urinary tract infections ( utis ) are one of the most common types of bacterial infections occurring both in the community and hospital settings . today it represents one of the most common diseases encountered in medical practices with the prevalence of uti varying from 21.8% to 31.3% in various parts of india . the current study was undertaken to assess the most common pathogens responsible for uncomplicated utis and the antimicrobial resistance pattern in a tertiary hospital in bangalore . additionally , the study throws light into the issues of overtreatment , under treatment and wrong treatment of uti . the study was conducted in bangalore baptist hospital , bangalore . assuming a prevalence of 24% of uti in symptomatic patients at 6% precision and 95% confidence level , the sample size calculated was 196 . patients who came to the medicine opd with symptoms ( dysuria , frequency , urgency and suprapubic tenderness with or without fever ) of uti or any patients in whom the physician suspected uncomplicated uti were recruited into the study . patients with signs of pyelonephritis ( a body temperature > 38c orally and flank pain or costovertebral angle tenderness ) , three or more episodes of uti in the past year , symptoms of uti in the last 3months , previous upper uti , other functional and structural urinary tract abnormalities , indwelling or recent use of a catheter , previous history of genitourinary system operation including urinary stones , current pregnancy , antibiotic use during the previous 2 weeks and patients who were hospitalized for any reason during past 3months were excluded from the study . the patients were interviewed using a semi - structured questionnaire which contained demographic information and symptomatology . a freshly voided , midstream urine sample was collected in a sterile container from each patient enrolled for the study . all of them were given clear instructions on how to collect a midstream urine specimen . the sample was inoculated for semi - quantitative culture on cystine - lactose - electrolyte - deficient ( cled ) media using a calibrated loop . the culture plate was incubated at 37c for 18 - 24 hours under aerobic conditions . antibiotic susceptibility was performed by the kirby - bauer disc diffusion method on mueller hinton agar . amoxiclav ( 20/10 mcg ) , ampicillin ( 10 mcg ) , amikacin ( 30 mcg ) , trimethoprim / sulphamethoxazole ( cotrimoxazole ) ( 1.25/23.75 mcg ) , norfloxacin ( 5 mcg ) , nalidixic acid ( 30 mcg ) , ciprofloxacin ( 5 mcg ) , nitrofurantoin ( 300 mcg ) , gentamicin ( 10 mcg ) , cefuroxime ( 30 mcg ) , ceftriaxone ( 30 mcg ) , ceftazidime ( 30 mcg ) , cephotaxime ( 30 mcg ) , netilmicin ( 30 mcg ) , piperacillin / tazobactam ( 100/10 mcg ) , cefoperazone / sulbactam ( 75/30 mcg ) , and vancomycin ( 30 mcg ) . the controls strains used were escherichia coli atcc 25922 , pseudomonas aeruginosa atcc 27853 , and staphylococcus aureus 25922 . urinary tract infection : a quantitative count of more than 10 colony forming units of one bacterial species per ml from a properly collected midstream uncomplicated uti : uncomplicated uti is defined as uti in a person with a normal urinary tract and function . 
 a person presented with symptoms of uti , had a positive urine culture and treated with an antibiotic which was effective against the uropathogen isolatedora person presented with symptoms of uti , had a negative urine culture and not treated with an antibioticora person who was started on empirical therapy with a resistant antibiotic , but was subsequently changed to an uropathogen sensitive antibiotic after culture report . a person presented with symptoms of uti , had a positive urine culture and treated with an antibiotic which was effective against the uropathogen isolated a person presented with symptoms of uti , had a negative urine culture and not treated with an antibiotic a person who was started on empirical therapy with a resistant antibiotic , but was subsequently changed to an uropathogen sensitive antibiotic after culture report . a person presented with symptoms of uti , and a positive urine culture but treated with antibiotic which was not effective against the uropathogen isolatedora person presented with symptoms of uti , had a negative urine culture but treated with an antibioticora person presented with symptoms of uti , had a positive urine culture but not treated with an antibioticora person who was started on empirical therapy with an antibiotic , but was not changed to an uropathogen sensitive antibiotic after culture report . 
  a person presented with symptoms of uti , and a positive urine culture but treated with antibiotic which was not effective against the uropathogen isolated a person presented with symptoms of uti , had a negative urine culture but treated with an antibiotic a person presented with symptoms of uti , had a positive urine culture but not treated with an antibiotic a person who was started on empirical therapy with an antibiotic , but was not changed to an uropathogen sensitive antibiotic after culture report . the study was conducted in accordance with the ethical standards of the helsinki declaration of 1975 , as revised in 1983 . the study was approved by the institution review board of bangalore baptist hospital . written informed consent was obtained from every recruited patients and confidentiality was maintained at every stage of the research . the data collected was first coded and then transferred to a master chart on microsoft excel which was programmed to minimize the error . the range of the continuous values was specified and codes were picked from drop down menu as a measure to reduce the error . data was validated by double - checking by randomly picking different segments to look for incorrectly entered data . descriptive analysis was done in spss to look for numbers that are out of range or errors in data entry . distribution as well as co - relation tables were prepared , analyzed and statistically evaluated by spss version 16.0 . the chi - square test was done to identify the variables associated with uti ( age , gender , presence of co morbidities ) . frequencies and percentages were calculated for distribution of uropathogens in different age groups , gender and among diabetics . antibiotic susceptibility was performed by the kirby - bauer disc diffusion method on mueller hinton agar . amoxiclav ( 20/10 mcg ) , ampicillin ( 10 mcg ) , amikacin ( 30 mcg ) , trimethoprim / sulphamethoxazole ( cotrimoxazole ) ( 1.25/23.75 mcg ) , norfloxacin ( 5 mcg ) , nalidixic acid ( 30 mcg ) , ciprofloxacin ( 5 mcg ) , nitrofurantoin ( 300 mcg ) , gentamicin ( 10 mcg ) , cefuroxime ( 30 mcg ) , ceftriaxone ( 30 mcg ) , ceftazidime ( 30 mcg ) , cephotaxime ( 30 mcg ) , netilmicin ( 30 mcg ) , piperacillin / tazobactam ( 100/10 mcg ) , cefoperazone / sulbactam ( 75/30 mcg ) , and vancomycin ( 30 mcg ) . the controls strains used were escherichia coli atcc 25922 , pseudomonas aeruginosa atcc 27853 , and staphylococcus aureus 25922 . urinary tract infection : a quantitative count of more than 10 colony forming units of one bacterial species per ml from a properly collected midstream uncomplicated uti : uncomplicated uti is defined as uti in a person with a normal urinary tract and function . 
 a person presented with symptoms of uti , had a positive urine culture and treated with an antibiotic which was effective against the uropathogen isolatedora person presented with symptoms of uti , had a negative urine culture and not treated with an antibioticora person who was started on empirical therapy with a resistant antibiotic , but was subsequently changed to an uropathogen sensitive antibiotic after culture report . a person presented with symptoms of uti , had a positive urine culture and treated with an antibiotic which was effective against the uropathogen isolated a person presented with symptoms of uti , had a negative urine culture and not treated with an antibiotic a person who was started on empirical therapy with a resistant antibiotic , but was subsequently changed to an uropathogen sensitive antibiotic after culture report . 
 a person presented with symptoms of uti , and a positive urine culture but treated with antibiotic which was not effective against the uropathogen isolatedora person presented with symptoms of uti , had a negative urine culture but treated with an antibioticora person presented with symptoms of uti , had a positive urine culture but not treated with an antibioticora person who was started on empirical therapy with an antibiotic , but was not changed to an uropathogen sensitive antibiotic after culture report . 
  a person presented with symptoms of uti , and a positive urine culture but treated with antibiotic which was not effective against the uropathogen isolated a person presented with symptoms of uti , had a negative urine culture but treated with an antibiotic a person presented with symptoms of uti , had a positive urine culture but not treated with an antibiotic a person who was started on empirical therapy with an antibiotic , but was not changed to an uropathogen sensitive antibiotic after culture report urinary tract infection : a quantitative count of more than 10 colony forming units of one bacterial species per ml from a properly collected midstream  clean catch uncomplicated uti : uncomplicated uti is defined as uti in a person with a normal urinary tract and function . 
 a person presented with symptoms of uti , had a positive urine culture and treated with an antibiotic which was effective against the uropathogen isolatedora person presented with symptoms of uti , had a negative urine culture and not treated with an antibioticora person who was started on empirical therapy with a resistant antibiotic , but was subsequently changed to an uropathogen sensitive antibiotic after culture report . a person presented with symptoms of uti , had a positive urine culture and treated with an antibiotic which was effective against the uropathogen isolated a person presented with symptoms of uti , had a negative urine culture and not treated with an antibiotic a person who was started on empirical therapy with a resistant antibiotic , but was subsequently changed to an uropathogen sensitive antibiotic after culture report . a person presented with symptoms of uti , and a positive urine culture but treated with antibiotic which was not effective against the uropathogen isolatedora person presented with symptoms of uti , had a negative urine culture but treated with an antibioticora person presented with symptoms of uti , had a positive urine culture but not treated with an antibioticora person who was started on empirical therapy with an antibiotic , but was not changed to an uropathogen sensitive antibiotic after culture report . 
  a person presented with symptoms of uti , and a positive urine culture but treated with antibiotic which was not effective against the uropathogen isolated a person presented with symptoms of uti , had a negative urine culture but treated with an antibiotic a person presented with symptoms of uti , had a positive urine culture but not treated with an antibiotic a person who was started on empirical therapy with an antibiotic , but was not changed to an uropathogen sensitive antibiotic after culture report . the study was conducted in accordance with the ethical standards of the helsinki declaration of 1975 , as revised in 1983 . the study was approved by the institution review board of bangalore baptist hospital . written informed consent was obtained from every recruited patients and confidentiality was maintained at every stage of the research . the data collected was first coded and then transferred to a master chart on microsoft excel which was programmed to minimize the error . the range of the continuous values was specified and codes were picked from drop down menu as a measure to reduce the error . data was validated by double - checking by randomly picking different segments to look for incorrectly entered data . descriptive analysis was done in spss to look for numbers that are out of range or errors in data entry . distribution as well as co - relation tables were prepared , analyzed and statistically evaluated by spss version 16.0 . the chi - square test was done to identify the variables associated with uti ( age , gender , presence of co morbidities ) . frequencies and percentages were calculated for distribution of uropathogens in different age groups , gender and among diabetics . among the 204 eligible patients approached , 196 people agreed to participate in the study , yielding a response rate of 96.1% . almost half ( 42.3% ) of the studied population presented with dysuria alone and another 33.2% had a combination of fever and dysuria . the prevalence of uti was higher in females ( 39.5% ) than males ( 20.8% ) and this was statistically significant . the prevalence of uti was more in diabetics ( 44.4% ) than non - diabetics ( 29.4% ) ; however this was not statistically significant ( p = 0.13 ) . even though the prevalence of uti is more in people above 80 years and those with co morbidities . of the total 196 urine specimens collected , 63 ( 32.1% ) showed significant bacterial growth . gram - negative bacteria constituted the largest group with a prevalence of 84.1% ( 53/63 ) while gram - positive bacteria constituted 15.9% ( 10/63 ) of the total isolates . the bacteria isolated were e. coli with a frequency rate of 69.8% followed by klebsiella pneumoniae ( 7.9% ) , coagulase - negative staphylococcus ( cons ) ( 4.8% ) , pseudomonas sp . ( 4.8% ) , streptococcus viridans ( 4.8% ) , enterococcus ( 4.8% ) , mrsa ( 1.6% ) and non - fermenting gram - negative bacilli ( 1.6% ) . uti and associated factors uropathogen distribution among females and males varied significantly ( p = 0.035 ) [ table 2 ] . in females , e. coli was responsible for most ( 78.7% ) of the cases whereas in males e. coli ( 43.8% ) , klebsiella ( 12.5% ) and s. viridans ( 12.5% ) were the major causative agents . the prevalence of cons ( 12.5% vs. 2.1% ) and pseudomonas ( 18.8% vs. 0% ) were higher in males than females . among the culture - positive diabetic patients , e. coli ( 68.8% ) , s. viridans ( 18.8% ) , mrsa ( 6.3% ) and klebsiella ( 6.3% ) were the common organisms [ table 2 ] . distribution of organism among culture - positive samples the antibiotic sensitivity pattern is shown in table 3 . amikacin ( 90.6% ) , nitrofurantoin ( 77.4% ) and cotrimoxazole ( 49.1% ) were the most effective antibiotics against gram - negative organisms . most of the gram - positive organisms were susceptible to nitrofurantoin ( 70% ) followed by gentamicin ( 50% ) and ampicillin ( 30% ) . ciprofloxacin was effective against 20% of gram - positive and 37.7% gram - negative organisms . antibiotic susceptibility percentage of the uropathogens isolated from culture - positive samples e. coli was susceptible to nitrofurantoin in 71.4% males and 86.5% females . sulfmethoxazole - resistant e. coli . only a few male patients ( 14.3% ) had fluoroquinolone ( ciprofloxacin and levofloxacin ) sensitive e. coli . out of the 196 patients , 77 ( 39.3% ) urine routine examination report of pus cells more than five was considered as an indication for prescribing an antibiotic by 62.5% of the physicians . fever and dysuria were considered as an indication to prescribe antibiotic by 41.5% of the physicians . it was found out that 30.1% of the patients were wrongly managed in spite of urine culture [ table 4 ] . wrong management included not treating culture - positive patients , treating with the incorrect ( resistant ) antibiotics and prescribing an antibiotic when the culture is negative . 14.3% of the patients were overtreated ( treatment not needed but treated ) and under treatment ( treatment needed but not treated ) was in 7.1% . among the people who needed treatment , only ( 32/63 ) almost one fifth of patients ( 28/133 ) who did not require treatment were treated with antibiotics . overtreatment was not associated with age , gender and the presence of co - morbidities . the presence of 6 - 15 pus cells was associated with overtreatment [ table 5 ] . the prevalence of uti in our study was 32.1% and it was significantly higher in females ( 39.5% ) compared to males ( 20.8% ) . several reports have also indicated that females are more prone to having utis than males , as the urethra is shorter in females than males thus being more readily and easily prone to micro - organisms . the bacteria isolated were e. coli with a frequency rate of 69.8% followed by k. pneumoniae ( 7.9% ) , cons ( 4.8% ) , pseudomonas sp . ( 4.8% ) , s. viridans ( 4.8% ) , enterococcus ( 4.8% ) , mrsa ( 1.6% ) and non - fermenting gram - negative bacilli ( 1.6% ) . all the micro - organisms isolated in this study were of clinical significance and were similar to the data recorded by manikandan et al . and al - sweih et al . the isolation frequency of the bacterial species reported in this study falls within the range of frequencies reported from other parts of india too . the microbiological and antibiotic sensitivity pattern observed in our study is similar to findings of banerjee et al . , and sharma et al . the alarming finding was amp , amc and most of the cephalosporins were resistant to most of the strains . the possible explanation may be because these antibiotics have been in use for a long period and more often due to the misuse of antimicrobial drugs , which has today led to a general rise in the emergence of resistant bacteria . overtreatment in elderly patients presenting with symptoms of uti has been reported in other studies . literature also rates uti as the second most common reason for empirical antibiotic therapy in secondary care . urine routine report of 6 - 15 pus cells in a symptomatic patient was associated with overtreatment . predictive value of 6 - 15 pus cells is low and therefore treating with antibiotic without consulting the culture report might have resulted in overtreatment . 8.7% were treated with resistant drugs which could have been avoided if the physician waited for the culture report . the patient could have been managed by other symptom relieving drugs or by empirical therapy with nitrofurantoin . among these 17 patients who were treated with a resistant drug , 11 ( 64.7% ) were sensitive to nitrofurantoin . the chance of treating with resistant antibiotic was higher when the physician started on cephalosporins ( cefixime , ceftriaxone and cefoperazone sulbactam ) . there are no country specific guidelines for treating uti ; the indian society of nephrology states that knowledge of local resistance pattern is needed to guide empirical therapy in the light of rising resistance to amoxicillin , sulfa drugs , cotrimoxazole and fluoroquinolones . according to an update by the infectious diseases society of america ( idsa ) guidelines , a short - course therapy ( 3 day ) with either nitrofurantoin or trimethoprim  sulfamethoxazole ( if the local resistance prevalence less than 20% ) sulfamethoxazole is not a good option for empirical therapy as there are many studies including the present study which reports a resistance of more than 20% . scottish intercollegiate guidelines network ( sign ) guidelines recommends a 7 day course of fluoroquinolones for cystitis in men , however a more detailed evaluation is recommended in men . fluoroquinolones may not be appropriate for empirical drug therapy as 85.7% of men with e. coli demonstrated resistance to fluoroquinolones in the present study . though empirical antibiotic treatment can be cost effective in primary and secondary care settings , it can promote antimicrobial resistance , hence should be cautiously initiated in tertiary care settings . consequently , evolving practice seeks to achieve good symptom control for uncomplicated acute cystitis while reducing antibiotic use . for example , european practice increasingly includes the option of offering a 48-hour delayed antibiotic prescription to be used at the patient 's discretion . almost one third of the patients were managed inappropriately in spite of the availability of a culture report . ciprofloxacin and cotrimoxazole were preferred by most of the physicians , with one fifth of patients being started on parenteral antibiotics with no apparent rationale . periodic surveillance of antimicrobial resistance of uropathogens , re - evaluation of empirical therapy , pre - therapy counseling for delayed antibiotic initiation and short - course antibiotic therapy with sensitive antibiotics are vital in an era of emerging antimicrobial resistance .
introduction : uncomplicated but symptomatic urinary tract infections ( utis ) are a common problem seen in practice . 
 the study was undertaken to assess the most common pathogens responsible for uncomplicated symptomatic utis and the antimicrobial resistance pattern in a hospital in bangalore . 
 the study also explores the issue of antibiotic usage for these patients.materials and methods : the study was conducted in the medicine department of a tertiary hospital in bangalore . in all , 196 patients presented with symptoms of uti . 
 bacterial growth was determined by standard microbiology techniques on freshly voided mid - steam urine samples collected from recruited patients . 
 patients demographic data , urine culture results , resistance rates to antimicrobial agents and prescribed empiric antimicrobial therapy were analyzed.results:the prevalence of uti was 32.1% ; majority ( 67.9% ) of the symptomatic did not have uti based on culture report . 
 gram - negative bacteria constituted the largest group with a prevalence of 84.1% ( 53/63 ) , with escherichia coli being the most common ( 70% ) uropathogen . 
 gram - negative isolates showed high level of sensitivity to amikacin ( 90.6% ) and nitrofurantoin ( 77.4% ) . 
 most of the gram - positive organisms were susceptible to nitrofurantoin ( 70% ) and gentamicin ( 50% ) . 
 uropathogens isolated demonstrated high resistance to cotrimoxazole , fluoroquinolones , and beta - lactam antibiotics . 
 it was found out that 30.1% of the patients were wrongly managed of which 14.7% were over treated.conclusion:uti can be over diagnosed and over treated on the basis of clinical signs , symptoms and urine microscopy . in the era of emerging anti - microbial resistance , 
 effective counseling and delay in antibiotic initiation or empirical therapy with a short course of nitrofurantoin is highly recommended . 
 empirical therapy guidelines should be updated periodically to reflect changes in antimicrobial resistance of uropathogens .