A random group of 100 symptomatic UTI patients were included in our cross-sectional study; these patients exhibited suprapubic pain, back pain, burning sensation, discomfort during urination, urinary frequency, urge incontinence and fever. UTI can be classified by different criteria; it can be symptomatic or asymptomatic, and complicated or uncomplicated. Uncomplicated UTI is infection associated with kidney or bladder without causing any functional abnormality, whereas complicated UTI is associated with diabetes mellitus, kidney transplantation, pregnancy, prostate enlargement, metabolic or immunologic illness. Infection is usually considered complicated when structural and functional abnormalities in the urinary tract and associated parts are found; otherwise, it is considered uncomplicated. In this study UTI patients were not investigated to find any structural and functional difficulties. Therefore, it was difficult to designate whether their UTIs were complicated or uncomplicated. However, 17 patients (3 males and 14 females) had history of recurrent symptoms for the last 6 months. Recurrent infections are typical with complicated UTIs so it is likely that these 17 patients would be classified as complicated UTIs.

A medical proformawas prepared to input the information associated with the study, including symptoms of the patients, their age, sex, laboratory diagnosis, and antimicrobial susceptibility. Bacterial isolates from suspected patients were tested to identify the species and the samples were evaluated for antimicrobial susceptibility by Kirby-Bauer disk diffusion techniques Bauer et al., 1966.

Urine samples were collected aseptically at the midstream level of urination with sterile labeled containers (100 ml) as described by Thomson and Miller Thomson, 2003. To define ‘positive UTI’ microscopic enumeration of urine leucocytes (WBCs) and quantitative urine culture were measured. In addition, enumeration of red blood cells (RBCs) was also determined to support ‘positive UTI’. For microscopic enumeration, 10-15 ml of mid-stream urine sample was centrifuged at 1500 to 3000 rpm for 5 min.

Supernatant was decanted using pipette, leaving 1 ml urine at the bottom of the test tube. Sediment in bottom of the test tube was resuspended with the retaining 1 ml of urine. Then 15 μl of resuspended sediment was applied on aaglass slide using calibrated pipette.

Cover slip was used to avoid any possible contamination. Then the slide was examined with a light microscope using the high dry objective (40x). At least 3 and 5leucocytes per high power field (HPF) in males and females, respectively, were considered as positive UTI.

A finding of 3 RBCs/HPF in both sexes was considered as a supportive indication for positive UTI. All positive samples were further subjected to urine culture. For each patient 10μl urine sample was plated for quantitative culture on nutrient agar media prepared according to the established methods. A cutoff point of 10⁵ colony forming a unit (CFU)/ml was considered as positive culture Cheesbrough, 2006.

10 μl urine samples plated on 20 ml of 3.62% cysteinelactose-electrolyte-deficient (CLED) media (Oxoid UK) was poured into a Petri dish. After drying, the plates were incubated at 350C (±1) for 24 h. Then, colonies were identified by the individual characteristics of the various organisms by colony size, colony shape, and colony color. After observing the bacterial colony and growth characteristics, a series of biochemical tests, including methyl red test, sugar fermentation, catalase, coagulase, urease, citrate utilization, and indole production. were conducted according to the standard methods Kass et al., 2000.

Antibiotic susceptibility test was performed according to the guidelines of the Clinical and Laboratory Standards Institute (CLSI)CLSI, 2009. Muller Hinton II agarwas used in an antibiotic susceptibility test by Kirby-Bauer disk diffusion techniques Bauer et al.,1966. The Muller Hinton II agar media was prepared according to the manufacturer’s recommendation (38g/l). Suspected organisms were grown on peptone water and allowed to incubate at 37°C for 6 to 8h. Peptone water was swabbed on Muller-Hinton agar petri dishes and dried for 8 to 10 min. After that, commercially produced antibiotic discs of different potency were placed into the media by sterile forceps and refrigerated for 3 to 4h. The zones of inhibition for different antibiotics were determined after 18 to 24h of incubation. The following antibiotic discs were used: Amikacin (30μg), Amoxicillin (10μg), Azithromycin (15μg), Cefixime (5μg), Ceftriaxone (30μg), Cephalexin (30μg), Ciprofloxacin (5μg), Cotrimoxazole (25μg), Doxycycline (30μg), Gentamicin (10μg), Levofloxacin (5μg), Nalidixic acid (30μg), and Nitrofurantoin (50μg).The diameter of inhibition zone was measured by digital slide calipers and interpreted as ‘sensitive’, ‘intermediate’ or ‘resistant’, according to CLSI standard interpretative charts.

All the data were routinely collected and were entered twice into the Epidata ® computer program 3.1 (http://www.epidata.dk)Lauritsen, 2008. Data were then validated and analyzed by simple percentages among related variables. The data were analyzed using SPSS version 16 statistical software for confidence interval (CI) and Pvalue. Statistical significance was defined when P value is <0.05. The confidence interval was set at 95% level of significance for all the proportions.

Out of the 100 patients tested, only 74 exhibited positive UTI, based on microscopic enumeration of leukocytes and RBCs, and quantitative urine culture, as described in Methods. Prevalence of UTI was found to be highest in the ages between 31-40 years, and females were mostly affected ( Figure 1 ).

It has been reportedthat in women between the ages of 20-40 years, 25%-35% have had a UTI (http://www.epidata.dk)which merges with the results of our study. Interestingly, from a study of Meerut City, India it was found that the prevalence of UTI is significantly higher in females than in males (females: 73.57%, age group of 26–36 years) Foxman et al., 2000. In case of males, elderly males of ≥48 years showed higher prevalence of UTI. In this study, we found higher prevalence of UTI in the age group between 26-36 years. Details of demographic and clinical characteristics of the patients have been mentioned in Table 1 .

Several explanations for higher UTI prevalence in females are shorter urethra and its anatomical relation to the genitourinary tract for women. This may cause pushing of bacteria into the urethra during intercourse and sometimes massaging up of bacteria from the urethra into the bladder during pregnancy/child birth Prakash and Saxena, 2013. The particular age groups of 31-40 years are more hazard-prone to UTI. It should be pointed out that the patients were selected randomly and more female patients were available with UTI symptoms which could impact our findings.Fifty three participants (71.62%) reported antibiotic use prior to participating in this study. Seventeen participants (22.97%) had history of recurrent symptoms in past the 6 months. Statistically, there was highly significant difference between males and females according to the distribution of the isolated bacteria (P value ≤ 0.05).

Out of 74 UTI patients, the prevalence of E. coli was 51(69%), whereas forStaphylococcusspp. the number was only 13(18%). Eight were identified as S. saprophytics while 5 were identified as S. aureus. On the other hand, the prevalence ofP. aeruginosa (n = 6) and K. pneumonia (n = 4) were considerably low (8% and 5%, respectively) ( Figure 2 ). E. coli was the most predominant uropathogenfound in our study, which is supported by everal previous works (http://dx.doi.org/10.1155/2013/749629) Okonko et al., 2009. For example, a study from Kathmandu, everal previous works (http://dx.doi.org/10.1155/2013/749629) Okonko et al., 2009. For example, a study from Kathmandu, Nepal showed that E. coli was the most prevailing organism ganism (81.3%) Kamenski et al., 2012. E. coli was also prevalent in studies from Tumkur and Bangalore, India (59.2%) Shanthi and Kayathri, 2012.

During analysis of antibiotic susceptibility most of the organisms were moderately resistant to Amoxicillin, Cotrimoxazole, and Nalidixic acid. E. coli showed 94.12% susceptibility to Amikacin. Staphylococcusspp. (S. saprophyticusand S. aureus) was susceptible to Amikacin (13/13, 100%) and resistant to Cotrimoxazole (0/13, 0%). P.aeruginosa was found to show susceptibility to Azithromycin, Cefixime, Ciprofloxacin, Doxycycline and Gentamicin (6/6, 100%) and 66.66% resistant to Amoxicillin, Nalidixic Acid, Nitrofurantoin (4/6,66.66%). K. pneumoniaewas found to be susceptible to Amikacin, Azithromycin, Ceftriaxone, Doxycycline (4/4, 100%) and 75% resistance to Amoxicillin, Ciprofloxacin, Cotrimoxazole (3/4, 75%) ( Table 2 ). Table 2 also showed that no (0/4, 0%) K. pneumoniastrains were resistant to Cephalexin and 2 (2/4, 50%) strains were resistant to Levofloxacin.

UTI in adults, gynaecological surgery in females, obstructive uropathy in males and complicated UTI in females with the occurrence of UTI with Ciprofloxacin resistant E. coli were noted Baral et al., 2012. Another study from India revealed that Ampicillin has the highest resistance by different uropathogens i.e. 80.4% followed by Ciprofloxacin (73%), Amoxicillin (70.4%), Norfloxacin (53.3%) while Penicillin, Furomycin, Azithromycin, Doxycycline, Linezolid and Novobiocin offered least resistant Shanthi and Kayathri, 2012.

Comparative prevalence of bacterial species in the urine samples.

However, our findings indicate that Amikacin is the most effective antimicrobial agent. Mos and co- workers also showed high sensitivity of bacteria to Amikacin (75%)(http://www.biomedcentral.com/1756- 0500/5/38). In Uganda and other developing countries, high level of resistance to the most commercially available antibiotics were found in UTI patients (Majumdar, 2012; Mandal et al., 2012). For Nitrofurantoin and Nalidixic Acid, P. aeruginosa and K. pneumonia showed considerable insensitivity. A list of the relative proportions of susceptibility and resistance profiles from all uropathogens against each antibiotic is presented in Table 3 , along with their confidence intervals set at 95% level of significance.

After the combination of sensitive and intermediate readings, the most favorable profiles were obtained with Amikacin (94.59%), Azithromycin (93.24%), Dox- ycycline (90.54%) and Ceftriaxone (89.18%). Uropathogen data showed that the uropathogens showed lowest (5.41%) resistance to Amikan, and highest resistance to Amoxicillin (85.14%)( Figure 3 ).

Some factors which largely contribute to the evolution of microbial drug resistance are incomplete doses (to cut treatment cost), access to antibiotics without prescription, prescription of higher generation antimicrobials, over prescription, and use of antibiotics without laboratory diagnosis Majumdar, 2012Mandal et al., 2012. It has been reported that antimicrobials used in agriculture, farm, household and industry are sources of antimicrobial resistance as well Mwaka et al., 2012.