Prevalence and antimicrobial susceptibility pattern of urinary tract

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Prevalence and antimicrobial
susceptibility pattern of urinary
tract infection among pregnant
women attending Hargeisa Group
Hospital, Hargeisa, Somaliland
Abdikhaliq Hussein Ali, Dawit Yihdego Reda & Moges Desta Ormago*

The aim of this study was to determine the prevalence, antimicrobial susceptibility pattern and
associated factors of urinary tract infection (UTI) among pregnant women attending Hargeisa Group
Hospital (HGH), Hargeisa, Somaliland. A cross-sectional study was conducted at HGH, Hargeisa,
Somaliland and participants were selected by systematic random sampling technique. Clean catch
midstream urine samples were collected from 422 participants and cultured and antimicrobial
susceptibility pattern was determined for the isolates. Univariable and multivariable logistic
regression analyses were utilized to identify the independent risk factors for UTI. The prevalence of
UTI was 16.4% (95% CI 13.3–19.9). The predominant bacteria isolate was E. coli (43.5%) followed
by Coagulase negative staphylococcus (CoNS) 11(16%), S. aureus 9(13%), K. pneumonia 6(8.7%),
Pseudomonas aeruginosa 5(7.2%), Proteus mirabilis 4(5.8%), Citrobacter spp 3(4.4%) and M. morganii
1(1.5%) Gram negative bacilli were resistant to ampicillin (96%) and tetracycline (71.4%) and Gram-
positive cocci were also resistant to ampicillin (90%), tetracycline (55%). Multidrug resistance
was observed in 85.5% of bacterial isolated. No formal education participants, previous history
of catheterization and previous history of UTI had 3.18, 3.22 and 3.73 times respectively more
likely to develop UTI than their counterparts. Culture and susceptibility test is vital for appropriate
management of UTI in the study area.

Abbreviations
ANC Antenatal care
HGH Hargeisa Group Hospital
MDR Multi drug resistance
UTI Urinary tract infection

Urinary tract infection (UTI) is one of the highest frequent problem caused by some bacteria in a pregnant
woman, which can lead to cause the significant complications for both mother and fetus1. The prevalence of the
infection is higher among pregnant women than non-pregnant women and it is a major health problem reported
among 20% of the pregnant women and a common cause of admission in obstetrical wards2.

If the infection is left untreated, it results in low birth weight fetus, intrauterine growth retardation, pre-
term labor and premature babies, intrauterine fetal death, and increased prenatal mortality and morbidity as
well as maternal complications including anemia, preeclampsia, renal failure, septicemia, and adult respiratory
syndrome3.

In Hargeisa Group Hospital, Hargeisa, Somaliland, routine culture and antimicrobial susceptibility testing of
UTI are not performed and the treatment is on an empirical basis. This may promote the overuse of antibiotics
and the development of resistant microbial strains. There was no published information on the prevalence of UTI
and antimicrobial susceptibility pattern in Somaliland. Therefore, this study was carried out to determine the
prevalence, antimicrobial susceptibility pattern and associated factors of urinary tract infection among pregnant
women attending antenatal care at HGH, Hargeisa, Somaliland.

OPEN

Hawassa University College of Medicine and Health Science, Hawassa, Ethiopia. *email: [email protected]

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Method
Cross-sectional study was conducted at antenatal care (ANC) in HGH, Hargeisa, Somaliland from May to
October 2020. Being pregnant and having a follow up in the ANC clinic of HGH were included in the study.
Pregnant women who received antibiotics within two weeks before ANC follow up were excluded. A structure
questionnaire was used by trained nurses for the collection of Clinical and Socio-demographic data.

Ten milliliters of clean catch midstream urine sample were collected in a wide mouthed sterile container
from each study participant. The collected urine sample was labeled and delivered to the hospital laboratory
within one hour4.

The collected urine samples were processed and using a calibrated loop (0.001 ml) urine specimens were
inoculated in to blood agar and MacConkey agar plates. After overnight incubation at 37 °C for 24–48 h’ colo-
nies were counted to check significant growth. Colony counts of bacterial growth of > 105/ml of urine were
significant5,6. All positive cultures with significance bacteriuria were then identified at species level by their colony
characteristics, Gram-staining reaction and by the pattern of biochemical profiles using the standard microbio-
logical technique . The enterobacteriaceae were identified by H2S production and carbohydrate fermentation
in KIA agar, indole production, citrate utilization, motility test, urease test and oxidase test. The Gram positive
cocci were identified using catalase and coagulase tests4.

Kirby-Bauer disc diffusion method was used for the antibiotic susceptibility test. Three to five pure colonies
were transferred into a tube containing 4–5 mL nutrient broth and mixed gently and then incubated at 35–37 °C
for 2–6 h. The turbidity of the suspension was compared with McFarland 0.5 tubes to standardize the inoculums
size7.

By using a sterile cotton swab dipping it into the suspension evenly over the entire surface of Mueller–Hin-
ton agar (MHA) (Oxide Ltd, Hampshire, UK). The inoculated plates were left at room temperature to dry for
3–15 min. The following commercially available antibiotic discs were used with their respective concentrations:
for Gram-negative bacilli augmentin, (AMC, 20/10 µg), ampicillin (AMP, 10 µg), ciprofloxacin (CIP, 5 µg), nor-
floxacin (NOR, 10 µg), trimethoprim + sulphamethazole (SXT, 25 µg, 1.25/23.75 µg), gentamicin (GEN, 10 µg),
ceftriaxone (CRO, 30 µg), nalidixic acid (NA, 30 µg), meropenem (10 μg), tetracycline (TE; 30 μg) and nitro-
furantoin (F, 300 µg) and for Gram-positive cocci erythromycin (ERY, 15 μg), penicillin (PEN, 10 µg), augmentin,
(AMC, 20/10 µg), ampicillin (AMP, 10 µg), ciprofloxacin (CIP, 5 µg), trimethoprim + sulphamethazole (SXT,
25 µg,1.25/23.75 µg), gentamicin (GEN, 10 µg), ceftriaxone (CRO, 30 µg), nitrofurantoin (F, 300 µg), tetracycline
(TE; 30 μg) and cefoxitin (CXT 30 µg) and finally, the result was reported as sensitive (S), intermediate (I) or
resistance (R) by measuring the diameter of zone of inhibition or hemolysis8.

All filled questionnaires for this study was checked visually, coded and entered into excel and then exported
to SPSS version25 software (SPSS Inc., Chicago, IL, USA) for analysis. Bivariate logistic regression was used to
determine predictors of culture confirmed UTI. For those variables, which P-value < 0.25 in the bivariate, the
analysis was further entered into the multivariable logistic regression model9. Associations between dependent
and independent variables were assessed and its strength was described using odds ratios at 95% confidence
intervals. A statistically significant association considered as P-value < 0.05.

Ethical approval was obtained from the institutional review board of Hawassa University, College of medicine
and health sciences (Ref No: IRB/204/12). Informed consent was obtained from all participants. All methods
were carried out in accordance with relevant guidelines and regulations.

Ethics approval and consent to participate. Ethical approval was obtained from the institutional
review board of Hawassa University, College of medicine and health sciences (Ref No: IRB/231/11). Informed
written consent was obtained from all participants. All methods were carried out in accordance with relevant
guidelines and regulations. Clinicians were communicated the findings of culture and sensitivity tests.

Consent for publication. Individual data such as images and videos did not accompany this particular
manuscript and hence consent for publication is not applicable.

Results
A total of 422 pregnant women were participated during the study period. In this study the mean age of study
participants was 30.9 (± 5.6 SD) years within the age range of 18–44 (Table 1).

Obstetrics and clinical characteristics are indicated in Table 2.
Overall prevalence of UTI were 16.4% (95% CI 13.3–19.9) of which 40(9.5%) was symptomatic UTI and

29(6.9%) was asymptomatic UTI. Of 69 positive cases, eight different types of bacteria were identified. The major-
ity of the isolates belong to the Gram negative bacilli 49(71%). Among the isolates the predominant bacteria
were E. coli 30(43.5%), followed by Coagulase negative staphylococcus (CoNS) 11(15.9%), S. aureus 9(13%), K.
pneumonia 6(8.7%), Pseudomonas aeruginosa 5(7.2%), Proteus mirabilis 4(5.8%), Citrobacter spp 3(4.4%) and
M. morganii 1(1.5%) (Fig. 1).

Gram negative bacilli were resistant to ampicillin (96%), tetracycline (71.4%), trimethoprim-sulfamethox-
azole (57.1%), amoxicillin clavulanic acid (55.1%) and nalidixic acid (51%) and high rate of sensitive were also
observed to meropenem (95.9%), ceftriaxone (79.6%), norfloxacin (77.5%), gentamicin (75.5%), nitrofurantoin
(75.5%) and ciprofloxacin (71.4%). With regard to specific isolated Gram negative bacilli, Escherichia coli were
highly resistant to ampicillin (93.3%), tetracycline (73.3%), trimethoprim–sulfamethoxazole (60%), nalidixic
acid (53.3%) and amoxicillin clavulanic acid (46.7%) but sensitive to meropenem (96.7%), norfloxacin (90%),
ceftriaxone (83.3%), nitrofurantoin (80%), gentamicin (73.3%) and ciprofloxacin (66.7%).

All K. pneumonia isolates showed resistant to ampicillin, and 66.7% were resistant to norfloxacin and amoxicil-
lin clavulanic acid each and 50% were resistant to tetracycline, nalidixic acid and trimethoprim-sulfamethoxazole

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each but K. pneumonia was sensitive to meropenem (100%), gentamycin (83.3%) and 66.7% were sensitive to
ceftriaxone, ciprofloxacin and nitrofurantoin each.

P. aeruginosa were resistant to ampicillin (80%), tetracycline (57.1%), trimethoprim- sulfamethoxazole
(57.1%) while highly sensitive were observed to meopenem, gentamicin, norfloxacin and ciprofloxacin to 80%
for each and 60% were sensitive to ceftriaxone and nitrofurantoin each. Proteus mirabilis were resistant to ampicil-
lin (100%) and 75% to each of tetracycline and amoxicillin clavulanic acid while 100% sensitive to meropenem,

Table 1. Sociodemographic characteristics of pregnant women attended antenatal care at HGH, Hargeisa,
Somaliland, 2020 (n = 422).

Variables Frequency Percent (%)

Age ( in years)

< 19 17 4.0

20–25 88 20.9

26–30 119 28.2

31–35 125 29.6

36–40 40 9.5

41–45 33 7.8

Residence
Urban 398 94.3

Rural 24 5.7

Marital status

Widowed 8 1.9

Married 407 96.4

Divorced 2 0.5

Separated 5 1.2

Educational status

No formal education 79 18.7

Primary education (1–8) 185 43.8

Secondary education(9–12) 112 26.5

Higher education (> 12) 46 10.9

Family Income

< $100 77 18.2

$101–200 191 45.3

$201–300 116 27.5

< $300 38 9.0

Occupational status

House wife 243 57.6

Merchant 92 21.8

Governmental employee 78 18.5

Student 9 2.1

Table 2. Obstetrics and clinical characteristics of pregnant women attended antenatal care at HGH, Hargeisa,
Somaliland, 2020 (n = 422).

Variables Frequency(n) Percent (%)

Gestational period

First trimester 87 20.6

Second trimester 137 32.5

Third trimester 198 46.9

Gravida
Primigravida 56 13.3

Multigravida 366 86.7

History of Catheterization
No 394 93.4

Yes 28 6.6

History of diabetes mellitus
No 412 97.6

Yes 10 2.4

History of abortion
No 405 96.0

Yes 17 4.0

History of obstetric and gynecologic surgery
No 413 97.9

Yes 9 2.1

History of premature labor
No 416 98.6

Yes 6 1.4

History of previous UTI
No 370 87.7

Yes 52 12.3

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gentamicin and ceftriaxone each and 75% sensitive to ciprofloxacin and norfloxacin each. Citrobacter spp were
highly resistant to ampicillin (100%) and 66.7% were resistant to tetracycline, nalidixic acid, trimethoprim-
sulfamethoxazole and amoxicillin clavulanic acid each but Citrobacter spp were highly sensitive to meropenem,
ciprofloxacin and nitrofurantoin and 66.7% were sensitive to gentamicin, norfloxacin and ceftriaxone each.

M. morganii were resistant to ampicillin, tetracycline, nalidixic acid, trimethoprim-sulfamethoxazole, nor-
floxacin and amoxicillin clavulanic acid but all M. morganii were sensitive to meropenem, ceftriaxone, cipro-
floxacin and nitrofurantoin (Table 3).

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Figure 1. Bacterial profile isolated from urine culture of symptomatic and asymptomatic pregnant women with
UTI attended antenatal care at HGH, Hargeisa, Somaliland, 2020. CONS coagulase-negative staphylococci, UTI
urinary tract infection.

Table 3. Antimicrobial susceptibility pattern of gram-negative bacilli isolated from pregnant women with
UTI attended antenatal care at HGH, Hargeisa, Somaliland, 2020 (n = 49). AMP ampicillin, CIP ciprofloxacin,
CRO ceftriaxone, AMC amoxicillin clavulanic acid, SXT trimethoprim–sulfamethoxazole, NOR norfloxacin,
GEN gentamicin, NA nalidixic acid, F nitrofurantoin, MER meropenem, TTC tetracycline, S, I, R sensitive,
intermediate, resistant.

Isolates Pattern

Antibiotics (%)

AMP CIP CRO AMC SXT NOR GEN NA F MER TTC

E. coli(N = 30)

S 1(3.3) 20(66.7) 25(83.3) 14(46.7) 9(30) 27(90) 22(73.3) 13(43.3) 24(80) 29(96.7) 4(13.3)

I 1(3.3) 2(6.7) 2 (6.7) 3(10) 1(3.3) 2(6.7) 1(3.3) 2 (6.7) 4(13.3)

R 28(93.3) 8(26.7) 5(16.37) 14(46.7) 18(60) 2(6.7) 6(20) 16(53.3) 4(13.3) 1(3.3) 22(73.3)

K. pneumonia (N = 6)

S 4(66.7) 4(66.7) 1(16.7) 1(16.7) 2(33.3) 5(83.3) 3(50) 4(66.7) 6 (100) 1(16.7)

I 2(33.3) 1(16.7) 2(33.3) 2(33.3)

R 6 (100) 2(33.3) 4(66.7) 3(50) 4(66.7) 1(16.7) 3(50) 2(33.3) 3(50)

P. aeruginosa (N = 5)

S 4(80) 3(60) 2(40) 1(20) 4(80) 4(80) 2(40) 3(60) 4(80) 1(20)

I 1(20) 1(20) 1(20) 1(20) 1(20)

R 5 (100) 1(20) 2(40) 3(60) 3(60) 1(20) 2(40) 1(20) 4(80)

P. mirabilis (N = 4)

S 3(75) 4(100) 1(25) 2(50) 3(75) 4(100) 2(50) 2(50) 4 (100) 1(25)

I 1(25) 1(25)

R 4 (100) 1(25) 3(75) 1(25) 1(25) 1(25) 2(50) 3(75)

Citrobacter spp.
(N = 3)

S 3(100) 2(66.7) 1(33.3) 1(33.3) 2(66.7) 2(66.7) 1(33.3) 3(100) 3(100)

I 1(33.3) 1(33.3)

R 3 (100) 1(33.3) 2(66.7) 2(66.7) 1(33.3) 2(66.7) 2(66.7)

M. morganii (N = 1)

S 1(100) 1(100) 1(100) 1(100)

I 1(100)

R 1(100) 1(100) 1(100) 1(100) 1(100) 1(100)

Total(N = 49)

S 1(2) 35(71.4) 39(79.6) 19(38.8) 14(28.6) 38(77.5) 37(75.5) 21(42.9) 37(75.5) 47(95.9) 7(14.2)

I 1(2) 2(4.1) 2(4.1) 3(6.1) 7(14.3) 3(6.1) 3(6.1) 3(6.1) 3(6.1) 1(2) 7(14.2)

R 47(96) 12(24.5) 8(16.3) 27(55.1) 28(57.1) 8(16.3) 9(18.4) 25(51) 9(18.3) 1(2) 35(71.4)

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The Gram-positive bacilli were resistant to ampicillin (90%), tetracycline (55%), trimethoprim-sulfameth-
oxazole (50%), and amoxicillin clavulanic acid (50%) while sensitive to erythromycin (85%), cefoxitin (85%),
ceftriaxone (75%), nitrofurantoin (75%), gentamicin (70%) and ciprofloxacin (85%).

Coagulase negative staphylococci (CoNS) were highly resistant to ampicillin (81.8%), tetracycline (54.5%),
and amoxicillin clavulanic acid (45.4%) but sensitive to erythromycin (81.8%), cefoxitin (81.8%), ceftriaxone
(72.7%), nitrofurantoin (72.7%) and gentamicin (72.7%), ciprofloxacin (63.6%) and trimethoprim–sulfameth-
oxazole (54.5%).

S. aureus were highly resistant to ampicillin (100%) and 55.6% were resistant to tetracycline, trimethoprim-
sulfamethoxazole and amoxicillin clavulanic acid each while sensitive to erythromycin (88.9%), cefoxitin (88.9%),
ceftriaxone (77.8%) and nitrofurantoin (77.8%), ciprofloxacin (66.7%) and gentamicin (66.7%) (Table 4).

Among the total isolates (n = 69) multi drug resistance (MDR) was observed in 59 (85.5%) of bacteria isolated.
In Gram-negative bacteria MDR were observed in 44/49 (89.8%) while gram-positive bacteria were observed in
15/20 (75%) respectively (Table 5).

In bivariate analysis, Age of respondents [COR = 2.600 95% CI 0.725–9.319], Educational status [COR = 2.780
95% CI 0.965–8.006], Family income [COR = 3.559 95% CI 0.978–12.954], History of catheterization
[COR = 3.154, 95% CI 1.388–7.170], History of abortion [COR = 2.220, 95% CI 0.756–6.517] and History of
previous UTI [COR = 3.31, 95% CI 1.740–6.300] were found to be significantly associated with UTI among
pregnant women and were to be a candidate for multivariate logistic regression analysis.

The result of multivariate analysis revealed that pregnant women with no formal education were 3.2 more
likely to have UTI than those with higher education (> grade 12) [ AOR = 3.183 95% CI 1.027–9.866], family
income ≤ $100 was 5.2 times higher risk of having UTI than those with family income > $300 [AOR = 5.225 95%
CI 1.270–21.500] , the odds of having UTI among pregnant women who have previously indwelling catheter were
3.2 times higher than the odds in pregnant women who have not previously indwelling catheter [AOR = 3.216,
95% CI 1.287–8.038], pregnant women who have previous history of UTI were 3.7 more likely to occur the UTI
compared with pregnant women that have not the previous history of UTI [AOR = 3.734, 95% CI 1.855–7.515]
(Table 6).

Discussion
The overall prevalence of UTI in pregnant women in this study was 16.4%. This is comparable to the prevalence
of UTI reported in in Mwanza City, Tanzania 16.8%10, in Nairobi, Kenya 15.7%11, in Kano, Northern Nigeria
15.8%12 and in Bangalore, India 15%13.

Whereas a higher prevalence was reported in Ambo Central Ethiopia 18.7%14, in Derna City Libya 49.3%15,
in Ismailia, Egypt 29%16, in Benin city, Nigeria 21%17, in Saudi Arabia 53.5%18, in Nepal 37.8%19 respectively. A
lower prevalence was reported from Iran 13.1%20, Gondar Northwest Ethiopia 10.4%21, Korela India 13.4%22,
Khartoum Sudan 14%23. This variation in prevalence might be due to across different studies from one country
to another and among regions of the same country might be attributed to the difference in associated factors,
sample size, social habits of the community, the standard of personal hygiene and education24.

The prevalence of UTI among symptomatic and asymptomatic pregnant women in this study was 9.5% and
6.9% respectively. The occurrence of UTI case among asymptomatic was in line with the previous study done
in Cameroon 7.8%25, in Kanpur, India 7.3%26 and in Makkah, Saudi Arabia 8%27, On the other hand, a low
prevalence of 0.13% In meta-analysis in Iran28, in Colombo, Sri Lanka 3.6%29 and in Ghana 5.5%30 was reported
asymptomatic UTI. While higher prevalence was recorded in Hawassa, Southern 21.2%31, in Bangladesh 10.2%32
and in Nairobi, Kenya 21.5%33.

In this study the symptomatic study was 9.5%, These result of symptomatic UTI were agree with a study con-
ducted from in Khartoum Sudan 12.1%23, in Makkah, Saudi Arabia 12%27 and in Northeastern Ethiopia 11.9%34.
But higher prevalence rate in Mekelle Northern Ethiopia 21.1%35, in Bangladesh 17.9%36, in in Goba and Sinana
Woredas, Bale Zone, Southeast Ethiopia 35.3%37 and in South-western Uganda 35%38. The differences may be
the variation of methodologies and study populations might affect prevalence in different sites.

Table 4. Antimicrobial susceptibility pattern of gram-positive cocci isolated from pregnant women with UTI
attended antenatal care at HGH, Hargeisa, Somaliland, 2020 (n = 20).

Isolates Pattern

Antibiotics (%)

AMP CIP CRO AMC SXT CXT GEN P ERY F TTC

CoNS (N = 11)

S 1(9.1) 7(63.6) 8(72.7) 5(45.4) 6(54.5) 9(81.8) 8(72.7) 5(45.4) 9(81.8) 8(72.7) 3(27.3)

I 1(9.1) 2(18.2) 1(9.1) 1(9.1) 2(18.2) 1(9.1) 1(9.1) 2(18.2)

R 9(81.8) 2(18.2) 3(27.3) 5(45.4) 5(45.4) 2(18.2) 2(18.2) 4(36.4) 1(9.1) 2(18.2) 6(54.5)

S. aureus (N = 9)

S 6(66.7) 7(77.8) 1(11.1) 4(44.4) 8(88.9) 6(66.7) 4(44.4) 8(88.9) 7(77.8) 3(33.3)

I 1(11.1) 1(11.1) 3(33.3) 2(22.2) 1(11.1) 1(11.1)

R 9(100) 2(22.2) 1(11.1) 5(55.6) 5(55.6) 1(11.1) 1(11.1) 4(44.4) 1(11.1) 2(22.2) 5(55.6)

Total (N = 20)

S 1(5) 13(65) 15(75) 6(30) 10(50) 17(85) 14(70) 9(45) 17(85) 15(75) 6(30)

I 1(5) 3(15) 1(5) 4(20) 3(15) 3(15) 1(5) 1(5) 3(15)

R 18(90) 4(20) 4(20) 10(50) 10(50) 3(15) 3(15) 8(40) 2(10) 4(20) 11(55)

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In this study, Gram-negative bacteria isolates were more prevalent (71%) than Gram-positive bacteria isolates
(29%). A similar finding was found from Ambo town, Central Ethiopia 69.6% and 30.4% for Gram negative and
Gram positive pathogens14, in Tanzania also Gram negative bacteria and Gram positive bacteria were reported
61.9% and 38.1%39 respectively. This could be due to the presence of unique structure in Gram negative bacteria
which help for attachment to the uroepithelial cells and prevent bacteria from urinary lavage, allowing for mul-
tiplication and tissue invasion–resulting in invasive infection and pyelonephritis in pregnancy40.

Among isolated pathogens, were E. coli was the most predominant bacteria 43.5%, which is similar with
previous studies in Ambo town, Central Ethiopia 46.4% of isolated cases14, in Bangalore, India 43.9%41 and in
Nairobi, Kenya 40.0% was reported42. However, it was lower than reported in the previous studies conducted
in different countries, which was India 53.8%, Italy 57.1% and Iran 57.25%22,43,44. E. coli is the most common
microorganism in the vaginal and rectal area. Because of anatomical and functional changes and difficulty of
maintaining personal hygiene during pregnancy, may increase the risk of acquiring UTI from E. coli45. The sec-
ond most common isolate was CoNS 16% and comparable findings have been reported in different studies like
in Karamara Hospital Jigjiga, Eastern Ethiopia 12%46, Saint Paul’s Hospital Millennium Medical College, Addis
Ababa, Ethiopia 14.3%47 and in Dil Chora Referral Hospital, Dire Dawa, Eastern Ethiopia19.2%48.

In this study, susceptibility pattern of Gram-negative bacteria showed that most of the isolates were sensitive
to meropenem (95.9%), ceftriaxone (79.6%), norfloxacin (77.5%), gentamicin (75.5%), nitrofurantoin (75.5%)
and ciprofloxacin (71.4%) and comparable studies conducted in different study area like in Addis Ababa, Ethiopia
that showed highly sensitive to meropenem (75.2%), nitrofurantoin (93.1%), gentamicin (85.2%), ceftriaxone
(82.2%), cefuroxime (79.3%), and ciprofloxacin (75.2%)47 and in South Nigeria showed sensitive to gentamicin
(53–100%), imipenam (67–93%), ciprofloxacin (between 57–75%)49, In Hawassa, Southern Ethiopia the present
study, 80% of Gram negative bacteria were susceptible to meropenem, ciprofloxacin, gentamicin, nitrofurantoin,
and norfoxacin50. In this study, the highest resistance was shown to ampicillin (93–100%) among gram-negative
bacteria, this due to the drug is with low cost and often can be purchased without prescription in different areas.
This implies that ampicillin cannot be used as empirical therapy for urinary tract infection particularly in the
study area. This also agrees with the study done in Karamara Hospital Jigjiga, Eastern Ethiopia46.

In this study the other drugs also showed highly resistance to Gram-negative were tetracycline (71.4%),
trimethoprim–sulfamethoxazole (57.1%), amoxicillin clavulanic acid (55.1%) and nalidixic acid (51%) and this
agree the other study done in Dil Chora Referral Hospital, Dire Dawa, Eastern Ethiopia AMP (89.5%), amoxicil-
lin (73.7%), and TTC (73.7%), NA (52.6%), except nitrofurantoin (57.9%)48 and in Mbarara Regional Referral
Hospital, South-western Uganda were highly resistant to Amoxicillin, Ampicillin, and Amoxicillin/Clavulanic
acid at 95.7%, 95.0%, and 72.9%38. The findings of this study is not in line with the reports from Kenya42. These
differences could be due to variations in antibiotic prescription patterns across various countries.

In this current study, the Gram-negatives, the predominant isolate was E. coli, which is resistant to ampicillin
(93.3%), TTC (73.3%), SXT (60%), nalidixic acid (53.3%) and AMC (46.7%). Similar findings have been reported
from previous studies in Dire Dawa, Eastern Ethiopia, South-western Uganda and Addis Ababa, Ethiopia38,47,48.
The other isolated Gram negative bacteria include K. pneumonia showed more than 65% sensitive to merope-
nem, gentamicin, ceftriaxone, ciprofloxacin and nitrofurantoin this agreed with the study done in South-western
Uganda38, K. pneumoniae was 100% resistant to ampicillin, Similar findings were done in Adigrat General Hos-
pital, Northern Ethiopia and Karamara Hospital Jigjiga, Eastern Ethiopia46,51.

In this study, the Gram positive bacterial isolates were relatively sensitive to erythromycin, cefoxitin, ceftri-
axone, nitrofurantoin, gentamicin, ciprofloxacin and each accounted 85%, 85%, 75%, 75%, 70% and 65%. This
was comparable with the finding from Ivory Coast, Dire Dawa, Eastern Ethiopia and Gonder Ethiopia48,52,53
However, in contrast with study report from Southern Ethiopia, which ceftriaxone was 100% resistant to gram-
positive bacteria54.

Table 5. Multi drug resistance pattern of bacterial isolates from pregnant women with UTI attended antenatal
care at HGH, Hargeisa, Somaliland, 2020 (n = 69). R2 = resistance to two drugs, R3 = resistance to three drugs,
R4 = resistance to four drugs, R5 = resistance to five drugs, R6 = resistance to six drugs and ≥ R7 = resistance to
seven and more drugs, MDR = resistance for three or more antibiotics.

Isolates

Frequency (%)

Total R3 R4 R5 R6 ≥ R7 MDR

Gram-negative 49(71) 9(20.5) 10(22.7) 17(38.6) 4(9.1) 4(9.1) 44(89.8)

E. coli 30(61.2) 7(77.8) 5(50) 11(64.8) 3(75) 1(25) 27(61.4)

K. pneumonia 6(12.2) 1(11.1) 2(11.8) 2(50) 5(11.4)

P. aeruginosa 5(10.2) 3(30) 2(11.8) 5(11.4)

P. mirabilis 4(8.2) 1(11.1) 1(5.8) 1(25) 3(6.8)

Citrobacter spp. 3(6.1) 2(20) 1(5.8) 3(6.8)

M. morganii 1(2.1) 1(25) 1(2.2)

Gram-positive 20(29) 1(6.7) 8(53.3) 2(13.3) 3(20) 1(6.7) 15(75)

CoNS 11(55) 7(87.5) 1(50) 1(33.3) 9(60.0)

S. aureus 9(45) 1(100) 1(12.5) 1(50) 2(66.7) 1(100) 6(40.0)

Total 69(100) 10(16.9) 18(30.5) 19(32.2) 7(11.9) 5(8.5) 59(85.5)

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In this study, Gram positive bacteria showed highly resistance to ampicillin 90% and tetracycline 55%. This
could be due to the infrequent use of the drug in the study area. Comparable result was reported in Gonder
Ethiopia53, in Lagos, Nigeria, and Benishangul Gumuz Region, Western Ethiopia55. Coagulase negative staphy-
lococci, which were the predominant isolates from Gram-positives 55% and was found 63% to 81% sensitive
to erythromycin, cefoxitin, ceftriaxone, nitrofurantoin gentamicin and ciprofloxacin. However, in contrast was
shown nitrofurantoin to 26.7% resistance in study done in Ethiopia56, while comparable studies done in Hawassa,
Ethiopia50.

Table 6. Bivariate and multivariate analysis for the assessment of factors associated with UTI among pregnant
women attending antenatal care at HGH, Hargeisa, Somaliland, 2020 (n = 422). I reference, AOD adjusted odds
ratio, COR crude odds ratio, N number, UTI Urinary tract infection.

Variables

UTI

COR(95% CI) P values AOR(95% CI) P valuesYes (%) No (%)

Age ( in years)

≤ 19 7(41.2) 10(58.8) 2.600 (0.725–9.319) 0.142 2.446(0.609–9.818) 0.207

20–25 17(19.3) 71(80.7) 0.889 (0.331–2.389) 0.816 0.903 (0.313–2.608) 0.851

26–30 20(16.8) 99(83.2) 0.750 (0.286–1.966) 0.559 0.813 (0.285–2.316) 0.698

31–35 18(14.4) 107(85.6) 0.625 (0.236–1.652) 0.343 0.606 (0.212–1.732) 0.350

36–40 0(0) 40(100) 0.000 (0.000) 0.998 0.000 (0.000) 0.997

41–45 7(21.2) 26(78.8) I

Residence
Urban 66(16.6) 332(83.4) 1.392[0.403–4.800] 0.601

Rural 3(12.5) 21(87.5) I

Marital status

Widowed 2(25) 6(75) I

Married 66(16.2) 341(83.8) 0.581 [0.115–2.940] 0.511

Divorced 0(0) 2(100) 0.000 [0.000] 0.999

Separated 1(20) 4(80) 0.750 [0.050–11.311] 0.835

Educational status

No formal education 20 59 2.780 [0.965–8.006] 0.058 3.183 [1.027–9.866] 0.045

Primary education
(1–8) 29 156 1.524 [0.555–4.183 0.413 1.624 [0.553–4.766] 0.378

Secondary education
(9–12) 15 97 1.268 [0.432–3.719] 0.665 1.767 [0.552–5.658] 0.338

Higher Education
(> 12) 5 41 I

Family Income

≤ $100 18 59 3.559 [0.978–12.954] 0.054 5.225 [1.270–21.500] 0.022

$101–200 32 159 2.348 [0.680–8.103] 0.177 2.940 [0.761–11.352] 0.118

$201–300 16 100 1.867 [0.513–6.793] 0.344 2.839 [0.694–11.615] 0.147

> $300 3 35 I

Occupational status

House wife 47 196 0.839 [0.169–4.171] 0.830

Merchant 12 80 0.525[0.097–2.830] 0.453

Governmental
employee 8 70 0.400 [0.071–2.264] 0.300

Student 2 7 I

Gestational Period

1st trimester 16 71 I

2nd trimester 23 114 0.895 [0.443–1.809] 0.758

3rd trimester 30 168 0.792 [0.407–1.544] 0.494

Gravida
Primigravida 12 44 I

Multigravida 57 309 0.676 [0.337–1.359] 0.272

History of Catheteri-
zation

No 59 335 I

Yes 10 18 3.154 [1.388–7.170] 0. 006 3.216 [1.287–8.038] 0.012

History of diabetes
mellitus

No 67 345 I

Yes 2 8 1.287 [0.267–6.196] 0.753

History of abortion
No 64 341 I

Yes 5 12 2.220 [0.756–6.517] 0.147 2.183 [0.672–7.092] 0.194

History of obstetric
and gynecologic
surgery

No 67 346 I

Yes 2 7 1.475 [0.300–7.258] 0.632

History of premature
labor

No 68 348 I

Yes 1 5 1.024 [0.118–8.899] 0.983

History of previous
UTI

No 51 319 I

Yes 18 34 3.311 [1.740–6.300] 0.000 3.734 [1.855–7.515] 0.000

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In this study, S. aureus which constituted for 45% of the Gram positive bacteria showed 66.7–88.9% were
sensitive to erythromycin, cefoxitin, ceftriaxone, nitrofurantoin, ciprofloxacin and gentamicin, this agree with
study done in Hawassa, Ethiopia, Benishangul Gumuz Region, Western Ethiopia and Nairobi, Kenya42,50,55. In
contrast to research done in Addis Ababa, Ethiopia, which erythromycin was highly resistant 60%47. However, this
study showed 100% ampicillin to S. aureus, similar study done in Jigjiga, Ethiopia, Dire Dawa, Eastern Ethiopia
and Addis Ababa, Ethiopia46,48,57. This is caused by use of empirical treatment against bacterial infections of the
urinary tract infection in the study area. This implies that ampicillin cannot be used as empirical therapy for
urinary tract infection particularly in the study area.

In this study, MDR was seen in 85.5% of all bacteria isolated. Our finding is higher than studies done in same
regions of Ethiopia like 57.1% in Addis Ababa, and 73% in Mekelle35,47, in Tanzania 77%39 and in Eastern Uganda
77.558. Our finding is lower than studies done in South-South Nigeria 100%49, in Kenya 96%11 and same regions
in Ethiopia like in Dire Dawa 100%, Gondar 95% and Jigjiga 96%21,46,48. This indicates that multi drug resistance
was found to be very high to the commonly used antibiotics. Antibiotic resistance has been recognized as the
consequence of antibiotic use and abuse59. Therefore, the reasons for this alarming phenomenon might be inap-
propriate and incorrect administration of antimicrobial agents in empiric therapies and lack of appropriate infec-
tion control strategies, which can cause a shift to increase prevalence of resistant organisms in the community.

In the present study, the result of multivariable logistic regression models revealed that socio-demographic
factors among pregnant women were statistically significance with no formal education and low level of fam-
ily income (≤ $100) [P = 0.045, AOR = 3.183 (1.027, 9.866)] and [P = 0.022, AOR = 5.225 (1.270, 21.500)]. The
non-formal education was agreed with study done in Goba and Sinana Woredas, Bale Zone, Southeast Ethiopia
[AOR = 6.617; CI = 1.87–9.94]37. in contract with low level education the studies done in Medan, Indonesia, and
Uyo, Nigeria49,60. Low-income status was another factor that was related with high prevalence of UTI among
pregnant women. A similar finding was reported in other studies on pregnant women in Dire Dawa, Eastern
Ethiopia and in Adigrat General Hospital, Northern Ethiopia48,51. This could be due to the relation of low socio-
economic status with nutrition and immunity especially in pregnant women. In contrast studies were done in
Jigjiga, Ethiopia, Medan, Indonesia, and Northeastern Ethiopia34,46,60.

In the study, obstetrics and clinical characteristics were shown that, highly significant proportion of UTI was
recorded among those study subjects with prior history of UTI. The multivariate logistic regression analysis of
current study showed that 3.7 more likely to occur the UTI compared with pregnant women that have not the
previous history of UTI [P = 0.000 AOR = 3.734 (1.855, 7.515)]. This finding is similar with report from Uganda
(P = 0.002), Libya (P = 0.00), Egypt (P = 0.001), India (P = 0.0423), and same regions of Ethiopia like Gondar,
(P-value = 0.001), Dire Dewa (P-value = 0.006) and Addis Ababa (P = 0.004)15,21,22,38,47,48,61. The possible explana-
tion for this association could be due to the existence of antibiotic-resistant strains from the previous infection.

In the current study, participants with the previous history of indwelling catheterization had about 3.2 times
chance of developing UTI [P = 0.012 AOR = 3.216 (1.287, 8.038)] among pregnant women. This finding agrees
with similar reports from Northeastern Ethiopia, Addis Ababa, Ethiopia and Gonder Ethiopia21,34,47. This could
be due to long duration of catheterization, frequent catheterization or contamination during inserting cath-
eters. However other studies done in Dire Dawa, Eastern Ethiopia and Jigjiga Eastern Ethiopia disagreed of this
study46,48.

In the present study, there was no statistical significant association between prevalence of UTI among preg-
nant women and maternal age, residence, marital status, occupation, gestational period, gravidity, History of dia-
betes mellitus, History of abortion History of obstetric and gynecologic surgery and History of premature labor.
this results were agreed the report from Bangladesh36, Nairobi, Kenya except the maternal age33, Nigeria49, Goba
and Sinana Ethiopia37, Dire Dawa, Eastern Ethiopia48 and Addis Ababa, Ethiopia except history of abortion47.

Conclusion
The overall prevalence was 16.4%.The isolated bacteria were E. coli, K. pneumonia, P. aeruginosa, P. mirabilis,
Citrobacter spp., CoNS and S. aureus.

. Majority of the isolates were resistant to the commonly prescribed antibiotics, therefore culture and anti-
biotic susceptibility testing was recommended before giving treatment to prevent antimicrobial resistance at
least at Referral Hospital Setup and health information dissemination to the patients recommended to avoid
self-medication practice.

Data availability
The datasets used and analyzed in the current study are available from the corresponding author on reasonable
request.

Received: 6 October 2021; Accepted: 3 January 2022

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at Puskesmas Kenangan, Deli Serdang district. E&ES 125(1), 012035 (2018).

61. Shaheen, H. M., Farahat, T. M. & Hammad, N.A.E.-H. Prevalence of urinary tract infection among pregnant women and possible
risk factors. Menoufia Med. J. 29(4), 1055 (2016).

Acknowledgements
We are grateful to Hawassa University Comprehensive Specialized Hospital microbiology laboratory staffs and
study participants for their contribution to this research work.

Author contributions
M.D.O., D.Y.R. and A.H.A conceived the study and participated in data analysis. A.H.A. carried out the lab work,
M.D.O. wrote the manuscript. All authors read and approved the final manuscript.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to M.D.O.

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© The Author(s) 2022

  • Prevalence and antimicrobial susceptibility pattern of urinary tract infection among pregnant women attending Hargeisa Group Hospital, Hargeisa, Somaliland
    • Method
      • Ethics approval and consent to participate.
      • Consent for publication.
    • Results
    • Discussion
    • Conclusion
    • References
    • Acknowledgements

TRAN
SCU

TAN
EO

U
S ELECTRICAL N

ERVE STIM
U

LATIO
N

FO
R PO

STO
PERATIVE PAIN

CO
N

TRO
L AFTER TO

TAL KN
EE ARTHRO

PLASTY. A M
ETA-

AN
ALYSIS O

F RAN
DO

M
IZED CO

N
TRO

LLED TRIALS
Authors: Jifeng

Li &
Yuze

Song. Affiliations: Departm
ent of O

rthopedics, Huaihe
Hospital, Henan U

niversity, Henan, China.

Li, J., &
Song, Y. (2017). Transcutaneous electrical nerve stim

ulation for postoperative pain control after total knee arthroplasty: A m
eta-analysis of random

ized
controlled trials.M

edicine,96(37), e8036. https://doi.org/10.1097/M
D.0000000000008036


First m

eta-analysis to evaluate the efficiency and safety of TEN
S

for pain control in TKA.

TEN
S could significantly reduce the VAS scores and opioid

consum
ption at 12 , 24, and 48 h, after TKA.


Effective pain control: early am

bulation and m
aintains m

otor
function. The risk of throm

botic events and m
edical costs w

ould
be decreased under adequate analgesia.


Reduction of opioid consum

ption decreased side effects such, as
(nausea and vom

iting).

Lim
itations:


Sam

ple size w
as relatively sm

all.

Som
e im

portant outcom
es, such as range of m

otion, w
ere not

included or fully described

The m
ethods of blinding w

ere unclear or not described

Short-term
follow

-up (underestim
ation of com

plications)

Publication bias inherent to m
eta-analysis studies.

Conclusions:
TEN

S could significantly reduce pain and opioid consum
ption

after TKA. In addition, there w
ere few

er adverse effects in the
TEN

S groups. Higher quality RCTs are required for further
research.


Significant differences in the incidence of nausea

(P=.020) and
vom

iting (P=.018)

Discussion/Im
plications

Lim
itations/Conclusions


Focus: Transcutaneous electrical nerve stim

ulation (TEN
S)

after total knee arthroplasty (TKA).

Problem
: N

o m
eta-analysis has investigated the effectiveness

and safety of TEN
S in the setting of postoperative relief of

pain after TKA.

Benefits: Increase scientific evidence on effectiveness of TEN
S

in pain m
anagem

ent after TKA.

Purpose: Evaluate the efficiency and safety of TEN
S for pain

control after TKA.


Setting /Sam

pling: A system
atic search w

as perform
ed in

M
edline PubM

ed, ScienceDirect and the Cochrane Library.
O

nly random
ized trials (RCT) w

ere included.

Study design: M
eta-analysis of RCTs


Search strategy: Key w

ords: ”total knee replacem
ent O

R
arthroplasty”, “transcutaneous electrical nerve stim

ulation“
and pain control.


Data extraction: Prim

ary outcom
es: VAS scores and opioids

consum
ption at 12, 24, and 48 h. Secondary outcom

es: Side
effects (nauseas and vom

iting)

Statistical M
ethods: The fixed /random

effect m
odel w

as used
according to the heterogeneity tested by I 2statistic.

Introduction

M
ethods/Data Collection/Data Analysis


Significant differences (P < .05) w

ere found
regarding opioid consum

ption at 2 h, 24 h, and
48 h.

O
utcom

es/Results/G
raphs


Five RCTs, including 472 patients m

et the inclusion
criteria. Study G

roup N
=237; Control G

roup N
=235


Significant differences (P < .05) betw

een groups
in term

s of VAS at 12, 24, and 48 h after TKA.

Excellent poster, not only visually appealing
but also in substance! W

ell-done!!~Dr. R.

G
raphs are

illegible due to
sm

all font size
w

hich further
detracts from

visual appeal…

Helpful to have
additional info
as you have
provided here

Poster # 5

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