Urinary tract infection (UTI) is one of the most common bacterial infections found in both community and hospital settings. Globally about 3 million UTI cases per year visit in health care centres(1). From 1990 to 2021, the number of UTI cases increased by 66.45%, reaching 4.49 billion cases, with an Age standardized Incidence Rate of 5,531.88 per 100,000 population. The greatest incidence of UTIs was seen in women and older adult men(2). At community level in India, 10.1% (250/2459) urine samples were positive with significant bacteraemia(3). The most common pathogen causing UTI is Escherichia coli and other common are Staphylococcus saprophyticus, Klebsiella and Proteus species. Inappropriate and non-judicious use of broad-spectrum antibiotics for the treatment of UTI, often initiated without culture confirmation, has contributed significantly to the rise in resistance among uropathogens. Antimicrobial resistance (AMR) has emerged as one of the most important global public health threats. A systematic analysis estimated that bacterial AMR was associated with nearly five million deaths worldwide in 2019 alone, with the highest burden more in low-resource settings(4). India has one of the highest burdens of infectious disease and, faces a maximal threat from the escalating global problem of antimicrobial resistance (AMR). In India in 2021, there were an estimated 267,000 UI (224,000-310,000) deaths attributable to AMR and 987,000 UI (855,000-1,120,000) deaths associated with AMR(5). Model-based estimates suggest that if current trends continue without any prompt intervention, AMR-associated deaths in India could reach up to 12 lakhs by 2030(5). Uropathogens have also shown high rates of multi-drug resistance majorly by third generation cephalosporin, carbapenems and methicillin(6). This limits the scope of successful treatment of UTI and increase its severity. Therefore, periodic and geographic specific surveillance of the bacteriological profile and antimicrobial susceptibility of uropathogens is essential. The data will guide rational empirical antibiotic selection, inform local antibiotic policy, and support antimicrobial stewardship efforts. This study was undertaken know the bacteriological profile and antimicrobial resistance pattern in urinary tract infections among adult patients attending a tertiary care hospital. Objective of the study: To determine the bacteriological profile and antimicrobial resistance pattern of uropathogens isolated from adult patients with suspected urinary tract infection at a tertiary care hospital in Barabanki, Uttar Pradesh.

Study Design and Setting This was a retrospective observational study conducted in the Bacteriology Laboratory, Department of Microbiology, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India. Study Period The study covered a period of six months, from 1 July 2023 to 31 December 2023. Study Population Adult patients with a probable clinical diagnosis of UTI, whose urine samples were submitted for culture and sensitivity testing to the Bacteriology Laboratory, Department of Microbiology, HIMS during the study period, were included. Sample Processing and Bacterial Identification Urine samples were processed by semi-quantitative culture on appropriate culture media. Bacterial identification was performed using standard microbiological protocols as described per standard guidelines. Antimicrobial susceptibility testing was performed by the Kirby Bauer disc diffusion method and results were interpreted using CLSI guidelines 2023(7). Data Analysis Data of all urine culture and sensitivity reports meeting the inclusion criteria were retrieved from the Microbiology Laboratory records. Descriptive data analysis was performed using Microsoft Excel 2007. Results are expressed as frequencies and percentages.

A total of 817 urine samples of patient were received and processed during the study period. (Table 1). Of these, 465 (56.9%) showed no bacterial growth (sterile), 41 (5.0%) showed non-significant growth, 1 sample yielded Candida species, and 21 (2.6%) were contaminated and significant bacterial growth was obtained in 289 samples (35.4%). Table 1. Distribution of urine samples received for culture and sensitivity (n = 817) Category N (%) Sterile 465 56.9 Non-significant growth 41 5.0 Candida spp. 1 0.1 Contaminated 21 2.6 Significant growth 289 35.4 Among the 289 culture-positive samples, 190 (65.7%) were from female patients and 99 (34.3%) were from male patients and median age of patient was 31 years (range 12–87 years). Fig 1. Distribution of uropathogens isolated (n = 289) About 220 (76.5%) uropathogens were gram negative. Escherichia coli was found in 138 (47.4%) isolates, followed by Enterococcus species (63, 21.4%) and Klebsiella pneumoniae (24, 8.3%). Other organisms isolated included Acinetobacter species (16, 5.5%), Pseudomonas species (15, 5.2%), Citrobacter species (11, 3.8%), Staphylococcus aureus (6, 2.1%), and Proteus species (2, 1.0%). (Fig 1) Table 2. Distribution of uropathogens isolated (n = 289) Uropathogen N (% ) Gram negative bacteria Escherichia coli 138 (47.4) Klebsiella pneumoniae 24 (8.3) Acinetobacter species 16 (5.5) Pseudomonas species 15 (5.2) Citrobacter species 11 (3.8) Proteus species 2 (1.0) Gram positive bacteria Enterococcus species 63 (21.4) Fig 2. Antimicrobial resistance pattern of major uropathogens (n=256) Ampicillin, cefuroxime, ceftriaxone, cefazolin and ciprofloxacin were found to be resistant to E. coli in more than 70% samples. Fosfomycin was resistant against E. coli (2.9%) while and Nitrofurantoin was resistant to E. coli (7.9%) and K. pneumoniae (16.6%). Ertapenem was found resistant among (54.2%) K. pneumoniae. Acinetobacter was resistant to Ceftazidime, cefepime and Ciprofloxacin in more than 50% samples. Pseudomonas was resistant to Ceftazidime in 80% samples. Enterococcus isolates showed resistance to tetracycline (69.8%) and ciprofloxacin (52.4%) and Ampicillin in more than 50% samples while resistant to teicoplanin and vancomycin in only 1 sample. (Fig 2)

In this retrospective analysis of urine culture and sensitivity data over a six-month period, 289 of 817 urine samples (35.4%) yielded significant bacterial growth. This culture positivity rate is broadly comparable to figures reported from other tertiary care centres in Uttar Pradesh and elsewhere in India, where positivity has ranged from as low as 16.9% to over 40%, depending on patient selection, sample handling, and prior antibiotic exposure(8). The marked female preponderance observed among culture-positive cases (65.7%) is consistent with the well-recognised anatomical and physiological predisposition of women to UTI. The median age of 31 years in the present study reflects a predominantly young, sexually active adult population. Gram-negative organisms accounted for 220 (76.5%) isolates in this study, with Escherichia coli remaining the most frequently isolated uropathogen (47.4%), consistent with its well-established role as the leading cause of both community-acquired and hospital-associated UTI worldwide and across India(9). Enterococcus species emerged as the second most common isolate overall (21.4%) and the leading Gram-positive organism, a pattern increasingly reported from Indian tertiary care hospitals and attributed to a growing proportion of catheter-associated, complicated, and hospital-acquired UTI, in which Gram-positive and less typical organisms are more frequently implicated(10). Klebsiella pneumoniae, the third most common isolate (8.3%), together with Acinetobacter and Pseudomonas species, reflects the continuing importance of non-E. coli Gram-negative bacilli, particularly in institutional and healthcare-associated infection. The finding of ertapenem resistance in 54.2% of Klebsiella pneumoniae isolates is notable, regional surveillance data have similarly documented a significant upward trend in imipenem, meropenem, and ertapenem resistance among Enterobacterales over successive years(11). Non-fermenting Gram-negative bacilli showed a concerning resistance profile: Acinetobacter species were resistant to ceftazidime, cefepime, and ciprofloxacin in more than half of isolates, while Pseudomonas species showed 80% resistance to ceftazidime. This pattern closely mirrors data from other Indian hospital-based surveillance, where Pseudomonas isolates have similarly shown resistance exceeding 80% to ceftazidime, cefepime, ciprofloxacin, and amikacin, and Klebsiella and Acinetobacter isolates have shown comparably high resistance to cephalosporins and fluoroquinolones(12). These organisms, frequently implicated in catheter-associated and hospital-acquired UTI, underscore the importance of infection-control measures and restrictive catheter use alongside antibiotic stewardship. Among Enterococcus isolates, high resistance to tetracycline (69.8%), ciprofloxacin (52.4%), and ampicillin (exceeding 50%) contrasted sharply with resistance to teicoplanin and vancomycin in only a single isolate each (1.6%). This near-universal glycopeptide susceptibility is consistent with, and somewhat more favourable with from a multicentric Indian community UTI study that reported vancomycin and teicoplanin resistance of 14.2% each among Enterococcus isolates, with no resistance detected to linezolid. Overall, these findings support an approach for empirical therapy at this institution.

Nitrofurantoin or fosfomycin shall be first-line options for uncomplicated UTI as they are still non-resistant against E. coli and fluoroquinolones and unprotected cephalosporins shall be cautiously used. The vancomycin, teicoplanin, and linezolid should be used for confirmed or strongly suspected enterococcal infection. These observations reinforce that local or institution specific antibiograms shall be mapped rather than generic or regional data for empirical antibiotic selection, and that judicious use of broad-spectrum agents, and shifting to specific antibiotic therapy once susceptibility results are available, and sustained clinician and public education will help in containing further increase of resistance among uropathogens. There is a pressing need for judicious antibiotic prescribing and for continued efforts to increase awareness of antimicrobial resistance among clinicians and the general public. Limitations This study is limited by its retrospective and single institution. The six-month study period may not fully capture seasonal variation in uropathogen prevalence and resistance patterns. The relatively small numbers of isolates for organisms limit the precision of resistance estimates.

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