Comparative in vitro activity of ciprofloxacin and levofloxacin against isolated uropathogens in Ghana: a pilot study

Comparative in vitro activity of ciprofloxacin and levofloxacin against isolated uropathogens in Ghana: a pilot study

Daniel Kwame Afriyie^1,&, Linda Brakowaah Adu², Marc Dzradosi², Seth Kwabena Amponsah³, Prince Ohene-Manu¹, Francis Manu-Ofei¹

 

¹Ghana Police Hospital, Pharmacy Department, Accra, Ghana, ²Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, Central University, Accra, Ghana, ³Department of Pharmacology and Toxicology, School of Pharmacy, University of Ghana, Accra, Ghana

 

 

^&Corresponding author
Daniel Kwame Afriyie, Ghana Police Hospital, Pharmacy Department, Accra, Ghana

 

 

 

 

Urinary tract infection (UTI) is one of the commonly reported microbial infections at healthcare settings. UTI can affect all ages and both sexes, although prevalence is known to be higher amongst females [1]. Reports suggest that there could be spontaneous resolution of UTI (rates between 50 - 70%) without any pharmacologic intervention [2]. Effective management of UTI would usually require the use of antimicrobial agents. However, reports show increasing resistance among certain urinary pathogens (uropathogens) to some commonly used antimicrobial agents. A number of studies report resistance of uropathogens to some first line antibiotic therapy: 10 - 20% for trimethoprim and sulfamethoxazole (TMP-SMX), 40% for ampicillin, 15 - 20% for nitrofurantoin and less than 10% for the fluoroquinolones [2-5]. Among the various antimicrobials used in the treatment of UTIs, the fluoroquinolones remain the preferred class. This is due to the fact that fluoroquinolones have high bacteriologic and clinical cure rates, low resistance rates, and few adverse drug reactions [6,7]. Fluoroquinolones are bactericidal antibiotics that target specifically DNA gyrase of the microorganism. Amongst the most frequently prescribed fluoroquinolones for empirical treatment of UTIs are ciprofloxacin and levofloxacin [3, 8, 9]. Ciprofloxacin, a second-generation fluoroquinolone, has greater activity against Gram-negative bacteria compared to nalidixic acid (a first-generation quinolone). Levofloxacin, a third-generation fluoroquinolone, is known to have broad spectrum of activity against Gram-positive and Gram-negative bacteria, and atypical pathogens [10]. Despite the preference for fluoroquinolones in the management of UTIs, there are current reports that suggest emergence of uropathogen resistance to commonly prescribed fluoroquinolones [11,12]. Data from Ghana and elsewhere show that isolated uropathogens have higher resistance to ciprofloxacin compared to levofloxacin [13-15]. As a result of this, healthcare professionals in Ghana may sometimes prescribe levofloxacin instead of ciprofloxacin (which is first-line treatment)for uncomplicated UTI. Two recent studies at a secondary level quasi-government hospital in Ghana showed that isolated uropathogen exhibited 35.9 % resistance to ciprofloxacin [16] and 51.6% resistance to levofloxacin [17]. Data from the latter study showed that levofloxacin resistance among uropathogens was on the rise. Therefore, the current study sought to compare the susceptibility of uropathogens (clinical isolates) to levofloxacin and ciprofloxacin concurrently.

 

 

Study site: the study was conducted at a secondary level quasi-government hospital, Ghana Police Hospital. The Hospital is a 100-bed facility providing healthcare to police personnel, their dependents, and the general public. The Out-patient Department of the Hospital provides service to over 100,000 patients each year.

 

Study design and population: this was a cross-sectional study that screened urine samples collected from suspected UTI patients (both In-and Out-patients) who visited this secondary level quasi-government hospital from July 2016 to March 2017.

 

Urine processing: midstream urine samples from patients were collected into sterile urine containers, stored between 2^o - 4^oC in a refrigerator, and analyzed not later than 4 hours. All analysis were done at the Microbiology Unit of the Ghana Police Hospital. Culture of urine was done with the aid of a calibrated wire. A loop-full (0.01 mL) of each sample of urine was inoculated onto a quarter-plate of Cysteine Lactose Electrolyte-Deficient (CLED) agar (Biotic Laboratories Ltd, UK). Specimen were streaked on agar plates to allow discrete colonies and incubated at 37^oC for 24 hours in Nodermann GMBH incubator (Germany). After the 24-hour incubation period, colonies were enumerated and those with significant growth identified. Significant microbial growth was defined as a culture of single microorganisms at a concentration ≥ 1×10⁵cfu/mL. Microbial colonies were identified using morphological features, standard biochemical and serological methods [18]. After identification, each colony, representing an isolate was emulsified in 2 mL sterile peptone water, and then transferred into sensitivity agar plates (Biotec laboratories, UK).

 

Susceptibility test: susceptibility of isolated uropathogens to levofloxacin and ciprofloxacin was done using the Kirby-Bauer disc diffusion method. Sensitivity discs of levofloxacin (5 µg) and ciprofloxacin (5 µg) obtained from Biomark Laboratories, India (BDR001, Lot: 0215/0686) were stored under recommended refrigeration (-200 C to 80 C) until used for tests. Inhibition zone diameters pertaining to levofloxacin and ciprofloxacin were measured using calipers and compared with standard interpretation charts, and scored as sensitive or resistant.

 

Statistical analysis: data was entered into Statistical Package for the Social Sciences (SPSS) Version 21 (IBM Corporation, USA) and checked for completeness. Thereafter, descriptive statistics (percentages and frequencies) was used to present findings. Student's t-test was used to compare difference between continuous variables. A p < 0.05 was considered statistically significant.

 

Ethics: ethical approval for this study protocol was obtained from the Ghana Police Hospital Administration. Patients' data were handled with utmost confidentiality and all patient identifiers were removed.

 

 

Of the 153 urine samples with significant bacteria growth that were examined, 114 (74.5%) were from females and 39 (25.5%) from males. Patients of ages between 20-39 years had the highest prevalence of clinical UTI, 76 (49.7%), whilst the lowest prevalence was observed in patients less than 20 years, 21 (13.7%). Age categories with respective UTI cases are presented in Table 1. Coliform spp was the most predominant urinary pathogen isolated, 66 (43.2%) out of the 153 isolates. Escherichia coli, Klebsiella spp and Staphylococcus aureus (the only Gram-positive) constituted 43 (28.1%), 40 (26.1%) and 4 (2.6%) respectively, of the total isolates. The overall sensitivity of isolated uropathogens to ciprofloxacin was 77.1%, and levofloxacin 62.8%. The only Gram-positive isolate Staphylococcus aureus was more susceptible to ciprofloxacin (75%) compared to levofloxacin (25%). On the whole, the Gram-negative isolates (Escherichia coli, Klebsiella spp and Staphylococcus aureus) were more susceptible to ciprofloxacin compared to levofloxacin, as shown in Table 2.

 

 

Regular laboratory-based surveillance is important for local and national action in the monitoring of antimicrobial resistance (AMR) and its spread [19,20]. Studies of such nature promote rational prescribing of antibiotics, and provide up-to-date information that direct policies aimed at addressing AMR. The current study showed that the prevalence of UTI was significantly (p < 0.05) higher in females (74.5%) compared to males (25.5%).This corroborates a study in Nigeria, where the prevalence of UTI was higher among females, 55.1%, than in males, 34.9% [21]. Other studies elsewhere have also showed that the prevalence of UTI in females is higher than in males [22,23]. Factors such as hormonal changes during pregnancy, anatomical difference between the male and female urethra, proximity of the male and female urethra to anal opening, poor personal hygiene, some cultural practices among women and the absence of prostatic secretion in females could be underlying factors for the moderately high UTI prevalence observed among females than their male counterparts [23]. The age range with the highest infection, 49.7%, was in patient within 20-39 years. Those with ages less than 20 years had the lowest infection (13.7%). The high rate of UTI among the age category 20-39 years could be due to the high incidence of sexual activity and/or multiple sex partners known to be associated with that age group [24]. UTI among patients within the age range of 40-59 (12.6%) and above 60 years (15%) observed in this study could be due to factors such as prostatic enlargement in males, reduced ambulation, catheterization, diabetes mellitus and weak bladder sphincters [25]. Studies conducted in Ghana have shown that, Escherichia coli, Klebsiella, Candida and Salmonella speciesare among the commonest isolated uropathogens from patients with UTI [26, 27]. Reports from similar studies elsewhere revealed that, common pathogens in laboratory cultures of urine are Escherichia coli and Enterobacteriaceae [28, 29]. Previous studies conducted at the Ghana Police Hospital reported the presence of fungi, mixed fungi and bacteria, and mixed bacteria isolates [16,17]. In the current study, bacteria were the pathogens isolated; Coliforms spp, Escherichia coli, Klebsiella spp and Staphylococcus aureus. The current study also showed that Escherichia coli and Coliform spp were the most prevalent uropathogens, accounting for 71.3% of the clinical isolates. Similar studies in Ghana; Kumasi and Cape Coast Hospitals, however, reported Escherichia coli and Klebsiella spp as the most prevalent bacteria isolates responsible for UTI [30, 31].

 

Although fluoroquinolones have been useful in the treatment of UTI, current reports in a number of countries, Ghana inclusive, suggest an increase in microbial resistance [13,14,32,33]. A possible reason for this could be indiscriminate use of fluoroquinolones in the treatment of human and animal infections [34]. The current study revealed that, overall susceptibility of microbial organisms to levofloxacin was 62.8% and to ciprofloxacin was 77.1%. This observation suggests that, isolated uropathogens were more susceptible to ciprofloxacin than levofloxacin. On the contrary, findings from a similar study in a tertiary-care hospital in India reported uropathogen susceptibility of 46.2% for levofloxacin and 14.5% for ciprofloxacin [35]. Resistance of isolated uropathogens to ciprofloxacin and levofloxacin in this study was 23.9% and 37.2% respectively. The level of resistance to these two fluoroquinolones were higher than the 10% resistance observed in a similar study in United States of America [5], but lower than findings from the study in India [35]. Further analysis of results also showed that, resistance of levofloxacin and ciprofloxacin to uropathogens in this study was lower than fluoroquinolone resistance (> 50%) reported after a recent nationwide antimicrobial resistance surveillance in Ghana [33]. Findings from this study (emerging resistance to fluoroquinolones) tend to agree with conclusions from a systematic review and meta-analysis of UTIs in West Africa from 1990 to 2012 by Bernabe et al [36]. Several studies have revealed that levofloxacin has better activity against Gram-positive bacteria, and less likely to select for resistant strains compared to the older quinolones [6,37,38]. However, the only Gram-positive isolate Staphylococcus aureus, identified in this study showed higher (75%) resistance to levofloxacin compared to ciprofloxacin (25%). This observation is contrary to the fact that third generation fluoroquinolones such as levofloxacin possess broad spectrum of activity against Gram-positive and Gram-negative bacteria than ciprofloxacin (second generation fluoroquinolone). Further analysis of data revealed that ciprofloxacin had greater activity against Gram-negative bacteria isolates; Coliforms spp, Escherichia coli and Klebsiella spp, than levofloxacin. Thus, suggesting ciprofloxacin has greater activity compared to levofloxacin. A limitation of this study was the fact that the study was conducted in only one health facility; hence findings may not be the reflection of what pertains elsewhere. Another limitation was the small sample size of the study (n = 153). This was due to the limited number of levofloxacin and ciprofloxacin discs available for the study.

 

 

In conclusion, this study showed that among uropathogens isolated at this quasi-government hospital, ciprofloxacin had greater activity than levofloxacin. The high resistance of isolated uropathogens to the relatively new levofloxacin (a third generation fluoroquinolone) observed in this study is noteworthy. Results from this study re-emphasize the need for rational use of fluoroquinolones during empirical treatment of UTIs, and/or the need for antimicrobial sensitivity tests before drug treatment. Furthermore, findings from this research provide a basis for a multicenter study. This would enhance rational, evidenced-based, and cost-effective use of these antibiotics in UTIs management in Ghana and elsewhere.

 

 

The authors declare no competing interests.

 

 

Daniel Kwame Afriyie, Marc Dzradosi and Seth Kwabena Amponsah designed and supervised the study. Collection, analysis and interpretation of data were done by Daniel Kwame Afriyie, Marc Dzradosi, Seth Kwabena Amponsah, Linda Brakowaah Adu, Prince Ohene-Manu and Francis Manu-Ofei. Manuscript was drafted by Daniel Kwame Afriyie, Marc Dzradosi, Francis Manu-Ofei and Seth Kwabena Amponsah. All the authors have read and agreed to the final manuscript.

 

 

Table 1: age and sex distribution of patients with UTIs at the quasi-government hospital

Table 2: susceptibility pattern of isolated uropathogens to ciprofloxacin and levofloxacin

 

 

1. Minardi D, d'Anzeo Gianluca, Cantoro D, Conti A, Muzzonigro G. Urinary tract infections in women: etiology and treatment options. Int J Gen Med. 2011; 4: 333-343. PubMed | Google Scholar


2. Lienerrozos HJ. Urinary tract infections: management rationale for uncomplicated cystitis. ClinFamPrac. 2004; 6: 157-173.


3. McLaughlin SP, Carson Culley. Urinary tract infections in women. Med Clin North Am. 2004; 88(2): 417-429. PubMed | Google Scholar


4. Ebell MH. Treating adult women with suspected UTI. AmFam Physician. 2006; 73(2): 293-296. PubMed | Google Scholar


5. Howes David, Kantor SS (2007). Urinary tract infection, male. Accessed May 17, 2007.


6. Kamberi M, Tsutsumi Kimiko, Kotegawa T, Kawano K, Nakamura K, Niki Y, Nakano S. Influences of urinary pH on ciprofloxacin pharmacokinetics in humans and antimicrobial activity in vitro versus those of sparfloxacin. Antimicrob Agents Chemother. 1999; 43(3): 525-529. PubMed | Google Scholar


7. Schaeffer AJ. The expanding role of fluoroquinolones. Am J Med. 2002; 113(suppl 1A): 45S-54S. PubMed | Google Scholar


8. Hooton TM, Bradley Suzanne, Cardenas DD, Colgan R, Geerlings SE, Rice JC et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(5): 625-663. PubMed | Google Scholar


9. Fu Y, Zhang Wenli, Wang H, Zhao S, Chen Y, Meng F et al. Specific patterns of gyrA mutations determine the resistance difference to ciprofloxacin and levofloxacin in Klebsiella pneumonia and Escherichia coli. BMC Infect Dis. 2013; 13: 8. PubMed | Google Scholar


10. King DE, Malone Robb, Lilley SH. New classification and update on the quinolone antibiotics. Am Fam Physician. 2000; 61(9): 2741-2748. PubMed | Google Scholar


11. Acar Jean, Goldstein FW. Trends in bacterial resistance to fluoroquinolones. Clin Infect Dis. 1997; 24 (suppl 1): S67-73. PubMed | Google Scholar


12. Stein GE, Havlichek Daniel. Newer oral antimicrobials for resistant respiratory tract pathogens: which show the most promise. Postgrad Med. 1998; 103(6): 67-70. PubMed | Google Scholar


13. Lesho E, Waterman Paige, Chukwuma U, McAuliffe K, Neumann C, Julius MD, Crouch H, Chandrasekera R, English JF, Clifford RJ, Kester KE. The antimicrobial resistance monitoring and research (ARMoR) program: the department of defense's response to escalating antimicrobial resistance. Clin Infec Dis. 2014; 59(3): 390-397. PubMed | Google Scholar


14. Onoh RC, Umero Odidika, Egwuatu VE, Eeonu PO, Onoh TJP. Antibiotics sensitivity patterns of uropathogens from pregnant women with urinary tract infection in Abakaliki, Nigeria. Infect Drug Resist. 2013; 6: 225-233. PubMed | Google Scholar


15. Labi AK, Obeng-Nkrumah Noah, Addision NO, Donkor ES. Salmonella blood stream infections in a tertiary care setting in Ghana. BMC Infect Dis. 2015; 14: 3857. PubMed | Google Scholar


16. Afriyie DK, Gyansa-Lutterodt Martha, Amponsah SK, Asare G, Wiredu V, Wormenor E et al. Susceptibility pattern of uropathogens to ciprofloxacin at the Ghana police hospital. PAMJ. 2015; 22: 87. PubMed | Google Scholar


17. Afriyie DK, Gyansa-Lutterodt Martha, Amponsah SK, Asare G, Wiredu V, Wormenor E et al A. In Vitro susceptibility of clinical uropathogens to Levofloxacin at the Ghana Police Hospital. Int J Pharm. 2017; 7(1): 22-28.


18. Jellheden B, Norrby Ragnar, Sandberg T. Symptomatic urinary tract infection in women in primary health care: bacteriological, clinical and diagnostic aspects in relation to host response to infection. Scand J Prim Health Care. 1996; 14(2): 122-128. PubMed | Google Scholar


19. WHO. World Health Organization's strategy to contain resistance to antimicrobial drugs. Rev Panam Salud Publica. 2001; 10(4): 284-294.


20. WHO. World Health Organization. Antimicrobial Resistance: Global Report on Surveillance, Geneva; 2014. Accessed April 27, 2014.


21. Agbagwa OE, Ifeanacho Emeka. The prevalence of UTI pathogens in urine specimen obtained from a hospital in Rivers State Nigeria. J Microbiol Res. 2015; 5(5): 143-148. Google Scholar


22. Johnson JR, Stamm Walter. Urinary Tract Infections in Women: diagnosis and treatment. An Int Med. 1989; 111(11): 109-117. PubMed | Google Scholar


23. Stamm WE, Norrby Ragnar. Urinary tract infections; disease panora and challenges. J Infect Dis. 2001 Mar 1; 183 Suppl 1: S1-4. PubMed | Google Scholar


24. Ani OC, Mgbechi Kelechukwa. Prevalence of urinary tract infections (UTI) in sexually active women of Abakaliki, Ebony State, Nigeria. Anim Res Int. 2008; 5(2): 876-887.


25. Moore KN, Day Rene, Albers M. Pathogenesis of urinary tract infections: a review. J ClinNurs. 2002; 11(5): 568-574. PubMed | Google Scholar


26. Newman MJ, Frimpong Enoch, Sampane-Donkor E, Opintan JA, Asamoah-Adu A. Resistance to antimicrobial drugs in Ghana. Infect Drug Resist. 2011; 4: 215-220. PubMed | Google Scholar


27. Feglo PK, Narkwa P. Prevalence and antifungal susceptibility patterns of yeast isolates at the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. Br Microbiol Res J. 2012; 2(1): 10-22.


28. Bonadio Mario, Meini M, Spitaleri P, Gigli C. Current microbiological and clinical aspects of urinary tract infections. Eur Urol. 2001; 40(4): 439-444. PubMed | Google Scholar


29. Antwi S, Bates Imelda, Baffoe-Bonnie B, Critchley J. Urine dipstick as a screening test for urinary tract infection. Ann Trop Paediatr. 2008; 28(2): 117-122. PubMed | Google Scholar


30. Bosu WK, Acquah Samuel. Susceptibility of urinary tract bacteria to antibiotics in Cape Coast, Ghana. East Afr Med J. 1996; 73(7): 468-470. PubMed | Google Scholar


31. Gyasi-Sarpong CK, Yenli Edwin, Idriss A, Arhin AA, Aboah K, Azorliade R, Boaitey YA, Annan AA. Bacterial urinary tract infections among males with lower urinary tract obstruction at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Open Access J Urol. 2012; 2: 131-136.


32. Almuzaini T, Choonara Imti, Sammons H. Substandard and counterfeit medicines: a systematice review of the literature. BMJ Open. 2013 Aug 17; 3(8): e002923 PubMed | Google Scholar


33. Opintah J, Newman Mercy, Arhin RE, Donkor ES, Gyansa-Lutterodt M, Mills-Pappoe W. Laboratory based nationwide surveillance of antimicrobial resistance in Ghana. Infect Drug Resist. 2015; 8: 379-389. PubMed | Google Scholar


34. Poppe C, Ayroud M, Ollis G, Chirino-Trejo M, Smart N, Quessy S, Michel P. Trends in antimicrobial resistance of Salmonella isolated from animals, foods of animal origin and the environment of animal production in Canada, 1994-1997. Microb Drug Resist. 2001; 7(2): 197-212. PubMed | Google Scholar


35. Gupta A, Chauhan Bimal, Pethani J, Shah P. Fluoroquinolones resistance among uropathogens at the tertiary-care hospital, Ahmedabad. Int J Med Sci Public Health. 2016; 5(8): 1583-1587. Google Scholar


36. Bernabe KJ, Langendorf Celine, Ford N, Ronat JB, Murphy RA. Antimicrobial resistance inWest Africa: a systematic review andmeta-analysis. Int J Antimicrob Agents. 2017; 50(5): 629-639. PubMed | Google Scholar


37. Lautenbach E, Strom Brian, Nachamkin I et al. Longitudinal trends in fluoroquinolone resistance among enterobacteriaceae isolates form inpatients and outpatients, 1989-2000: Difference in the emergence and epidemiology of resistance across organisms. Clin Infect Dis. 2004; 38(5): 655-662. PubMed | Google Scholar


38. Avgustin JA, Keber Rok, Zerjavic K, Orazem T, Grabnar M. Emergence of quinolone resistance mediating Gene acc(6')-Ib-cr in Extended-Spectrum β lactamase producing Klebsiella Isolates Collected in Slovenia between 2000 and 2005. Antimicrob Agents Chemother. 2007; 51(11): 4171-4173. PubMed | Google Scholar