Nosocomial Urinary Tract Infections in Baghdad Teaching Hospital

: Objectives: The objectives of the present study are to identify both, the rate of urinary tract infections (UTI) in medical and surgical wards in Baghdad Teaching Hospital and the common types of microorganisms that cause this type of NIs, study the resistance of isolated microorganisms to several types of antibiotic and the effect of some disinfection material like Iodine, chlorhexidine and septicin on the growth of these isolates


Introduction:
ospital acquired infections (HAI s ) are a common, costly, and potentially lethal patient safety problem (1)(2) .It also called nosocomial infections; they are the infections which developed during hospitaliza on between 2-4 days a er admi ed pa ent to hospital and were not incubating or present at the time of admission to the hospital (3) .The common types of (HAI s ) include: urinary tract infections (UTI s ), pneumonia, surgical site infections (SSI s ), and blood stream infections (BSI s ).
Urinary tract infections account for almost 60% of all nosocomial infec ons (3,4) .Most HAI s of urinary tract are associated with urethral catheteriza ons.Up to 25% of with hospital patients placed urinary catheter during their hospitalization (5) .Any pathogen present in the hospital environment can cause infection, because of the compromised immune status of some of the patients.However, organisms which can survive for long periods in hospital environment and in disinfections are specially equipped to cause hospital infections.Escherichia coli and pseudomonas aeuroginosa (G-ve bacteria) are the most frequently causative agents of urinary tract infections.From the other hand, the gram positive cocci Staphylococcus aureus is one of the most important organisms in nosocomial infections (6) .Nosocomial infections are often caused by antibiotic resistant microorganism, which became a major clinical and public health problem during the lifetime of most people (7) .The transmission of the microorganism in the health care is occurring specific control measures are necessary.Some strains of Methicillin resistant Staphylococcus aureus MRSA strains are often resistant to several antibiotics in addition to the B. Lactams antibiotic, and occasionally are sensitive only to Vancomycin (8).
Some chemical agents are used to control the growth of microbes on both of living tissue and inanimate objects, few chemical agents are a achieve sterility.For example, phenol and phenolics, Bisphenol, (hexachlorophene), Biguanides (Chlorhexidine), which are frequently used for microbial control on skin and mucous membranes, it is much used for surgical an hand scrubs and preoperative skin preparation in patients.Halogens particularly iodine and chlorin are effective antimicrobial agent, both alone and as constitutes of inorganic compounds.Iodine (I 2 ) is one of the oldest and most effective antiseptics.The most common commercial preparation is Betadine (povidone iodine) which is a surface-active iodophor used for skin disinfection and wound treatment (7) .Benzalkonium chloride (Septicin) is popular Quaternary ammonium compounds (Qauts).It is strong antimicrobial stable, tasteless, easily diluted and nontoxic, expect at high concentration, effect on G+ve bacteria but less on G-ve bacteria (9)(10) .Several practices have been evaluated to prevent hospital acquired UTI, such practices include using indwelling catheters only when necessary, using antimicrobial catheters only in patients at highest risk of infection, using external or (condom-style) catheter, maintaining proper insertion technique, hand washing, intelligent use of instrumentation and limiting the use of antibiotics (11)(12) .The study aims to determine the rate of UTIs at medical and surgical wards in Baghdad Teaching Hospital, find out the best way to control this type of infections, identify the most common types of microorganisms that cause this type of NIs and determination the susceptibility of isolated microorganisms to several mostly used of antibiotic, and study the effect of some disinfection materials like Iodine, Chlorhexidine and Septicin on the growth of these isolates.

Samples:
A total of 200 pa ents admi ed to Baghdad Teaching Hospital from 1/6/2009 to 1/11/2009 are selected from both medical and surgical wards (100 pa ents of each).Urine samples are collects from all the patients at least after one week of their admission, using sterilized plastic containers.Some of the important information was recorded from each patient.This table shows that the highest rate of infec on was found in males, 74%, and 58% in surgical and medical ward respectively.This table illustrated the most common pathogen isolated from UTIs patient in both wards.The Gram negative bacteria were more commonly reported as etiologic agents of UTI s as NCIs in medical surgical wards.The most common bacterial isolates were Pseudomonas aeuroginosa (42, 56) isolated from UTI pa ents in medical and surgical ward respectively.On the other hand the most common isolates of gram positive bacteria were Staphylococcus aureus (13,  5) isolates in medical and surgical ward respectively.Candida albicans (fungi) was isolated from 9 pa ent (7, 2) isolates from medical and surgical wards respectively.This table shows the number and percentage of antimicrobial resistance among pathogenic bacteria isolated from patients acquired UTI s as nosocomial infections in medical and surgical wards.There was variation in the resistance to antibiotics among different bacterial isolates.Ps. aeuroginosa isolated from urine samples were resistant to several types of antibiotics.Multidrug -resistance (Amikacin, Ampicillin, Cephalexin, Gentamycin, Nalidixic acid, Methicillin, Rifampicin and Trimethoprim) was observed in Methicillin-resistant S. aureus (MRSA).Nitrofurantion was the most effective drug on all bacterial isolates.

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Nosocomial Urinary Tract Infection
Table 5. Number and percentages of resistance to some disinfectants against isolated bacteria from urine samples
This table Explains the effect of some disinfection material like Benzalkonium Chloride (Septicin,commercial), Chlorhexidine and Povidone-iodine (Betadine, commercial) on the growth of isolated bacteria form UTIs patients were studied on the limited concentration for controlling the growth of isolated bacteria.The results indicated that bacterial isolates showed varied response towards different concentration of disinfectant, povidone-iodine 15% (Pi3) was more effec ve against all bacterial isolates rather than other disinfectants.Septicin was more effective than Chlorhexidine on gram positive bacteria isolated from urine samples of UTI patients, this result showed high significant difference (p˂0.01).The an bacterial ac vity of sep cin was higher against gram nega ve bacteria.

Discussion:
Hospital acquired infections are infections that are neither present nor incubating when a pa ent enters the hospital.About 9% of inpatients have a hospital ac within age group (36-45 years) in surgical ward and (46-55 years) in medical ward acquired infection at any one time, equivalent to at least 100,000 infec ons yearly (1- 2).
The highest rate of UTIs found in patients within age group (36-45) years in surgical ward and (46-55 years) in medical ward table (1), most of patients were males in both wards table (2), whom usually infected with UTI s during these age (1, 2).So, we should be sure from hygiene and medical care by hand washing, using surgical gloves and intelligent use of instrumentation before using catheterization or preparing patients for surgical operations will be necessary (16) .
In this study, the Gram negative bacteria were more commonly reported as etiologic agents of UTI s as NCIs in medical and surgical wards.The most common bacterial isolates were Pseudomonas aeuroginosa, followed by Escherichia coli were isolated from UTI s patients in medical and surgical wards table (3).The ability of these types of pathogenic bacteria to grow in moist conditions with simple nutrients, colonize sites catheter insertion (annular insertion) and its amazing high resistance to antibiotics, has established them to be the most pathogens and cause serious infections (6) .The most common isolates of gram positive bacteria were Staphylococcus aureus, this bacteria still one of the most important G+ve bacteria in UTI s (7, 17) .Many different pathogens may cause nosocomial infections.The infecting organisms vary among different patient populations.Different health care settings, different facilities and different countries.Our results were consistent with (18) they were found that urinary tract infections topped the list of nosocomial infections in ICUs medical centers and the top three pathogens of nosocomial infections for patients were Ps.aeruginosa, E.coli and Staph.aureus.
In the present study, there was variation in the resistance to antibiotics of the different bacterial isolates but the most important findings of significance in this study was the multi-drugresistance (an, amp.kf, gm, na, sxt) observed in most isolated bacteria (Table 4).There are many reasons for this problem, one of which is an over use of antibiotics by doctors as well as patients (19- 20).The quantity of antibiotic prescribed is the major factor in increasing rates of bacterial resistance, single dose of antibiotics leads to a greater risk of resistant organisms to that antibiotic in the person for up to a year, while taking antibiotics dose less than those recommended by the doctor may increase rates of resistance.Poor hand hygiene by hospital staff has been associated with the spread of resistant organisms (3,7) .In addition to the chromosomal change or exchange of the genetic material via plasmid and transposes.While, help in transmission and spread of drug resistance among bacteria (21).Our results were consistent with recent reports (21)(22) which had cited evidence from increased the resistance of common use antibiotic like ciprofloxacin, cefotaxime, in addition to the penicillins and other cephalosporins.P. aeuroginos is a highly prevent opportunistic pathogen.One of worrisome characteristics of P. aeuroginos consists in its low antibiotic susceptibility.This low susceptibility may attributable to a concerted action of multidrug efflux pump with chromosomally encoded antibiotic resistance genes and the low permeability of bacterial cellular envelopes (3) .
The current study showed the antibacterial activity of three commonly used as hand wash product disinfectants listed in table (5).Iodine is a non-metallic essential nutrient with a potent broad range of microbicide action against almost all off important health-related microorganisms, including bacteria, fungi, viruses and protozoa.Although the high content of iodine species with free molecular form (I 2 ) and hypoiodous acid (HOI) in aqueous solution has powerful microbicidal effects but can causes volatility stinging and cytotoxicity (24) .To overcome these problems, iodine was combined with neutral carrier polymers to increase its solubility.This will keep release iodine as a solubilizing agent, be siding act as iodine reservoir and decrease the cytotoxicity (25) .The most popular carrier in current use is povidone which was no microbicidal activity, since povidione slowly and continuously releases free iodine into solution; these properties help to maintain antimicrobial capacity for a long period and to decrease toxicity beside alternated fatty acids (6,26) .
A recent comparative investigation of the antiseptics, Povideone-iodine, Chlorhexidine and Octenidine, found that only Octenidine and povidone-iodine were the most effective agent against pathogenic bacteria like Ps. aeuroginosa, E. coli, MRSA, Enterococcus faecalis and other pathogenic bacteria (27) .
Speticin is popular quaternary ammonium compounds (Quits), it is cationic detergents, widely used as a surface-active agents for pre surgical antisepsis and antiseptic treatment of skin, wounds and mucous membranes.The cleansing ability is related to its positively charged, and is considering strong bactericidal against gram positive bacteria but less active against gram negative bacteria.Speticin change the cells permeability and causes the loss of essential cytoplasm constituent such as potassium (7).Massager et al (2001) found that speticin was more effective than Chlorhexidine against the same pathogenic G+ve bacteria (27) .Ps.aeuroginosa isolates needs high concentration of speticin to be inhibited because Pseudomonas not only survive in Quits but grow actively in them, because the fibers tend to neutralize the Quits (7) .Recent study found that 200 µg /ml of aqueous Chlorhexidine solution inhibit most experimented G+ve pathogenic bacteria and some G-ve bacteria, except the isolates of Pseudomonas aeuroginosa needs more than 250 µg/ml of Chlorhexidine.These results are consistent with our results (10) .

Recommendations:
The study recommends that the catheter should be changed every 2 days, especially if signs of urinary tract infections appear, using antimicrobial catheters and intelligent use of aseptic techniques, limiting use of antibiotics and the use of most effective disinfectant in the exact concentration specified by the manufacture, and detecting antibiotic resistance gene using Polymerase Chain Reaction (PCR) technique.

Table 1 .
Distribution of patients according to their ages HResults:

Table 2 .
Distribution of patients according to their gender