Disparity in Microbiological Pattern of CAuti in Precisely Tribal Patients in Relation to Impacting Factors from the Known Pattern in the Medical Intensive Care Unit in a Tribal Tertiary Care Centre

© The Author(s) 2021. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License which permits unrestricted use, sharing, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Subudhi et al. | J Pure Appl Microbiol | 15(2):949-957 | June 2021 Article 6758| https://doi.org/10.22207/JPAM.15.2.53


iNtROduCtiON
Urinary tract infection (UTI) is an infection in any part of the urinary system, including kidney, ureter, bladder, or urethra. Urinary tract infection is the presence of the microorganism in the urine 1 . It is a common health care associated infection (HAI) accounting for 30-50% of HAI and comprising 8% to 21% of all HAI in intensive care units (ICUs) 2,3 . The incidence of UTIs among hospitalized patients with indwelling catheters is approximately 15% 4 . The Centers for Disease Control and Prevention (CDC) simplified the definition of CA-UTI, the indwelling catheter must be in place for >2 calendar days on the date of event, with day of device placement being Day 1, with at least one of the following clinical features like fever (> 38°C), frequency, urgency, suprapubic tenderness, dysuria and a positive urine culture of a bacterium ≥ 10 5 colony forming unit (CFU) /ml 5

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Because of frequent use of urinary catheter in the ICU than hospital ward,to calculate intake and output in sick patient, the risk of CAUTI is significantly higher in the ICU. Not only use of urinary catheter but also duration of use of catheter is a major risk factor for development of CAUTI in the ICU [6][7][8] . The other risk factors associated with the cause of CAUTI are female gender, poor nutrition, severity of illness, and immuno compromised status 8,9 . It is also associated with many complications leading to increase morbidities and mortalities in the ICUs. Even if it is the most preventable health care associated infection (HAI), the management of CAUTI is still a challenge . In CAUTI the incidence of infection is Escherichia coli in 21.4%, Candida spp in 21.0%, Enterococcus spp in 14.9% Pseudomonas in 10.0%, Klebsiella in 7.7% and remaining part with other organisms 6,9 . We know, what are the potential risk factors and pattern of microbiological profile of CAUTI, in the ICU of Rural and Urban area tertiary care centers. But we do not have any knowledge or any recent studies describing the factors and microbiological pattern of CAUTI in specially tribal people. Because of unawareness, lack of health consciousness and living style, make them more prone for infection leading to more ICU admission,morbidity and mortality. Here we tried to explore the factors (demographic as well as risk factors) responsible for more incidence of CAUTI and also their influence on the microbiological profile of CAUTI, which vary according to all this. So that, preventive strategies should be planned such as antibiotic policy, protocol for using device, health awareness in the ICU to give quality health care and reduce morbidity and mortality in tribal people in the ICU of any hospital in Tribal area. The aim of our study was to find out the 1

Study population
The study population was all adult patients, aged ≥ 18 years, admitted to MICU with different complaints with an indwelling urinary Foley's catheter. catheter more than 48 hours during their admission, in a Tribal tertiary care centre. between the study period from April 2019 to March 2020, developed features of symptomatic urinary tract infection following catheterization were included in the study.

Sample Collection
The urine sample was collected aseptically from the sampling port of indwelling urinary catheter with sterile syringe and needle and distal 5 cm of the aseptically removed urinary catheter was cut and sent to microbiology Department for routine microscopic examination and Culture sensitivity test.Infection surveillance and consent form with necessary details were filled up simultaneously. Urine culture showing, more than 10 5 colony-forming units per ml, with one or two micro-organisms isolated was considered as a confirmation of UTI. CAUTI was considered when urine showed Pyuria (more than 10 leucocyte /ml of urine) or more than 3 WBC were seen per HPF in centrifuged urine and organism seen on gram stain. Standard culture methods MacConkey's agar, and cysteine lactose electrolyte deficient (CLED) agar, were used, to identify the microorganism,. Susceptibility of antimicrobials was done by the disk diffusion method on isolates.

Data collection
The demographic and clinical data of patients were collected as follows: age, gender, Socioeconomic status, area, admission date, indication and duration of catheterization, risk factors,co morbidities like presence of Diabetes mellitus, Sickle cell anemia, length of ICU stay, previous antibiotic use, and severity of illness. Detailed investigations of the patients were taken. Culture and sensitivity and antimicrobial susceptibility and resistance pattern of isolates were collected.

Statistical analysis
Microsoft Excel was used for data entry and analyzed with SPSS software version 20.0. For quantitative variable, median and for qualitative variable,frequency (percentage) were used to present the results.

Results
The study was conducted in a 20 bedded medicine intensive care unit, over a period of one year from April 2019 to March 2020 in a Tribal tertiary care centre. Total 190 patients were exposed to indwelling urinary catheter device for a total duration of 1712 device days and treated for an aggregated duration of 2772 days with different complaint in the MICU. The Device utilization rate (DUR) was 0. 61 . Out of 190 catheterized patients, 46(24.2%) were diagnosed microbiologically as CAUTI with an incidence of 24.2% and Deviceassociated infection rate in total was 26.8/1000 days. Where as, the CAUTI rate in 33 Tribal patients was 19.2 per 1000 device days with an incidence of 17.3% . (Table 1).
The type of patients developed CAUTI in our MICU,were Tribals 33 (71.7%) and Nontribals 13 (28.3%). Among these 33 Tribal patients, females were 20 (60.6%) as compared to males 13 (39.4%). Where as in factor, age of tribal patient, 6 (18.1%) were under upto 20 years, 7 (21.2%) in >20-40 years, 15 (45.4%) in >40-60 years and 5 (15.1%) cases in above 60 years old respectively. Depending upon the Socioeconomic status, most of the tribal patients 21 (63.6%) were under low socioeconomic status group than 11 (33.3%) in medium and 1(3.0%) in high status group. Considering the risk factors associated with Tribal patients in the study, Diabetes Mellitus in 4 (12.1%) case, Sickle cell anemia in 13 (39.3%) cases and others in 16(48.4%) were without any risk factors in the study. Length of ICU stay was an another risk factor to develop CAUTI in our study, according to which 22(66.6%) patients stayed for 7-14 days,8 (24.4%) for less than 7 days and 3(9.0%) stayed for more than 14 days. Single organism responsible for CAUTI in tribal people of our study were Bacteria  (Table 2) In our study, CAUTI in Tribal patients was affected by the Gram positive cocci 14(50%) and Gram negative bacilli 14 (50%) in equal proportion and the remaining pathogens were the fungal Candida albicans 5(55.5%). Over a period of one year, the Bacterial microbiological pattern of CAUTI in Tribal patients, were Staphylococcus aureus 10 (30.3%) gram positive cocci followed by CONS 2(6.0%) and Streptococcus Pneumoniae 2(6.0%). Whereas in gram negative bacilli, E.coli 8 (24.2%) were the most common pathogen followed by Klebsiella pneumoniae 3 (9.0%), Pseudomonas aeruginosa 2 (6.0%) and Acinetobacter baumannii 1(3.0%). Candida albicans was the only common fungal pathogen accounting in 5(55.5%) cases. The microbiological trend in the Low socioeconomic status group of Tribal patients were Staphylococcus aureus 6 (28.5%), E.coli 5(23.8%), Candida albicans 5(23.8%),CONS 2 (9.5%)and Klebsiella pneumoniae in 2 (9.5%) cases,which was almost same in Medium socioeconomic status except Candida albicans and CONS which were totally not identified. The only organism detected in High socioeconomic status group was Acinetobacter baumannii 1 (100%) in case. (Table 3) In this study, most affected patients in gender wise were Females,where E coli 6 (30%) the most common organism followed by Staphylococcus aureus 4(20%), Candida albicans 3(15%) and in male Staphylococcus aureus 6 (38.4%) followed by Klebsiella pneumoniae 2 (15.3%) and Candida albicans 2(15.3%) . Patients under 20 to 40 years of age, were most commonly affected by Staphylococcus aureus 6(40%) and in 2 (28.5%) cases in more than 40 to 60 years. Candida albicans 4 (26.6%) was the second pathogen found predominantly only in age group 20 to 40 years but in case of more than 40 to 60 years of age group, it was E.coli 3(42.8%). The pathogens recovered   (20) in the age group below 20years was E. coli 3 (50%) predominantly. In our study, a significant association was found of Klebsiella pneumoniae 2 (40%) with the age group above 60 years. (Table  4) A c c o r d i n g t o t h e d u r a t i o n o f catheterization in our study,more isolates were identified between7 to 14 days. These isolates were Staphylococcus aureus 9 (40.9%), E.coli 7(31.8%), Candida albicans 2(9.0%). But in less than 7 days , the isolates were Candida albicans 3 (37.5%) predominantly followed by Streptococcus pneumoniae 2 (25%). Pseudomonas aeruginosa 2 (66.6%) was the most common isolate with Acinetobacter baumannii in 1 (33.3%) case, were found in catheterization more than 14 days. Among the 33 tribal patient with CAUTI, 14 (42.4%) were stayed for a duration of less than 14 days, where the isolates were Staphylococcus aureus 5(35.7%), E.coli 3(21.4%), Streptocococcus pneumoniae 2 (14.2%). In case of,length of stay for more than 14 days, the potential isolates identified were E.coli and Staphylococcus aureus, in equal proportion in 5 (26.3%) cases followed by Candida albicans 4 (21.0%), (Table 5) In our study, we not only identified single but also mixed infections due to more than one organism in tribal patients associated with Type-2 Diabetes mellitus and Sickle cell anemia in our MICU. CONS 2 (50%) was the most common single infection found in Tribal patient with Diabetes mellitus, Where as in patients with Sickle cell anemia, Staphylococcus aureus 7 (53.8 %) was the most common pathogen as single infection preceding Streptocococcus pneumoniae and E.coli, each in 2 (15.3%) cases. (Table 6) disCussiON Urinary tract infections (UTIs) are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter. The Incidence of CAUTI in our study was 24.2%, which was less than the findings of 29.55% in one study by Sawsan et al. 10 . In their study they considered patients from both Ward and ICU, so their incidence was high because of large sample size as compared to our study in MICU only.
The potential significant risk factors other than urinary catheterization are gender, age, uncontrolled diabetes and long hospital stay 14,15 . D. M. Livermore et al. 16 conducted a study over antibiotic resistance of pathogen in different location,where they found that prevalence of pathogens and their features may vary with time and geographical area. In our study, the common causative organism in group were Gram positive cocci 14 (50%) and Gram negative bacilli 14 (50%) in equal proportion and the remaining were 5 (55.5%) fungal in patient of tribal area. In one study by Muhammad D.H. et al. 17 where they found that female gender is a common risk factor for CAUTI in Intensive care units 17 . This is similar to our study. E coli 6 (30%) was the most common organism in female Tribal patients followed by Staphylococcus aureus 4 (20%), Candida albicans 3 (15%) and Pseudomonas aeruginosa 2 (10%),which was near to the findings observed in their major female group, in the year 2018 studied by Govinda Maharajan et al as Escherichia coli 56.9% (37/65) followed by Klebsiella pneumoniae 10 (15%). In Both the study, E. coli was the common pathogen isolated in CAUTI in the ICU.
Muhammad D H et al. 17 also observed in their study that, CAUTI caused by E. coli, was higher in patients of reproductive age (21-30 years) group, irrespective of catheterization and a higher percentage of P. aeruginosa was also found in catheterized patients of the same age group. But in our study, it was observed in tribal patients below 20 years of age, may be due to a lack of sufficient knowledge of hygiene practices. Similar trend was observed for E. coli in tribal patients of age group above40 to 60 years,where as Klebsiella pneumoniae was recovered in patients of age group above 60 years. In both the groups, the variation in pathogens, may be due to the association of co morbidity Diabetes mellitus. The highest proportion of Staphylococcus aureus was found in the age group 20 to 40 years followed by Candida albicans. This observational finding may be due to association of SCA and sexually active reproductive age.
Education, income, marital status, are all components of socioeconomic status and connected to overall health and well-being. Lower income was significantly associated with higher risk of developing moderate/severe Lower Urinary Tract infection. This was reflected in our study as Low socioeconomic status group 21 (63.6%) were most affected than medium 11 (33.3%) and high group,where the isolates in frequency were, Staphylococcus aureus 6 (28.5%), E.coli 5 (23.8%), Candida albicans 5 (23.8%), CONS 2 (9.5%) and Klebsiella pneumoniae 2 (9.5%). We were expected, E. coli and Candida as the major pathogen in low socio economic group because of unawareness of hygiene practices and life style but came after Staphylococcus aureus in order of frequency and in equal proportion. The only organism detected in High socioeconomic status group was Acinetobacter baumannii in 1 (100%) case.
Duration of Catheterization is an important risk factor for CAUTI because, the duration of time should be sufficient for the biofilm of the pathogen to form on the surface of the catheter and the drainage system to developed CAUTI 18 . In our study,the risk of CAUTI was three times more, in patients used catheter 7 to 14 days, than less than 7 days. This finding is similar to a study conducted by Anggreiny Anggi et al. 19 . Candida albicans was the most frequent pathogen detected in Tribal patients with less than 7 days of duration of catheterization.The most higher risk group using catheter 7 to 14 days were associated with common pathogen Staphylococcus aureus followed by E.coli, that may be due to the infection prone Sickle cell anemic young Tribal patients.
Length of ICU stay is associated with increased risk of CAUTI because in the presence of catheter for long time will inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesions and causing mucosal irritation leading to CAUTI. Talaat M et al. 20 found in their study that prolonged hospital stay had significant higher risk to develop CAUTI. The Tribal patients Who stayed in MICU for less than 14 days were more commonly affected with Staphylococcus aureus 5 (35.7%) followed by E.coli 3 (21.4%), CONS 2 (14.2%). But CAUTI was more in Patients staying for more than 14 Days in MICU, where the pathogen were E.coli 5 (26.3%) and Staphylococcus aureus 5 (26.3%) in equally proportionately detected followed by Candida albicans.
Platt et al. 21 in their study, documented, presence of diabetes as a risk factor for CAUTI due to two possibilities : an increased prevalence of perineal colonization by potential pathogens and an increased ability of the urine of some patients with diabetes to support microbial growth 20 . In our study,CONS 2 (50%) was the pathogen responsible for, CAUTI in Tribal patient with Diabetes mellitus and Staphylococcus aureus 7 (53.8%)was the pathogen in Tribal patient with Sickle cell anemia followed by Streptocococcus pneumoniae 2 (15.3%) and E.coli 2 (15.3%). The pathogens detected in Tribal patients without any risk factors were E. coli 5 (31.2%) followed by Candida albicans in 4 (25%) cases.

CONClusiON
From the present study, We reached in a conclusion that,mainly three common pathogens Staphylococcus aureus, E.coli and Candida albicans were identified in Tribal patients with CAUTI, depending on the factors influencing them. Our analysis precisely of this population, brings several important and unique findings, which will aid in the development of some new or update guidelines for the prevention of CAUTI in the ICU. With the knowledge of antibiotic resistance pattern of these pathogens, new antibiotic policy will be developed to reduce empirically use of antibiotics, their by reduce length of ICU stay, morbidity and mortality in these Tribal patients in the ICU of Tribal tertiary care centre.

Recommendation
More surveillance study on CAUTI over these Tribal patients with large sample size over a long time period was recommended to reach a solid guideline with antibiotic policy in MICU of Tribal tertiary care centre. None.

DATA AvAILAbILITy
All datas generated or analyzed during this study are included in the manuscript.

ethiCs stAteMeNt
Data from patients obtained after proper consent.