Coliforms Associated With Bacteriuria In Human Immunodeficiency Virus (HIV) Positive Patients Attending The Bamenda Provincialhospital
L Njunda, H Kamga, J Palle, J Mokube, J Assob Nguedia, E Achidi, S Akuro, J Mbuagbaw, P Ndumbe
antibiotic susceptibility pattern, bacteriuria, coliform, coliforms, gram negative bacteria, hiv positive
L Njunda, H Kamga, J Palle, J Mokube, J Assob Nguedia, E Achidi, S Akuro, J Mbuagbaw, P Ndumbe. Coliforms Associated With Bacteriuria In Human Immunodeficiency Virus (HIV) Positive Patients Attending The Bamenda Provincialhospital. The Internet Journal of Infectious Diseases. 2008 Volume 7 Number 2.
The prevalence and antibiotic susceptibility pattern of coliform associated with bacteriuria among HIV positive patients attending the Bamenda Provincial Hospital was studied. Out of the 240 urine specimens from HIV positive patients, coliforms were isolated in 49 (20.4%). HIV positive patients with CD4 counts between 1-50 cell/mm3 had more coliforms with significant bacteriuria than those with higher counts from 151-200 (22.5% vs. 6.1%, p < 0.05). Female HIV positive patients had a higher prevalence of coliform organisms than their male counterparts (21.4% vs. 18.9%, P > 0.5). Eleven different species of coliform organisms were isolated with
The Gram-negative bacilli of the genera
Objective of Study
The aim of this research project was to identify coliform bacteria in the urine of HIV positive patients and their antibiotic sensitivity pattern.
Bacteriuria due to coliforms occurs with increased frequency in HIV positive AIDS patients and represents an important cause of morbidity.
Materials And Methods
Study area and design
This study was based on laboratory investigations. A total of three hundred urine samples were collected. Two hundred and forty (240) urine specimens came from HIV /AIDS patients (obtained from both in – and outpatients for whom the CD4 count was requested for control and also from patients who came for voluntary testing) and sixty were obtained from healthy HIV negative individuals (control).
Demographic data including age and sex of patients was taken into consideration.
The HIV test
The HIV test was carried out following the HIV test algorithm established by the Cameroon Ministry of Public Health in 2001. A rapid test to screen for the presence of HIV antibodies was performed using the rapid test kid, DermineTM 3. All positive tests were confirmed with the ImmunoComb® II HIV 1 & 2 Bispot kit 4 according to manufacturer’s instructions.
All samples were collected by the mid-stream catch technique into sterile wide-mouth screw-capped bottles according to methods previously reported 5. All specimens were examined within 60 minutes.
Isolation and identification of organisms
Specimens were inoculated onto MacConkey agar plates which were prepared as previously described 6; and incubated at 37ºC for 18 hours; after which the plates were then examined for reddish, mucoid, or dark-centered colonies.These suspect colonies were subjected to oxidase test to rule out oxidase positive gram-negative bacilli. Suspect colonies were sub cultured on chocolate agar plates to obtain pure colonies. They were gram stained, inoculated KIA slants on and tested for motility test (7).
Species identification made use of the Analytical Profile Index (API) 20E Scheme. This was performed according to the manufacturer’s instructions.
Antibiotic susceptibility testing
The disc diffusion (Kirby-Bauer) technique was employed as previously described 58. Mueller-Hinton (MH) agar, which is a standard medium for the disc diffusion method, was used. Antibiotics used in this study included the Quinolones: Ciprofloxacin and Perfloxacin; Aminoglycoside: Netilmicin; Macrolide: Erythromycin; Tetracycline: Doxycycline; the third generation cephalosporin: Ceftriazone and Cefotaxime; Bacitracin, Trimethoprime and Cotrimoxazole. Apart from bacitracin, these are drugs commonly used to treat infections due to enterobacteriaceae 9.They were compared with recommended standards which conform to those of the National Committee for Clinical Laboratory Standards, 10.
Data was analyzed using SPSS. The chi-square (χ²) test was employed where appropriate for statistical analysis. Differences were considered significant at P ≤ 0.05 11.
Prevalence of coliforms in HIV /AIDS patients and control.
A total of three hundred (300) urine samples were analyzed. Out of these, 240 came from HIV/AIDS patients, attendees of the laboratory who came for check up or patients referred to the laboratory from the wards. The remaining 60 individuals constituted the control group i.e. they were made up of healthy volunteers who came to donate blood; seronegative for both HIV and Hepatitis B surface antigens.
Of the 240 urine samples from HIV positive patients, coliform organisms were isolated from 49, giving an overall prevalence of 20.4%,
Out the 95 male and 145 female samples collected, 18(18.9%) and 31(21.4%) had coliform organisms isolated respectively. The difference was not statistically significant (P > 0.05) Out of the 18 male that had coliform, 7 (38.9%) were symptomatic whereas 19(61.3%) of females were symptomatic (Table 2).
Of the 50 hospitalized and 190 nonhospitalised cases sampled, coliform were isolated from 23(46%) and 26(13.7%) patients respectively. The difference was statistically significant (P < 0.05) (Table 3).
The prevalence of the organism was highest in the age group 30 – 39 (26.4%) and lowest in the age group ≥ 49(11.1%), but the difference was not statistically significant (P > 0.05) (Table 4).
Lactose fermentation, motility (except for
Out of the 49 species isolated, 38 (77.5%) were susceptible to Ceftriazone, a third generation cephalosporin. 36 (73.5%) were sensitive to perfloxacin and 35 (71.4%) were sensitive to netilmicin, an aminoglycoside, but the difference was not statistically significant (P > 0.05).
All species isolated were resistant (100%) to Bacitracin. None of the isolates were completely sensitive to Trimethoprime and co-trimoxazole, however, 11(22.4%) and 7(14.3 %) of the isolates were intermediate to these antibiotics respectively.
Generally, isolates were resistant to at least three antibiotics (Table 5).
Of the 49 isolates 19(38.9%), corresponded to patients with CD 4 count from 1 to 50; 14(28.5%) to those with CD4 count from 51 to 100, 8(16.3%) to those with CD4 count from 101 to 150 and 8(16.3%) to those with count from 151 to 200. Generally, those with very low CD4 counts had significant bacteriuria than those with higher counts (p < 0.05). (Table 6).
Discussion And Conclusion
People with AIDS are predisposed to urinary tract infections by common bacteria and pathogens 12. These pathogens may affect any urologic organ and treatment therefore should be culture specific and long-term 13. Voiding dysfunction in patients with AIDS is usually a result of opportunistic infections 1415 that might include coliforms as well. Vulnerability to bacterial infection in the HIV/AIDS patient correlates inversely with the CD4 lymphocyte count. When the count falls to less than 200/mm³, the risk of bacterial and opportunistic infections, including UTI rises dramatically. This may be compounded by neutropenia that accompanies long-term treatment with some antiretroviral drugs. Patients with CD4 counts greater than 200/mm³ were often asymptomatic in this study. The intensive use of quinolones in the treatment of common infections has led to the spread of resistant microorganisms 16.
This study was conducted to determine the prevalence of coliform bacteria and their antibiotic sensitivity in urine of HIV/AIDS patient by employing biochemical profiles for species identification; and comparing this prevalence with non HIV healthy control. The organisms were isolated from urine with an overall prevalence of 20.4% in the HIV/AIDS patients compared to 3.3% in the control group (P < 0.05). This result tie with those previously reported 1718. They found that bacteriuria was higher in HIV patients especially in those that were symptomatic. In the HIV/AIDS patients, the prevalence of the organisms was higher in females (21.4%) compared to 18.9% in males. However, the difference was not statistically significant (P > 0.05). This could be because of the anatomy of the female genitourinary system. The female urethra, being short and close to the anal opening predisposes her to infections by coliforms which can easily contaminate the urethral opening from one’s anus 719.
Generally hospitalized patients (46.0%) were significantly (P < 0.05) prone to coliform infections than nonhospitalised patients (13.7%). This may be indicative of a nosocomial infection risk probably because patients might have acquired infection following hospitalization with factors such as prolonged hospitalization and impaired immunity compound risk of being infected 19.
There was no statistical significant difference between the prevalence of the organisms in the different age groups. (P > 0.05) however, a high occurrence was observed in the age group 30-39 (26.4%). This may be attributed to inadequate health education, poverty and risks associated with the acquisition of nosocomial infections. Most of the hospitalized cases fell in this age group. Reports have shown that inherent resistance (age, nutritional status, severity of underlying disease and breaks in the integrity of the skin or mucous membrane) of patience to infection is an important determinant of acquiring nosocomial infections 192021. The age group ≥ 49 had the lowest occurrence probably because these individuals are less exposed to sexual hazards, injuries and contamination.
Those with very low CD 4 count had highly significant bacterial counts (P < 0.05). The high prevalence and significant counts of coliform with low CD4 count emphasizes the enumeration of CD4 cell to check disease progression in HIV. Those with very low CD4 counts were more immunocompromised than those with higher counts. This agrees with the previous findings 22.
Antibiogram of the organisms revealed good susceptibility with three antibiotics. 77.5% of the isolates were sensitive to the third generation cephalosporin, ceftriazone. This was probably due to the fact that the high cost of the drug limited its use in the locality thus bacteria could not acquire resistance due to abusive use of the antibiotic. Moreover, third generation cephalosporin are highly active against gram negative bacteria. Similarly, high susceptibility was observed for the quinolone, perfloxacin (73.5% of isolates) and the Aminoglycoside, Netilmicin (71.4% of isolates). Fluoroquinolones do have advantages in the treatment of complicated UTI secondary to host factors, resistant organisms, or difficult-to-treat pathogens such as Pseudomonas aeruginosa 23. Isolates showed complete resistance to Bacitracin. The use of antibiotics in hospital and community at large serves as a major selective pressure for antibiotic resistant bacteria. Multidrug resistant nosocomial infections by these organisms are increasing world wide 24. Complete resistance to bacitracin could be because the outer membrane of the gram negative cell wall prevented the antibiotic from penetrating to its site of action. Also, bacitracin has toxic effects unrelated to its antimicrobial activity that limits its use as a chemotherapeutic agent 9.
Results revealed that
Antibiotic susceptibility testing revealed that, Ceftriazone, Perfloxacin, and netilmicin could be employed for the treatment of infections caused by coliforms in HIV/AIDS patients. Patients with very low CD4 counts were more immunocompromised hence posses significant bacteriuria. Bacteriuria in HIV/AIDS patients represents a relevant cause of morbidity.
Thanks to the management team of the Bamenda Provincial Hospital for their collaboration and assistance in sample collection.