Memoire Online - Etiology profile and antimicrobial susceptibility pattern of urinary tract infection among patients attending the district hospital of Nylon

ETIOLOGICAL PROFILE AND ANTIMICROBIAL SUSCEPTIBILITY PATTERN OF URINARY TRACT INFECTIONS AMONG PATIENTS ATTENDING THE DISTRICT HOSPITAL OF NYLON

This memory is my original work and has not been presented for the award of a Higher National Diploma in this university.

This memory has been submitted for examination with my full approval as a university

· The proprietor of this institution Mr. Louis-Marie DJAMBOU for this opportunity to be trained by putting in place this institution.

· My supervisor Mr. SAMA Leonard for his invaluable support and scholarly advice towards my work from its inception.

· I am greatly indebted to the entire staff of ISA and the staff of the District Hospital of Nylon for their guidance throughout my study, as well as to their patients.

· I wish to express my sincere gratitude to Mrs. EKOBO Crescence who was available when I needed any guide.

· Likewise special recognition goes to the families; TAGNE, DIPANDA, DEUKO, TSIMI and my lovely grandfather TAGNE Jean De Dieu for their support.

· . The understanding and support I received from my friends; MADEFEU, FONKEM, YANGO, CHANGEH and my classmates cannot be overemphasized. Thank you to all that participated near or far to this work

ABSTRACT

Introduction: Urinary tract infection (UTI) is the pathological invasion of the urinary tract by microorganisms. It poses a major public health problem in terms of morbidity and financial cost. UTI is considered as one of the most common bacterial infections acquired in the community and in hospitals. It may be asymptomatic, acute, chronic, and its clinical manifestations depend on the portion of the urinary tract involved, the etiologic organisms, the severity of the infection, and the patient's ability to mount an immune response to it. Both asymptomatic and symptomatic UTIs possesses a serious threat to public health care, hence reducing the quality of life. This study aim to determine uropathogens causing UTIs and their susceptibility pattern to common antimicrobial drugs among patients attending the DHN. Method: To achieve this, information on the patients were collected from the laboratory register of 2019 (December to June). These data was then analyzed using the software Graph Part version 20.1 and the Chi square test was used to compare variable. Results: of the 248 participants, 79.03% were females whereas 20.97% were males. Patients of age between 21-30 and 1-10 were more prevalent while patients of 71-80 been less represented. E.coli was the most infectious uropathogen (31.45%) follow by Staphyloccocus Sp (27.02%). Multiple or mix infection was common with E coli and Candidas (2.42%). Males were more infected with Klebsiella Sp, Proteus Sp, Staphyloccocus SP, while females were more infected with E.Coli, Providencia Stuartii and C. albicans. High prevalence was observed in the age ranges [21-30] (29.84%), [1-10] (18.95%),[31-40] (16.53%) and [11-20] (10.08%) respectively. The repartition of microorganism according to their susceptibility to classes of antimicrobial drugsshows that Candida albicans was more sensible both in azole (75.00%) and polyenes (58.33%). E. coli was more sensitive to Macrolides (78.21%) whereas it was more resistant to cephalosporine (55.13%), penicillin (84.62%), Fluoroquinolones (68.57%) and Carbapenem (58.97%). Conclusion: This study reveals a familiar pattern with respect to the uropathogens involved in UTIs with the principal cause being gram-negative bacteria, E. coli and Klebsiella spas the leading ones. However gram positive bacteria were also among the etiology with Staphylococcus sp being the leading one and fungi as well. This study alsoshowed considerable bacterial resistance to common empirically prescribed antimicrobial drugs.

RESUME

Introduction ; Les infections urinaire sont les invasions pathologique de voies urinaire par des micro-organismes. Il constitue un problème majeur de sante publique en termes de morbidité et cout financier. Les infections urinaires sont considérées comme l'une des infections bactériennes les plus courantes acquises dans la communauté et dans les hôpitaux. Cette étude avait pour objectif d'étudier le profil des micro-organismes impliques dans les infections urinaire et leurs profil de sensibilité aux antimicrobiens courant chez les patients fréquentant l'hôpital de district de Nylon. Méthode : Pour obtenir cela, les informations sur les patients ont été collectées à partir des registres du laboratoire de 2019 (Décembre à Juin). Ces données ont ensuite été analysées à l'aide du logiciel graph part version 20.1 et le test de Chi Carre a été utilisé pour comparer les variables. Résultats : Des 248 participants ,79.03% étaient des femmes tandis que 20.97% des hommes. Les patients entre les tranches d'âge 21-30 et 1-10 étaient plus répandus tandis que ceux d'entre 71-80 étaient moins répandus .E coli était l'uropathogen le plus infectieux (31.45%), suivi des espèces de staphylocoque (27.02%). Les infections multiples ou mixes étaient courantes avec E coli et les espèces de candida (2.42%). Les hommes étaient plus infecter avec les espèces de klebsielles, proteus et staphylocoque, tandis que les femmes étaient plus infecter avec E. coli, Providencia stuartii et Candida albicans. Une prévalence élevée a été observée dans les tranches d'âge [21-30] (29.84%), [1-10] (18.95%),[31-40] (16.53%) et [11-20] (10.08%) respectivement. La répartition des micro-organismes en fonction de leurs sensibilité aux classes d'antimicrobiens montre que candida albicans était plus sensible à la fois dans les azoles (75.00%) et les polyenes (58.33%). E. coli était plus sensible aux macrolides (78.21%) tandis qu'il était résistant aux céphalosporines (55.13%), Pénicilline (84.62%), fluoroquinolones (68.57%) et carbapeneme (58.79%). Conclusion : Cette étude révèle un schéma familier avec les uropathogens impliques dans les infections urinaires, la principale cause étant les bactéries gram négatives, E. coli et les espèces de Klebsielle comme les principaux .Les bactéries gram positive étaient également parmi l'étiologie, les espèces de staphylocoque étant le principal. Les champignons aussi étaient présents .Cette étude a également montré une résistance bactérienne considérable aux antimicrobiens prescrit empiriquement.

Table 6: Repartition of microorganism according to their susceptibility to classes of antimicrobial drugs

Table 7; Comparison of the susceptibility of microorganisms to classes of antimicrobial drugs according to sex

Table 8;Comparison of the susceptibility of microorganism to antimicrobial drugs according to age range

Figure 1: Relationship between virulence and host factors (Adopted from WHO 2000)

4.5 Repartition of microorganism according to their susceptibility to the class of antimicrobial drugs 32

4.6 Comparison of the susceptibility of antimicrobial drugs to microorganism according to sex 33

4.7; Comparison of the susceptibility of microorganisms to antimicrobial drugs according to age range 36

Urinary tract infection (UTI) is the pathological invasion of the urinary tract by microorganisms. It poses a major public health problem in terms of morbidity and financial cost (Oluwafemi et al., 2018). UTI is considered as one of the most common bacterial infections acquired in the community and in hospitals (Foxman, 2010).

It may be asymptomatic, acute, chronic and complicated or uncomplicated, and its clinical manifestations depend on the portion of the urinary tract involved, the etiologic organisms, the severity of the infection, and the patient's ability to mount an immune response to it. Both asymptomatic and symptomatic UTIs possesses a serious threat to public health, hence reducing the quality of life and resulting into work absenteeism (Otajevwo et al., 2015). About 50% of women would have experienced symptomatic UTI during their lifetime while approximately 20% of all UTIs occur in men (Griebling, 2005). The main cause of UTIs are bacteria but other cause can also include, fungal and viral infections (Wubalem et al., 2017). Females are more susceptible to this infection than males due to the small and wide size of their urethra and also hormonal activities (Jane-francis et al., 2012). The prevalence can also be age and sex dependent (Singh et al., 2016).

Urinary tract infection is also known to cause short-term morbidity in terms of fever, dysuria, and lower abdominal pain (LAP) and complications may result in permanent scarring of the kidney (Griebling, 2005)

The symptoms of UTIs such as fever, burning sensations while urinating, lower abdominal pains (LAP), itching, formation of blisters and ulcers in the genital area, genital and suprapubic pain and pyuria generally depend on the age of the person infected and the location of the urinary tract infected (Foxman, 2010). The prevalence of UTIs vary from one geographical location to another. Several factors such as gender, age, race, circumcision, HIV, diabetes, urinary catheter, genitourinary tract abnormalities, pregnancy, infants, elderly, and hospitalization status bear signi?cant risk for recurrent UTIs (Odoki et al., 2019).

The emergence of antimicrobial drugs resistance in the management of UTIs is a serious public health issue particularly in developing countries where there is high level of poverty, illiteracy, poor hygienic practices and drugs of questionable quality (Fagan et al., 2015).

A high prevalence of UTIs resulting from illiteracy, poverty and poor quality of drugs leading to antimicrobial drug resistance, a short-term morbidity in terms of fever, dysuria and LAP that may lead to a permanent scarring of the kidney. This situation serve as a motivation to evaluate the major pathogens causing UTIs among patients attending" The District Hospitalof Nylon"(DHN) and their susceptibility to common antimicrobial drugs.

1- What are the most common Uropathogens causing UTIs among patients attending the DHN?

2- What are the susceptibility pattern of UTI isolates to common antimicrobial drugs among patients attending DHN?

This study aim at determining, uropathogens causing UTIs and their susceptibility pattern to common antimicrobial drugs among patients attending the DHN.

· To identify the strains of microorganisms causing UTIs among patients attending the DHN.

· To identify the susceptibility of the isolated microorganism to common antimicrobial drugs.

- The most commons uropathogens causing UTI among patients attending the DHN are bacteria.

- The isolates from patients attending DHN are resistant to common antimicrobial drugs.

- The most common uropathogens causing UTIs among patients attending DHN arenot bacteria.

- The isolates of patients attending DHN are sensitive to common antimicrobial drugs.

To evaluate the microorganisms responsible for UTIs and their susceptibility to common antimicrobial drugs as a major diagnosis for a reduction in cases of UTIs and patients resistance to antimicrobial drugs. This would serve as information to policy makers in order to guide the health workers on the necessity of creating awareness about the modes of prevention of these infections and the necessity of antimicrobial tests before prescriptions.

UTIs is a term that describes infection resulting from invasion of the urinary tract by microorganisms. This may be caused by bacteria, fungi, protozoans or viruses with the bacteria been the most invasive microorganism. This is due to their virulence factors, their adaptive capacity but also the susceptibility of the host (Oluwafemi et al.,2018; Gachuhi,2017).

It is considered as one of the most common bacterial infections acquired in the community and hospitals with a range of symptoms which generally depends on the age, sex and the infected location of the urinary tract of the infected person (Foxman, 2010). Females are usually more susceptible to this infections than males due to the short and wide size of their urethra, absence of prostatic secretions and hormonal changes resulting from pregnancy(Singh et al.,2016). It is the common cause of acute illness in infants and children less than five worldwide accounting for the heaviest burden disease (Dorgelesse et al.,2019).

Figure 1:Relationship between virulence and host factors (Adopted from WHO 2000)

UTIs are one of the most common microbial diseases encountered in medical practices. Worldwide, it has an estimated prevalence of around 150 million persons per year (May et al.,2016). It is a considerable health problem which ranks as the second leading cause of infections after the respiratory tractinfections. Healthcare-associated urogenital tract infections (HAUTI) are some of the most-frequently occurring health associated infections thatconstitute 19.0% according to the European point prevalence survey (Rahimi et al.,2018; Wagenlehneret al.,2016). It is also considered as one of the severe public health problem imposing a high morbidity and mortality rate as well as severe economic consequences worldwide (Gemzu et al.,2016).

All individuals are susceptible to UTIs; however the prevalence very with age, sex and certain predisposing factors. Among the, urinary tract infections (UTIs) are most common encountered diseases by clinicians in developing countries with an estimated annual global incidence of at least 8.3 million doctor visit yearly (Annuli et al.,2016).

UTI bacteria are often from fecal origin, and anaerobic bacteria rarely cause UTI. Among this bacteria, 90% are E. coli, 10-20% Staphylococcus saprophyticus and 5% is caused by Enterobacter. Young sexually active females are the most prevalent according to(Emiru et al., 2013)

Urinary tract infection usually develops in the lower urinary tract (urethra and bladder) and if not properly treated they ascend to the upper urinary tract (ureters and kidneys) and may cause severe kidney damages.The diseases are bladder infection (cystitis), urethra infection(urethritis), andkidney infection (pyelonephritis).

The major cause of UTIs are bacteria, with the most common agents been from the Enterobacteriaceae family that is (E.coli , Klebsiella spp, Proteus spp, Serratia spp, Enterobacter spp,Pseudomonas spp) with E coli been the most prevalent. Others include: S saprophyticus,E. faecalis, S. agalactiae, S. pyogenes , S.aureus.Gram negative bacteria account for 90% while gram positive have only 10%.Other causes of UTIs include: parasites, fungi and viruses (Wubalem et al.,2017). Also etiology varies depending on health status, residential status(institutionalized or not), age, history of current catheterization, spinal cord dysfunction, history of antimicrobial drugs, sexual activities, type of pants used, type of toilet (Martha and Edgardo, 2019).

UTIs can be gotten from sexually transmitted infection, injury from an instrument such as urinary catheter,an exposure to an irritating chemical substances such as antiseptic or spermicide, bacteria resulting from fecal pathogens, exchanging under wears, using chemical substances for vaginal douching and the type of toilet (Annuli et al.,2016).

The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. Often, urinary tract infections (UTIs) are characterized as being either upper or lower based primarily on the anatomical location of the infection. The lower urinary tract encompasses the bladder and urethra, while the upper urinary tract encompasses the kidneys and the ureters. The kidneys filter the blood to remove wastes and produce urine. The ureters, urinary bladder, and urethra together form the urinary tract, which acts as a plumbing system to drain urine from the kidneys, store it, and then release it during micturition. Besides filtering and eliminating wastes from the body, the urinary system also maintains the homeostasis and blood pressure (Annuli et al.,2016)

UTI are amongst the most common bacterial infections. They occur either as an uncomplicated host setting characterize by no underlying structural or functional abnormality in the patients genitourinary tract, or complicated characterize by clinical manifestations. The two major predisposing factors are the presence of a foreign body like the urinary catheter and a disruption in normal urine flow as a result of obstruction or retention. The presence of urinary catheter or any other urine drainage device leads to the developments of a biofilm which in turn shields them from being eradicated completely (Walsh and Collyns,2017). Initially, about 95% of UTI occur when bacteria ascend the urethra to the bladder, and in cases of pyelonephritis ascend the ureter to the kidney.The remainder of UTIs are hematogenous (Imam,2018).

Adherence is a key event initiating each step in UTI pathogenesis. A UTI typically starts with periurethral contamination by a uropathogen, followed by colonization of the urethra and subsequent migration of the pathogen to the bladder. The eventrequires appendages such as flagella and pilli. In the bladder, the consequences of complex host pathogen interactions ultimately determine whether uropathogens are successful in colonization or eliminated.Multiple bacterial adhesins recognize receptors on the bladder epithelium (also known as the uroepithelium) and mediate colonization. Uropathogens such as UPEC

(Uropathogenic E.coli) survive by invading the bladder epithelium, producing toxins and proteases to release nutrients from the host cells, and synthesizing siderophores to obtain iron(Ana et al., 2015). By multiplying and overcoming host immune surveillance, the uropathogens can subsequently ascend to the kidneys, again attaching via adhesins or pili to colonize the renal epithelium and then producing tissue-damaging toxins. Consequently, the uropathogens are able to cross the tubular epithelial barrier to access the blood stream, initiating bacteremia. Also, uropathogens often form biofilms that are responsible for colonization and persistence leading to drug resistance. Catheterization also brings in uropathogens which developpe a biofilm that adhere, colonize and persist in causing UTI (Ana et al.,2015).

The urinary system is biologically structured to help ward off infections. The ureters and bladder are supposed to prevent urine from backing up towards the kidneys. The flow of urine from the bladder is designed to wash bacterial out of the body. Despite all these, infections still occurs due to some factors such as:

The host natural flora is usually altered due to actions such as extreme use of antimicrobial agent, use of contraceptives like spermicide and obstruction of urine flow.

Also illness such as diabetes mellitus, HIV infection and other diseases impacting the immune system and kidney.

Anatomical and physiological factors contribute to a greater prevalence of UTIs in females compared to males. Female pelvic anatomy plays an important predisposing role for recurrent UTIs. A study carried by Hooton et al. (2010) investigated differences in perianal anatomical measurements and discharge characteristics in 100 females with a history of recurrent UTIs and in 113 females with no prior history of UTIs. Analysis of the results demonstrated that the urethra and anus were significantly closer together in cases of UTI (4.8 #177; 0.6cm) compared to controls (5.0 #177; 0.7cm). Other important physiological and anatomical factors that predispose tobacterial adherence in females (compared to males) include a shorter urethra and the absence of antibacterial properties provided by prostatic fluid.

In premenopausal women, 90% of the vaginal flora is Lactobacilli, which protect the system against colonization with uropathogens such as E. coli, with estrogen loss at menopause, it results in the thinning of the vaginal epithelium and decreased amount of glycogen. The resulting environment is usually hostile to Lactobacilli thereby decreasing their numbers. Biological changes due to menopause put these women at particular risk of contracting both primary and recurring UTIs because with estrogen loss, the walls of the urinary tract becomes weak and as such it reduces its ability to resist bacteria colonization (Nicolle, 2008).

The incidence of urinary tract infection increases with age. During the first few months of life, the incidence of urinary tract infections in male exceeds that of females. From the first year onwards, both first time and recurrent urinary tract infection is much more common in females. The female urethra appears to be particularly prone to colonization because of its proximity to the anus.Men's risk for UTI increases with age, men become more susceptible to UTIs after 50 years of age, when they are more likely to develop prostate problems due to loss of prostate fluid. Enlarged prostate gland can also impede and slow the flow of urine, thus raising the risk of infection. Nicolle, (2008) observed that men who are not circumcised tend to also be more prone to developing UTIs because these bacterial build up much more easily in the folds of the extra skin on the penis thereby making them more susceptible to developing UTIs.

Obstruction to the flow of urine from the kidney through the pelvis, ureter, bladder, and urethra, is a common disorder. It causes a rise in pressure within urinary tract, which predispose to urinary tract infection. Obstruction may occur at any level but is most often found at the pelvis ureteric junction. Obstruction to the easy flow of urine may be the result of some gross anatomical abnormalities such as congenital or acquired pathological conditions in the urinary tract. Obstruction can also lead to reflux of infected urine in the urethra back into the ureter and kidney with consequent pyelonephritis.

Bacteria develop in at least 10-15% of hospitalized patients with indwelling urethral catheters. Factors associated with an increased risk of catheter associated urinary tract infection include, prolonged catheterization, severe underlying illness, disconnection of the catheter and drainage tube and lack of systemic antimicrobial therapy. Bacteria usually enter the catheter system at the catheter collecting tube junction or at the drainage bag portal. The organisms then ascend into the bladder within causing annoying symptoms.

Management of urinary tract infections typically involves drug therapy and patients' education. The ideal treatment of urinary tract infection is an antimicrobial agent that effectively eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infections. The antibacterial agent used for the management of uropathogensshould be affordable, produce few side effects and oflow resistance. Various treatments regimen have been used successfully to treat uncomplicated lower urinary tract infections in women.Early recognition of urinary tract infection and prompt treatment are essential to prevent recurrent infection and complications such as renal failure and sepsis (Annuli et al.,2016).

UTIs can either be symptomatic or asymptomatic characterized by a wide spectrum of signs and symptoms depending on the part of the urinary tract infected. Infections may either involve only the lower part of the urinary tract or both the lower and upper part. This may include cystitis,pyelonephritis,fever, chills, nausea, vomiting, and diarrhea. Also, in about 30% of cases patient urine become cloudy malodorous and bloody. White blood cells and bacteria can be detected by examination in the urines of an infected person. Pyelonephritis can be determined by bacteremia that is bacteria in blood (Gachuhi,2010; Khoshbakht et al., 2013).

Evaluation of UTI relies on both laboratory analysis and clinical manifestations.Laboratory analysis for UTIs can be done in four ways: dipstick urinalysis, microscopic urinalysis, urine culture and molecular identification (Christineet al.,2018). Technic for specimen collection is important in order to avoid contaminants (Gachuhi,2010)

In adults, most urine specimens for laboratory examination are obtained by the clean catch-voided midstream technique. This technique is widely accepted and applied because it is simple, inexpensive and non-invasive and there is no risk of complications. Colony counts from urine specimens collected by this method correlate reasonably well compared with those of specimens collected by supra-pubic aspiration or straight catheterization. A disadvantage of this technique is that the urine can be contaminated with commensal bacteria during its passage through the distal urethra. Simple procedures to decrease contamination rate include cleaning of skin and mucousmembranes adjacent to the urethral before micturition and the collection of the midstream part of the urine.

Proper collection ofsamples by this method may be problematic in young children, elderly and disabled patients. Supra-pubic aspiration is the best method to avoid urethral contamination, especially in young children. But it is infrequently used because it is invasive, uncomfortable and time-consuming. Collection of urine by use of a single catheter (straight catheter technique) is the next-best technique to obtain urine specimens with minimal contamination risk. However, the technique is not widely applied because of several disadvantages: it is labor intensive, costly and invasive. By the insertion of the catheter through the urethra, bacteria can be forced into the bladder, which involves a risk of infection.For babies one method is to place a specially designed absorbent pad in a nappy (supplied by a doctor). Urine is sucked into a syringe from the wet pad. Another method is to use a plastic bag that sticks on to the skin and collects urine

Because laboratory procedures for urine cultures depend upon the type of urine specimen, it is indispensable that the collection method is specified on the laboratory request form. Some essential information includes date and time of specimen collection and any clinically relevantinformation (e.g. antimicrobial treatment, predisposing urological conditions such as anatomic abnormalities, stones or the presence of foreign material) (Gachuhi, 2010;Oyaert et al., 2018).

The report on the appearance (that is the colour, odour and the clearance or turbidity) of the urine collected is done by eye observation. From it, some possible causes might be suspected. For UTIs (Cheesbough, 2006).

Urine testing often begins with dipstick urinalysis, which is easily available in laboratories and takes minutes for interpretation.The most common type of dipstick urinalysis permits analysis of multiple urine components, the most important being leukocyte esterase (LE), nitrite, and red blood cells. LE is expressed in white blood cells (WBCs), which are elevated in urine during infection. Dipstick testing is fairly sensitive to LE in the urine and turns positive in the presence of (>5-15 WBC/ high-power field (hpf)). Nitrite is indicative of the presence of bacteria, as some uropathogens containing bacterial enzymes that convert nitrates into nitrites. Urine dipsticks are able to detect nitrites in the presence of bacteria (>105 colonies forming unit CFU/mL). Urine dipsticks can detect very low levels of blood in the urine (correlates with >1-4 red blood cells/hpf).Although blood may be associated with other pathology, in the presence of symptoms or positive nitrite and LE testing, its presence may increase the probability of UTI. Several conditions can influence the interpretation of dipstick urinalysis. Uropathogens such as Enterococci and Staphylococcus Saprophyticus do not reduce nitrates and would result in false negatives. Although testing for nitrites and red blood cells requires only 1 minute before interpretation, LE requires 2 minutes for accurate interpretation. Urine that is too dilute may result in lysis of cells, increasing the risk of false-negative results. Lastly, urine dipsticks cannot distinguish between myoglobin and hemoglobin, so hematuria based on dipstick urinalysis should always be checked with microscopic urinalysis (Christine et al., 2018). The various techniques for urinalysis include;

Automated screening systems are used for a large output with minimal labour and a rapid turn-around time compared with conventional cultures. These methods are expensive and often these costs can be justified only in laboratories that receive many samples. Several automated urine screening systems are either bacterial growth independent or dependent. By examining images of un-centrifuged urine samples using a video camera one is able to recognize many cellular structures, including leucocytes, erythrocytes, epithelial cells and microorganisms. A robotic instrument has been introduced for urine screening using fluorescent stain probes to detect bacterial membrane from urine sample. After staining, the membrane is examined using fluorescent microscopy imaging technology to detect the presence of uropathogens in urine. Although this method is faster there is a need to culture negative urine specimens to eliminate few organisms which may not have been detected by this method .The Coral UTI Screen system uses a somatic-cell which releases the adenosine triphosphate (ATP). On the contrary, in bacterial cells the bacterial ATP remains protected within the bacterial cell. This then is liberated and detected by the instrument which is directly proportional to number of present bacteria. This test has a sensitivity of 86 % and specificity of 76 % (Gachuhi,2010)

Like the automated screening system this technique is used for large output with minimal labour and a rapid turn-around time. Combi 11-test M strips on a Miditron-M semi-automate reflectance photometer (Roche diagnostic Gmbh,Mannheim,Germany) have been use in our routine laboratory for this analysis.The strips include reagent pads for the semi quantitative assessment of nitrite, leukocyte esterase, pH, specific gravity, protein, glucose, ketones, urobilinogen, bilirubin and blood. For analysis a strip is simply immersed in an un-centrifuged urine sample and placed on the miditron-M semi-automate reflectance photometer which measures the various parameters and reads on the screen (Ramazan et al.,2014)

In this condition, analysis is simply done by immersing a combur 11-test M strip in un-centrifuge urine allowing to stand for 1-2 minutes and comparing the colour change on the strip with that on the container of the strips and reporting the values.

Microscopic urinalysis is performed with a manual or automated light microscope. For this preparation a drop of the sediment of centrifuge urine is place on a slide and covered with a cover slide then observed on a manual microscope at objective 10X or 40X with the condenser down and the iris closed.The presence of leukocytes (pyuria, defined as >5-10 leukocytes/hpf) or bacteria (bacteriuria,>15 bacteria/hpf) in the urine can be helpful in diagnosingUTI. Occasionally, hematuria in the presence of bacteriuria or pyuriamay also indicate UTI. The presence of squamous epithelial cells may occasionally indicate contamination, and WBC casts may indicate upper urinary tract inflammation or infection (Chu and Lowder,2018)

After observing bacteria or white cells in the wet mount preparation amicroscopic examination is performed again by preparing a gram stain of the urine that will indicate the morphology of the organism, viewed under a light microscope at objective 100X with the condenser up and the iris open. The presence of one organism per oil-immersion field in a centrifuged sample correlates with 100,000 bacteria/ml. White blood cells > 10 WBC/mm3 it only signifies the presence of inflammation. Sterile pyuria is associated with urinary tuberculosis, chlamydial, and fungal infections. Hematuria, non-specific, may indicate other disorders such as calculi or tumor. Proteinuria is found in the presence of infection.

After observing bacteria in the gram stain, cells, casts,protein, nitrite or urine with markedly alkaline or acid reaction culturing is next. It is defined by the presence of more than 105 colony forming units (CFUs/ml) of single bacteria in cultured urine (cheesebrough,2006).Normally culture ofnon-invasivespecimens should allowthe detection of 10⁴ or 10⁵ CFU/mL. This detection is usually accomplishedby inoculation of 50 ìL of urine onto appropriate media. For more invasively collected specimens (i.e. supra-pubic aspirations)or for the culture of yeasts, 100 ìL of urine should be culturedon appropriate media (Sabouraud Dextrose Agar) to achieve a detection limit of 10² CFU/mL. Inoculationof an additional routine 1 ìL sample can facilitate interpretationof heavily grown culture media.

Urinary specimens can be inoculated by stricking a quantity of the sediment of centrifuged urine on a culture media and incubating under stated conditions. Unless calibrated pipettes are used, colony counts are only approximations and can be deranged by as much as a hundred-fold. The delivered isolated colonies can be used for identification andsusceptibility testing especially at higher counts. One colony does not represent one CFU, nor is this accuracy necessary for urine culturing. Due to the several practical advantages,it is suggested to use sterile, calibrated and disposable or automated 1 and 10 ìL loops for inoculation of urinary specimens.

Besides CLED (Cysteine lactose electrolyte deficient) agar, which is the best culture media of choice for urine pathogens as stated by (Cheesbough, 2006), a variety of chromogenic selective media are available for the identification and differentiation of urine pathogens. These chromogenicmedia can be used for all urine specimens or those that might be considered to be at a higher risk for contamination. Specific organisms will produce colored colonies, depending upon interaction between the enzymes they produce and the substrates incorporated into the medium, allowing direct identification of the most relevant urinary Enterobacteriaceae and Enterococci. In addition to CLED or chromogenic media, a more universal blood agar plate could be inoculated allowing the detection of Gram-positive and fastidious bacteria(Oyaert et al.,2018).

On the CLED media, culture is by inoculating a loopful of urine carried with a sterile calibrated wire loop, strick on a plate of CLED media and incubating the plate aerobically at 35-37°C (Cheesbough,2006).

After culture on any of the stated media the bacterial isolates are further characterized using standard microbiology techniques such as colony morphology, Gram-staining, catalase test and other biochemical tests which include oxidase, Kia, indole, citrate utilization, H₂S production Voges-Proskauer, methyl red, urease and sugar fermentation testes (Ndamason et al., 2019)

Urine samples are collected from UTI patients with clean catch midstream technique. The samples are centrifuged and cotton swabs used for inoculation of brain heart infusion broth. The media then incubated for 3h at 37°C and the culture saved in refrigerator for deoxyribonucleic acid (DNA) extraction purpose for analysis (Ibraheam et al., 2016).

Lateral flow assays are a good choice for point-of-care screening tests; they are inexpensive and easy to use, as the sample and reagents are mixed on a paper support with liquid transport driven by capillary action and a colorimetric readout. Dipstick tests for urine nitrite and leukocyte esterase are widely used for lateral flow assays, but they are limited by shortcomings of poor sensitivity (Davenport et al.,2017).

It is a rapid screening based on the detection of cells in solution by light scattering.It has been employed in many devices and can detect most bacterial species as well as fungi. Flow cytometry systems, uses a combination of light scattering and fluorescence to rapidly screen for the presence of bacteria in urine. Flow cytometry is a good system for selecting samples for further analysis, and has been used to identify pathogen-positive urine for further complex testing, such as mass spectrometry analysis. Initial screening of urine samples by flow cytometry might improve clinical laboratory workflow by reducing the number of samples sent for further analysis; however, flow cytometry is only a screen for bacteriuria as it does not provide species identification(Davenport et al.,2017).

The aim of the laboratory in the management of UTI is for accurate and timely diagnosis with appropriate antimicrobial susceptibility testing. However global data shows an increasing multidrug resistance among uropathogens to conventional drugs. Some factors favoring this antimicrobial resistance are; mutations, exposure to cells with new genetic material and use of antimicrobial agents as growth promoters in animal feeds destined for human consumption give rise to multidrug resistance. However, the misuse of antimicrobial agents resulting from the mal-administration of antimicrobial drugs, incorrect use of antibiotics for the prophylaxis of recurrent UTIs, self-medication and use of drugs over the counter without prescription of the clinicians has highly contributed to antimicrobial resistance.

A diagnosis, along with early initiation of appropriate antimicrobial drug therapy would have a potential to minimize the risk of a poor outcome, reduces chronicity & drug resistance thus decreasing patient's sufferings and financial expenditure (Gachuhi,2017; Parvee et al.,2015).

A spectrum of antimicrobial drugs exist for the treatment of UTIs but a good treatment should be used when culture results become available to avoid drug resistance therefore antimicrobial sensitivity test should be used to direct therapy. Management of uncomplicated UTIs should be done on two important principle organisms especially E.coli which accounts for more than half of all urinary isolates and Staphylococcus saprophyticus which accounts for less than a quarter of the urinary isolates. Nosocomial and uncomplicated community acquired UTIs rate the highest in antimicrobial drugs resistance. In the treatment of UTIs some of the following antibiotics may be recommended for cases of bacterial infections; ciprofloxacin, ofloxacin and ceftriazones. Their efficiency is seen when given for 3 days to treat acute symptomatic and uncomplicated lower urinary tract infections (Gachuhi,2017)

The following practices are recommended to promote overall urinary health, thereby reducing or preventing the occurrence of UTIs.

Dehydration results in concentrated urine and less frequent voiding, conditions that support bacterial growth in the bladder. Dehydration is a concern for residents who may also be on medications that increase diuresis or who have a disease such as diabetes that may cause excessive urination. Adequate hydration is indicated by pale-coloured urine, moist mucous membranes, and/or normal specific gravity of the urine. The following strategies may be used to promote adequate hydration in residents:

· Routinely encourage fluid intake during social activities such as «Happy Hour» or «Tea Time», as well as in therapeutic group activities.

· Educate residents, healthcare providers, and families on the importance of hydration and urinary health.

· Document the resident's preference for type and temperature of fluids, and customize a plan that will best meet the hydration needs of the client.

· Ensure that personal hygiene is performed correctly to prevent prolonged contact with urine or feces.

· Perineal hygiene with mild soap and water should be done daily, and after episodes of bowel incontinence.

· Completely emptying the bladder is best accomplished by providing a relaxed voiding environment with a comfortable toilet seat at the appropriate height and convenient safety hand rails.

· Ensure that any issues with constipation or fecal impaction are addressed (Valerie .,2013)

DHN is a hospital enclosed by a fence with three sky blue gates and 4 main buildings painted in sky blue and white within possessing sixteen services,

DHN was brought about from the transformation of the progressive former Infant and maternal protection (IMP) Tergal to a maternity then an integrated health center (IHC). It was inaugurated as the DHN on the 24/09/1999 by professor Monekosso minister of public health

DHN is a district hospital located in the littoral region of Cameroon, in the Wouri division at the sub-division of Douala III, more precisely in the quarter whose name is carried by the hospital. It is 200metres from the main road limited to the north by stores, to the west by a craft shop, east by stores and to the south by Chococam industry.

DHN is a hospital that falls under the secondary stage of prevention of the pyramid of prevention. This stage has to do with people at the onset of health problems and the measures of prevention here include; early screening, intervention and control of risks factors which are the objectives of my study.

This study was carried out within a period of 5 days that is from the 27^th - 31^st December 2019.

The study targets both male and female out patients and inpatients of all age groups with diagnosed cases of UTIs from November 2019 to June 2019.

The minimum sample size for this study was calculated according to the method described by Daniel in 1999.

Taking the prevalence of UTIs in Ethiopia proven to be 88.5% in 2018(Wubalem et al.,2018)

All patients attending DHN diagnosed with UTI and susceptibility pattern to drugs were included in the study.

All patients attending DHN not diagnosed with UTI and susceptibility pattern to drugs.

Data were collected from laboratory registers. A copy of consent from the administration were been given to the laboratory technician and analysis were made from the date collected in registers. From that analysis results were obtained and statistic drawn from it and given in percentage, tables and charts.

During the period of collection specimen were collected from patients who presented clinical manifestations of UTIs and analyzed practically by three methods;

Data collected or obtained from the laboratory registers were inserted in an Excel sheet then transfer to SPSS version 20 for analysis.

The Chi square test was used to compare variable whereas the logistic regression analyses was used the association.

· All informations collected from the register are kept strictly confidential.4.1 Clinical characteristics

Of a total of 248 samples that was included in our study, 79.03%(196/248) were from females whereas 20.97%(52/248) from males.

The mean age of the population was 29.15 (19-40) years with the mean age of the female population being35.28 #177; 1,26 years while for male it was 28.37 #177; 3,21 years with significant difference (P= 0,044) observe between the two means groups. The variation of age was between 1 and 79 years.

The repartition of the study population according to the age shows that patients of age between 21-30 and 1-10 with the respective percentages of 29.84% and 16.53% were more prevalent while patients of 71-80 been less represented (0.40%). Significant difference (P =0.0001) was observein the repartition of the population according to age.

Significant difference (P<0.0001) was observe in the infectious repartition of microorganisms with E.coli been the most infectious UTIs microorganism (31.45%) follow by Staphyloccocus Sp (27.02). The multiple infection was common with E coli and Candidas sp (2.42%).

The reparation of microorganism according to sex show significant difference in the variation between both sexes with males more infected withKlebsiella Sp, Proteus Sp, Staphyloccocus SP, while female was more infected with E. Coli, P Stuatii and C. albicans. No significant difference was observe in the infection between male and female in Serratia Sp, Streptococcus Sp, and also in all multiple infection.

Significant difference was observe in the repartition of microorganism according to age range with C. albicans, E. coli, Klebsiella sp, Proteus sp, P. stuartii, and Staphylococcus sp, with E coli been the most abundant in majority of the age groups. High prevalence was observe in age range of [31-40] (9.76%), [41-50] (56.52%), [11-20] (32.00%), [51-60] (15.38%), [11-20] (10.64%) [21-30] (41.89%) respectively to microorganism

4.5 Repartition of microorganism according to theirsusceptibility to the class of antimicrobial drugs

The repartition of microorganism according to their susceptibility to classes of antimicrobial drugsshows that C. albicans was more sensible both in azole (75.00%) and polyenes (58.33%). E. coli was more sensitive to Macrolides (78.21%) whereas it was more resistant to cephalosporine (55.13%), penicillin (84.62%), Fluoroquinolones (68.57%) and Carbapenem (58.97%).

Table 6: Repartition of microorganism according to theirsusceptibility to classes of antimicrobial drugs

4.6 Comparison of the susceptibility of antimicrobial drugs to microorganism according to sex

No significant difference was observe on susceptibility of microorganism according to sex except with Streptococcus where significant difference were observe with penicillin and Fluroquinolonesand with these, the resistance was high in females.

Table 7;Comparison of the susceptibility of microorganisms to classes of antimicrobial drugs according to sex

	Macrolides				Cephalosporin			Penicillin			Azole			polyenes			Fluoroquinolones		Carbapenem
Microorganisms	Sensitive		Resistant	Sensitive		Resistant	Sensitive		Resistant	Sensitive		Resistant	Sensitive		Resistant	Sensitive		Resistant		Sensitive	Resistant
C. albicans	NA		NA	NA		NA	NA		NA	9		3	7		5	NA		NA		NA	NA
Female	NA		NA	NA		NA	NA		NA	9		3	7		5	NA		NA		NA	NA
Male	NA		NA	NA		NA	NA		NA	0		0	0		0	NA		NA		NA	NA
P-value	NA	NA			NA			>0,9999			>0,9999			NA			NA
E. coli	61		17	35		43	12		66	NA		NA	NA		NA	32		46		32	46
Female	53		14	28		39	8		59	NA		NA	NA		NA	27		40		30	37
Male	8		3	7		4	4		7	NA		NA	NA		NA	5		6		2	9
P-value	0.6968	0.2058			0.0599			NA			NA			0.7526			0.1134
Klebsiella sp.	27		8	17		18	6		29	NA		NA	NA		NA	11		24		11	24
Female	13		5	8		10	2		16	NA		NA	NA		NA	6		12		6	12
Male	14		3	9		8	4		13	NA		NA	NA		NA	5		12		5	12
P-value	0.6906	0.7395			0.4018			NA			NA			>0,9999			>0,9999
Proteus sp.	18		8	7		19	5		21	NA		NA	NA		NA	11		15		8	18
Female	15		4	6		13	4		15	NA		NA	NA		NA	9		10		6	13
Male	3		4	1		6	1		6	NA		NA	NA		NA	2		5		2	5
P-value	0.149	0.6288			>0,9999			NA			NA			0.6576			>0,9999
P. stuartii	10		1	7		4	3		8	NA		NA	NA		NA	3		8		7	4
Female	9		1	6		4	3		7	NA		NA	NA		NA	3		7		6	4
Male	1		0	1		0	0		1	NA		NA	NA		NA	0		1		1	0
P-value	>0,9999	>0,9999			>0,9999			NA			NA			>0,9999			>0,9999
P. aeruginosa	3		0	1		2	2		1	NA		NA	NA		NA	1		2		2	1
Female	3		0	1		2	3		0	NA		NA	NA		NA	1		2		2	1
Male	0		0	0		0	0		0	NA		NA	NA		NA	0		0		0	0
P-value	>0,9999	>0,9999			>0,9999			NA			NA			>0,9999			>0,9999
Serratia sp.	1		0	0		1	0		1	NA		NA	NA		NA	0		1		0	1
Female	1		0	0		1	0		1	NA		NA	NA		NA	0		1		0	1
Male	0		0	0		0	0		0	NA		NA	NA		NA	0		0		0	0
P-value	>0,9999	>0,9999			>0,9999			NA			NA			>0,9999			>0,9999
Staphylococcus sp.	52		15	28		39	24		43	NA		NA	NA		NA	22		45		24	43
Female	40		12	20		32	22		30	NA		NA	NA		NA	12		40		18	34
Male	12		3	8		7	1		14	NA		NA	NA		NA	10		5		6	9
P-value	>0,9999	0.3777			0.0125			NA			NA			0.0036			0.7643
Steptococcus sp.	1		1	0		2	1		1	NA		NA	NA		NA	0		2		1	1
Female	1		1	0		2	1		1	NA		NA	NA		NA	0		2		1	1
Male	0		0	0		0	0		0	NA		NA	NA		NA	0		0		0	0
P-value	>0,9999	>0,9999			>0,9999			NA			NA			>0,9999			>0,9999
E. coli + Candida sp.	4		2	2		4	1		5	4		2	5		1	3		3		0	6
Female	4		1	1		4	1		4	3		2	4		1	3		2		0	5
Male	0		1	1		0	0		1	1		0	1		0	0		1		0	1
P-value	0.3333	0.3333			>0,9999			>0,9999			>0,9999			>0,9999
Klebsiella sp. + Candida sp.	2		1	1		2	0		3	0		3	2		1	1		2		2	1
Female	2		1	1		2	0		3	0		3	2		1	1		2		2	1
Male	0		0	0		0	0		0	0		0	0		0	0		0		0	0
P-value	>0,9999	>0,9999			>0,9999			>0,9999			>0,9999			>0,9999			>0,9999
Staphylococcus sp. + Candida sp.	2		1	3		0	1		2	2		1	0		3	1		2		1	2
Female	2		1	3		0	1		2	2		1	0		3	1		2		1	2
Male	0		0	0		0	0		0	0		0	0		0	0		0		0	0
P-value	>0,9999				>0,9999			>0,9999						>0,9999			>0,9999
Steptococcus sp. + Candida sp.	1		0	0		1	0		1	1		0	0		1	0		1		0	1
Female	1		0	0		1	0		1	1		0	0		1	0		1		0	1
Male	0		0	0		0	0		0	0		0	0		0	0		0		0	0
P-value	>0,9999	>0,9999			>0,9999			>0,9999			>0,9999			>0,9999			>0,9999

4.7; Comparison of the susceptibility of microorganisms to antimicrobial drugs according to age range

Apart fromC. albicans where significant difference was observe in Azoles with (P=0.0273), no significant difference was observe with other microorganism according to age range.

Table 8; Comparison of the susceptibility of microorganism to antimicrobial drugs according to age range

Microorganisms	Macrolides		Cephalosporin		Penicillin		Azole		polyenes		Fluoroquinolones		Carbapenem
Microorganisms	Sensitive	Resistant	Sensitive	Resistant	Sensitive	Resistant	Sensitive	Resistant	Sensitive	Resistant	Sensitive	Resistant	Sensitive	Resistant	TOTAL
C. albicans	NA	NA	NA	NA	NA	NA	9	3	7	5	NA	NA	NA	NA	12
[1-10]	NA	NA	NA	NA	NA	NA	1	2	2	1	NA	NA	NA	NA	3
[11-20]	NA	NA	NA	NA	NA	NA	0	0	0	0	NA	NA	NA	NA	0
[21-30]	NA	NA	NA	NA	NA	NA	5	0	3	2	NA	NA	NA	NA	5
[31-40]	NA	NA	NA	NA	NA	NA	4	0	2	2	NA	NA	NA	NA	4
[41-50]	NA	NA	NA	NA	NA	NA	0	0	0	0	NA	NA	NA	NA	0
[51-60]	NA	NA	NA	NA	NA	NA	0	0	0	0	NA	NA	NA	NA	0
[61-70]	NA	NA	NA	NA	NA	NA	0	0	0	0	NA	NA	NA	NA	0
[71-80]	NA	NA	NA	NA	NA	NA	0	0	0	0	NA	NA	NA	NA	0
P-value	NA		NA		NA		0.0273		0.9767		NA		NA
E. coli	61	17	35	43	12	66	NA	NA	NA	NA	32	46	32	46	78
[1-10]	16	4	9	11	3	17	NA	NA	NA	NA	3	17	10	10	20
[11-20]	3	1	1	3	1	3	NA	NA	NA	NA	2	2	1	3	4
[21-30]	12	2	4	10	1	13	NA	NA	NA	NA	8	6	4	10	14
[31-40]	8	3	5	6	1	10	NA	NA	NA	NA	7	4	3	8	11
[41-50]	9	4	8	5	4	9	NA	NA	NA	NA	5	8	8	5	13
[51-60]	5	2	4	3	1	6	NA	NA	NA	NA	2	5	1	6	7
[61-70]	8	1	4	5	1	8	NA	NA	NA	NA	5	4	5	4	9
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value	0.9526		0.6725		0.6972		NA		NA		0.0938		0.2408
Klebsiella sp.	27	8	17	18	11	24	NA	NA	NA	NA	11	24	11	24	35
[1-10]	6	0	2	4	3	3	NA	NA	NA	NA	2	4	4	2	6
[11-20]	5	3	6	2	2	6	NA	NA	NA	NA	3	5	2	6	8
[21-30]	7	2	3	6	5	4	NA	NA	NA	NA	3	6	3	6	9
[31-40]	1	1	1	1	0	2	NA	NA	NA	NA	1	1	1	1	2
[41-50]	3	0	1	2	0	3	NA	NA	NA	NA	0	3	1	2	3
[51-60]	5	2	4	3	1	6	NA	NA	NA	NA	2	5	1	6	7
[61-70]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value	0.4657		0.5326		0.2367		NA		NA		0.865		0.4712
Proteus sp.	18	8	7	19	5	21	NA	NA	NA	NA	11	15	8	18	26
[1-10]	3	0	1	2	0	3	NA	NA	NA	NA	0	3	3	0	3
[11-20]	2	0	0	2	0	2	NA	NA	NA	NA	2	0	1	1	2
[21-30]	7	4	3	8	4	7	NA	NA	NA	NA	5	6	2	9	11
[31-40]	5	0	3	2	0	5	NA	NA	NA	NA	2	3	1	4	5
[41-50]	0	1	0	1	0	1	NA	NA	NA	NA	1	0	0	1	1
[51-60]	1	1	0	2	0	2	NA	NA	NA	NA	1	1	0	2	2
[61-70]	0	2	0	2	1	1	NA	NA	NA	NA	0	2	1	1	2
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value	0.0689		0.4908		0.4947		NA		NA		0.2484		0.1303
P. stuartii	10	1	7	4	3	8	NA	NA	NA	NA	3	8	7	4	11
[1-10]	4	1	3	2	0	5	NA	NA	NA	NA	0	5	4	1	5
[11-20]	2	0	1	1	1	1	NA	NA	NA	NA	1	1	2	0	2
[21-30]	1	0	0	1	0	1	NA	NA	NA	NA	1	0	0	1	1
[31-40]	2	0	2	0	1	1	NA	NA	NA	NA	1	1	1	1	2
[41-50]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[51-60]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[61-70]	1	0	1	0	1	0	NA	NA	NA	NA	0	1	0	1	1
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value							NA		NA		0.1634		0.1983
P. aeruginosa	3	0	1	2	2	1	NA	NA	NA	NA	0	3	2	1	3
[1-10]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[11-20]	1	0	0	1	0	1	NA	NA	NA	NA	0	1	0	1	1
[21-30]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[31-40]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[41-50]	1	0	0	1	1	0	NA	NA	NA	NA	0	1	1	0	1
[51-60]	1	0	1	0	1	0	NA	NA	NA	NA	0	1	1	0	1
[61-70]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value							NA		NA		NA		>0.9999
Serratia sp.	1	0	0	1	0	1	NA	NA	NA	NA	0	1	0	1	1
[1-10]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[11-20]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[21-30]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[31-40]	1	0	0	1	0	1	NA	NA	NA	NA	0	1	0	1	1
[41-50]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[51-60]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[61-70]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value							NA		NA		>0.9999		>0.9999
Staphylococcus sp.	52	15	28	39	24	43	NA	NA	NA	NA	17	50	24	43	67
[1-10]	3	4	3	4	2	5	NA	NA	NA	NA	2	5	2	5	7
[11-20]	4	2	4	2	3	3	NA	NA	NA	NA	2	4	2	4	6
[21-30]	25	6	12	19	13	18	NA	NA	NA	NA	8	23	16	15	31
[31-40]	10	1	3	8	4	7	NA	NA	NA	NA	2	9	1	10	11
[41-50]	5	0	2	3	2	3	NA	NA	NA	NA	1	4	1	4	5
[51-60]	2	1	1	2	0	3	NA	NA	NA	NA	2	1	0	3	3
[61-70]	2	1	2	1	0	3	NA	NA	NA	NA	0	3	1	2	3
[71-80]	1	0	1	0	0	1	NA	NA	NA	NA	0	1	1	0	1
P-value							NA		NA		0.5855		0.1397
Steptococcus sp.	1	1	0	2	1	1	NA	NA	NA	NA	0	2	1	1	2
[1-10]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[11-20]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[21-30]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[31-40]	0	1	0	1	1	0	NA	NA	NA	NA	0	1	0	1	1
[41-50]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[51-60]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
[61-70]	1	0	0	1	0	1	NA	NA	NA	NA	0	1	1	0	1
[71-80]	0	0	0	0	0	0	NA	NA	NA	NA	0	0	0	0	0
P-value	7		NA		NA		NA		NA		>0.9999		>0.9999
E. coli + Candida sp.	4	2	2	4	1	5	4	2	5	1	3	3	0	6	6
[1-10]	1	1	1	1	0	2	1	1	2	0	0	2	0	2	2
[11-20]	0	1	1	0	1	0	1	0	1	0	0	1	0	1	1
[21-30]	1	0	0	1	0	1	1	0	1	0	1	0	0	1	1
[31-40]	2	0	0	2	0	2	1	1	1	1	2	0	0	2	2
[41-50]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[51-60]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[61-70]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[71-80]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
P-value	0.2898		0.2898		0.1116		0.8266		0.4936		0.1116		>0.9999
Klebsiella sp. + Candida sp.	2	0	1	1	0	2	0	2	2	0	1	1	2	0	2
[1-10]	1	0	0	1	0	1	0	1	0	1	1	0	0	1	1
[11-20]	1	0	0	1	0	1	0	1	1	0	0	1	1	0	1
[21-30]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[31-40]	0	1	1	0	0	1	0	1	1	0	0	1	1	0	1
[41-50]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[51-60]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[61-70]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[71-80]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
P-value	0.3865		0.6592		NA		NA		0.2231		0.2231		0.2231
Staphylococcus sp. + Candida sp.	2	1	3	0	1	2	2	1	0	3	1	2	1	2	3
[1-10]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[11-20]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[21-30]	1	1	2	0	0	2	1	1	0	2	0	2	1	1	2
[31-40]	1	0	1	0	1	0	1	0	0	1	1	0	0	1	1
[41-50]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[51-60]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[61-70]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[71-80]	0	0		0	0	0	0	0	0	0	0	0	0	0	0
P-value	0.3865		NA		0.0833		0.3865		NA		0.0833		0.3865
Steptococcus sp. + Candida sp.	1	0	0	1	0	1	1	0	0	1	0	1	0	1	1
[1-10]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[11-20]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[21-30]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[31-40]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[41-50]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[51-60]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
[61-70]	1	0	0	1	0	1	1	0	0	1	0	1	0	1	1
[71-80]	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
P-value	NA		NA		NA		NA		NA		NA		NA

Studies have demonstrated a geographicvariation in etiologic characteristics of UTI and their resistance patterns to antimicrobial drugs. Therefore to successfully eradicate UTI by treatment, knowledge of local etiologic agents and their antimicrobial drugs susceptibility is of great value (Nzalie et al 2016).

Out 248 samples of the isolates of UTI collected94.75% (235/248) showed single growth and 5.25% (13/248) showed mix or multiple growth. This may be justify by the fact that a typical infection may result from a single pathogen or the association of more than one pathogen, as well as aco-infection arising from poor or no treatment of a typical infection.Nine strains of uropathogens were isolated, of which 8 were bacteria and 1 fungus. This may be justify by the fact that bacteria are found in the bowel and live as normal flora and often result from fecal and perianal areas as such easily invade the tissues of the urinary tract. This result corroborate with those obtain by Akoachere et al. (2012). In this study, the rate of positivity of UTI in females was higher than in males. Thishigh prevalence among females is due to the nature of their urinogental tract; the urethra of the female is much shorter and closer to the anus than in males .Such result have beenreportedby Oyaert (Oyaert et al., 2018). Furthermore, gram positive isolates in this study accounts for 29.44% (27.83% for single growth and 1.61% for mix growth) while gram negative accounts for 65.72% (62.09% for single growth and 3.63% for mix growth) with the most common gram negative isolates beenE coli (31.45%) and the most common gram positive isolate been Staphylococcus sp (27.02%).Such result results have been reported in two towns in Cameroon by Akoachere et al. (2012).The fungus(Candida albicans) account for 4.84% of the uropathogens this low prevalence of fungi infection may be due lack of identification process in our study area. This result is differ from what obtain by Rahimi et al. (Rahimiet al., 2018). In addition, a variation in distribution of etiologic agents with age was observed in this study with age range [21-30] been the most infected and the least infected was the age range [71-80] this high prevalence found in the age range from [21-30] is due to the fact that it is this age that people are more sexually active in our environment and most of them are not using preventive materials and this sexuality decrease with age and occupation.

Susceptibility pattern wasanalyzed according to classes of antimicrobial drugs, we observe that, no matter the class of antimicrobial drugs and no matter the susceptibility this was high in female compare to male and the most susceptible microorganism was E. Coli with macrolide whereas Proteus sp found to be more resistant to all the class of antimicrobial drugs. This high resistance though not been significant among female may be due to multiple infection thatlead to non-specificity of drugs prescribe but it may also due to incomplete medication that is once the treatment is prescribe, the take it well but once they feel a little bit good the abandon the remaining treatment. This result corroborate with the study carried out in Kenya byGachuhi. (2017)

Availability and indiscriminate use of commonly used antibioticswithout health care workers prescription (self-medication) lead to an increased multidrug resistance. Due to the increasing multidrug resistance among uropathogens, the health care workers are left with a limited choice of routinely used antibiotics to choose from for the treatment of urinary tract infections. It is seen in this study where Nitrofurantoin which is mostly used as the drug of choice for treatment was not present among the antimicrobial drugs .This can be attributed the fact that bacteria undergo mutation which makes their susceptibility vary from one geographical area to the other (Jaiswal et al., 2013).

This study reveals a familiar pattern with respect to the species of uropathogens involved in UTIs with the principal cause being the gram-negative bacteria, E. coli and Klebsiella spas the leading ones. However gram positive were also among the etiology with Staphylococcus sp being the leading one .This study alsoshowed considerable bacterial resistance to common empirically prescribed antibiotics.The worldwide trend of empirically treating UTI may not apply to specific geographical regions. This is as a result of the etiological variation from one region to another.Macrolides still has a very high sensitivity level against P. aeruginosa and Serratia Sp (100%) as well as to other etiologic agents. As such this study suggests that macrolides are better for the empirical treatment of UTIs.

A limitation to this study is the inability to sort out the major risk factors of UTIs and the leading cause of antimicrobial drugs resistance among the patients attending the DHN given that it's a retrospective study and there is no interaction with the patients. Also due to the large number of isolates obtained from this study, we were unable to characterize the Gram positive isolates and some gram negative as well to permit their identification to species level.

· A continuous surveillance of etiological profile and antimicrobial drugs to the currently used antibiotics in management of urinary tract infections in the whole country Cameroon.

· Enforcement of policies to be followed in pharmacy and by medical doctors like to prevent misuse of antimicrobial drugs by giving prescription to only patients with results of culture and sensitivity and therefore treatment of UTIs should be based on the etiology and sensitivity in order to limit multidrug resistance.

· Health care workers should enforce health education to patients in order to create awareness of the risk factors and how to avoid them as well as to adhere to the treatment therebyreducing drug resistance.

· The need to establish local and national antimicrobial resistance monitoring systems in Cameroon to provide information for the development of treatment guidelines.

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