Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 55543

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : DC31 - DC35 Full Version

Susceptibility Profile and Clinical Response of Fosfomycin and Other Antibiotics against Multidrug Resistant Gram Negative Urinary Isolates: A Cross-sectional Study


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52109.16161
Chinmoy Sahu, Sweta Singh, Sangram Singh Patel, Nidhi Yaduvanshi, Sanjay Singh, Ujjala Ghoshal

1. Associate Professor, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. 2. Senior Resident, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. 3. Assistant Professor, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. 4. Senior Resident, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. 5. PhD Student, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. 6. Professor and Head, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dr. Sweta Singh,
Senior Resident, Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India.
E-mail: swetasinghkarn@gmail.com

Abstract

Introduction: Irrational use of antibiotics to treat Urinary Tract Infections (UTI) has led to the development of Multidrug Resistant (MDR) bacteria in both community as well as the hospital settings. Fosfomycin has emerged as a novel therapeutic option to treat these UTI patients along with empirically used routine antibiotics.

Aim: To assess the sensitivity, molecular resistance mechanisms and clinical response of fosfomycin along with other urinary antibiotics like nitrofurantoin, colistin, and imipenem.

Materials and Methods: It was a cross-sectional observational study conducted from July 2018 to June 2019 in SGPGIMS, Lucknow, India. Stream urine samples of 24,782 patients were collected with clinical suspicion of UTI. The antibiotics were tested by disc diffusion and Minimum Inhibitory Concentration (MIC) methods. Genotypic analysis was done for testing resistance mechanisms in fosfomycin resistant isolates. Statistical tests were performed using Statistical Package for the Social Sciences (SPSS) software for Windows version 14.0.

Results: Out of the 24,782 urine samples, 2,776 (11.2%) showed significant growth of pathogens with 334 drug resistant isolates among them. Gram negative bacilli 1846 (66.50%) was the most predominantly isolated pathogen in the cultures. Among the 334 drug resistant specimens, Escherichia coli {124 (37.13%)} were maximum in number. Total 79.6% (266/334) of the isolates were sensitive to fosfomycin including 88.7% (110/124) of E. coli, and 91.3% (105/115) of K. pneumoniae isolates. Colistin showed sensitivity in 87.1% (108/124) of the E. coli isolates; followed by Imipenem in 49.2% (61/124) and nitrofurantoin in 37.1% (46/124) of the isolates. Fos A genes were found to be the most prevalent in Fosfomycin resistant. About 41% of the patients showed favourable outcome and were cured with initiation of treatment as per sensitivity pattern.

Conclusion: Fosfomycin has emerged as a safer option in MDR urinary isolates as compared to other urinary antibiotics including colistin. The drug needs to be more widely studied for its possible pharmacokinetics and dynamics as well as it’s possible implications in healthcare settings and patient management.

Keywords

Colistin, Disc diffusion test genotype analysis, Minimum inhibitory concentration method

The Urinary Tract Infections (UTI), both complicated as well as uncomplicated are on a rise in today’s scenario. Irrational use of antibiotics is leading to UTI by MDR bacteria in both community as well as the hospital settings (1),(2). Empirical antibiotics used commonly for treating UTI consist of nitrofurantoin, fluroquinolones, aminoglycosides; whereas carbapenems and colistin are used as salvage therapy for otherwise untreatable gram negative infections, most notably MDR and Extensively Drug Resistant (XDR) strains (3).

Fosfomycin, originally named phosphonomycin, was discovered in Spain in 1969 (4). Synergistic action may be seen with beta-lactam antibiotics, aminoglycosides, etc., (5),(6),(7),(8). It is also effective against MDR pathogens like Extended Spectrum Beta Lactamase (ESBL) producing Enterobacteriaceae, Klebsiella Pneumoniae Carbapenemase (KPC) producing bacteria and Vancomycin Resistant Enterococci (VRE). Currently, it has been approved by Food and Drug Administration (FDA) for use in uncomplicated UTI infections (8).

Bacterial resistance to fosfomycin is exerted by different mechanisms-genetic mutation in phosphoenol pyruvate synthase (murA) and/or chromosomally encoded transport systems GlpT and UhpT; or by a fosfomycin modifying enzyme that brings structural changes in fosfomycin with no antibacterial activity (9),(10), e.g., fosfomycin (FosA), L-cysteine-fosfomycin (FosB), ATP-fosfomycin (FosC), and water-fosfomycin (FosX) adducts. These plasmid mediated resistance genes can be of significant concern in heathcare settings because it can give rise to a clone of fosfomycin resistant bacterial isolates (11).

Fosfomycin has the potential to replace other parenteral antibiotics for the treatment of both complicated and uncomplicated UTI. Fosfomycin can be a good oral alternative to colistin and carbapenems in hospital acquired UTI especially for E. coli. It’s activity is good against other Enterobacteriaceae and Pseudomonas aeruginosa. Hence, this study was planned to assess the sensitivity, Minimum Inhibitory Concentration (MIC) ranges, molecular resistance mechanisms, clinical response for fosfomycin and other urinary antibiotics like nitrofurantoin, colistin, imipenem in UTI isolates of gram negative bacteria.

Material and Methods

This study was a cross-sectional observational study and undertaken for a period of one year from July 2018 to June 2019 in SGPGIMS, Lucknow, India. Institutional Ethics Committee (IEC) permission was taken before the study (IEC Code: 2018-56-IMP-103). Informed consent was obtained from all the patients and their legal guardians (in case of minors) regarding the publication of images and clinical information in the journal.

Inclusion criteria: Patients presenting with symptoms of UTI (fever, burning micturition, frequency, urgency) were included in the study. Both inpatients and outpatients were included.

Exclusion criteria: Rest all other patients not presenting with the symptoms of UTI and having other diagnosis were excluded from the study.

Mid-stream urine specimens were collected in wide mouthed universal plastic containers. For catheterised patients, urine was collected from port site after proper disinfection. The samples were processed and cultured as per standard protocol (11).

Study Procedure

1. Sample selection: A total of 24,782 urine samples were collected with clinical suspicion of UTI. Among these, 334 drug resistant cases were further studied for their clinical outcome and involved resistance mechanisms.
2. Culture: Cultures that yielded significant bacterial growth of atleast 104 colony forming units/mL were included for further sensitivity testing and follow-up in the study (12).
3. Identification:
a. Conventional method using biochemical tests: The bacterial isolates were first identified using routine staining and biochemical tests as per existing laboratory protocols (11),(12).
b. Automated methods: The identity of bacteria was later confirmed by Vitek 2 system (Biomerieux, France), an automated identification and susceptibility testing system (13).
4. Resistance detection method:
a. Disc diffusion test: Antibiotic susceptibility testing of all the isolates were done by Kirby-Bauer’s disk diffusion method on Muller Hinton agar and interpreted based on Clinical and Laboratory Standards Institute (CLSI) guidelines (14). Interpretations of zone diameters were as follows: Fosfomycin ≥16 mm as sensitive, 13-15 mm as intermediate and ≤12 mm as resistant; Nitrofurantoin: ≥17 mm sensitive, 15-16 mm intermediate, ≤14 mm as resistant; Imipenem: ≥23 mm sensitive, 20-22 mm intermediate, ≤19 mm as resistant (Oxoid Ltd, Basingstoke, Hampshire, England).
b. Minimum Inhibitory Concentration (MIC): Fosfomycin MIC were determined initially by E-test (15) and finally confirmed by agar dilution method in cation adjusted Mueller-Hinton medium supplemented with 25 mg/L of G-6-P (glucose-6-phosphate; Sigma Chemical Co., India) (13). Interpretative criteria according to CLSI guidelines are as follows: ≤64 μg/mL as sensitive, 128 μg/mL as intermediate, ≥256 μg/mL as resistant (14),(16). Colistin MIC was detected by microbroth dilution method. The MICs of colistin were determined by the broth microdilution method with cation adjusted Muller-Hinton broth (Oxoid, Code: CM0405, UK) according to Clinical Laboratory Standard Institute (CLSI) guidelines (14),(17). Colistin sulfate (Sigma-Aldrich, St. Louis, MO, USA) was tested over a range of dilutions (0.06-32 μg/mL), and (0.25-256 μg/mL), respectively. One hundred microliters of freshly prepared colistin were added to 96-well U bottom microplates. Bacterial suspensions prepared from non selective culture media, were inoculated in microplates and incubated for 24 hour at 37°C in ambient air (14). The MIC breakpoints for colistin according to CLSI guidelines was ≤2 ug/mL as sensitive/intermediate and ≥4 ug/mL as resistant.
c. Genotypic method: All fosfomycin resistant strains according to CLSI guidelines were characterised genotypically for plasmid mediated resistance gene FosA and FosC by Polymerase Chain Reaction (PCR) using the primers as described in earlier studies (14),(18),(19). Sequence analysis was performed with a dye primer and a dye terminator cycle sequencing kit (Applied Biosystems) and with a 310 gene analyser (ABI Prism). The primers used were as shown in (Table/Fig 1).
5. Patients’ follow-up: Culture, sensitivity and other study parameters like co-morbidities/risk factors were kept in computer database along with patient’s profile. The culture follow-up was done upto six months (July to December 2019) for any repeat culture, new isolates, change in antibiotic sensitivity pattern and other study parameters.

Statistical Analysis

Statistical tests were performed using Statistical Package for the Social Science (SPSS) software for Windows version 14.0 (SPSS, Inc., Chicago, IL, USA). Categorical data was described using numbers and percentages. Geometric MIC was calculated by Graph Pad Prism Software and one-way Analysis of Variance (ANOVA) with two-sided Bonferroni multiple comparison test was used for calculation of significance. The p-values <0.05 were taken as statistically significant.

Results

A total of 24,782 urine samples with clinical suspicion of UTI were received in the laboratory. Of these; 2,776 (11.2%) showed significant growth of pathogens and the rest were either sterile or contaminated with more than three different types of bacterial growth. The predominant pathogen in these cultures were gram negative bacilli in 66.50% (1846/2776) cases and rest cultures comprised of gram positive isolates like Staphyloccoccus and Enterococcus group. Among these isolates; 18.1% (334/1846) were drug resistant; which were MDR, XDR or PDR (according to standard definitions). Majority of these isolates were from males (56.2%) and the maximum age group was of adolescents with mean age of 39 years. These 334 isolates was further studied for their co-morbidities, present diagnosis, sensitivity pattern and follow-up or outcomes. Among, these drug resistant isolates catheterisation was identified as the most common risk factor (47%); followed by renal calculi and diabetes mellitus. Urological surgical procedures, chronic kidney and liver diseases were also identified as important risk factors in these drug resistant cases (Table/Fig 2). Among the 194 (58%) MDR isolates, were of mixed infections since mixed infections are common in UTIs and rest were single isolates.

Of these 334 isolates, Escherichia coli 124 (37.1%) was the predominant one; followed by, Klebsiella pneumoniae 115 (34.4%), and Pseudomonas aeruginosa 73 (21.9%) (Table/Fig 3).

Tests for drug resistance revealed maximum isolates as Extensively Drug Resistant (XDR) in both E. coli (93%) and Klebsiella pneumonia (98%) subgroup. Pseudomonas comprised of 55% of the isolates as XDR and 14% as Pandrug Resistance (PDR). (Table/Fig 4) highlights the percentages of various isolates as XDR, MDR and PDR.

Drug sensitivity testing of these 334 isolates, revealed 79.6% (266/334) of the isolates as sensitive to fosfomycin (Table/Fig 5). An 88.7% (110/124) of E. coli and 91.3% (105/115) of K. pneumoniae isolates were sensitive to fosfomycin. Of the other urinary antibiotics which are commonly used for drug resistant UTI, colistin showed sensitivity of 87.1% (108/124) in the E. coli isolates; followed by Imipenem 49.2% (61/124) and nitrofurantoin 37.1% (46/124). On the other hand; 78.3% (90/115) of K. pneumoniae isolates were sensitive to colistin. On the other hand, colistin showed a higher sensitivity (72%) in P. aeruginosa isolates as compared to fosfomycin (58%). Comparison of the sensitivity patterns of various first line drugs in contrast with fosfomycin has been depicted for the isolates of E. coli, K. pneumoniae and Pseudomonas in (Table/Fig 5).

Further, the MIC values of fosfomycin were also studied for the different isolates. The sensitive E. coli isolates 110/124 (88.7%) in the present study had lower MICs with range of 0.064-64 mg/L and K. pneumoniae had MIC range of 0.064-32 mg/L. On the other hand, sensitive Pseudomonas strains had MIC in the range of 2-64 mg/L. The MIC values for colistin resistant isolates ranged from 8-256 mg/L for Enterobacteriaceae group (Table/Fig 6).

Finally, patients were studied for their outcomes after initiation of treatment and follow-up was planned for a period of three months. Of these 137 (41%) were reported as cured and cultures became sterile while; 50 (15%) of the patients were lost to follow-up. Detailed outcome of the cases is described in (Table/Fig 7).

Genotype analysis for testing resistance mechanisms in the drug resistant isolates by PCR revealed 7 K. pneumoniae isolates as positive for Fos A4, 9 for Fos A5 and one for Fos C. Two E. coli isolates were positive for both Fos A4 and Fos A5 (Table/Fig 8), (Table/Fig 9).

Discussion

Fosfomycin with its broad spectrum of action, oral dosing regimen and good bioavailability acts as a novel and suitable treatment option for drug resistant UTI isolates.

Current study showed E. coli and K. pneumoniae as the predominant isolates causing drug resistant UTI. This finding is in concordance with other similar studies by Demir T and Buyukguclu T (6.1%) (20) and Hirsch EB et al., (5.6%) (21). Overall, fosfomycin showed much greater sensitivity of 79.6% as compared to other urinary drugs. Majority of the E. coli and Klebsiella isolates were sensitive to fosfomycin with very low MIC values (0.064- 32 mg/l). In a similar study by Maraki S et al., fosfomycin emerged as the most active drug against a majority of drug resistant urinary isolates (22). In another similar study by Rajenderan S et al., maximum UTI isolates of E. coli and Klebsiella were again found to be maximally sensitive to fosfomycin (23).

Of the 334 isolates, maximum isolates were reported as XDR in both E. coli and K. pneumoniae. All these isolates were mostly sensitive to fosfomycin. In a previous study; done by Gupta V et al., from Chandigarh, 52.6% of his isolates were drug resistant and all strains were susceptible to fosfomycin (24). De Cueto M et al., also demonstrated the high in-vitro activity of drug resistant E. coli and K. pneumoniae strains on exposure to fosfomycin in his study (25).

Klebsiella pneumoniae isolates of our study showed sensitivity of 91.3% to fosfomycin with MIC range of 0.064-32 mg/L. This finding is very much similar to the previous studies by Demir T and Buyukguclu T, and Perdigao Neto LV et al., who reported similar sensitivity patterns (20),(26). The Pseudomonas aeruginosa isolates in present study had sensitivity of 58% which was in contrast to the study by Perdigao Neto LV et al., in which almost all P. aeruginosa isolates were sensitive to fosfomycin (26). This disconcordance in results may be due to the fact that CLSI has no clear MIC breakpoints for Pseudomonas isolates while; for E. coli and Enterococcus isolates, susceptibility to fosfomycin have been defined as an MIC ≤64 mg/L (16). On the other hand; MIC ≤32mg/L of fosfomycin has been described as susceptible for urinary isolates by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines for Enterobacteriaceae and Pseudomonas isolates (14). This difference in interpretation of breakpoints by two established documents makes interpretation of results and comparison between different studies difficult. A 71% of the Pseudomonas isolates in present study had MIC values quite close to the breakpoint of 64 mg/L and there was perfect correlation between the results of disc diffusion and E-test.

Present study highlighted colistin as the second most effective drug against these drug resistant UTI isolates showing overall sensitivity of 87.1% (108/124) in the E. coli isolates and surprisingly showed greater sensitivity than fosfomycin in Pseudomonas isolates; 72.6% (53/73). However, Colistin is not a good option to treat UTI in all the cases due to many serious side-effects; Nephrotoxicity being the major one. Other therapeutic options like carbapenems, aminoglycosides, nitrofurantoin were much less effective as compared to fosfomycin in the current study.

During the follow-up period, 41% of the patients showed cure after initiation of treatment as per reported sensitivity pattern and subsequently; cultures were reported as sterile. Majority 73/137 (53%) of these patients showed improvement within 15 days; however 5.8% (8/137) of these showed remission within a time period of one to three months. A 23% (77/334) of the cases showed growth of the same isolate but with a different sensitivity pattern and 12% (40/334) cases revealed growth of a different isolate with a different sensitivity a pattern within a span of three months. The overall sensitivity pattern in these new isolates showed resistance to fosfomycin in 42.7% (50/117). A portion of the participants 15% (50/334) was also lost to follow-up. These cases could not be traced due to improper telephonic/contact details or only a single Outpatient Department (OPD) visit to our hospital.

Fos A genes were found to be most prevalent in the Fosfomycin resistant isolates of our study. This was in concordance with similar genotype studies done in other parts of the world. Ho PL et al., studied the low prevalence (<2%) of plasmid-mediated fos genes in clinical E. coli isolates of his study. Present study also reported maximum prevalence of resistance genes in K. pneumoniae and E. coli isolates (27),(28).

Based on the study findings, Fosfomycin can be a good oral alternative to colistin and carbapenems in hospital acquired UTI especially for E. coli. The study here reported UTIs in 2776 cases of which approximately 39% were hospital acquired UTIs occurring most commonly due to urinary catheters in the patients. Current study also highlighted catheterisation procedures as the most important risk factor in 47% of the drug resistant cases and urinary catheters were seen in majority of the patients. Its activity is good against other Enterobacteriaceae and Pseudomonas aeruginosa. However, plasmid mediated fosA resistant genes can be problem especially in Klebsiella pneumoniae and Enterobacter spp isolates.

Limitation(s)

The study was planned for a time span of one year only, similar studies with a larger time frame will add more value to this work; also clinical trials will be of more help in this direction.

Conclusion

Fosfomycin has the potential to replace other parenteral antibiotics for the treatment of both complicated and uncomplicated UTI. It’s safety profile and the ease of oral dosage adds to its pros as a suitable treatment option for such cases. We strongly advocate the addition of this novel antibiotic in the routine sensitivity panel for drug resistant UTI cases. Hence, further studies and research work needs to be planned to explore this potential urinary antibiotic for its future use in hospital settings.

References

1.
Ventola CL. The antibiotic resistance crisis: Part 1: Causes and threats. P T. 2015;40(4):277-83.
2.
Antimicrobial resistance trends-WHO Factsheet. https:www.who.int/newsroom. 13 oct 2020.
3.
Tsuji BT, Pogue JM, Zavascki AP, Paul M, Daikos GL, Forrest A. International Consensus Guidelines for the Optimal Use of the Polymyxins: Endorsed by the American College of Clinical Pharmacy (ACCP), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), International Society for Anti-infective Pharmacology (ISAP), Society of Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). Pharmacotherapy. 2010;39:10-39. https://doi.org/10.1002/phar.2209. [crossref] [PubMed]
4.
Hendlin D, Stapley EO, Jackson M, Wallick H, Miller AK, Wolf FJ, et al. Phosphonomycin. A new antibiotic produced by strains of Streptomyces. Science. 1969;166:122-23. [crossref] [PubMed]
5.
Dijkmans AC, Zacarías NVO, Burggraaf J, Mouton JW, Wilms EB, van Nieuwkoop C, et al. Fosfomycin: Pharmacological, clinical and future perspectives. Antibiotics (Basel). 2017;6(4):24. Published 2017 Oct 31. Doi: 10.3390/antibiotics6040024. [crossref] [PubMed]
6.
Hashemian SMR, Farhadi Z, Farhadi T. Fosfomycin: The characteristics, activity, and use in critical care. Ther Clin Risk Manag. 2019;15:525-30. https://doi.org/10.2147/TCRM.S199119. [crossref] [PubMed]
7.
Wang L, Di Luca M, Tkhilaishvili T, Trampuz A and Gonzalez Moreno M. Synergistic activity of fosfomycin, ciprofloxacin, and gentamicin against escherichia coli and pseudomonas aeruginosa biofilms. Front Microbiol. 2019;10:2522. Doi: 10.3389/fmicb.2019.02522. [crossref] [PubMed]
8.
Uncomplicated urinary tract infections: Developing drugs for treatment guidance for industry. US Department of health and human services. FDA. August 2019. clinical/antimicrobial.
9.
Silver LL. Fosfomycin: Mechanism and resistance. Cold Spring Harb Perspect Med. 2017;7(2):a025262. Published 2017 Feb 1. Doi:10.1101/cshperspect.a025262. [crossref] [PubMed]
10.
Falagas ME, Athanasaki F, Voulgaris GL, Triarides NA, Vardakas KZ. Resistance to fosfomycin: Mechanisms, Frequency and Clinical Consequences. Int J Antimicrob Agents. 2019;53(1):22-28. Doi: 10.1016/j.ijantimicag.2018.09.013. Epub 2018 Sep 27. PMID: 30268576. [crossref] [PubMed]
11.
Anand M, Sahu C, Negi A, Singh A. In vitro assessment of fosfomycin: A beacon of hope in drug resistant organisms causing urinary tract infections. JAMMR. 2019;30(2):01-09. [crossref]
12.
Collee JG, Mackie TJ, McCartney JE. Processing of Samples. Mackie & McCartney practical medical microbiology. New York: Churchill Livingstone. 1996, 14th edition.
13.
Hay AD, Birnie K, Busby J, et al. On behalf of the DUTY team. The Diagnosis of Urinary Tract infection in Young children (DUTY): A diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness. Southampton (UK): NIHR Journals Library; 2016 Jul. (Health Technology Assessment, No. 20.51.) Chapter 4, Microbiological diagnosis of urinary tract infection by NHS and research laboratories. Available from: https://www.ncbi.nlm.nih.gov/books/NBK373515/. [crossref] [PubMed]
14.
CLSI. Performance Standards for Antimicrobial Susceptibility Testing 27th ed. CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
15.
Ling TKW, Tam PC, Liu ZK, Cheng AFB. Evaluation of VITEK 2 rapid identification and susceptibility testing system against gram-negative clinical isolates. J Clin Microbiol. 2001;39:2964-66. [crossref] [PubMed]
16.
López-Cerero L, de Cueto M, Díaz-Guerrero MA, Morillo C, Pascual A. Evaluation of the Etest method for fosfomycin susceptibility of ESBL-producing Klebsiella pneumoniae. J Antimicrob Chemother. 2007;59(4):810-12. [crossref] [PubMed]
17.
The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 7.0, 2017. http://www.eucast.org.
18.
Li Y, Zheng B, Li Y, Zhu S, Xue F, Liu J. Antimicrobial susceptibility and molecular mechanisms of fosfomycin resistance in clinical Escherichia coli isolates in mainland China. PLoSONE. 2015;10(8):e0135269. https://doi.org/10.1371/journal.pone.0135269. [crossref] [PubMed]
19.
Takahata S, Ida T, Hiraishi T, Sakakibara S, Maebashi K, Terada S, et al. Molecular mechanisms of fosfomycin resistance in clinical isolates of Escherichia coli. Int J Antimicrob Agents. 2010;35:333-37. [crossref] [PubMed]
20.
Demir T, Buyukguclu T. Evaluation of the in vitro activity of fosfomycin tromethamine against gramnegative bacterial strains recovered from community and hospital acquired urinary tract infections in Turkey. Int J Infect Dis. 2013;17(11):96670. [crossref] [PubMed]
21.
Hirsch EB, Raux BR, Zucchi PC, Kim Y, McCoy C, Kirby JE, et al. Activity of fosfomycin and comparisonof several susceptibility testing methods against contemporary urine isolates. Int J Antimicrob Agents. 2015;46(6):6427. [crossref] [PubMed]
22.
Maraki S, Samonis G, Rafailidis P, Vouloumanou EK, Mavromanolakis E, Falagas ME. Susceptibility of urinary tract bacteria to fosfomycin. Antimicrob Agents Chemother. 2009;53(10):4508-10. Doi: 10.1128/AAC.00721-09. [crossref] [PubMed]
23.
Rajenderan S, Balaji V, Anandan S, Sahni RD, Tansarli GS, Falagas ME. Determination of MIC distribution of arbekacin, cefminox, fosfomycin, biapenem and other antibiotics against gram-negative clinical isolates in South India: A prospective study. PLoS One. 2014;9(7):e103253. Doi: 10.1371/journal.pone.0103253. [crossref] [PubMed]
24.
Gupta V, Rani H, Singla N, Kaistha N, Chander J. Determination of extended-spectrum β-lactamases and ampc production in uropathogenic isolates of escherichiacoli and susceptibility to fosfomycin. J Lab Physicians. 2013;5(2):90-93. Doi: 10.4103/0974-2727.119849. [crossref] [PubMed]
25.
De Cueto M, Lopez L, Hernandez JR, Morillo C, Pascual A. In vitroactivity of fosfomycin against extended-spectrum-β-lactamase producing Escherichia coli and Klebsiella pneumoniae: Comparison of susceptibility testing procedures. Antimicrob Agents Chemother. 2006;50(1):368-70. Doi: 10.1128/AAC.50.1.368-370.2006. [crossref] [PubMed]
26.
Perdigao Neto LV, Oliveira MS, Rizek CF, Carrilho CM, Costa SF, Levin AS. Susceptibility of multi resistant gram negative bacteria to fosfomycin and performance of different susceptibility testing methods. Antimicrob Agents Chemother. 2014;58(3):17637. [crossref] [PubMed]
27.
Ho PL, Chan J, Lo WU, Lai EL, Cheung YY, Lau TC, et al. Prevalence and molecular epidemiology of plasmid-mediated fosfomycin resistance genes among blood and urinary Escherichia coli isolates. J Med Microbiol. 2013;62:1707-13. [crossref] [PubMed]
28.
Lee SY, Park YJ, Yu JK, Jung S, Kim Y, Jeong SH, et al. Prevalence of acquired fosfomycin resistance among extended spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae clinical isolates in Korea and IS26-composite transposon surrounding fosA3. J Antimicrob Chemother. 2012;67:2843-47. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/52109.16161

Date of Submission: Aug 25, 2021
Date of Peer Review: Nov 27, 2021
Date of Acceptance: Jan 27, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 26, 2021
• Manual Googling: Jan 21, 2022
• iThenticate Software: Jan 22, 2022 (16%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com