Patterns of Extended-Spectrum β-Lactamase Producing Uropathogens Detection in Tertiary Care Hospital of Bangladesh

It is a great concern that extended-spectrum β-lactamase (ESBL) and non-ESBL uropathogenic microorganisms have been worldwide illustrated to increase multidrug resistance. To study the prevalence and patterns of uropathogens, and antimicrobial susceptibilities profiles of ESBL and non-ESBL producing bacterial infection in a tertiary level health service center of Bangladesh. The prevalence of ESBL producing uropathogens and their antimicrobial resistance patterns were identified in 176 isolates from patients with UTI. ESBL and non-ESBL producing bacterial isolates and their antibiotic sensitivity and resistance patterns were distinguished from the 176 patients of suspected urinary tract infection. The Double-disc diffusion test was done to determine the presence of ESBL-producing bacterial strains. The most widely ESBL positive uropathogen was Escherichia coli (87%), followed by Pseudomonas aeruginosa, (6.8%), Enterococcus spp. (3.4%), Acinetobacter spp. (2.5%) and non-ESBL positive E. coli (41.4), Staphylococcus saprophyticus (25.9%), Pseudomonas aeruginosa (17.2%), Staphylococcus aureus (10.3%), and Klebsiella pneumoniae (5.2%). The current investigation found most frequently Escherichia coli in both ESBL and non-ESBL uropathogen group as 87% and 41.4% respectively. Generally, a large number of antibiotic resistance patterns and ESBL producing common bacterial isolates were found in this study which increases the public health problem. Therefore, for safe human life, we ought to be taking appropriate action against the threat.

resistance (Ronald et al., 2003). Enhancing the tendency of developing antibiotic resistance among uropathogens is a global problem (Mathai et al., 2000;Sarker et al., 2019). The uropathogens produce extended-spectrum β-lactamase (EBSL) enzymes through which they hydrolyze oxyimino βlactam compounds and it is one of the prime factors contributing to highly decrease antimicrobial susceptibility against β-lactam antibiotics (Gniadkowski et al., 2001).
The rate of multidrug resistance increases due to improper treatment of UTI caused by the ESBL and non-ESBL uropathogenic bacteria (Du et al., 2002). For the therapy of infections with antibiotics due to ESBL and non-ESBL-producing uropathogens is still a great challenge to solve the risk factors, treatment options, and infection control measures for its infection (Paterson et al., 1999). It has been a considerable problem with appropriate antimicrobial therapy due to ESBL and non-ESBL positive uropathogens. The point of this investigation was to observe patterns and prevalence of antimicrobial susceptibility in patients of Khwaja Yunus Ali Medical College & Hospital in the tertiary region of Bangladesh.

MATERIALS AND METHODS:
Sample Collection -The study was carried on 589 non-consecutive and non-duplicate midstream cleancatch urine samples. The specimens were collected from the patients aseptically and processed at the microbiology laboratory of Khwaja Yunus Ali Medical College & Hospital Laboratory Services Department from January 2020 to June 2020.
For the isolation and identification of bacterial isolates, we conducted the following standard bacteriological technique (Ahmed et al., 2016). For these purposes, the following dehydrated culture media were used namely Blood agar, MacConky agar, XLD, TSI, Urea, and Citrate. Urine samples showing significant bacterial growth, of >105 colony-forming units (CFU/mL) with a single type of bacteria isolates, were considered uropathogens.
Testing for the ESBL Production -The identification of ESBLs production by 176 uropathogens out of 589 urine samples was conducted by a modified double-disc synergism test (Ahmed et al., 2017). Bacterial suspension of 0.5 McFarland standards was plated in Muller-Hinton agar with Amoxycillinclavulanic acid (30 µg) disc in between and 20 mm apart from Ceftazidime (30 µg) and Ceftriaxone (30 µg) discs. Expansion of the zone of inhibition around Ceftriaxone and/or ceftazidime disc towards the amoxicillin-clavulanic acid disc was considered ESBL production.
Antimicrobial Susceptibility Test -Antimicrobial susceptibility testing (AST) for all isolates was conducted on commercially available common antibiotics disc. Information on these antibiotics and their concentrations are shown in Table 1.

DISCUSSION:
Multidrug-resistant uropathogens expressing extended-spectrum β-lactamase pose worldwide serious challenges to clinicians for the therapeutic management of clinical cases in urinary tract infection (UTI). In our study, both males and females were the commonest pervasive of bacterial infections and 35% of sound healthy women were warning indications of UTIs (Rezwana et al., 2015).
The current study was embraced to demonstrate the presence of ESBL-producing uropathogen isolates in clinical samples of patients in the tertiary medical clinic of Bangladesh. The predominance of ESBLproducing pathogens was found to be 67%. ESBL production occurred more frequently in E. coli (87%) than P. aeruginosa (6.8%), Enterococcus spp. E. coli are the most well-known uropathogens and considered as normal flora of the gastrointestinal and distal urogenital, but they can ascend the urethra and get access to the urinary tract. Explicit harmfulness factors found in E. coli permit it to hold fast to and attack have cells, produce poisons, use have supplements, and avoid the host's immune system (Abedin et al., 2020). ESBLs constitute a serious threat to the β-lactam therapy. Because of the difficulty in their detection by the current clinical methods, many of these bacterial isolates have been falsely reported to be susceptible to the widely used broad-spectrum β-lactams (MacKenzie et al., 2002). We found such an associated resistance with gentamicin (36%) and the flouroquinolones (67%

CONCLUSION:
This study was illustrated to find out the prevalence and patterns of ESBL and non-ESBL producing uropathogens in clinical isolates from the tertiary level hospital of Bangladesh against commonly prescribed antibiotics. The prevalence of ESBL producing E. coli is 87%. Multidrug resistance patterns were discovered to be altogether higher in ESBL (67%) producer isolates when contrasted with non-ESBL (33%) producer isolates. This finding highlights the importance of constant observing programming of multidrug resistance in our hospitals. It also showed the need for developing atempts to decrease the prevalence of ESBL producing uropathogens. ESBLs are clinically significant and patients infected with ESBL-producing uropathogens are vitally important to treat with appropriate antibiotics.
Finally, many studies had varied findings according to place and time casting doubt on their quality and making comparisons among them difficult. Subsequently, there is a requirement for normalization of observation methodology and routine surveillance in the country, alongside appropriate activities to abate the overall rate of resistance.