INTRODUCTION- In ordinary clinical practice and hospital settings, urinary tract infection is one of the most common nosocomial diseases ^[1]. It refers to the presence of harmful organisms in the urinary system and is usually categorised as the bladder (cystitis), kidney (pyelonephritis), or urine (bacteriuria) depending on the site of infection ^[2]. The clinical signs are determined by the affected portion of the urinary tract, the causative organisms, the severity of the disease, and the patient's ability to build an immune response. Urinary tract infection, both chronic and acute, can cause high blood pressure, renal damage, and death ^[3].

UTIs can occur in all age groups of patients and both genders. UTI is 14 times more common in females than in males due to clinical reasons such as anatomical variance, hormone influence, and behavioural patterns ^[4,
5]. Antibiotics for UTIs come in various forms, and the best option is determined by several factors, including the severity of the infection and whether it is acute or recurrent ^[6]. Unfortunately, due to the widespread use of antimicrobial drugs, which has created antibiotic-resistant bacteria ^[7], this infection may become much more complex. These resistance traits can be easily transferred across bacteria of other genera via plasmids and other non-genetic mechanisms ^[8]. Uropathogens have a high rate of resistance ^[9].

The use of antibiotics is frequently connected to establishing antibiotic resistance and drug resistance. In most cases, UTI treatment is initiated on an empirical basis, with therapy based on data derived from the antimicrobial sensitivity pattern of urinary pathogens in a given community ^[10]. UTI can be caused by various microbes, although E. coli and other Enterobacteriaceae are the most frequent culprits, accounting for around 75% of all isolates. In recumbent, complex, and catheterized patients, Proteus sp., Klebsiella sp., Enterobacter sp., Serratia sp., and Pseudomonas sp. were also isolated ^[11].

Regular monitoring of resistance patterns is required to update guidelines for empirical antibiotic therapy due to the evolving and continuous antibiotic resistance phenomena. Furthermore, there is an increasing demand for innovative medications. However, there is very minimal data on multidrug resistance among UTI isolates ^[12], and ongoing monitoring of antibiotic resistance is essential.

The purpose of this study was to establish the prevalence of microorganisms that cause UTIs and assess the current antibiotic susceptibility pattern of these bacterial pathogens. Clinicians will be able to treat and manage patients with UTI symptoms more effectively.

MATERIALS AND METHOD

Study area and population- From June to December 2020, a seven-month study was conducted in the Department of Microbiology, Khwaja Yunus Ali University, and the Lab Zone and Hormone Center, Tangail, Bangladesh. The population investigated was varied, with people of all ages and sex. A total of 1288 clinical urine samples were obtained from patients from Bangladesh who visited the Lab Zone and Hormone Center. This study included 398 positive instances.

Sample Collection- Tangail's Lab Zone and Hormone Center received clinically suspected UTI patients (both male and female) for this study. Patients with urinary tract infections had their samples taken in clean, sterile, screw-capped vials. The samples were then taken to a laboratory for additional examination.

Isolation and Identification of Microorganisms- A variety of selective media were used to identify bacterial pathogens. All media were sterilized at 121°C for 15 minutes at 15 lb pressure, as directed by the manufacturer. Bacterial inoculums were inoculated onto chromogenic UTI agar and MacConkey media and incubated at 37°C for 24 hours. After 24 hours, the media showing no signs of bacterial development were incubated for another 48 hours before being declared bacterial-free. Cultural, morphological, and microscopic analysis followed standard methods to isolate and identify all bacteria. Catalase, Citrate, Oxidase, Indole, Motility, and Urease biochemical testing supported the findings ^[13].

In-vitro antibiotic susceptibility testing- Using Mueller–Hinton agar medium, the Kirby–Bauer disc diffusion method was employed to determine antimicrobial susceptibility against a panel of 14 marketed antibiotics. Bacterial isolates from 24-hour culture plates were taken in the nutrient broth, and then a lawn of test pathogen was produced by evenly spreading inoculums on the Muller Hinton agar plate. The antibiotic-impregnated discs were firmly placed on plates with sterile forceps and then incubated at 37°C for 24-hour; susceptibility was classified as sensitive, resistant, or intermediate based on the zones size ^[14].

Statistical Analysis- To evaluate the data, Excel and SPSS were utilized. The statistical evaluation was checked using descriptive statistics and chi-square tests. The p-value examined in this investigation has a significant value of "0.5."

RESULTS

During the study, 1288 urine samples were obtained, with 398 (30.9%) showing positive results and the rest showing negative results. Following the further investigation of positive growth samples, it was discovered that the majority of infected people (50.5 %) were between the ages of 21 and 40, with 41-60 years, 20 years, and >60 years following (Fig. 1), with the majority of infected people (72.6 %) being female (Table 1).

Fig. 1: Distribution of infected persons based on age

Table 1: Prevalence of UTI based on gender

Sex	Number of Samples	Frequency (%)
Female	289	72.6 %
Male	109	27.4 %

The bulk of the organisms detected were E. coli (82.86%), followed by E. faecalis (8.44 %t), K. pneumoniae (5.63%), P. aeruginosa (2.81%), and P. mirabilis (0.26 %) in biochemical and microbiological testing (Fig. 2).

Fig. 2: Prevalence of bacterial pathogens in UTIs

Only Meropenem (97.8%) was shown to be extremely sensitive against E. coli, while four antibiotics were found to be extremely resistant: Clindamycin (98.7%), Cefixime (98.4%), Cefuroxime (84.5%), and Cephradine (84.5%). The remaining drugs, Amoxicillin, Azithromycin, Ceftriaxone, Ciprofloxacin, Cefepime, Gentamicin, Nitrofurantoin, Levofloxacin, and Trimethoprim, were moderately sensitive to E. coli (Fig. 3).

Fig. 3: Antibiotic susceptibility pattern of E. coli

Meropenem (100 %) was the most sensitive antibiotic against E. faecalis, while Cephradine (100 %), Clindamycin (100 %), Cefixime (96.9%), Ceftriaxone (87.8%), Cefuroxime (78.8%), and Trimethoprim (78.8%) had increased antibiotic resistance (75.7 %). Against E. faecalis, the remaining drugs were moderately sensitive (Fig. 4).

Fig. 4: Antibiotic sensitivity pattern of E. faecalis

Meropenem (100%), Cefepime (95.4%), Gentamicin (95.4%), Nitrofurantoin (95.4%), and Ciprofloxacin (95.4%) were found to be susceptible antibiotics against K. pneumoniae in our investigation (81.8 %). Cefixime (100%), Cephradine (100%), Cefuroxime (100%), Clindamycin (100%), Ceftriaxone (95.4%), Amoxicillin (86.3%), and Levofloxacin (86.3%) were all extremely resistant drugs in this case (86.3 %). The antibiotics trimethoprim (90.9%) and azithromycin (86.3%) were moderately effective against K. pneumoniae (Fig. 5).

Figure 5: Antibiotic sensitivity pattern of K. pneumoniae

Meropenem has a higher sensitivity to P. aeruginosa (100 %). On the other hand, Cefixime (100%), Cephradine (100%), Cefuroxime (100%), Clindamycin (100%), Nitrofurantoin (100%), Ceftriaxone (90.9%), Trimethoprim (81.8%), and Cefepime (63.6%) were all resistant to P. aeruginosa. It was moderately susceptible to Amoxicillin, Azithromycin, Ciprofloxacin, Gentamicin, and Levofloxacin (Fig. 6).

Fig. 6: Antibiotic sensitivity pattern of P. aeruginosa

Only Meropenem (100%) and Nitrofurantoin (75%) were highly sensitive to P. mirabilis; the majority of the antibiotics used, Cefixime (100%), Cephradine (100%), Ceftriaxone (100%), Cefuroxime (100%), Clindamycin (100%), Cefepime (100%), Trimethoprim (100%), and Levofloxacin (75.0%), were highly resistant, and the remaining antibiotic (Fig. 7).

Fig. 7: Antibiotic sensitivity pattern of P. mirabilis

Clindamycin (98.9%), Cefixime (98.50%), Cefuroxime (87.43%), Cephradine (83.1%), Trimethoprim (64.9%), and Ceftriaxone (63.1%) were all highly resistant to E. coli, E. faecalis, P. aeruginosa, K. pneumoniae, and P. mirabilis in an antimicrobial susceptibility analysis of various isolates from urinary

The remaining experimental antibiotics were reasonably responsive to all isolated pathogens, with Meropenem demonstrating the highest sensitivity (98.25%) to all pathogens examined (Table 2).

Table 2: Overall antibiotic sensitivity pattern against UTI pathogens

Antibiotics	Intermediate (I)		Resistance (R)		Sensitive (S)
Antibiotics	No.	Prevalence (%)	No.	Prevalence (%)	No.	Prevalence (%)
Amoxicillin	120	30.15	170	42.71	108	27.14
Azithromycin	128	32.17	141	35.43	129	32.42
Cefixime	06	1.50	392	98.50	0	0
Cephradine	37	9.30	330	83.1	31	7.78
Ceftriaxone	102	25.7	251	63.1	45	11.30
Cefuroxime	45	11.31	348	87.43	05	1.26
Ciprofloxacin	168	42.2	108	27.2	122	30.65
Clindamycin	02	0.51	394	98.9	02	0.51
Cefepime	106	26.64	182	45.8	110	27.64
Gentamicin	130	32.67	117	29.4	151	37.94
Meropenem	07	1.76	0	0	391	98.25
Nitrofurantoin	95	23.9	168	42.3	135	33.92
Levofloxacin	75	18.85	108	27.13	215	54.0
Trimethoprim	84	21.1	258	64.9	56	14.0

DISCUSSION- Urinary tract infection is one of the most common community-acquired illnesses in Bangladesh, owing to the advent of antibiotic-resistant uropathogens. This study found a greater prevalence of UTIs in females (72.6%) than in males (27.4%), which is consistent with Akhtar et al. ^[15], who found a higher prevalence of UTIs in females (59.3%) than in males (40.7%), which is practically identical to our findings. Even in pediatric patients up to 16 years of age, female UTIs were more prevalent than males to Bitew et al. ^[16]. Unlike us and other regular studies, Isac et al. ^[17]portrayed males (58.07%) as being more predominant than females (41.93%) in being caught by UTIs in their recent study.

Pondei et al. ^[18] found that age groups 21–40 years were more prone to UTIs. The age group of 21–30 years old had the highest incidence in this study. UTIs are growing more common as people age, with prostate enlargement in males and neurogenic bladder in women being the primary causes ^[15].On the other hand, findings by Isac et al. ^[17]about the age distribution of UTIs contradict our current study as they found patients of <1 year of age (46.15%) to be more frequently infected by uropathogens than the three-year-old age group was displayed to be more prevalent in UTIs by Bitew et al. ^[16]. On the contrary, 53% of patients with UTIs were older, ranging from 60 to 90 years, by Alamri et al. ^[19].

Total 324 of the 398 positive samples contained bacteria, with E. coli (82.86%) being the most common, followed by E. faecalis (8.44%), K. pneumoniae, P. mirabilis and P. aeruginosa were among the microorganisms recovered from UTI cases. These findings are supported by a recent study by Abedin et al. ^[11]. E. coli was the most prevalent uropathogen with a considerably high %age of 42.9% and 38.84%, respectively, by Bitew et al. ^[16]and Isac et al. ^[17], which corroborates our current findings. However, the %age of supremacy was quite higher in our study (82.86%). Unlike us, Klebsiella sp. was the second most frequent isolate in both studies. Nevertheless, the high prevalence of E. coli (79.6%) in our study was also displayed by Unsal et al. ^[20]. Aalpona and Kamrul-Hasan ^[21] also said that Proteus (21.6% of the time) was the second most common uropathogens.

In our study, the most prevalent uropathogen, E. coli, was sensitive only to Meropenem (97.8%). In contrast, other antibiotics were ineffective by a significantly high margin, such as Clindamycin (98.7%), Cefixime (98.4%), Cefuroxime (84.5%), and cephradine (79.0%) against the pathogen. E. coli was found to be sensitive to Meropenem (90%) in a study by Aalpona and Kamrul-Hasan ^[21]at Mymensingh Medical College in Bangladesh; however, the fatal concerns, Gentamycin (83%) and Nitrofurantoin (76%), which were effective against E. coli in that study, were found to be impotent to be used as antibiotic therapies in our current study. Islam et al. ^[22]discovered that E. coli was resistant to a large number of first- and second-line antibiotics, including Amoxicillin (100%), Amoxiclav (72%), Co-trimoxazole (89%), Nalidixic acid (78%), Ceftazidime (94%), Ceftriaxone (73%), Cefuroxime (100%), Ciprofloxacin (59%), Cefotaxime (80%), and Cefixime (100%).

In the overall uropathogenic sensitivity pattern, Meropenem had the highest sensitivity (98.25%) against all isolated uropathogens, while Cefixime had no sensitivity. Meropenem had the maximum sensitivity (98.25%), and there was no resistance. This finding was similar to that of Abedin et al. ^[6], who found Meropenem and Imipenem to have the maximum sensitivity against uropathogens. Aalpona and Kamrul-Hasan ^[21]also found Meropenem (85%) to be the most effective, along with Gentamycin (79%) and Nitrofurantoin (71%). However, Gentamycin (83%) and Nitrofurantoin (76%) were found non-potential as therapeutics in our current study due to developing resistance mechanisms of uropathogens against such antibiotics, which is a matter of grave concern ^[21]. Clindamycin showed the most significant resistance (98.9%), while Meropenem showed no resistance.Ciprofloxacin had the highest intermediate resistance (42.2%), and Clindamycin had the lowest sensitivity (0.51%). Majumder et al. ^[23] found substantially identical results in Bangladesh.At Mymensingh Medical College, Bangladesh, 80% of the uropathogens were found impractical by Aalpona and Kamrul-Hasan ^[21]at Mymensingh Medical College, Bangladesh, which was somewhat close to our study. The increasing bacterial resistance to antibiotics in our region could be attributed to a higher prevalence of antibiotic use, even when purchased over-the-counter and without a prescription ^[24]. As a result of the frequent development of resistance to antibiotics in this certain region, Meropenem (98.25%) was found to be the only considerably effective antibiotic therapy to treat UTIs in that particular area brutally alarming.

CONCLUSIONS- The findings of our current study could provide physicians with guidance in that area when prescribing antibiotics to patients with urinary tract infections. Our future research will focus on the potential causes of antibiotic resistance and ongoing research to determine the diversity of uropathogens and their antibiotic susceptibility patterns, which will help physicians, continue to prescribe appropriately to UTI patients. Eventually, it will play an enormous role in controlling antibiotic resistance development and proper antibiotic therapeutics for urinary tract infections (UTIs).

ACKNOWLEDGEMENT- We would like to appreciate the contribution of Md. Sobur Mia, Lab Zone and Hormone Center, was enormously cooperative during sampling.

CONTRIBUTION OF AUTHORS

Research concept- Mohammad Zakerin Abedin, Abdullah Aktar Ahmed

Research design- Mohammad Zakerin Abedin, Abdullah Aktar Ahmed

Supervision- Abdullah Aktar Ahmed, Md. Babul Aktar, Md. Oyes Quruni

Materials- Md. Babul Aktar, Rubait Hasan, Farjana Akter Koly, Muhammad Irfanul Islam

Data collection- Md. Anisur Rahaman, Farjana Akter Koly, Md. Easin Arfat

Data analysis and Interpretation- Muhammad Irfanul Islam, Noor-E-Kashif Farnaz

Literature search- Sajjad Hossen Chowdhury, Md. Babul Aktar, Md. Anisur Rahaman

Writing article- Farjana Akter Koly, Jamiatul Husna Shathi

Critical review- Md. Oyes Quruni, Rubait Hasan, Jamiatul Husna Shathi

Article editing- Md. Easin Arfat, Mohammad Zakerin Abedin

Final approval- All Authors

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Research Article (Open access)