CHAPTER ONE

INTRODUCTION

1.1   Background.

Urinary tract infection (UTI) is defined as the bacterial invasion of the urinary tract. It is primarily caused by Escherichia coli (E.coli), accounting for 75% of bacterial UTI cases. Other bacteria such Klebseilla pneumonea, Proteus mirabilis, Staphylococcus aureus, Pseudomonas aeruginosa and Enterococcus faecalis have been reported as causative agents by studies in Ghana, Nigeria and other parts of the world (Antwi et al., 2008;  Boye et al., 2012; Gyansa-Lutterodt et al., 2014). UTI occurs as a result of significant microbial growth in the urinary tract, especially between the urethra and the kidneys. Thus, the classification of UTI is based on the site of infection. Infection of the bladder is known as cystitis, and infection of the kidneys is called pyelonephritis. It can also be classified clinically as either complicated or uncomplicated depending on the extent of infection (Bennett et al., 2014). Complicated urinary tract infection is known to occur in men and women at any point of their lives and usually has the tendency to produce severe outcomes resulting in death in serious situations. They are highly intricate and are difficult to treat. Complicated urinary tract infections can lead to structural abnormalities that blight the capability of the urinary tract to flush out the urine hence bacteria are provided with better scope for growth (Fihn, 2003). On the contrary, uncomplicated UTI is a consequence of bacterial infection and the prevalence is higher in female than in male. It is not as fatal as complicated UTI (Fihn, 2003).

Globally, UTI is a major public health burden leading to increased morbidity and the associated high healthcare cost (T.M. Hooton et al., 1995; Orenstein & Wong, 1999). It is

the second most common infection among patients visiting primary healthcare facilities. In United States, where comprehensive data is available, it is estimated that UTI accounts for seven million hospital visits per year, with millions of those infections leading to visits at the emergency department (Foxman, 2002). The associated cost of health care is enormous accounting for $659 million in direct cost for treating and $936 million in indirect cost, totaling to $1.6 billion annually (Foxman, 2002). Worldwide, it is evident that UTI is more common among young girls, except in neonatal period where boys predominate (Foxman, 2002). Furthermore, it is estimated that about 20% of all women develop UTI during their lifetime (Fihn, 2003).

A number of studies have been conducted in the sub-region that suggested a range of prevalence of UTIs in some selected populations. Reports have indicated that most of these studies were done on febrile and malnourished infants and children below age 12 years, with study sites being primarily hospitals and other health facilities (Wolff & Maclennan). In addition, a few studies were done on male and females adults, including pregnant women. In Kenyatta National Hospital, a cross sectional study on antenatal women presenting with lower abdominal pains showed a prevalence of 26.7% bacterial urinary tract infection (Nabbugodi W. F., 2009).

A demonstrative study conducted at a large Ghanaian hospital in Accra showed that 93% of isolates from urine samples were bacteria species and 7% were yeast (Odonko ST et al., 2011). A retrospective review of urine results of antenatal attendants with asymptomatic UTI at a private hospital in Kumasi indicated a prevalence of 9.9% significant bacterial growth (Ado VN, 2012). A secondary data analysis of urine culture and sensitivity results for 2005 to 2008 at Eastern Regional Hospital, Koforidua, showed

UTI prevalence of 29% with E. coli as the most common uropathogens followed by

Klebseilla spp.

Antibiotics play an important role in minimizing morbidity and mortality associated with infectious diseases. The most common antibiotics used for the treatment of UTI are cefuroxime, amoxicillin/clavulanic acid, trimethoprim/sulpmethoxazole and fluoroquinolones. However, the efficacy of these treatment is affect by bacterial resistant to many of the antibiotics leading to treatment failure, spread of resistant bacterial strains, increased morbidity and ultimately high cost of treatment. The extensive and inappropriate use of antimicrobial agents has invariably resulted in the development of antibiotic resistance which, in recent years, has become a major public health problem worldwide (Gupta et al., 2001; Mordi & Erah, 2006). Furthermore, antibiotic resistance is compounded by the unorthodox treatment of patients with suspected UTI with antibiotics without a valid microbial culture and sensitivity laboratory results. One way to avert this problem is detailed knowledge on the prevalence of bacteria causing UTI and their antibiotic susceptibility pattern. Thus, this study investigated the prevalence and antibiotic susceptibility pattern of Uropathogenic bacteria isolated from urine samples of patients with suspected UTI, in Eastern Regional Hospital, Koforidua.

1.2   Problem Statement.

Bacterial resistant to most antibiotic is a global public health concern leading to treatment failure, high cost of treatment, increased morbidity and mortality. However, this is more of a problem in sub-Saharan Africa, for example Ghana, where bacterial infection is very common, and knowledge on antibiotic resistance pattern is very limited. Most patients with suspected UTI, out of frustration, visit local chemical stores often run by untrained

personnel to buy antibiotics without any prescriptions, leading to antibiotic resistance and treatment failure. Also due to the complexity and time it takes to undertake a bacterial culture and susceptibility laboratory test, doctors mostly start patients with a broad spectrum antibiotics before the lab results are out. Although this is aim at early treatment to alleviate the pain and anguish associated with UTI, it is also a primary contributor to the development of antibiotic resistance. In view of the above limitations, this study envisaged to add to the knowledge base on the bacteria causing UTI and their antibiotic susceptibility pattern, and to assess, if there is any, association between the isolates and socio-demographic characteristics of study participants such as age, sex, marital status and educational background in this catchment area, Eastern Region.

1.3   Justification.

Ghana, as some other Sub-Saharan African countries, has a very high prevalence of bacterial infections, and treatment of these infections is generally very poor due to poor health care delivery facilities and minimal training on proper management of infectious diseases. Most cases of uncomplicated UTIs can be mild and transient, however, sequelae of untreated UTIs can include renal scarring, hypertension, and  eventually end-stage renal disease, hence correct and timely diagnosis of UTI is imperative. Antibiotic resistance is a global challenge as it is on increase from one geographical area to another. For instance, the secondary data analyses done on urine culture and sensitivity results at Regional Hospital laboratories in Ghana including Eastern Regional Hospital, Koforidua, show high resistance in commonly used antibiotics against urinary tract infections. Therefore, for effective treatment, clinicians need some baseline information such as the

most prevalent bacteria-causing UTI and their antibiotic susceptibility to guide in the administration of treatment. This study envisaged to provide that critical information by investigating the prevalence of local UTI-aetiologic agents in urine samples and their antibiotic resistant pattern in patients with suspected UTI.

1.4   Objectives.

The overall objective of this study was to determine the prevalence and antibiotic susceptibility pattern of Uropathogenic bacteria in urine samples of patients with suspected UTI in Eastern Regional hospital (Koforidua).

1.5   Specific objectives.

·         To determine the prevalence of bacteria causing UTI in urine samples of patients with suspected UTI in Eastern Regional Hospital, Koforidua.

·         To determine the antibiotic susceptibility of bacteria isolated from urine samples of patients with suspected UTI.

·         To determine the association between the isolated bacteria species and demographic characteristics of study participants.

·         To assess an association between the isolated bacteria species from patients and the different hospital units within the Regional Hospital, Koforidua.

Conceptual framework

Diagrammatic

Figure 1 CONCEPTUAL FRAME WORK

Narrative of the Conceptual framework.

Urinary tract infection is known to be one of the most common infectious disease in both adults and children. In children, they are a common cause of febrile illnesses in their first two years of life, and the majority of urinary tract infections may remain undiagnosed if specific tests like urine culture are not performed. In adults, the infection is common in females than in males.

Urinary tract infections are very serious infections and if untreated, are associated with adverse outcomes to the patient. A number of risk factors are associated with development of UTI. These risk factors may be either modifiable or inherent and are both demographic and obstetric, including, pregnancy, age, sex, sexual behavior, socio- economic status, personal hygiene, medical illnesses and previous history of the infection.

Though prevalence of bacteriuria during pregnancy is similar to that in non-pregnancy, pregnancy enhances the possibility of the infection. UTI occurrence is at its peak during pregnancy which in turn relies on several other factors. In addition to pregnancy, sexual intercourse and family history also play a pivotal role in conferring the infection. During sexual intercourse, bacteria present in the vagina are more easily transferred to the urethra and the urinary tract. This increases the risk of UTI in females.

Age is a known predisposing factor to UTI. For instance, about 3% of prepubertal girls and 1% of prepubertal boys are diagnosed with UTI. In elderly persons, there are many factors that predispose them to UTI including chronic diseases, functional abnormalities, and specific medications.

Though it is uncommon in young men compare to women, UTI becomes progressively more frequent after middle age, and may eventually affect as many as a third of all men. A report by Nicolle, L. E. et al., (1983) stated that after age 70, in men the prevalence of asymptomatic bacteriuria and symptomatic infections in men approach or even excess that in women.

Among this group, asymptomatic bacteriuria is prevalent, though it frequently resolves without treatment and has no long-term sequelae. However, symptomatic UTI among them requires antimicrobial treatment.

Urinary Tract Infection can involve the lower or the upper parts of the urinary tract, each giving different symptoms. Generally, lower urinary tract infections cause symptomatic voiding without constitutional symptoms. Symptoms indicative of upper tract infection or pyelonephritis include fever, chills and flank pains. However, abdominal pain is common to both of them. Despite the high morbidity and mortality associated with untreated UTI, the process of diagnosis and treatment is not standardized. Often patients who present with lower abdominal pains (LAPs) are empirically treated for UTI as presumptive diagnosis.

The causative agents of UTI are known but their relative prevalence as well as their antibiotic susceptibility patterns may vary from location to location and time to time, and with the emergence of HIV, the epidemiology of most other diseases have been significantly altered.

The most commonly used antibiotics that have been highly effective are becoming resistant as microbes develop resistance against them. This usually is as a result of their