Highlights for management of a child with a urinary tract infection

Examination of Complementary Medicine for Treating Urinary Tract Infections Among Pregnant Women and Children

Urinary tract infections (UTIs) are a significant clinical problem that pregnant women and children commonly experience. Escherichia coli is the primary causative organism, along with several other gram-negative and gram-positive bacteria. Antimicrobial drugs are commonly prescribed to treat UTIs in these patients. Conventional treatment can range from using broad-spectrum antimicrobial drugs for empirical or prophylactic therapy or patient-tailored therapy based on urinary cultures and sensitivity to prospective antibiotics. The ongoing emergence of multi-drug resistant pathogens has raised concerns related to commonly prescribed antimicrobial drugs such as those used routinely to treat UTIs. Consequently, several natural medicines have been explored as potential complementary therapies to improve health outcomes in patients with UTIs. This review discusses the effectiveness of commonly used natural products such as cranberry juice/extracts, ascorbic acid, hyaluronic acid, probiotics, and multi-component formulations intended to treat and prevent UTIs. The combination of natural products with prescribed antimicrobial treatments and use of formulations that contained high amounts of cranberry extracts appear to be most effective in preventing recurrent UTIs (RUTIs). The incorporation of natural products like cranberry, hyaluronic acid, ascorbic acid, probiotics, Canephron® N, and Cystenium II to conventional treatments of acute UTIs or as a prophylactic regimen for treatment RUTIs can benefit both pregnant women and children. Limited information is available on the safety of natural products in these patients' populations. However, based on limited historical information, these remedies appear to be safe and well-tolerated by patients.

Plasma D-Dimer as a Marker of Urinary Tract Infection in Children

Background: Urinary tract infections (UTIs) are very common in children. Several biomarkers have been used for the diagnosis of UTI and prediction of renal parenchymal involvement. Objectives: This study aimed to evaluate plasma D-dimer as a diagnostic marker of UTI in children. Methods: This cross-sectional study included 41 children aged 1 month to 14 years with their first febrile UTI confirmed by positive urine culture referred to Bandar Abbas Children’s Hospital, Iran, from October 1, 2017, to April 1, 2018. Participants’ demographic features, including age and gender were recorded. White blood cell (WBC) count, percentage of neutrophils, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum D-dimer were measured in random blood samples for all the patients. Results: Out of 41 children (mean age: 5.50 ± 4.01 years) evaluated in this study, 6 (14.6%) were male, and 35 (85.4%) were female. The mean plasma D-dimer level was 1496.49 ± 2787.55 µg/L. A significant positive correlation was found between D-dimer with ESR (r = 0.647, P = 0.026) and CRP (r = 0.525, P = 0.001). Plasma D-dimer was not associated with age; however, age was inversely correlated with WBC count (r = -0.327, P = 0.037). No significant relationship was found between plasma D-dimer, ESR, CRP, WBC count, and neutrophil percentage with gender (P > 0.05). Conclusions: According to our results, in children aged 1 month to 14 years with culture-confirmed UTI, plasma D-dimer is positively correlated with ESR and CRP. Nevertheless, D-dimer appears not to be influenced by age or gender. Further studies are required to confirm the utility of D-dimer as a diagnostic marker of UTI in children.

Sex effects in pyelonephritis

Urinary tract infections (UTIs) are generally considered a disease of women. However, UTIs affect females throughout the lifespan, and certain male populations (including infants and elderly men) are also susceptible. Epidemiologically, pyelonephritis is more common in women but carries increased morbidity when it does occur in men. Among children, high-grade vesicoureteral reflux is a primary risk factor for upper-tract UTI in both sexes. However, among young infants with UTI, girls are outnumbered by boys; risk factors include posterior urethral valves and lack of circumcision. Recent advances in mouse models of UTI reveal sex differences in innate responses to UTI, which vary somewhat depending on the system used. Moreover, male mice and androgenized female mice suffer worse outcomes in experimental pyelonephritis; evidence suggests that androgen exposure may suppress innate control of infection in the urinary tract, but additional androgen effects, as well as non-hormonal sex effects, may yet be specified. Among other intriguing directions, recent experiments raise the hypothesis that the postnatal testosterone surge that occurs in male infants may represent an additional factor driving the higher incidence of UTI in males under 6 months of age. Ongoing work in contemporary models will further illuminate sex- and sex-hormone-specific effects on UTI pathogenesis and immune responses.

American cranberries and health benefits - an evolving story of 25 years

Cranberries contain various types of bioactive components. Scientists have been studying cranberries' beneficial effects on urinary tract health since the 20th century. In the 21st century, the protection provided by cranberry phytochemicals against cancer and vascular diseases has drawn more attention from researchers. Anthocyanins, procyanidins, and flavonols in cranberries were all documented to have potential effects on cancer prevention. The cardiometabolic effects of cranberries have been investigated in several clinical trials. It was found that cranberries positively affect atherosclerotic cholesterol profiles and that they reduced several cardiometabolic risk factors. Nowadays, growing evidence suggests other important roles of cranberries in maintaining digestive health. Cranberry juice or cranberries have been shown to inhibit the colonization of H. pylori in stomach, and protect against intestinal inflammation. For future research, clinical trials with improved study design are urgently needed to demonstrate cranberries' benefits on urinary tract health and cardiometabolic diseases. Hypothesis-driven studies using animals or cell culture are needed to elucidate the mechanisms of cranberries' effects on digestive health. © 2018 Society of Chemical Industry.

Selection of Effective Antibiotics for Uropathogenic Escherichia coli Intracellular Bacteria Reduction

Urinary tract infections (UTI) are one of the most frequent bacterial infections in humans, being Uropathogenic Escherichia coli (UPEC), the most common etiological agent. The ability of UPEC to invade urothelial cells and to form intracellular bacterial communities (IBC) has been described. Therefore, UPEC can persist in the urinary tract producing recurrent infections, resisting antibiotic activity. The objective of the present work was to analyze the ability of a collection of UPEC clinical isolates to invade bladder epithelial cells in vitro and the activity of different classes of antibiotics on intracellular bacteria. We selected 23 UPEC clinical isolates that had been previously detected intracellularly in desquamated bladder epithelial cells from patients' urine. A cellular invasion assay using the T24 bladder cell line was used. Intracellular bacteria was confirmed by laser confocal microscopy. All the strains were able to invade the cells with different percentages of intracellular bacterial survival (0.7 to 18%). However, no significant relationship was found between the percentage of in vitro infection and the presence of IBC in desquamated urine cells. In vitro, intracellular bacteria were confirmed in four representative strains by confocal laser microscopy. Ceftriaxone, ciprofloxacin and, azithromycin in vitro activity on intracellular bacteria were evaluated. Amikacin was used as a negative control. All the antibiotics tested, except amikacin, significantly decreased the number of intracellular bacteria. Ciprofloxacin was the antibiotic that induced the highest decrease percentage. Conclusions: All UPEC clinical isolates could invade bladder epithelial cells in vitro. Ceftriaxone, ciprofloxacin, and azithromycin can reduce the percentage of intracellular bacteria in vitro. In vivo studies are needed to confirm the utility of these antibiotics for intracellular bacteria reduction in UTI.

Susceptibility patterns of uropathogens identified in hospitalized children

BACKGROUND

Urinary tract infection (UTI) is the most common serious bacterial infection in childhood. The aim of the present study was therefore to identify the organisms responsible for community-acquired febrile UTI in children, to investigate their susceptibility to commonly used antibiotics, and to identify possible risk factors for antibiotic resistance.

METHODS

A total of 284 children (male, 38%; female, 62%), who were hospitalized due to a community-acquired UTI over a 5 year period in a general district hospital of southern Greece, were enrolled in the study.

RESULTS

Escherichia coli was the leading uropathogen followed by Klebsiella spp. (9.15%) and Proteus spp. (5.28%). E. coli isolates were most commonly resistant to ampicillin (41.8%), followed by piperacillin (40.3%), amoxicillin-clavulanic acid (28.6%) and trimethoprim-sulfamethoxazole (17.8%), while 27 strains (12.6%) were multi-drug resistant (MDR). Of the E. coli strains, 4.21% were producing extended-spectrum beta-lactamases. Parenteral second- and third-generation cephalosporins, the most commonly used antibiotic agents (81.3%) in the present cohort, remained highly active against E. coli and other urinary isolates, given that >95% of E. coli strains were susceptible to cefuroxime and cefotaxime. Vesicoureteral reflux was a significant risk factor for MDR (P = 0.04).

CONCLUSION

Contrary to current local practice, amoxicillin/clavulanic acid may not be the best option for the empirical treatment of community-acquired UTI in southern Greece.

Clinical, etiological and antimicrobial susceptibility profile of pediatric urinary tract infections in a tertiary care hospital of Nepal

Background

Urinary tract infection (UTI) is one of most common pediatric infections. The study was designed to assess the clinical profile, common bacterial microorganisms causing UTI and their antimicrobial susceptibility patterns at B. P. Koirala Institute of Health Sciences (BPKIHS) hospital.

Methods

This is a prospective cross-sectional study conducted at Department of Microbiology and Infectious Diseases for 6 months (January to June 2018). A total of 1962 non-repetitive urine specimens (midstream, nappy pad, catheter aspirated) of pediatric patients (0–14 years age) suspected of UTI were obtained in the Microbiology laboratory. Clinical data was obtained from requisition form and hospital software. Culture and bacterial identification was done by using standard microbiological guidelines. Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method following clinical and laboratory standards institute (CLSI) guidelines. Resistance to methicillin and vancomycin were confirmed by calculating minimum inhibitory concentration using broth dilution method.

Results

Among 1962 samples, 314 (16%) were positive for bacterial infection. Fever, irritability and poor feeding was the most common symptoms in neonates while older children presented with fever and urinary symptoms. E. coli was reported the most common etiological agent (53%), followed by Enterococcus faecalis (22%), Klebsiella pneumoniae (7%) and Staphylococcus aureus (7%). Multidrug resistant (MDR) isolates accounted for 32% of isolates, while 5% were extensively drug resistant (XDR). Fourty percentage of gram-negative bacilli were ESBL producer, 38% of S. aureus were methicillin resistant Staphylococcus aureus (MRSA) and 5% E. faecalis were vacomycin resistant enterococci (VRE). E coli was highly resistant to Ampicillin (87%), Ceftriaxone (62%) and Ofloxacin (62%). Amikacin (11% resistance) and Nitrofurantoin (5% resistance) are the most effective drugs for gram-negative bacilli (GNB) while vancomycin and linezolid are functional against gram-positive cocci.

Conclusions

High-level antimicrobial resistance was observed in pediatric UTI with alarming incidence superbugs like MDR, XDR, ESBL and MRSA. Regular surveillance should be carried out to determine the local prevalence of organisms and antimicrobial susceptibilities in order to guide the proper management of children.

Pediatric Urinary Tract Infection as a Cause of Outpatient Clinic Visits in Southern Ethiopia: A Cross Sectional Study

Background

Failure to timely diagnose and treat urinary tract infections is associated with grave long term consequences. The objectives of this study included assessing the proportion and predictors of Urinary Tract Infection (UTI) as a cause of pediatric outpatient department (OPD) visits and determining common uropathogens with antimicrobial susceptibility pattern.

Methods

A cross sectional study was conducted from May to September 2015 among children of less than 15 years old at a tertiary center in Hawassa, Ethiopia. Children who fulfilled predefined eligibility criteria were recruited to undergo urine culture and urine analysis.

Results

A total of 863 children visited the OPD during the study period among which 269(31.2%) fulfilled the predefined eligibility criteria. Urine culture was positive for 74/269(27.5%) of the clinically suspected children. Male uncircumcision (adjusted odds ratio (aOR) 3.70; 95% CI 1.34–10.16) and under nutrition (aOR 5.41; 95%CI 2.64–11.07) were independent predictors of culture positivity. More than 5 WBC per high power field (aOR 4.7, 95% CI 1.8–12.7) on microscopy, urine PH > 5.0 (aOR 2.6, 95%CI 1.2–5.8), and positive leukocyte esterase (aOR 9.9, 95%CI 4.1–25.7) independently predicted positive growth on urine culture. Escherichia coli (34/74, 45.9%) and Klebsiella spp (18/74, 24.3%) were the most frequent isolates. High resistance was noted against amoxicillin (70.6%) and cotrimoxazole (97.1%) by E. coli.

Conclusion

UTI accounted for a tenth of total OPD visits. Commonly used first line antibiotics showed high level resistance to common etiologies of UTI. UTI should be suspected in febrile children, and antibiograms should be done to tailor prescription of antibiotics.

Urine Collection Methods in Children: Which is the Best?

Urinary tract infection is one of the most common bacterial infections in infants and young children. There are 5 collection methods commonly used to obtain a urine sample from an infant or small child: suprapubic aspiration, urethral catheterization, clean catch void, urine collection bag, and urine collection pad. Although invasive, suprapubic aspiration and urethral catheterization are less likely to cause contamination of the specimen. When deciding which method to use, providers must take into consideration the clinical presentation of a child as well as presenting and past medical history, while weighing benefits versus risks.

Urinary tract infection in Uruguayan children: Aetiology, antimicrobial resistance and uropathogenic Escherichia coli virulotyping

Uropathogenic Escherichia coli (UPEC) is the most frequent cause of urinary tract infection (UTI). Virulence factors (VFs) of UPEC in children are not well known. Circulating antibiotic resistance mechanisms in the community are increasing. In this study, the aetiological agents of UTI and antibiotic resistance mechanisms of 124 strains isolated from urine cultures from children with community-acquired UTI were determined. Virulotyping of isolated E. coli strains was also described. β-Lactam, fluoroquinolone and sulfonamide resistance genes as well as integrons were detected by PCR. E. coli phylogenetic groups and 25 VFs were sought by multiplex PCR. E. coli was the most frequent aetiological agent (88.7%), of which 48.2% belonged to phylogenetic group D and 35.5% to group B2. Moreover, 81.8% were considered UPEC and >93% had virulence structures, with kpsMTII, fimH and iutA being the most frequent. Most of the E. coli isolates were susceptible to amoxicillin/clavulanic acid (AMC) (87.3%), nitrofurantoin (97.3%), cefuroxime and third-generation cephalosporins (100%). Resistance levels to oxyimino-cephalosporins were higher in non-E. coli isolates, with circulation of integrons, bla_CTX-M-2 and bla_CMY-2 detected in the community. Moreover, 8.1% of isolates were resistant to fluoroquinolones, with qnrB found in two isolates. Resistance to trimethoprim/sulfamethoxazole was found in 37.9% of isolates, with 85.5% harbouring sul genes. E. coli isolated from children with UTI presented high rates of VFs. Nitrofurantoin, AMC and cefuroxime would be suitable antibiotics to treat UTI in children. However, the presence of integrons (fundamentally class 1) and circulation of broad-spectrum β-lactamases in the community makes continuous surveillance necessary.

Intracellular bacteria in the pathogenesis of Escherichia coli urinary tract infection in children

BACKGROUND

Uropathogenic Escherichia coli (UPEC) is the most common agent of urinary tract infection (UTI). The classic model of pathogenesis proposes the ascent of UPEC by the urethra and external adherence to the urothelium. Recently, the ability of UPEC to invade urothelial cells and to form intracellular bacterial communities (IBCs) has been described.

METHODS

The objective of the present study was to determine the presence of intracellular bacteria (IB) in children with UTI caused by E. coli and to characterize its virulence attributes and its relation with clinical outcomes. One hundred thirty-three children with E. coli UTI who attended a reference children's hospital between June and November 2012 were included. Urine samples were analyzed by optical and confocal microscopy looking for exfoliated urothelial cells with IB. Phylogenetic group and 24 virulence factors of UPEC were determined using multiplex polymerase chain reaction. Medical records were analyzed.

RESULTS

The presence of IB was detected in 49 of 133 (36.8%) samples by confocal microscopy, in 30 cases as IBC, and in 19 as isolated intracellular bacteria (IIB). Only 50% of these cases could be detected by light microscopy. Seventy-four medical records were analyzed, 34 with IBC/IIB, 40 without IB. Any virulence gene was associated with IBC/IIB. The presence of IBC/IIB was associated with recurrent UTI (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.3-9; P = .017), especially in children without urinary tract functional or morphological abnormalities (OR, 8.0; 95% CI, 2.3-27.4; P = .000). IBCs were associated with lower urinary tract syndrome (OR, 3.6; 95% CI, 1.1-11.8; P = .05) and absence of fever (P = .009).

CONCLUSIONS

IBCs/IIB could explain a high proportion of children with recurrent UTI.

Bacterial pathogens and antimicrobial resistance patterns in pediatric urinary tract infections: a four-year surveillance study (2009-2012)

The aims of this study were to assess the common bacterial microorganisms causing UTI and their antimicrobial resistance patterns in Bandar Abbas (Southern Iran) during a four-year period. In this retrospective study, samples with a colony count of ≥10(5) CFU/mL bacteria were considered positive; for these samples, the bacteria were identified, and the profile of antibiotic susceptibility was characterized. From the 19223 samples analyzed, 1513 (7.87%) were positive for bacterial infection. UTI was more frequent in male (54.9%). E. coli was reported the most common etiological agent of UTI (65.2%), followed by Klebsiella spp. (26%), Pseudomonas aeruginosa (3.6%), and Staphylococcus coagulase positive (3.7%). Results of antimicrobial susceptibility analysis for E. coli to commonly used antibiotics are as follows: Amikacin (79.7%), Ofloxacin (78.3%), Gentamicin (71.6%), Ceftriaxone (41.8), Cefotaxime (41.4%), and Cefixime (27.8%). Empirical antibiotic selection should be based on awareness of the local prevalence of bacterial organisms and antibiotic sensitivities rather than on universal or even national guidelines. In this study, Amikacin and Gentamicin were shown to be the most appropriate antibiotics for empiric therapy of pyelonephritis, but empirical therapy should only be done by specialist physicians in cases where it is necessary while considering sex and age of children.

The long-term incidence of urinary tract infection after endoscopic management of vesicoureteral reflux

OBJECTIVE

To evaluate the long-term urinary tract infection (UTI) rates after endoscopic correction of vesicoureteral reflux and the possible risk factors for urinary infection.

MATERIALS AND METHODS

A retrospective study of patients who underwent endoscopic management of vesicoureteral reflux at a single institution from 2001 to 2011 was performed. Patients were followed up for a minimum of 1 year. Voiding cystourethrograms were completed 3 months postoperatively. UTI questionnaire pertaining to the patient's UTI history before and after the surgery was mailed to each patient. Data were first evaluated looking only at culture-confirmed UTIs, and a second analysis included all patient-reported and culture-confirmed urinary infections. Factors considered in the analysis included sex, age, preoperative dimercaptosuccinic acid (DMSA) scan, reflux on postoperative voiding cystourethrogram, voiding dysfunction, and preoperative reflux grade.

RESULTS

Data on 175 patients for a minimum of 1 year were collected. There were 34 of 175 confirmed UTIs after endoscopic management, and 11 confirmed febrile UTIs. There were no significant predictors of febrile or afebrile UTIs in this group. Fifty-three of 175 patients (30%) experienced any UTI, 19 of which were febrile (10%). In this group, recurrent reflux was the only significant predictor of UTI (P=.03) and febrile UTIs (P=.04). Patients with more UTIs preoperatively were more likely to have a postoperative febrile UTI.

CONCLUSION

Rates of UTI and febrile UTI in endoscopic management are similar and no better than those for open ureteral reimplantation. Longer follow-up suggests an association of recurrent reflux and preoperative UTI rates as predictors of postoperative febrile UTIs. These patients benefit from closer postoperative observation.

Resistance profile for pathogens causing urinary tract infection in a pediatric population, and antibiotic treatment response at a university hospital, 2010-2011

INTRODUCTION

Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and causes acute and chronic morbidity and long-term hypertension and chronic kidney disease.

OBJECTIVES

To describe the demographic characteristics, infectious agents, patterns of antibiotic resistance, etiologic agent and profile of susceptibility and response to empirical treatment of UTI in a pediatric population.

METHODS

This is a descriptive, retrospective study.

RESULTS

Included in the study were 144 patients, 1:2.06 male to female ratio. The most common symptom was fever (79.9%) and 31.3% had a history of previous UTI. 72.0% of the patients had positive urine leukocyte count (>5 per field), urine gram was positive in 85.0% of samples and gram negative bacilli accounted for 77.8% for the total pathogens isolated. The most frequent uropathogens isolated were Escherichia coli and Klebsiella pneumoniae. Our E.coli isolates had a susceptibility rate higher than 90% to most of the antibiotics used, but a resistance rate of 42.6% to TMP SMX and 45.5% to ampicillin sulbactam. 6.3% of E. coli was extended-spectrum beta-lactamases producer strains. The most frequent empirical antibiotic used was amikacin, which was used in 66.0% of the patients. 17 of 90 patients who underwent voiding cistouretrography (VCUG) had vesicoureteral reflux.

CONCLUSION

This study revealed that E. coli was the most frequent pathogen of community acquired UTI. We found that E. coli and other uropathogens had a high resistance rate against TMP SMX and ampicillin sulbactam. In order to ensure a successful empirical treatment, protocols should be based on local epidemiology and susceptibility rates.

Detection of intracellular bacterial communities in a child with Escherichia coli recurrent urinary tract infections

The formation of intracellular bacterial communities (IBC) has been proposed as a new pathogenic model for urinary tract infections. Scarce reports describe this phenomenon in humans. We describe the presence of IBC in uroepithelial cells of a child with recurrent urinary infections. Urine specimen was collected from a child with Escherichia coli UTI and analyzed by light and confocal laser scanning microscopy (CLSM). The capability of this strain to produce intracellular infection in bladder tissue was confirmed in mice models. Escherichia coli phylogenetic group, presence of virulence factors genes, and its multiple locus sequence type were determined. CLSM showed large collections of morphologically coccoid and rod bacteria in eukaryotic cells cytoplasm, even seemingly protruding from the cells. Escherichia coli EC7U, ST3626, harbored type 1, P, and S/F1C fimbriae and K1 capsule genes. In this report, we confirm the presence of IBC in children with UTI, as it has been described before in women.

Urinary tract infection among symptomatic outpatients visiting a tertiary hospital based in midwestern Nigeria

Microbial pathogens implicated in urinary tract infection and their antibiotic susceptibility patterns as prevalent in UTI symptomatic outpatients resident in Benin City, Nigeria was the focus of this study. One hundred (100) midstream urine samples were collected into sterile plastic universal bottles from outpatients who visited the University of Benin Teaching Hospital, Nigeria and who were tentatively diagnosed as manifesting symptoms of UTI. Patients were referred to the Medical Microbiology department by the consulting doctors. Significant bacterial counts and neutrophil (pus cells) counts were carried out on samples by standard methods. Positive samples for both counts were inoculated aseptically on sterile MacConkey agar, Cystine Lactose Electrolyte Deficient (CLED) agar and Sabouraud Dextrose agar plates and incubated appropriately. Microbial isolates were identified and antibiotic sensitivity testing was carried out on isolates by standard methods. Thirty nine (39.0%) and 61 (61.0%) samples recorded significant microbial growth and no growth respectively. Gram negative bacilli constituted 86.1% (of which enterobacteriaceae made up 49.9%) while gram positive cocci made up 13.9%. Strains of uropathogens isolated were Alcaligenes spp (19.4%), Klebsiella aerogenes (16.7%), Escherichia coli (13.9%), Staphylococcus aureus (13.9%), Candida albicans (11.1%), Proteus mirabilis (8.3%), Pseudomonas aeruginosa (5.5%), Enterobacter spp (5.5%) and Providencia spp (5.5%). Occurrence of UTI in male and female patients were 58.3% and 41.7% respectively of which UTI occurred highest in the 25-46, 15-54 and 27-54 age groups in that decreasing order. Alcaligenes spp occurred most in very old female patients. Candida albicans (the only fungal uropathogen) occurred in an 8day old male patient. Other isolates occurred in much older patients. A significantly high microscopic neutrophil count or pyuria was recorded from deposits of UTI positive patients (i.e. < 5/HPF). Eighteen (representing 50.5%) and 15 (47.8%) of total microbial strains isolated were sensitive to nitrofurantoin and ceftriaxone respectively. Antibiotic susceptibility profile also showed 13(41.6%), 13(41.6%), 13(41.6%) for ciprofloxacin, cefuroxime and ofloxacin respectively suggesting moderate sensitivity of the fluoroquinolones and second/third generation cephalosporins. Gentamicin, ampicillin and augmentin recorded over 70.0% resistance level each. A total of nineteen bacterial strains made of E.coli, Enterobacter spp, Proteus mirabilis, Providencia spp, Staph. aureus and Pseudomonas aeruginosa were multi drug resistant as they resisted 3, 3, 4, 4, 5 and 8 antibiotics respectively.