pneumoniae ) ( n= 24 ; 13 . 3 % ) . T he other
bacterial isolates obtained in the study were Enterococcus
faecalis ( E. faecalis ) , Staphylococcus saprophyticus ( S.
saprophyticus), Staphylococcus aureus (S. aureus), Proteus
mirabilis ( P. mirabilis ) , Proteus vulgaris ( P. vulgaris ) ,
Pseudomonas aeruginosa (P. aeruginosa), Citrobacter koseri
(C. koseri) and Citrobacter amalonaticus (C. amalonaticus).
The frequency of occurrence of other bacterial isolates
were E. faecalis (n=12; 6.7%), S. saprophyticus (n=10; 5.5%),
S118 Sibi G, Pinki Kumari and Kabungulundabungi Neema /Asian Pac J Trop Med 2014; 7(Suppl 1): S116-S120

P. mirabilis (n=9; 5.0%), S. aureus (n=4; 2.2%), P. aeruginosa and clindamycin was observed with P. aeruginosa, P.
(n=3; 1.7%), P. vulgaris (n=2; 1.1%), C. koseri (n=1; 0.6%) and vulgaris, C. koseri and C. amalonticus.
C. amalonaticus (n=1; 0.6%). The isolated uropathogens revealed the presence of high

19.4%
levels of single and multiple antimicrobial resistances
E. coli against commonly prescribed drugs as shown in Table
K. oxytoca
3 . A mikacin had the highest overall sensitivity ( n= 138 ;
K. pneumoniae
76.7%) against the 180 isolates tested. This was followed
E. faecalis
43.9% 13.3%
S. saprophyticus by ciprofloxacin (n=132; 73.3%) and clindamycin (n=124;
P. mirabilis 68.9%). Cefotaxime and nalidixic acid were exhibited 65.0%
6.7% S. aureus and 63.9% sensitivity against the isolates. Ceftriaxone had
5.5% P. aeruginosa the overall sensitivity of 52.8%. The other antibiotics were
5.0%
recorded lesser than 50 % of the sensitivity as follows:
P. vulgaris
C. koseri
co-trimoxazole 45.0%, cloxacillin 31.6%, oxacillin 31.1%,
C. amfalonaticus
0.6% 0.6% 1.1% 1.7% 2.2% norfloxacin 29.4%, vancomycin 28.9%, amoxicillin 28.3%,
Figure 1. Distribution of bacterial population in pregnant women with UTI. gentamycin 27.2% and erythromycin 18.3%.
Table 3
Antibiotic sensitivity pattern of the bacterial isolates Antibiotic sensitivity pattern of the isolates.
revealed that E. coli with 89.9% sensitivity to amikacin, Antibiotics Frequency Percentages
Sensitive Resistance
83.5% to co-trimoxazole, 79.7% to clindamycin and 77.2%
Penicillin Amoxicillin 51 28.3 71.7
to ciprofloxacin (Table 2). The antibiotics which had poor Oxacillin 56 31.1 68.9
activity against E. coli were cloxacillin (13.9%), gentamycin Cloxacillin 57 31.6 68.4
(12.6%), vancomycin (8.9%), erythromycin (7.6%), amoxicillin Cephalosporin Cefotaxime 117 65.0 35.0
( 5 . 1 % ) and oxacillin ( 2 . 5 % ) . K. oxytoca showed 88 . 5 % Ceftriaxone 95 52.8 47.2

sensitivity to ciprofloxacin and 62.8% to nalidixic acid while Fluoroquinolones Nalidixic acid 115 63.9 36.1
Ciprofloxacin 132 73.3 26.7
sensitivity to erythromycin was 0%. Most of the antibiotics
Norfloxacin 53 29.4 70.6
were effective against K. pneumoniae with co-trimoxazole
Aminoglycosides Amikacin 138 76.7 23.3
has significant activity (91.6%) followed by cefotaxime (83.3%). Gentamycin 49 27.2 72.8
Gross 100% sensitivity was noted on nalidixic acid against E. Macrolide Erythromycin 33 18.3 81.7
faecalis and P. mirabilis. S. saprophyticus was 90% sensitive Lincosamides Clindamycin 124 68.9 31.1

to co-trimoxazole and 80% to nalidixic acid, clindamycin Glycopeptide Vancomycin 52 28.9 71.1

and vancomycin. A complete 100% sensitivity to cefotaxime Sulfonamide Co-trimoxazole 81 45.0 55.0

Table 2
Antibiotic sensitivity pattern of urinary isolates. n(%).
Antibiotic E. coli K. oxytoca K. E. faecalis S. P. mirabilis S. aureus P. P. vulgaris C. koseri C.
pneumoniae saprophyticus aeruginosa amalonticus
Amoxicillin (10 µg) 4 (5.1) 11 (31.4) 8 (33.3) 9 (75.0) 7 (70.0) 7 (77.7) 2 (50.0) 2 (66.6) 0 (0.0) 0 (0.0) 1 (100.0)

Oxacillin (10 µg) 2 (2.5) 12 (34.2) 16 (66.7) 9 (75.0) 7 (70.0) 6 (66.6) 1 (25.0) 2 (66.6) 0 (0.0) 0 (0.0) 1 (100.0)

Cloxacillin (5 µg) 11 (13.9) 8 (23.0) 10 (41.6) 11 (91.6) 3 (30.0) 8 (88.9) 3 (75.0) 1 (33.3) 1 (50.0) 0 (0.0) 1 (100.0)

Cefotaxime (10 µg) 53 (67.0) 17 (48.5) 20 (83.3) 7 (58.3) 4 (40.0) 8 (88.9) 1 (25.0) 3 (100.0) 2 (100.0) 1 (100.0) 1 (100.0)

Ceftriaxone (30 µg) 47 (59.5) 8 (22.8) 15 (62.5) 7 (58.3) 6 (60.0) 8 (88.9) 0 (0.0) 2 (66.6) 1 (50.0) 1 (100.0) 0 (0.0)

Nalidixic acid (30 µg) 38 (48.1) 22 (62.8) 17 (70.8) 12 (100.0) 8 (80.0) 9 (100.0) 3 (75.0) 2 (66.6) 2 (100.0) 1 (100.0) 1 (100.0)

Ciprofloxacin (5 µg) 61 (77.2) 31 (88.5) 11 (45.8) 8 (66.6) 6 (60.0) 8 (88.9) 2 (50.0) 3 (100.0) 1 (50.0) 1 (100.0) 0 (0.0)

Norfloxacin (10 µg) 45 (56.9) 10 (28.6) 14 (58.3) 9 (75.0) 4 (40.0) 6 (66.6) 1 (25.0) 2 (66.6) 1 (50.0) 1 (100.0) 1 (100.0)

Amikacin (30 µg) 71 (89.9) 18 (51.4) 19 (79.1) 9 (75.0) 5 (50.0) 8 (88.9) 3 (75.0) 2 (66.6) 2 (100.0) 0 (0.0) 1 (100.0)

Gentamycin (10 µg) 10 (12.6) 5 (14.2) 17 (70.8) 4 (33.3) 5 (50.0) 3 (33.3) 2 (50.0) 2 (66.6) 1 (50.0) 0 (0.0) 0 (0.0)

Erythromycin (10 µg) 6 (7.6) 0 (0.0) 7 (29.1) 5 (41.6) 7 (70.0) 4 (44.4) 3 (75.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0)

Clindamycin (2 µg) 63 (79.7) 18 (51.4) 10 (41.6) 9 (75.0) 8 (80.0) 6 (66.6) 3 (75.0) 3 (100.0) 2 (100.0) 1 (100.0) 1(100.0)

Vancomycin (30 µg) 7 (8.9) 3 (56.0) 18 (75.0) 8 (66.6) 8 (80.0) 2 (22.2) 4 (100.0) 1 (33.3) 1 (50.0) 0 (0.0) 0 (0.0)

Co-trimoxazole (30 µg) 66 (83.5) 20 (57.1) 22 (91.6) 10 (83.3) 9 (90.0) 6 (66.6) 3 (75.0) 3 (100.0) 2 (100.0) 0 (0.0) 0 (0.0)
 Sibi G, Pinki Kumari and Kabungulundabungi Neema /Asian Pac J Trop Med 2014; 7(Suppl 1): S116-S120
4. Discussion
While treating UTI in pregnancy, proper investigation
and treatment are needed to prevent serious life
threatening condition and morbidity rate[17]. In this study,
it was observed that most of the uropathogens were same
as over the years but the antibiotic resistance pattern
were varying and increasing.
F emales of the age group between 25 - 34 years were
more susceptible to UTIs (98.9%) than the elderly ones.
H igh sexual activities, recent use of diaphragm with
spermicide are associated with high incidence of UTI in
young females[18]. The occurrence of asymptomatic and
symptomatic bacteriuria was increased with gestational
period as 31.1% in second trimester and 57.2% in third
trimester.
The Gram negative bacteria were predominated with E.
coli being the most common pathogen (43.9%) followed by
K. oxytoca (19.4%) in this study. E. coli and Klebsiella spp
are most common in each of three trimesters of pregnant
women with UTI[19]. Among the Gram positive organisms,
E. faecalis and S. saprophyticus were formed the majority
of uropathogens isolated. Enterococcus is reported as a
frequent cause of UTIs[20]. S. saprophyticus has been found
to colonize the urinary tract in earlier reports[21,22]. Most
of the E. coli strains were sensitive to amikacin (89.9%)
and similar kind of results was seen with Rizvi et al[23]. K.
oxytoca was resistant to cefotaxime and ceftriaxone which
is in accordance with earlier report where cephalosporin
resistant strains were isolated from UTIs[24]. However, K.
pneumoniae was highly sensitive to cefotaxime (83.3%) and
the findings are similar with previous study[25]. Nalidixic
acid and co-trimoxazole were highly effective against E.
faecalis with 100% and 83.3% sensitivity. Cephalosporins
and quinolones were shown to effective against UTI
causing organisms in pregnant women[26].
Antimicrobial susceptibility testing revealed the high
resistance to penicillins ( beta lactam group ) by the
urinary isolates and similar results were reported in
earlier studies[27,28]. This could be a result of extensive
usage of these antibiotics and increased spreading of beta
lactamase producing strains. This finding restricts the
use of beta lactam group of antibiotics though they are
considered as traditional drugs safe in pregnancy. Most
of the isolates had poor sensitivity to gentamycin (27.2%)
which is known to be nephrotoxic[29], and should therefore
be avoided. Previous report of trimethoprim as effective
S119
drug[30] against uropathogens is becoming less effective
with only 45% sensitivity from this study. Sensitivity to
flouroquinolones especially with ciprofloxacin ( 73 . 3 % )
and nalidixic acid (63.9%) were significant in this study
thus revealing their potency against the uropathogens.
However, widespread usage may lead to resistance against
fluoroquinolones[31]. It was found that the resistance to
amikacin and ciprofloxacin were low which suggests that
these drugs may be considered as first line agents for
treatment of UTIs among the pregnant women. Empirical
use of antimicrobials may cause the development of
more resistant bacteria which complicates the therapy in
UTIs[32]. The results revealed that uropathogens were more
resistant to penicillins, macrolides and glycopeptides
which restrict their use in treating UTIs.
In conclusion, the susceptibility patterns of the urinary
isolates suggest the necessity of sensitivity reports before
initiation of antibiotic therapy in pregnant women with
UTIs. Further, this data would help to formulate antibiotic
prescription policies while treating pregnant women.
Conflict of interest statement
We declare that we have no conflict of interest.
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