Literature Review
UTIs rank high among the most common complaints in any outpatient clinic in any hospital worldwide. UTIs are also among the most commonly treated diseases among inpatients. However, a considerable number of inpatients being treated for UTIs were not admitted with urinary signs and symptoms. According to a 2011 report by the World Health Organization, UTIs are only second to pneumonia among the most frequent hospital-acquired infections (WHO, 2011). The report further says that some patients may not present with urinary symptoms while still in hospital but start having the signs and symptoms shortly after being discharged; a phenomenon called health-care associated community-acquired UTIs (WHO, 2011). As is explicitly revealed in the first part of this assignment, procedures like catheterization, the unhygienic hospital environment, and host factors like immunosuppression are at the heart of hospital-acquired UTIs. Most microorganisms in the hospital environment have been exposed and developed resistance to commonly used antibiotics hence the high rates of antibiotic resistance for nosocomial infections (WHO, 2011). This paper is a review of the various literature laying the ground of past scientific studies into the issues that have been raised.
A 2010 study conducted by Dr. Mansoor Ahmed of Queen’s Hospital in Staffordshire, U.K, and colleagues to confirm antibiotic resistance among pediatric UTIs is the first paper in this literature review. The study took the form of a case series with all the children with culture-proven UTI in the hospital between 2002 and 2008 being included in the study (Ahmed, et al., 2010). The participants were 337 in total and the UTIs reported were 547 as recurrences did occur among the patients (Ahmed et al., 2010). The cultures proved that the UTIs were being caused by multiple organisms. However, Escherichia coli was present in up to 98% of the cultures (Ahmed et al., 2010). The organism was also noted to be present in all recurrent cases of the disease. Antibiotic sensitivity studies showed reducing sensitivity and increasing the resistance of the organism to trimethoprim and Augmentin over the course of the study (Ahmed, et al., 2010). Almost all the recurrent cases had antibiotic resistant organisms. This somewhat shades the light to the increasing antibiotic insensitivity with exposure to hospital-acquired bugs. The study presented similar results to Chakupurakal et al. (2010) and concluded that there are cases of antibiotic resistant UTIs caused by Escherichia coli are increasing and that resistance to antibiotics is something that should be monitored in all regions.
A study by Silvia Aguilar-Duran and colleagues that was published in a 2012 journal concluded that community-acquired UTIs and hospital-associated community-acquired UTIs differed slightly. The study took the form of a prospective observational cohort study (Aguilar-Duran et al., 2012). All patients with UTI requiring hospital admission between July 2009 and February 2010 in a 600-bed hospital in Barcelona, Spain, were included in the study. A total of 251 patients were included (Aguilar-Duran et al., 2012). The study activities included taking the bio data of patients, examining them for comorbidities and, culturing urine for antibiotic sensitivity and identification of causative organisms. Similar to Chakupurakal et al. (2010), Aguilar-Duran et al. (2012) concluded that patients with hospital-associated community-acquired UTIs had more comorbidities especially diabetes mellitus and solid neoplasms and that there was a higher incidence of antibiotic-resistant Escherichia coli among such patients with most of them having used antibiotics before or still on antibiotic therapy (Aguilar-Duran et al., 2012). The study also concluded that UTIs associated with Pseudomonas aeruginosa was associated with more mortality. However, the study did not get enough data to make any conclusion on the effect of empiric antibiotic treatment of UTI. This is unlike a 2014 report by Medicinewise, which seemed to conclude that use of empiric antibiotics was associated with more resistance (NPS Medicinewise, 2014).
Sood and Gupta conducted a cross-sectional study to find out antibiotic resistance among patients with UTIs in a hospital in India in 2010 (Sood & Gupta, 2012). They collected urine in 2012 patients and cultured the urine (Sood & Gupta, 2012). Of the cultures inspected, 346 were positive with up to 23% showing multidrug-resistant Escherichia coli and 8% showing multidrug resistant Klebsiella pneumonia (Sood & Gupta, 2012). The study concluded that there were many cases of resistance to commonly used empiric antibiotics except nitrofurantoin.
A study conducted by Mauldin and colleagues between 2000 and 2008 in one hospital found that 662 patients developed hospital-acquired infections attributable to Gram-negative bacilli like Escherichia, klebsiella, Pseudomonas, Actinobacter, and Enterobacter (Mauldin et al., 2010). The study took the form of an observational comparative cohort study. The study activities included the collection of infected samples especially sputum, urine, and bronchial washings from the patients, culturing them, and testing for antibiotic sensitivity. Up to 29% of the positive cultures showed resistance to at least one antibiotic agent (Mauldin et al., 2010). Sixteen percent were multidrug-resistant (Mauldin et al., 2010). The study concluded that drug-resistant hospital-acquired infections especially bacterial pneumonia and UTIs were significantly increasing the cost of healthcare.
As the various literature that has been reviewed reveal, hospital-acquired drug-resistant UTIs are a significant health problem that has been taking a good proportion of the health budget of many countries. From the literature review, it has been shown that hospital-acquired UTIs are likely to be severer that community-acquired UTIs and are associated with higher incidence of antibiotic resistance. However, the literature review also reveals information gaps; for instance, the role of empiric antibiotics in curbing or enhancing hospital-acquired UTIs and development of drug resistance is not clear. Moreover, the role of other organisms that can cause hospital-acquired drug-resistant UTIs like ESBL producing Klebsiella pneumonia has not been clarified. It is such information gaps which warrant the study that I would like to undertake on UTIs.
References
Aguilar-Duran, S., Horcajada, J. P., Sorlí, L., Montero, M., Salvadó, M., Grau, S., … & Knobel, H. (2012). Community-onset healthcare-related urinary tract infections: comparison with community and hospital-acquired urinary tract infections. Journal of Infection, 64(5), 478-483. https://dx.doi.org/10.1016/j.jinf.2012.01.010
Chakupurakal, R., Ahmed, M., Sobithadevi, D. N., Chinnappan, S., & Reynolds, T. (2010). Urinary tract pathogens and resistance pattern. Journal of clinical pathology, 63(7), 652-654. doi:10.1136/jcp.2009.074617
Mauldin, P. D., Salgado, C. D., Hansen, I. S., Durup, D. T., & Bosso, J. A. (2010). Attributable hospital cost and length of stay associated with health care-associated infections caused by antibiotic-resistant gram-negative bacteria. Antimicrobial agents and chemotherapy, 54(1), 109-115. doi: 10.1128/AAC.01041-09
NPS Medicinewise. (2014). Antibiotic resistance and UTIs. Retrieved from http://www.nps.org.au/publications/health-professional/nps-news/2014/reducing-antibiotic-resistance
Sood, S., & Gupta, R. (2012). Antibiotic resistance pattern of community acquired uropathogens at a Tertiary Care Hospital in Jaipur, Rajasthan. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 37(1), 39–44. http://doi.org/10.4103/0970-0218.94023
World Health Organization. (2011). Report on the burden of endemic health care-associated infection worldwide. Retrieved from http://apps.who.int/iris/bitstream/10665/80135/1/9789241501507_eng.pdf
