Track your Manuscript
Enter Correct Manuscript Reference Number:
Get Details
Top Editors

Dr. Nanjappaiah H. M.
Assoc. Prof. Dept. of Pharmacology BLDEA’s SSM College of Pharmacy & Research Centre Vijayapur – 586103, Karnataka, India

Dr. Shek Saleem Babu
English Language and Literature, English Language Teaching, and Poetry, IIIT, RGUKT, Nuzvid, Krishna Dt. AP, India

Dinh Tran Ngoc Huy
Bank for Investment and Development of VietNam (BIDV)

Dr. Abd El-Aleem Saad Soliman Desoky
Professor Assistant of Agricultural Zoology, Plant Protection Department Faculty of Agriculture, Sohag University - Egypt

Prof. Dr. Elsayed Ahmed Ahmed Elnashar, Ph.D.
Full-Professor of Textiles &Apparel, Faculty of Specific Education, Kaferelsheikh, University, Egypt
Top Reviewers

Dr. Shabnum Musaddiq
Assistant Professor, Department of Microbiology, Narayana Medical College, Nellore, Andhra Pradesh, India, 524003

Dr. Biman Kumar Panigrahi
Associate professor, Seemanta Instt. of Pharma. Scs., Jharpokharia, Odisha, 757086, India

Efanga, Udeme Okon
Finance, Accounting and Economics, niversity of Calabar, Nigeria

Aransi Waliyi Olayemi
Department of Adult Education, University of Ibadan, Ibadan, Nigeria
Why Us
Open Access
Peer-reviewed
Rapid publication
Lifetime hosting
Free indexing service
Free promotion service
More citations
Search engine friendly
Go Back       Himalayan Journal of Applied Medical Sciences and Research | Volume:3 Issue:2 | April 20, 2022
26 Downloads73 Views

DOI : 10.47310/Hjamsr.2022.v03i02.011       Download PDF       HTML       XML

Prevalence and Antimicrobial Susceptibility of Gram Negative Bacteria in Urine of Students of Federal Polytechnic Nekede, Owerri


Abba-Father C. A. M.*, Ibe I. J., Edward O. C., Etoamaihe U. E., Iroka P. C. and Ekere I. C

Department of Biology/Microbiology, Federal Polytechnic Nekede, Owerri, Imo State, Nigeria



*Corresponding Author

Abba-Father C. A. M


Article History

Received: 04.04.2022

Accepted: 13.04.2022

Published: 20.04.2022


Abstract: In order to access the prevalence and sensitivity pattern of urinary pathogens, aseptically collected 50 midstream urine samples from some students of Federal Polytechnic Nekede were investigated using standard microbiological cultural methods. Samples were cultured on CLED and Nutrient agar media. Disk diffusion method was used for antibiotic testing. Of the 50 urine samples 28 yielded significant growths with a prevalence rate of 50%. It was observed that females were more infected than the males with a prevalence rate of 53.6% and 46.4% respectively (ages 22-28 years). Pseudomonas species and Escherichia coli were the most predominant isolates. The isolates were sensitive to Gentamycin, Chloramphenicol and Ofloxacin, but were mostly resistant to Septrin, Sparfloxacin, Perfloxacin and Amoxacillin. Therefore, Chloramphenicol, Gentamycin, Ofloxacin are strongly recommended for the treatment of urinary tract infection (UTI) as indicated in the study.


Keywords: Gram negative, Urine, Age, Sex, Susceptibility.


INTRODUCTION

Most bacteria causes urinary tract infection (UTI), but the most common is Escherichia coli which is responsible for about 80-85% of UTI, Ortho women’s report, 2004 according to (Azubuike, C. N. et al., 2002), urinary tract infections are categorised as ascending or descending routes. Three years later, (Stamm, W. E & Newby, S. S. 2005) stated that infections occurs when microorganism usually bacteria from digestive tract cling to the opening of the urethra and begin to multiply. Four routes have been purposed the ascending routes, from the urethra to bladder, then by the urether to kidney, the haematogenous routes, with seeding of the urether to the kidney during the course of bacteraemia; intestine to kidney by way of lymphatic and direct infections. These bacteria may be present in the vaginal and rectal areas.


Gram negative bacteria are bacteria that do not retain their crystal violet dye in the gram staining protocol. They are differentiated by their cell wall structure. The following characteristics are displayed by gram negative bacteria as follows; Cytoplasmic membrane, thin peptidoglycan layer (much thinner than gram positive), outer membrane containing lipopolysaccharide outside the peptidoglycan layer, porin exists in the outer membrane, which acts like pores, there is a space between the layer of peptidoglycan and the secondary cell membrane called the periplasmic space, if present, flagella have four (4) supporting rings instead of two  No techoic acid or lipopolysaccharide.


Some examples of gram negative bacteria include; Escherichia coli, Salmonella species, Pseudomonas species, Klebsiella species, Proteus species, Helicobacter species, Mosoxella species, Cyanobacteria species, Spirochetes species.


They also constitute a serious problem in urinary tract infections in many parts of the world. Appropriate antimicrobial treatments are often critical to decreasing morbidity and mortality among hospitalized patients having the infections caused by the pathogens. Gram negative bacteria are non-spore forming bacilli that grow rapidly on ordinary laboratory media under both aerobic and anaerobic conditions. It has been estimated that symptomatic urinary tract infects (UTI) occurs in as many as 7million visits to emergency units and 100,000 hospitalised annually. UTI has been the most common hospital acquired infections, accounting for as many as 35% of nosocomial infection. It is the second most common cause of bacteraemia in hospitalised patients (Prah, J. K. et al., 2019). UTI is known to occur in all populations but has a particular impact on females of all ages and males at two extremes of life, immuno-compromised patients and anyone with function or structural abnormalities of the urinary and excretory system.


UTI is known to be the microbial invasion of any of the tissues of the urinary tract reaching from the renal cortex to the urethrameatus (Nicolle, L. E. 2000). It is also known to be the presence in two consecutive urine samples of greater than 100rods (105 ) organisms per ml of a single bacterial strain in the urinary tract. UTI can be categorized in ascending or descending. Infections which are confined to the urethral or the bladder are ascending and referred to as uretitis or cystitis respectively. On the other hand, the pathogens spread from one or other infected body site to the kidney down along the ureter to the bladder. Such descending UTI cause severe kidney infection, a condition called pyelonephritis (Rahman, F. et al., 2009). This is potentially more serious; infections to the urethra are called urethritis and to the prostrate gland are called prostitis. This classification is the presence or absence of symptoms, reoccurrence or absence or presence of complicating factors which are host factors facilitating establishment and maintenance of bacteraemia or worsening the prognosis of UTI`s engaging the kidney.


Majority of pathogens are gram negative species with predominance of members of Enterobacteriace (Salles, M. J. C. et al., 2013). Escherichia coli accounts for majority of urinary tract infections in young women but other gram negative

Majority of pathogens are gram negative species with predominance of members of Enterobacteriace (Salles, M. J. C. et al., 2013). Escherichia coli accounts for majority of urinary tract infections in young women but other gram negative rods of different genera such as proteus species and pseudomonas aeruginosa an aerobic gram negative rod is also troublesome. As a urinary tract pathogens because of its resistance to antimicrobial medicine make it difficult to treat successfully.


Antibiotics are used for the control of bacterial infections in human. Generally, gram negative bacteria are sensitive to many antimicrobial agents but strains from different patients and carriers differ in the pattern and degrees of sensitivity to different drugs. Increasing antimicrobials resistance in bacterial pathogen is a worldwide concern. The prevalence of antimicrobial resistance among urinary tract infectious agents is also increasing (Mathai, D. et al., 2001; Karlowsky, J. A. et al., 2001) and its treatment has become more complicated due to increasing resistance and empirical therapy leading to treatment failures of most associated with gram negative bacteria. The present study investigated the pattern of gram negative uropathogens and their antimicrobial resistance pattern among the clinical isolates to the commercially available antibiotics that are often prescribed in urinary tract infectious cases. Therefore the aim of this study is to find out the prevalence of gram negative organisms in the urinary tract among some students of Federal Polytechnic Nekede, to investigate their antibiotic sensitivity pattern to enable formulation of drugs for urinary tract infection in the school community using age and sex prevalence, to determine the prevalence of bacterial strains and their antimicrobial  susceptibility in urine, to find the pathogenic bacteria commonly responsible with UTI and susceptibility patterns this will help the clinicians to choose the right empirical treatment.


MATERIALS AND METHODS:

Collection of Samples:

A total of 50 mid-stream urine (15-20mL) samples were collected from both male and female students referred to the medical center laboratory of the Federal Polytechnic Nekede Owerri for suspected cases of urinary tract infection (UTI) in sterile, dry, wide-necked, leak-proof containers. The samples were collected between May 2021 and July 2021, and taken to microbiology department laboratory of the Federal Polytechnic Nekede, Owerri for microbial analysis according to (Cheesbrough, M. 2006; Dielubanza, E. J., & Schaeffer, A. J. et al., 2011). All the samples were kept in a fridge, so that the bacteria in the urine sample will not multiply. On the urine sample were indicated the name, age, sex, including the date and time of collection. Each of the samples were observed with the naked eyes to ascertain if the urine was clear or cloudy (turbid) and the colour of the urine was also observed. Only students who had not been on antibiotic preceding one week of sample collection were enrolled.


Isolation and Characterization:

The urine was mixed thoroughly by rotating the container clockwise and anticlockwise directions. A loopful of the urine samples were inoculated on Cystine-Lactose-electroyte-deficient agar (CLED) and nutrient agar by streaking and incubated at 370c aerobically for 24hrs. The plates were examined macroscopically. The bacterial colonies were counted and multiplied by 100 to give an estimate of the number of bacteria present per millimetre of urine. A significant bacterial count was taken as any count equal or in excess of 10,000 cfu ml. Representative of growing colonies were picked with repeated streaking. Resulting pure cultures obtained were used for biochemical test aimed at identifying the bacteria isolates and its microscopy was also carried out. The pure cultures were further characterized microscopically by Gram staining and biochemically using the following biochemical test,; Indole test, Methyl Red – Voges-Proskauer test, Citrate utilization test, Sugar fermentation test, Urease test and Motility test as described by (Cowan, S. T. & Steel, K. J. 2013).


Antimicrobial Susceptibility Test:

Antimicrobial sensitivity was tested for each isolated organism using the disk diffusion method of each isolated organism using the disk diffusion method of Kirby-Baurer as described by the (Clinical Laboratory Standard Institute. 2015).the multi disc contains the following antibiotic for gram negative organisms and they are (Septrin) (SXT) Chloranphenical (CH) sparfloxacin (sp) Ciprogloxaan (CPX) Amoxacillin (AM) Augmentin (AU) Gentamycin (CN) Pefloxacin (PEF) Tarivid (OFX), Streptomycin (S) Ofloxacin and Cephalexin (CEPH). Two fold dilution was carried out by extraxcting 1ml of the test organisms from the test tube, into another test bube containing Iml of peptone water. Labelled as TUBE 1 with a dilution factor of 10-1. From TUBE 1, 1ml of the mixture was extracted into TUBE 3, with the dilution factor of 10-3 to dilution factor of 10-5 and the last was discarded. 10-2 dilution factor was used, because it matches Macfarland standard of 0.5ml. 0.5ml of the test organism was extracted from the dilution factor of 10-2 into each petridish containing muller-Hinton Agar and it was spread uniformly on the surface of the medium using glass bent rod.


A cmmercially prepared gram-ve sensitivity disc was placed and impregnated on the medium containing the 0.5ml of test organism. The anti-microbial diffused from the disc to the medium and the growth of the organism was inhibited at a distance from the disc, where as resistant strains had smaller zones of inhibition. 5-8mm zones of inhibition signifies sensitivity/susceptibility while below 5mm were regarded as resistance.


A disc of blotting paper was impregnated with a known volume and appropriate concentration of an antimicrobial and it was placed in a plate of sensitvity testing agar that was uniformly inoculated with test organism. The antimicrobial diffused from the disc to the medium and the growth of the organism was inhibited at a distance from the disc that was associated to the sensitivity of the organism. Strains that were sensitive to the antimicrobial were inhibited at a distance from the disc where as resistant strains had smaller zones of inhibition. Zones of inhibitions from 8-12mm signifies sensitivity while and below 8mm were regarded as resistance.


RESULT:

A total of 50 samples were collected from some student of Federal Polytechnic Nekede Owerri students were investigated. Out of the 50 samples, 24 samples were females while 26 samples were males with age range of 22-28yrs. Out of the 50 samples, 28 samples were positive (gram-ve), 13 were female while 15 were males. The remaining samples that showed no significant bacterial growth were discarded. Out of 27 samples from males 13 were positive with prevalence rate of 46.4% while 23 samples from females gave 15 were positive with prevalence rate of 56.7% as shown in table 1.Therefore, the prevalence rate of positive cases of (gram-ve bacteria) for male and females were 40.9% and 50.1% respectively. Out of the 50 student examined pseudomonas spp were isolcated and identified from 12 student, proteus spp from 7 student while E.coli from 3 student.


Pseudomonas had the highest prevalence rate of 50% followed by E.coli spp 25%, Proteus spp 10.70% and the other gram positive organisms put together had 21.4% as shown in table 2.


It was also observed that Gentamycin, Chloraphenical and tarivid were the most sensitive antibiotics in the study while tetracycline Cephalexin, septrin, sparfloxacin perfloxacin and Amoxacillin gave poor sensitivity or resistance. As shown in table 3 from this measures above. Gentamycin , Chloraphenical and Tarivid proved the best antibiotics against gram negative bacteria.


Table 1: Shows Sex Distribution of cases and their Prevalence rate (22-28yrs)

Sex

Total case

Positive cases

% Positive cases

Male

27

13

46.4%

Female

23

15

53.6%

Total

50

28

100.00


Table 2: Shows the bacteria distribution of positive cases with prevalence rate.

Bacteria isolate

Positive cases

% Positive cases

E.coli.

27

25.0

Pseudomonas spp

12

42.9

Proteus spp

3

10.7

Others (gram positives)

6

21.4

Total

28

100.00


Calculation of prevalence as shown in the Table 2 above.

E. coli- spp 7 x 100

28 1 = 25%


Pseudomonas spp 12 x 100

28 1 = 42.9%


Proteus spp 3 x 100

28 1 = 10.7%


Others (Gram + ve) 6 x 100

28 1 = 21.4%


Overall prevalence for positive cases is

28 x 100

50 1 = 56%


Table 3: Shows the sensitivity pattern of bacteria isolated and their antimicrobial resistance

Bacteria Isolates

Antibiotics


SXT

CH

SP

CPX

Am

AU

CN

PEF

OFX

S

E-coli

3mm

7mm

0mm

1mm

2mm

0mm

9mm

0mm

3mm

0.5mm

Pseudo Spp

0mm

6mm

1mm

2mm

0mm

0mm

0mm

6mm

1mm

1mm

Proteus spp

0mm

1mm

0mm

2mm

1mm

2mm

3mm

0mm

6mm

6mm

Key:

0-5mm shows antibiotics resistivity.

5-8mm shows antibiotic sensitivity.

SXT => Septrin

CH => Chloranphenicol

SP => Sparfloxacin

CPX => Ciprofloxacin

AM => Amoxacillin

AU => Augmentin

CN => Gentamycin

PEF => Pefloxacin

OFX => Tarivid

S => Streptonycin


Table 4: Urinalysis result from the student midstream urine samples

S/N

COLOUR

APPREANCE

PH

PROTEIN

GLUCOSE

KETONE

BILIRIBIN

UROBIL

NITITE

LEU

BLOOD

1.

Yellow

Clear

5.0

Trace

Neg

Neg

Neg

Normal

Neg

Neg

Neg

2.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

3.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

4.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

5.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

6.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

7.

Yellow

Turbid

7.0

Neg

Neg

Neg

Neg

Normal

POS

Neg

Neg

8.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

POS

9.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Trace

Neg

Neg

10.

Yellow

Clear

7.5

Trace

Neg

Neg

Neg

Normal

Neg

Neg

Neg

11.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

12.

Ember

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

13.

Ember

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

14.

Ember

Clear

7.0

Neg

Neg

Neg

Neg

Normal

POS

Neg

Neg

15.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

16.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

17.

Yellow

Clear

5.0

++

Neg

Neg

Neg

Normal

Neg

Neg

Neg

18.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

19.

Yellow

Clear

5.0

+

Neg

Neg

Neg

Normal

Neg

Neg

Neg

20.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

21.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Trace

Neg

Neg

22.

Yellow

Clear

7.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

23.

Yellow

Clear

7.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

24.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

25.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

26.

Ember

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

POS

27.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

28.

Yellow

Clear

7.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

29.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

30.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

31.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

32.

Amber

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

POS

33.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Trace

Neg

Neg

34.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

35.

Yellow

Clear

7.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

36.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

37.

Yellow

Clear

5.0

Trace

Neg

Neg

Neg

Normal

Neg

Neg

Neg

38.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

39.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

40.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Normal

Neg

Neg

Neg

41.

Yellow

Turbid

6.5

Neg

Neg

Neg

Neg

Neg

Neg

Neg

Neg

42.

Yellow

Clear

5.0

Trace

Neg

Neg

Neg

Neg

Neg

Neg

Neg

43.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Neg

Neg

Neg

POS

44.

Yellow

Clear

6.5

Neg

Neg

Neg

Neg

Neg

Neg

Neg

Neg

45.

Amber

Turbid

5.0

Trace

Neg

Neg

Neg

Neg

Neg

Neg

Neg

46.

Amber

Clear

5.0

Neg

Neg

Neg

Neg

Neg

Neg

Neg

Neg

47.

Yellow

Clear

7.0

Neg

Neg

Neg

Neg

Neg

Neg

Neg

Neg

48.

Yellow

Turbid

5.0

Neg

Neg

Neg

Neg

Neg

Neg

Neg

POS

49.

Yellow

Clear

5.0

Neg

Neg

Neg

Neg

Neg

Neg

Neg

Neg

50.

Amber

Clear

5.0

Neg

Neg

Neg

Neg

Neg

Neg

Neg

Neg


DISCUSSION:

The overall prevalence of UTI in this study was 56% and females were significantly more affected than males, previous repents (Schmiemann, G. et al., 2010) of studies carried out in different parts of the world indicates higher incident among females than males, this may be explained by the fact that females pass short urethra and easy fecal contamination of the vaginal entry due to the close proximity of the anus. The spread of normal flora in faecal materials from the anus to the vagina from where the bladder could be infected as a result of poor anal cleaning could be responsible for the observed result in female urine sample.


Secondly, having sex with numerous partners whose life style and sexual history one do not know cannot only lead to venereal disease but to urinary tract infection. The result obtained from the urinalysis, it was seen that most urine has a pH level of 5.0 urine under 5.0 is acidic and urine higher than 8.0 is alkaline. According to the American association for clinical chemistry. The prevalence of UTI of some student in Federal Polytechnic Nekede, which is found to be 53.6% for the female is quite alarming.


This calls for caution among the female students in Federal Polytechnic Nekede. The high rate may be due to the increase in female with poor hygienic practice and also indiscriminate sexual behaviour among the female students pseudomonas spp and E. Coli were the commonest organism isolated, this is in conformity with the previous work done by other researchers. The least resistance by the bacterial isolates to antimicrobial agents was observed to be Sparfloxacin, Perfloxacin, Amoxiallin, Aprofloxacin. The factors contributing to those resistance may be due to indiscriminate abuse of antibiotic by students. Other factors may include poor quality of drugs, poor storage and exposed drug (Okeke, I. N. et al., 1999). The reduction of antibiotics prescription. and dispensation have been associated with reduced antibiotic resistance (Schmiemann, G. et al., 2010). It is quite alarming to note that almost all of the isolates included in this study were found resistant drugs of three or more antibioltics.


CONCLUSION:

This study has revealed that UTI among female students is a very difficult health problem which must be properly addressed. This has also revealed that the most causative organisms of UTI in this Federal Polytechnic Nekede community among the female students are the gram negative organism which were shown to be sensitive to the following drugs. Gentamycin, Ofloxacin and Chlorophenical, Tarivid. It could be suggested that in the face of clear UTI symptons and in the absence of physician or clinician of these four drug abuse (Gentamycin, Ofloxacin and Tarvid, Chloraphenical could be procured and used and with an experienced doctor is seen for confirmation. The mis-used of antibiotics which mighty lead to drug resistant can be eradicated, if is to be formulate a strict antibiotics prescription policy in our country.

Recommendation:

This is the appropriate time to investigate infection control measures which are lacking in the most health care institutions, firm, industries etc. There is also need to establish the sense and control surveilliance agencies. There is need for interaction between physicians and microbiology department because there have been cases where by the antibiotics tested are different from those frequently prescribed since the laboratories use only the susceptibility diffusion disc available to them. In addition, given the high resistance rates in enterobacteriaceae family, causing comuity acquired UTIS and lack of therapeutic options.


It can also be recommended that, anti-microbial prescribing be guided by considering infection severity, established patient risk factors for multi-drug-resistant infections acquaintance with local antimicrobial sysceptibility data and culture collection.


REFERENCES:

  1. Mathai, D., Jones, R. N., Pfaller, M. A., & America, T. S. P. G. N. (2001). Epidemiology and frequency of resistance among pathogens causing urinary tract infections in 1,510 hospitalized patients: a report from the SENTRY Antimicrobial Surveillance Program (North America). Diagnostic microbiology and infectious disease40(3), 129-136.

  2. Dielubanza, E. J., & Schaeffer, A. J. (2011). Urinary tract infections in women. Medical clinics95(1), 27-41.

  3. Azubuike, C. N., Nwamadu, O. J. & Uzoije, N. (2002). Prevalence of UTI among Patients. West Africa Journal of medicine 13, 48-52.

  4. Cheesbrough, M. (2006). District Laboratory Practice in Tropical Countries.(2ndedn.) Cambridge University Press. United Kingdom. 187.

  5. Clinical Laboratory Standard Institute. (2015). Performance standards for antimicrobial susceptibility testing;n twenty-fourth informational supplement. CLSI document M100-S25, 35(3).

  6. Cowan, S. T. & Steel, K. J. (2013). Manual for the identification of Medical Bacteria 3rd ed. / edited and rev. by G. I. Barrow and R. K. A. Feltham. Cambridge University Press London.

  7. Rahman, F., Chowdhury, S., Rahman, M. M., Ahmed, D., & Hossain, A. (2009). Antimicrobial resistance pattern of gram-negative bacteria causing urinary tract infection. Stamford journal of pharmaceutical sciences2(1), 44-50.

  8. Karlowsky, J. A., Jones, M. E., Thornsberry, C., Critchley, I., Kelly, L. J., & Sahm, D. F. (2001). Prevalence of antimicrobial resistance among urinary tract pathogens isolated from female outpatients across the US in 1999. International journal of antimicrobial agents18(2), 121-127.

  9. Salles, M. J. C., Zurita, J., Mejía, C., & Villegas, M. V. (2013). Resistant Gram-negative infections in the outpatient setting in Latin America. Epidemiology & Infection141(12), 2459-2472.

  10. Nicolle, L. E. (2002). Asymptomatic Bacteruria. The New England of Medicine,343, 1037-1039.

  11. Okeke, I. N., Lamikanra, A., & Edelman, R. (1999). Socioeconomic and behavioral factors leading to acquired bacterial resistance to antibiotics in developing countries. Emerging infectious diseases5(1), 18-27.

  12. Mathai, D., Jones, R. N., Pfaller, M. A., & America, T. S. P. G. N. (2001). Epidemiology and frequency of resistance among pathogens causing urinary tract infections in 1,510 hospitalized patients: a report from the SENTRY Antimicrobial Surveillance Program (North America). Diagnostic microbiology and infectious disease40(3), 129-136.

  13. Prah, J. K., Amoah, S., Ocansey, D. W., Arthur, R., Walker, E., & Obiri-Yeboah, D. (2019). Evaluation of urinalysis parameters and antimicrobial susceptibility of uropathogens among out-patients at University of Cape Coast Hospital. Ghana Medical Journal53(1), 44-51.

  14. Schmiemann, G., Kniehl, E., Gebhardt, K., Matejczyk, M. M., & Hummers-Pradier, E. (2010). The diagnosis of urinary tract infection: a systematic review. Deutsches Ärzteblatt International107(21), 361.

  15. Stamm, W. E & Newby, S. S. (2005). UTI Disease Panoramas and Challenges of Infections, 183, 51-54.

Copyright © 2020 Inlight Publisher (IARCON INTERATIONAL LLP). All Rights Reserved.