Antibiotic Resistance Patterns of Uropathogens in Long Term Care Facilities

Background Multidrug-resistant organisms (MDROs) are serious challenges on clinical treatment, infection control and public health 1,2 . The complexity and recurrent features of MDROs pose a threat to affected patients worldwide and frequently lead to poorer outcomes such as longer hospital stays, increased mortality, and higher hospitalization cost 3 . Residence at a LTCF and older age are both recognized as significant risk factors for harboring MDRGNB 4 . Residents of LTCFs for the elderly had more than double the rate of E. coli and Klebsiella UTI and more than four times the rate of E. coli and Klebsiella UTI caused by antibiotic-resistant bacteria compared with those living in the community 5 . The availability of antimicrobial agents that target uropathogens has become increasingly limited due to increasing rates of antibiotic resistance, especially in LTCF, as reported in local antibiogram data in Calgary and Edmonton 6,7 . The objective of this study is to detect the commonest multidrug resistant bacteria and its antibiotic sensitivity in urine of elderly residents with urinary tract infection (UTI) at long term care facility.

difficult; a specimen was obtained by a new sterile urinary catheter under aseptic condition.
Analysis and culture were done within 2 h of specimen collection.When urine analysis showed pus cells more than 5 WBCs / hpf (white blood cells per high power field) with positive nitrate and leukocyte esterase in urine, those urine samples proceeded to culture and sensitivity to a range of different antibiotic groups.Samples with resistance to 2 or more antibiotic groups were included in the study.All samples were processed as per standard techniques and bacteria identified by standard biochemical tests.
Demographic data collected and comorbidities established for included cases.Duration of Stay (DOS) stands for the time period in weeks elapsed between admission and start of Isolation for urine resistant infection.DOS Zero stands for 1 st 48 hours of admission to LTCF while DOS 1 stands for the rest of 1 st week of admission starting after 48hours of admission (i.e from day 3 till end of day 7).

Statistical Analysis
IBM SPSS statistics (version 24, IBM corp., USA, 2016) was used for data analysis.Data were expressed as Mean ± SD for quantitative parametric measures in addition to both number and percentage for categorized data.Chisquare test was used to study the association between each 2 variables or comparison between 2 independent groups as regards the categorized data.The probability of error at 0.05 was considered significant, while at 0.01 and 0.001 are highly significant.There is highly statistically significant correlation between diagnoses (comorbidity) and resistant organisms with Proteus found mainly in patients with renal impairment while pseudomonas in patients with dementia (p value = 0.000).

A
Meronam, Cefuroxime, Amikin, and Colistin are effective against the 3 resistant strains to variable extents.

Piperacillin,
Ciprofloxacin, and piperacillin/ tazobactam are effective only for Proteus related infections.

Gentamycin and Tobramycin are effective only against E coli. [Figure 1]
The resistant uropathogens spectrum for each antibiotic are demonstrated in figure 2 None of Klebsiella or E coli infections are resistant to Meronam.Proteus is the only resistant pathogen to clindamycin, Ceftriaxone, piperacillin, and erythromycin.
DOS is highly statistically significant related to sex with 45% of males having DOS 110-250 weeks while 61.9% of females having DOS 1-8 weeks (p=0.001).There is statistically significant difference between sensitive patients and resistant patients to GM as regards DOS 75% of sensitive patients to GM have DOS zero while 44.6% of resistant to GM have DOS(1-80 weeks) p=0.026.

Discussion
For many worldwide regions, our knowledge regarding the scope of the resistance problem is imprecise and unreliable.Surveillance of resistance is an integral part of combating resistance 8 .
This study tried to describe the most prevalent resistant bacteria in urine of elderly patients resident at LTCF with UTI and to find which antibiotics still are those organisms sensitive to and which are resistant to.
On the other hand Joseph M. Mylotte et.al, 2001 detected E Coli as the most detected organism in urine of LTCF residents under the study, but Enterococci as the most common resistant organisms in their urine then S. aureus (MRSA) then E coli and Pseudomonas aeruginosa then lastly, Klebsiela pneumoniae and no proteus were isolated. 9cording to Azad L. 2016, 01 E Coli was the commonest isolated organism in urine 10, but current study found Proteus to be the most predominant resistant organism and this cannot be explained by higher percentage of males in the sample as no statistically significant relation between sex and different detected organisms.
Differences between current study and previous studies findings can be explained by differences in samples.
In current study, younger age group (60 -70 years) is highly statistical significant sensitive to CPM and IMP and highly statistical significant resistant to GM, TS, and Tobramycin this findings may be explained by Proteus which is found to be significantly present in younger age group under the study and is highly statistical significant sensitive to CPM and IMP and highly statistical significant resistant to GM, CT, TS, and Tobramycin.
According to current study, there is statistically significant difference between sensitive organisms and resistant organisms to GM as regards DOS 75% of sensitive organisms to GM have DOS zero while 44.6% of resistant organisms to GM have DOS(1-80 weeks) p=0.026.This means newly admitted cases are mostly sensitive to GM then resistance was acquired by admission to LTCF.
There is statistically significant difference between organism sensitivity to CP and DOS as100% of sensitive organisms to CP have DOS 1-8weeks, while 100% of intermediately sensitive organisms to CP have DOS(100-250 weeks) p=0.037.This can show decreasing sensitivity as DOS increase .
Current study is showing statistical significant relation between comorbidity of Cancer colon and sensitivity to

Figure ( 1 )
Figure (1): Frequency of all studied antibiotics as regards their sensitivities.

Figure ( 2 )
Figure (2 ): Frequency of all studied antibiotics as regards their resistance

Table ( 3): Correlation between comorbidities (diagnosis) and detected resistant organisms in urine of long term care facility elderly.
FD,MEM, and CT but patients with comorbidities of Diabetes Mellitus + Bed sore + Dementia are statistical significant sensitive to MEM whereas Dementia is statistical significant resistant to MEM.These statistical significant relations may be explained by Statistically significant relation between cancer colon and E Coli which is significantly sensitive to FD, MEM, and CT also Statistically significant relation between comrbidities of Diabetes Mellitus+ Bed sores +Dementia and Proteus which is Statistically significantly sensitive to MEM.On the other hand, Statistical significant relation between Dementia and Pseudomonas which is Statistical significant resistant to MEM.Further studies are recommended on larger numbers of elderly patients to confirm or not to confirm significant findings in this study, try to explain these findings and make use of it in clinical practice.According to current study's significant results, maybe we can recommend that LTCF patients with UTI with suspected resistant bacteria we can predict that: -It can be mostly Proteus especially in younger patients (60-70 years old) and having comorbidities of DM +Dementia + Pressure ulcer.Certain antibiotics are recommended for this Proteus such as CPM, CP, and IMP and avoid other antibiotics as CT, GM, and Tobramycin.