Prevalence of E. coli as a causative agent of urinary tract infections and its drug susceptibility patterns among pregnant mothers seeking medicare at Kisii teaching and referral hospital, Kenya

INTRODUCTION

Urinary tract infections (UTIs) are diseases that affect the urinary tract from the bowel to the kidney, urethra and bladder.¹ These infections affect both sexes although occur 50 times more in women than men due to their short urethra and moist peri-urethral environment.² In pregnant women UTIs occurrence has been attributed to decreased abdominal strength in urine voiding and lack of oestrogen that causes introital colonization with E. coli and UTI recurrence.³ Because of reduced immunity, HIV-infected pregnant women and those with diabetes tend to suffer from UTIs more often than non-infected ones.⁴

These UTIs are caused majorly by members of the Enterobacterioceae family which includes E coli, Proteus mirabilis, Klebsiella species and Pseudomonas aeruginosa.⁵ According to many studies, E. coli is the leading amongst the major UTI causing bacteria and can be found at the community level and in hospital environments.⁶ Some of its strains can survive for a long time in the outside environment and has several pathogenic strains including Enterotoxigenic E. coli, Enteropathogenic E. coli and Uropathogenic E. coli.⁷ Despite this bacterium existing as a commensal, it’s the main reservoir for spreading antibiotic resistance to other enteric pathogenic bacteria via mobile genetic elements.⁸ Antibiotic resistance, according to world health organization (WHO) is a global public health problem resulting from antibiotic misuse due to poor medical knowledge, inappropriate prescription and lack of proper laboratory diagnosis.⁹ Millions of people in the United States and Europe for instance, acquire antibiotic-resistant infection every year causing deaths.¹⁰ In Latin America, a study done in Colombia on pregnant women indicated that Uropathogenic E. coli was the most common isolate (25%) followed by E. faecalis 20.8%.¹¹ In Argentina, it was again the most common isolate with 74% prevalence.¹² This was also the case in Pakistan where E. coli 33% lead in prevalence followed by K. pneumonia (18%) and Proteus spp. (10%). E. coli strains have not only indicated high prevalence rates, but also the highest overall resistance to various antibiotics amongst them imipenem 80%, ciproxacin 72% and amoxyclave 68%.¹³ High prevalence rates have also been noted in Africa, for instance in Harare Zimbabwe, a study shows that E. coli (43.2%) was the most common pathogen isolated followed by S. aureus (15.8%) and was very resistant (100%) to ampicillin and penicillin (70%).¹⁴ Similarly, at Mulago hospital in Uganda, E. coli isolates were reported to be highly resistant to cefuroxime (100%), ceftazidime (100%), nalidixic acid (90%), and ciprofloxacin (90%).¹⁵ In another study conducted on 99 households in Nairobi Kenya, E. coli isolates showed high levels of prevalence and resistance of over 80% to sulphonamides, trimethoprim, aminoglycosides and penicillin.¹⁶ All these studies clearly demonstrate that E. coli is one of leading UTI causing pathogens that has also become resistant to most of the commonly used antibiotics across the world.

As much as this has been documented in most parts of the world less scientific validation and documentation have been done locally. Therefore, it’s against this background that this study aimed at isolation, characterization and deducing susceptibility patterns of E. coli among other organisms associated with UTIs among women attending antenatal care at Kisii teaching and referral hospital.

METHODS

Study design and site

This hospital based experimental-cross sectional study was conducted between March and June 2020 at Kisii teaching and referral hospital, Kenya.

Study population

The study involved pregnant women who sought for ANC services from KTRH whose urine samples contained 10 pus cells (leucocytes)/mm³ who had consented to participate.

Sample size calculation

The sample size was calculated using a formula for cross sectional studies ¹⁷ with the following assumptions: 95% level of confidence (p=0.05), p=Expected proportion in population based on the previous studies’ prevalence of E. coli producing extended spectrum of beta lactamases.

N= Z₁-α_/2² p (1-p)/d²

A sample size of 119 pregnant women was achieved.

Recruitment and sample collection

The study applied consecutive sampling technique (total enumerative sampling) where every subject of interest who met the criteria of inclusion was selected until the required sample size was achieved.

Inclusion criteria

The study involved all pregnant women attending antenatal clinic at KTRH who had consented to participate and whose early morning mid-stream urine contained 10 pus cells (leucocytes) /mm³ of urine.

Exclusion criteria

Pregnant women not willing to participate in this study or had not consented.

Bacterial identification and isolation

The process commenced by the collection of early morning midstream urine specimen. In the laboratory, the urine was centrifuged at 1500 R.P.M for 3 minutes using DSC-200T electrical centrifuge and the deposit was observed microscopically under power 10x objective of Olympus CX22LEDRFS1 electrical microscope for pus cells. The samples with 10 pus cells (leucocytes)/mm³ were processed for culture overnight on cysteine leucine electrolyte deficiency (CLED) media at 37⁰C aerobically. The grown pure colonies were identified by gram staining and further by IMViC (Indole, methyl red, Voges Proskaur and citrate) biochemical tests.

Antimicrobial susceptibility testing

All the 28 identified E. coli isolates were tested for susceptibility against eight antibiotics (combi-44 Oxoid company REMEI Inc, USA) using Kirby Bauer disc diffusion technique on Mueller-Hinton agar. The negative control used was E. coli American type culture collection (ATCC) 25922) a non-ESBL producer and the positive control was K. pneumonia K6 ATCC 700603.

Data analysis

Data entry and cleaning were routinely performed using Microsoft excel and analysis was done at 95% confidence level using SPSS version 25.0 (IBM SPSS statistics Inc., Chicago, IL, USA). The data on isolated pathogens were subjected to descriptive statistics using frequency tables and graphs. One sample chi-square test was used to determine statistical significance (p≤0.05).

Ethical consideration

Confidentiality and privacy were strictly observed and participants were prior informed on their personal rights and benefits. They were required to sign a written consent form before participating. Permission was granted by the board of postgraduate studies (BPS) of Kisii university and Kisii county health research committee. The ethical approval was offered by the institutional research ethics committee (IREC) of university of Eastern Africa Baraton (Ref. No. UEAB/REC/23/01/2020) and the National Commission of Science, Technology and Innovations (NACOSTI)-Ref. no. 382068.

RESULTS

Gram stain and colonial morphology

A total of 119 pregnant women were investigated representing 100% of the total cases observed in the study. After an overnight culture and gram staining, 67 (56.3%) gram positive cocci, 0 (0%), gram positive bacilli, 6 (5.04%), gram negative cocci and 46 (38.65%) gram negative bacilli were isolated as shown in Table 1. The gram-negative bacilli appeared as red rods and gram-negative cocci appeared round and red. Gram positive cocci appeared singly or in clusters, were round and bluish purple in colour. There weren’t any gram-positive bacilli isolated in this study. Again, as illustrated in Table 1, 28 (23.52%) of the isolates had large yellow opaque colonies with deep centres to a yellowish medium while 9 (7.56%) had large translucent blue colonies to blue medium. Six (5.04%) had extremely mucoid colonies varying in color from yellow to whitish to a yellowish medium. Majority of the isolates 40 (33.61%) had small deep yellow and white colonies uniform in colour, 27 (22.68%) were Small pale yellow white opaque colonies, 3 (2.52%) had large yellow dry colonies and 6 (5.04%) of the isolates were small greyish and white colonies.

Biochemical characterization

After gram staining, the cultured colonies were biochemically tested for further identification and results are shown in table 3.2. From the findings, 28 (23.5%) of the isolates that tested as gram negative bacilli were found to be lactose fermenters, indole, methyl red, catalase and coagulase tests positive but negative for citrate and voges-Proskauer highly suggestive of the presence of E. coli. Also, 9 (7.56%) of the isolates exhibited the same characteristics except for lactose fermenting suggestive for Proteus species. Another gram-negative bacillus that had 6 (5.04%), fermented lactose, was coagulase, catalase, Voges Proskauer, Citrate tests positive but tested negative for Indole and Methyl red, suggestive of the presence of Klebsiella species. The last gram-negative bacilli isolate fermented lactose, was catalase, coagulase, Methyl red and Citrate positive but tested negative for indole and Voges-proskaur suggesting the presence of Citrobacter species. Again, from same table, 40 (33.61%) of the gram-positive cocci isolates fermented lactose, were positive for catalase and coagulase tests suggesting the possibility of the presence of S. aureus while 27 (22.68%) of them had the same characteristics except were coagulase negative suggesting the presence of S. epidermidis. The only Gram-negative cocci present was a non-lactose fermenter, catalase positive and coagulase negative diplococci highly suggestive of N. gonorrhoea.

Therefore, based on the biochemical tests carried out on these isolates, it can be concluded that E. coli 28 (23.5%) was second prevalent after S. aureus 40 (33.6%) followed by S. epidermidis 27 (22.7), Proteus spp. Nine (7.56%), Klebsiella 6 (5.04%), N. gonorrhoea 6 (5.04%) and lastly Citrobacter species 3 (2.5%) as shown in the Figure 1.

Antimicrobial susceptibility pattern of E. coli

All the 28 E. coli isolates were resistant to sulfamethoxazole 28 (100%). Amoxyclave 26 (85%) was second, followed by ceftriaxone 20 (71.42%), nalidixic acid 20 (71.42%), nitrofurantoin 16 (57.14%), norfloxacin 10 (35.71%), ofloxacin 6 (21.42%) and lastly gentamycin 4 (14.28%). This is shown in Table 3.

One sample chi square was applied to determine the statistical significance in the drug susceptibility testing. Gentamycin, ofloxacin and norfloxacin were the most sensitive drugs while sulfamethoxazole, amoxyclav and ceftriaxone proved to be the most resistant.

L.F-Lactose fermenter; INDL- Indole; M-R-Methyl Red; V-P -Voges Proskauer; CIT- Citrate; CAT- Catalase; COAG - Coagulase. The dashes in the Table 2 above indicate that, the biochemical tests did not apply to those particular organisms, 0 (0%) indicated test negative results while the numbers and percentages showed the positivity rate.

PC-Positive control, AMC-Amoxyclav, GEN-Gentamycin, NITR-Nitrofurantoin, NA-Nalidixic Acid, OFLOX-Ofloxacin, NRX-Norfloxacin, SMX-Sulfamethoxazole, CTR- Ceftriaxone, AMC-Amoxyclav, R-resistant, I-oIntermediate, S-sensitive.

a. 0 cells (0.0%) have expected frequencies less than 5. The minimum expected cell frequency is 9.3.

b. 0 cells (0.0%) have expected frequencies less than 5. The minimum expected cell frequency is

DISCUSSION

This study was designed to find out the prevalence of E. coli among other bacteria causing UTI in pregnant women attending ANC clinic of Kisii teaching and referral hospital (KTRH) and to establish the drug susceptibility patterns of the isolated E. coli. The findings indicate that out of the 119 isolates, E. coli 28 (23.5%) was second most prevalent bacteria isolated from pregnant women with UTIs after S. aureus 40(33.6%) which led as a causative agent of UTIs.

Then followed S. epidermidis 27(22.7%), Proteus spp. 9(7.56%), Klebsiella spp. 6(5.04%), N. gonorrhoea 6 (5.04%) and lastly Citrobacter spp. Three (2.5%). This is a finding that can easily be attributed to the fact that E. coli and S. aureus are normal floras in our systems, and they could easily take advantage of the hormonal changes such as the progesterone effect on smooth muscles which decreases bladder capacity on pregnant women hence becoming pathogenic, inducing UTI in them.^3,18 Such findings have been reported in various parts of the world for instance in a study at Mbarara regional referral hospital, South-Western Uganda, E. coli 28.78% was second most prevalent causative agent after Klebsiella pneumoniae 37.41% in urine samples cultured from pregnant women. In this study other causative agents of UTI included S. aureus 23.57% and P. mirabilis 5.04%.¹⁹ This study also agrees with another one done at Sri Vijay hospital, India on UTIs causing pathogens amongst the pregnant women where S. aureus had a leading frequency of 43.53%, followed by E. coli 35.89 %, K. pneumoniae, 10.25%, Pseudomonas aeruginosa 7.69% and Proteus spp. 2% ²⁰. The same applies to clinical findings from referral hospitals in Tanzania which saw S. aureus 28.4% lead in prevalence followed by E. coli 15.2% (59), P. aeruginosa 10.6% (41) and P. mirabilis 7%.²¹

The gram-negative bacteria dominated in the isolates just like in the previous studies and this can easily be associated with the fact that many of these bacilli live in the gut and the urinary tract system as commensals but can turn pathogenic when there are physiological body changes especially in cases of reduced immunity.^3,22 In many cases E. coli is the major UTI causing agent and this was observed at Puskesmn Kenangan, Indonesia where pregnant women had Escherichia coli prevalence of 35.7%, followed by Staphylococcus aureus 28.6%, Staphylococcus epidermidis 28.6%, and Klebsiella pneumonia 7.1%.²³ In Ethiopia, a study on asymptomatic bacteriuria isolated Escherichia coli (43%) and Staphylococcus aureus (20%) as the most predominant bacteria while in Uganda at Bushenyi, E. coli 41.9% lead in Uropathogenic infections followed by Staphylococcus aureus 31.4% and Klebsiella pneumoniae 11.6%.^15,24 Similar findings were also documented in Nairobi Kenya, where a study on UTI in pregnant women from some selected county council clinics had 38.8% prevalence for E. coli followed by S. aureus at 29.7%, Klebsiella spp. 7.8%, Pseudomonas 2.7% Proteus spp. 2.7%, Citrobacter spp. 2.3% and Enterococcus 0.9%.²⁵ Epidemiologically this indicates a change in trend whereby E. coli and other bacterial are equally gaining virulence to dominate in UTIs aetiology in different regions.

The current study shows that, although the E. coli isolates were fairly susceptible to common antimicrobial agents used against it, there was a clear indication of multidrug resistance limiting and narrowing the choice of antimicrobials which can be attributed to several reasons. The emergence of resistant bacteria such as E. coli represent a substantial global public health crisis and the majority are in WHO’s list of priority bacterial pathogens for research and development of new antibiotics.²⁶

All the E. coli isolates were resistant to sulfamethoxazole 28 (100%) disqualifying it as a choice for UTI treatment in the area of study. This drug being a sulphonamide, competes with p-aminobenzoic acid causing sequential blockage of folic acid synthesis required for bacterial DNA and protein synthesis. Its resistance has been attributed to the formation of the sul1 and dfrA genes located in integrons and the sul2 genes linked to transposase in bacteria.²⁷ It has been the first-line treatment for UTIs in Kenya, and it is commonly prescribed for gastrointestinal tract infections, respiratory tract infections and skin infections. The wide usage, uncontrolled and over the counter access and also with the fact that it is relatively cheap may have contributed towards the emergence of its resistance. Similar findings were observed in Germany where E. coli resistance to trimethoprim and sulfamethoxazole at 15.2% and 13.0% respectively and were the most resistant.²⁸ This was also the case in Mexico 54% and USA 74.5%.^29,30 Locally, resistance for sulfamethoxazole was noted at Kenyatta National hospital (83%) and 75% in a study at Thika referral hospital, Kenya.^31,32 The world health organization (WHO) guidelines recommends sulfamethoxazole-trimethoprim and ampicillin as the first choice for the UTI treatment and empiric treatment is recommended for treatment of uncomplicated UTI, however from this revelation it does not make a suitable choice.³³ There is a possibility that lack of improved access to reference laboratories, efficiency and quality control assay schemes would again be some the contributing factors towards the resistance by specific priority pathogens such as E. coli.³⁴

Ceftriaxone resistance to E. coli exhibited a big percentage rate 20 (71.42%) in this study. This drug is commonly used to treat UTIs, upper respiratory infections and gastrointestinal diseases. This drug is among the most stocked drugs in chemists and drug stores in Kenya and is easily acquired over the counter without a doctor’s prescription. Because of this, the current study links its resistance to misuse and over subscription by clinicians like in the cases of suspected meningitis, sepsis, and febrile illnesses.³⁵ For this reason, again, it cannot be utilized as an option for treatment of UTIs in Kenya. It’s a third-generation cephalosporin which works by binding to penicillin binding proteins on the membrane protoplasm blocking bacterial cell wall synthesis. It gains resistance by bacteria altering the penicillin-binding protein sites on the cell wall and drug efflux from bacterial cells.³⁶ The current findings agree with several studies globally where for instance in India E. coli was reported to be having a resistance of 71.4%, in Victoria and Australia 89%.^37,38 It is however very susceptible in other parts of the world and is recommended for use in places like Ankara, Turkey where resistance to E. coli is only 2.7%.³⁹

Nitrofurantoin is another drug commonly used against UTIs and was bio assayed against E. coli isolates. This drug acts by attacking bacterial ribosomal proteins non-specifically, causing complete inhibition of protein synthesis.⁴⁰ It had a resistance of 57.14% in the present study, a result that is contrary to what was found in Tunisia where it was found to be the most sensitive antimicrobial agent with susceptibility rate of 91.8% on community acquired E. coli in urinary tract infection.³⁷ This drug is fairly susceptible making it still usable for UTI treatment despite being in use for a long time and much attention and care is necessary to protect it from misuse.

Resistance to ofloxacin 21.42% and Norfloxacin 35.71% for the E. coli isolates was relatively low. These drugs’ mode of action is by blocking the bacterial nucleic acid synthesis and their resistance is associated with bacteria chromosomal mutations that alter the target enzymes and increase in drug efflux.⁴² From the findings of this study, it is clear that there is need for these group of drugs to be closely safeguarded as they are still effective against E. coli isolates. Because of the narrowing choice of antibiotics in UTIs treatment such drugs should strictly be under prescription.²⁵ This study concurs with previous studies globally like in Turkey where ofloxacin showed high sensitivity (86.9%)³⁹ and in Nairobi, Kenya 45.2%.⁴² In Thika county hospital Kenya, up to 80% of the E. coli isolates were susceptible to Norfloxacin recommending it as a drug of choice UTI treatment in that area.²⁵

Gentamycin an aminoglycoside proved to be the drug with least resistance (14.28%). It was the most susceptible among the drugs tested against E. coli and the drug of choice in this case for treating UTI infections despite the fact it should not be used alone. This class of drugs remains useful for treating serious infections due to multidrug resistant enteric and Uropathogenic bacteria.²⁵ This drug was found to be the most effective against E. coli and recommended for use in Kisii county. Its mechanism of action is by irreversibly binding to receptors on the 30S ribosomal subunit of bacteria, preventing attachment of aminoacyl-transferable ribonucleic acid (tRNA) to the transferable ribonucleic acid (RNA)-ribosome complex. This blocks the formation and initiation of bacterial protein synthesis and eventual bacterial cell death. Resistance although rare, results from plasmid mediated drug inactivation by transferase enzymes.⁴³ This observation was also noted in Turkey where gentamicin 97.6% was very sensitive to E. coli, at Kisii teaching and referral hospital in Kenya on diabetic patients 100% and in Nairobi 83.5% in a study by Adelaide Ogutu on UTI in pregnant women.^25,39,44

Amoxyclave (Augmentin), another broad-spectrum antibiotic showed a considerable resistance of 85% to E. coli isolates on the invitro susceptibility tests. This drug is normally recommended for UTIs and upper respiratory tract infections according to WHO.²⁶ However, with this resistance, it fails as a drug of choice against E. coli in the study area which is Kisii county, Kenya. The component Clavulanic acid is a beta-lactamase inhibitor often used in conjunction with amoxicillin to broaden its spectrum further to combat drug resistance. This drug is readily available in drug stores and because of its frequent use, its resistance can closely be associated with inappropriate use and hyper production of the chromosomal class C β-lactamase of E. coli and that of plasmid-mediated TEM enzymes.⁴⁵

Kisii county falls under the sub-Saharan Africa where majority of its population suffers from social economic burdens and low levels of hygiene hence most likely have its environment contaminated with bacteria such as E. coli existing as normal flora. Many of the pregnant women have a tendency of eating soil most often from this contaminated environment.⁴⁶ From these findings, this can be seen as one of the reasons for resistance noting that, when bacteria in environments with poor sanitation are enriched from antibiotic use, ideal conditions for a steady production of antibiotic-resistant bacteria are achieved.⁵⁰ This observation is agreeable to studies in India where 74.4% resistance is observed and in Uganda 72.9%.^15,47

Nalidixic acid had a resistance of 71.42% in this study. Its continued use for a long time and oversubscription may be the reason for the observed treatment failure although its resistance is primarily associated with the presence and development of bacteria conjugative plasmids. Several factors determine the variance in drug resistance between different geographical locations and from many studies there is direct relationship between antibiotic consumption and the emergence and dissemination of resistant bacteria strains.⁴⁸ The inappropriate use of drugs clearly drives the creation of resistance and despite any cautions concerning this, they are still overprescribed worldwide.

CONCLUSION

E. coli is the second most prevalent causative agent of UTI after S. aureus at KTRH, showing high rates of resistance to the first-line antibiotics mainly the Amoxyclave, sulfamethoxazole and ceftriaxone. This study recommends strict rules when dispensing prescribed drugs. Routine culture and drug sensitivity should be practiced often and enough resources be put in place to do more research on antimicrobial resistance.

Limitations

There were a few challenges during sample collection where some of the participants could not produce the right sample. This also happened when looking out for a polymerase chain reaction (PCR) machine for gene sequencing since they were not readily available within the research area.

ACKNOWLEDGEMENTS

Author would like to acknowledge the study participants (the pregnant women) and the staff and management of Kisii teaching and referral hospital for making this study successive. In a special way, we appreciate Mrs. Ruth Ayanga, Mr. Peter Kyondi, and Awour Silas for their support during the research process.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Olin SJ, Bartges JW. Urinary Tract Infections. Treatment/Comparative Therapeutics. Vet Clin North Am Small Anim Pract. 2015;45(4):721-46.
2. 2. Ebidor UL, Tolulope A, Deborah O. Urinary tract infection amongst pregnant women in Amassoma, Southern Nigeria. Afr J Microbiol Res. 2015;9(6):355-9.
3. 3. Jhang JF, KuoTzu HC. Recent advances in recurrent urinary tract infection from pathogenesis and biomarkers to prevention. Chi Med J. 2017;29(3):131-7.
4. 4. Nj M, Mogaka G, Nyambane L, Eilu E. Prevalence and susceptibility pattern of bacterial Urinary Tract Infections among pregnant HIV positive women in Gucha sub county, Kenya 1. AIDS SBPJ Special Bacterial Pathogens J. 2015;1(1):10-15.
5. 5. Sharifinia M, Karimi A, Rafiee S, Anvaripour N. Microbial sensitivity pattern in urinary tract infections in children: a single centre experience of 1177 urine cultures. Jap J Infect Dis. 2006;59:380-82.
6. 6. Chukwudozie Onuoha S, Fatokun K. Prevalence and antimicrobial susceptibility pattern of Urinary Tract Infection (UTI) among pregnant women in Afikpo, Ebonyi State, Nigeria. Am J Life Sci. 2014:2(2):46-52.
7. 7. Johnson TJ, Nolan LK. Pathogenomics of the Virulence Plasmids of Escherichia coli. Microbiol Mol Biol Reviews. 2009;73(4):750-74.
8. 8. Nji E, Kazibwe J, Hambridge T. High prevalence of antibiotic resistance in commensal Escherichia coli from healthy human sources in community settings. Sci Rep. 2021;11:3372.
9. 9. Talebi Bezmin Abadi A, Rizvanov AA, Haertlé T. World Health Organization Report: Current Crisis of Antibiotic Resistance. Bio Nano Sci. 2019;9:778-88.
10. 10. World Health Organization. 2019 Antibacterial Agents in Clinical Development: Analysis of the Antibacterial Clinical Development Pipeline; WHO: Geneva, Switzerland, https://www.who.int/medicines/areas/rational_use/antibacterial_agents_clinical_development/en/. Accessed on 24 April 2020.
11. 11. Campo-Urbina M. Caracterización y perfil de susceptibilidad de uropatógenos asociados a la presencia de bacteriuria asintomática en gestantes del departamento del Atlántico, Colombia, 2014-2015. Estudio de corte transversal. Rev Colomb Obstet Ginecol. 2017;68:62-71.
12. 12. Córdova E, Lespada MI, Cecchini D. Prevalencia de gérmenes multirresistentes enh ninfecciones del tracto urinario de la comunidad y asociadas a los cuidados de la salud. Actual SIDA Infectol. 2014;22:33-8.
13. 13. Fatima T, Rafiq S, Iqbal A. Prevalence and Antibiogram of MDR E. coli Strains Isolated from UTI Patients-1-Year Retrospective Study at Nishtar Medical Hospital, Multan. SN Compr Clin Med. 2020;2:423-31.
14. 14. Mhondoro M, Ndlovu N, Bangure D. Trends in antimicrobial resistance of bacterial pathogens in Harare, Zimbabwe, 2012-2017: a secondary dataset analysis. BMC Infect Dis. 2019;19:746.
15. 15. Odongo I, Ssemambo R, Kungu JM. Prevalence of Escherichia Coli and Its Antimicrobial Susceptibility Profiles among Patients with UTI at Mulago Hospital, Kampala, Uganda. Interdiscip Perspect Infect Dis. 2020;2020:8042540.
16. 16. Muloi D, Melissa J, Ward, James M. Epidemiology of antimicrobial-resistant Escherichia coli carriage in sympatric humans and livestock in a rapidly urbanizing city. Int J Antimicrob Agents. 2019;54(5):531-7.
17. 17. Charan J, Biswas T. How to Calculate Sample Size for Different Study Designs in Medical Research. Indian J Psychol Med. 2013;35(2):121-6.
18. 18. Habak PJ, Griggs, Jr RP. Urinary Tract Infection In Pregnancy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.
19. 19. Johnson B, Stephen BM, Joseph N, Asiphas O, Musa K, Taseera K. Prevalence and bacteriology of culture-positive urinary tract infection among pregnant women with suspected urinary tract infection at Mbarara regional referral hospital, South-Western Uganda. BMC Pregnancy Childbirth. 2021;21(1):159.
20. 20. Ahmed MA, Shukla GA and Bajaj HK. Incidence of Urinary Tract Infections and determination of their susceptibility to antibiotics among Pregnant Women Department of medical Laboratory Technology, Sam Higginbottom. 2017.
21. 21. Mnyambwa NP, Mahende C, Wilfred A, Sandi E, Mgina N, Lubinza C et al. Antibiotic Susceptibility Patterns orbgf Bacterial Isolates from Routine Clinical Specimens from Referral Hospitals in Tanzania: A Prospective Hospital-Based Observational Study. Infect Drug Resist. 2021;14:869-78.
22. 22. Mulvey MA, Schilling JD, Hultgren SJ. Establishment of a persistent Escherichia coli reservoir during the acute phase of a bladder infection. Infect Immun. 2001;69:4572-9.
23. 23. Laily F, Lutan D, Amelia S, Tala MRZ, Nasution TA. Associated risk factors for urinary tract infection among pregnant women at Puskesmas Kenangan, Deli Serdang district. Conf Ser Earth Environ Sci. 2018;125:012035.
24. 24. Wabe, Awol Y. Prevalence of Asymptomatic Bacteriuria, Associated Factors and Antimicrobial Susceptibility Profile of Bacteria Among Pregnant Women Attending Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Therapeutics Clin Risk Manag. 2020;16:923-32.
25. 25. Ayoyi AO, Kikuvi G, Bii C, Kariuki S. Prevalence, aetiology and antibiotic sensitivity profile of asymptomatic bacteriuria isolates from pregnant women in selected antenatal clinic from Nairobi, Kenya. Pan Afr Med J. 2017;26:30-41.
26. 26. WHO. Prioritization of Pathogens to Guide Discovery, Research and Development of New Antibiotics for Drug Resistant Bacterial Infections, Including Tuberculosis, 2017. Available at: https://apps.who.int/iris/handle/10665/. Accessed on 01 November 2021.
27. 27. Hu L-F, Chen G-S, Kong Q-X, Gao L-P, Chen X, Ye Y et al. Increase in the Prevalence of Resistance Determinants to Trimethoprim/Sulfamethoxazole in Clinical Stenotrophomonas maltophilia Isolates in China. PLoS ONE. 2016;11(6):e0157693.
28. 28. Klingeberg A, Noll I, Willrich N, Feig M, Emrich D, Zill E et al. Antibiotic-Resistant E. coli in Uncomplicated Community-Acquired Urinary Tract Infection. Dtsch Arztebl Int. 2018;115(29-30):494-500.
29. 29. Ramírez-Castillo FY, Moreno-Flores AC, Avelar-González FJ. An evaluation of multidrug-resistant Escherichia coli isolates in urinary tract infections from Aguascalientes, Mexico: cross-sectional study. Ann Clin Microbiol Antimicrob. 2018;17:34.
30. 30. IA Critchley, N Cotroneo, MJ Pucci, R Mendes. The burden of antimicrobial resistance among urinary tract isolates of Escherichia coli in the United States in 2017. PloS one. 2019.
31. 31. Ndung’u C, Muigai AWT, Kariuki S. Prevalence and Antibiotic Resistance Patterns of Escherichia Coli Among Hospitalised Patients At Thika District Hospital East African. Med J. 2014;91(6)2014.
32. 32. Nyamache AK. Isolation and antimicrobial susceptibility testing of Escherichia coli causing urinary tract infections. J Applied Biosci. 2020;22(24):1320-25.
33. 33. WHO: Antimicrobial Resistance: Global Report on surveillance. Available at: http://www.appswhoint/iris/bitstream/10665/188783/1/9789241549400_engpdf?ua=1 2015. Accessed on 2021 Feb 17.
34. 34. Kariuki S, Okoro C, Kiiru J, Njoroge S, Omuse G, Langridge G et al. Ceftriaxone-resistant Salmonella enterica serotype typhimurium sequence type 313 from Kenyan patients is associated with the blaCTX-M-15 gene on a novel IncHI2 plasmid. Antimicrobial agents chemotherapy. 2015;59(6):3133-9.
35. 35. Wolff O, Maclennan C. Evidence behind the WHO guidelines: hospital care for children: what is the appropriate empiric antibiotic therapy in uncomplicated urinary tract infections in children in developing countries? J Trop Pediatr. 2007;53:150-2.
36. 36. Bui T, Preuss CV. Cephalosporins. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK551517/. Accessed on 2021 Feb 17.
37. 37. Alanazi MQ, Alqahtani FY, Aleanizy FS. An evaluation of E. coli in urinary tract infection in emergency department at KAMC in Riyadh, Saudi Arabia: retrospective study. Ann Clin Microbiol Antimicrob. 2018;17(1):3.
38. 38. Niranjan V, Malini A. Antimicrobial resistance pattern in Escherichia coli causing urinary tract infection among inpatients. Indian J Med Res. 2014;139(6):945-8.
39. 39. Chua KYL, Stewardson AJ. Individual and community predictors of urinary ceftriaxone-resistant Escherichia coli isolates, Victoria, Australia. Antimicrob Resist Infect Control. 2019;8:36.
40. 40. Gunduz S, Uludağ Altun H. Antibiotic resistance patterns of urinary tract pathogens in Turkish children. Glob health res policy. 2018;3:10.
41. 41. McOsker CC, Fitzpatrick PM. Nitrofurantoin: mechanism of action and implications for resistance development in common uropathogens. J Antimicrob Chemother. 1994;33(A):23-30.
42. 42. Daoud N, Hamdoun M, Hannachi H, Gharsallah C, Mallekh W, Bahri O. Antimicrobial Susceptibility Patterns of Escherichia coli among Tunisian Outpatients with Community-Acquired Urinary Tract Infection (2012-2018). Curr Urol. 2020;14(4):200-5.
43. 43. Correia S, Poeta P. Mechanisms of quinolone action and resistance: where do we stand? J Med Microbiol. 2017;66:551-9.
44. 44. Dinah Moraa Dr. Scholastica Mathenge, Dr. Arodi Washington,Torome Tom, Oliver Mbuthia,Martin Kinyu Antibiotic Susceptibility Pattern among Male Patients with Urinary Tract Infection in Special Treatment Centre,Nairobi County, Kenya.
45. 45. Kotra LP, Haddad J, Mobashery S. Aminoglycosides: perspectives on mechanisms of action and resistance and strategies to counter resistance. Antimicrob Agents Chemother. 2000;44(12):3249-56.
46. 46. Vincent Mogaka Mageto V. Uropathogens antibiotic resistance patterns among type 2 diabetic patients in Kisii Teaching and Referral Hospital, Kenya. Pan African Medical J. 2018;30:286.
47. 47. Wise R, Andrews JM, Bedford KA. In vitro study of clavulanic acid in combination with penicillin, amoxycillin, and carbenicillin. Antimicrob Agents Chemother. 1978;13(3):389-93.
48. 48. Kutalek R, Wewalka G, Gundacker C, Auer H, Wilson J, Haluza D et al. Geophagy and potential health implications: geohelminths, microbes and heavy metals. Transactions Royal Society Trop Med Hygiene. 2010;104(12):787-95.
49. 49. Zur Wiesch PA, Kouyos R, Engelstädter J, Regoes RR, Bonheoffer S. Population biological principles of drug-resistance evolution in infectious diseases. Lancet Infect Dis. 2011;11(3):236-47.