Prevalence and Molecular Characterization of Extended Spectrum Beta Lactamase Bacteria Causing Urinary Tract Infections in Pregnant Mothers at Itojo Hospital, South Western Uganda
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Background Extended-spectrum β-lactamase (ESBL) producing bacteria pose a global challenge because of resistance developing against a wide range of antimicrobial agents that complicate available treatment options. Thus, identifying the prevalent bacterial species producing ESBL enzymes and understanding how they are susceptible to antibiotics is necessary internationally to inform the effective treatment guidelines. Objective To determine the prevalence and molecular characterization of ESBL bacteria causing Urinary Tract Infections (UTIs) in women who are pregnant at the Itojo Hospital, Ntungamo District. Methods We conducted cross-sectional study where we collected and analyzed 340 urine samples. We did antimicrobial susceptibility testing using the Kirby Bauer disk diffusion method. Isolates were screened for ESBL production and confirmed using the combination disk test (CDT). Genotypic characterization was confirmed using multiplex PCR to detect blaTEM, blaCTX-M and blaSHV genes. Results The prevalence of ESBL – producing bacteria was 29.7% (101/340). Escherichia coli (35.6%) and Klebsiella species (32.7%) were predominant ESBL producers. Genotypic analysis revealed blaTEM (49.5%) and blaCTX-M (30.7%) as the most prevalent genes, while blaSHV was less common (7.9%) Conclusion The high prevalence of ESBL–producing bacteria and their resistance to commonly used antibiotics highlight the need for targeted antibiotic therapy, antimicrobial stewardship, and regular molecular surveillance.
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Comments to Author
1. Methods: The study population needs to be clarified, reflected in the analysis and title. In Line 90, the selection criteria states that two groups of patients were studied: 1) Patients with features of urinary tract infection and 2) Patients with asymptomatic bacteriuria. However, the manuscript reports one study population with urinary tract infection. 2. Presentation of results: Table 1 is better presented as percentages to add up to 100 %. Table 3 to be renamed Table 2 and it is best placed as Table 1 while the current table 1 is renamed Table 2. The antibiotics in the current Table 3 should be re-arranged chronologically placing the discs for testing ESBL towards the end of the table at the right-hand side. Similarly, Table 4 should be renamed Table 3. In addition to the figures in the …
Comments to Author
1. Methods: The study population needs to be clarified, reflected in the analysis and title. In Line 90, the selection criteria states that two groups of patients were studied: 1) Patients with features of urinary tract infection and 2) Patients with asymptomatic bacteriuria. However, the manuscript reports one study population with urinary tract infection. 2. Presentation of results: Table 1 is better presented as percentages to add up to 100 %. Table 3 to be renamed Table 2 and it is best placed as Table 1 while the current table 1 is renamed Table 2. The antibiotics in the current Table 3 should be re-arranged chronologically placing the discs for testing ESBL towards the end of the table at the right-hand side. Similarly, Table 4 should be renamed Table 3. In addition to the figures in the current Table 4, percentages should be added as % (n) for improved data visualization. 3. Style and organization of the paper. Line 90: As mentioned in methods, the title only reports patients with urinary tract infections, but the study population also comprised of patients with asymptomatic bacteriuria. In the main text, it is important to focus the background information on ESBL producing bacteria and urinary tract infection. Line 42: The first sentence on hormonal changes and urinary tract infection and the following sentences on other risk factors of urinary tract infection were not studied, therefore, misleading. From Line 64, the background information improves but it should be tailored to ESBL-producing bacteria in UTI. 4. Literature analysis or discussion. More focused information on molecular signatures of ESBL-producing bacteria causing urinary tract infection would be improve the literature flow. The literature can also be improved with more studies from Uganda.
Please rate the manuscript for methodological rigour
Good
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Thank you for submitting your manuscript to Access Microbiology. It has now been reviewed by two experts in the field, whose comments are attached at the bottom of this email. They both agree that this is a valuable contribution to the field, however the manuscript needs further work and amendments. The results and discussion sections are currently hard to follow, and this lack of readability can affect the understanding of the study. Furthermore, the bioinformatic and experimental methods are vague in places and need to provide a greater level of detail in order to be reproducible. The reviewers have also spotted a number of typos and grammatical errors that need to be corrected. In addition to this, when indicating the number of CFU/ml, is it possible that the numbers should be 10^2, 10^4 or similar, rather than 102, 104, etc.? Please …
Thank you for submitting your manuscript to Access Microbiology. It has now been reviewed by two experts in the field, whose comments are attached at the bottom of this email. They both agree that this is a valuable contribution to the field, however the manuscript needs further work and amendments. The results and discussion sections are currently hard to follow, and this lack of readability can affect the understanding of the study. Furthermore, the bioinformatic and experimental methods are vague in places and need to provide a greater level of detail in order to be reproducible. The reviewers have also spotted a number of typos and grammatical errors that need to be corrected. In addition to this, when indicating the number of CFU/ml, is it possible that the numbers should be 10^2, 10^4 or similar, rather than 102, 104, etc.? Please provide a revised version of the manuscript addressing the reviewers' concerns (along with a tracked-changes document) and a point-by-point response to the reviewers' comments within 2 months. Individual Reviewer Comments to Author (Editor's Copy)
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Comments to Author
The authors have presented work on the important topic of antibiotic resistant UTIs in pregnant women in Southwestern Uganda. The manuscript details a well-designed study that meets the objectives presented at the outset of this work. However, the comparison of the phenotypic and genotypic results need further work to ensure that the correct messages are being conveyed. Comparing ESBL gene co-carriage within isolates will also provide greater insight as to how well ESBL genes act as predictors for the ESBL resistant phenotype, which is of clinical importance. Major comments: The materials and methods section lacks detail in places, which hinders the reproducibility of this work. Please address the following: Line 90: "reported or did not report" is a confusing criterion, please explain further. Line …
Comments to Author
The authors have presented work on the important topic of antibiotic resistant UTIs in pregnant women in Southwestern Uganda. The manuscript details a well-designed study that meets the objectives presented at the outset of this work. However, the comparison of the phenotypic and genotypic results need further work to ensure that the correct messages are being conveyed. Comparing ESBL gene co-carriage within isolates will also provide greater insight as to how well ESBL genes act as predictors for the ESBL resistant phenotype, which is of clinical importance. Major comments: The materials and methods section lacks detail in places, which hinders the reproducibility of this work. Please address the following: Line 90: "reported or did not report" is a confusing criterion, please explain further. Line 102: please explain how the "adequate" number of samples was determined. Line 109: how was your threshold for significance determined? Line 111: please quantify what is "noticeable" bacteriuria. Is this significant and dubious or doubtful? Just significant? Line 128: please quantify what a "pronounced difference" is. Line 131: what was the minimum difference to define a "smaller" zone of inhibition? How were inhibition zones measured? Line 133: please state the predetermined threshold and explain how it was determined. Figure 2 shows important data and could be made a lot clearer. Please order the species from highest ESBL-producing prevalence to lowest and ensure that no species names are cut off on the x axis labels. These also need to be italicised. The title can be removed and added to the figure caption which needs to be more descriptive. Y axis label needs clarification, please change to "Number of ESBL producers". Similarly for Figure 3, the title should be removed and added to the figure caption which needs to be more descriptive. Axis labels are needed e.g. "ESBL gene" and "Number of ESBL producing isolates". Check for consistent capitalisation throughout figure. The choice of terminology in the genotypic characterisation section (line 204 onwards) makes the results very hard to follow and needs to be rewritten. Please refer to isolates in terms of phenotype and genotype, i.e. "positive ESBL producing bacteria" are "ESBL producers" and isolates with a blaTEM gene are "blaTEM-positive isolates" for example. I am also not convinced by the conclusion that "blaTEM genes are essential for the genotypic analysis of ESBL generation" if they are only present in half of the ESBL producing isolates. Careful consideration of wording is needed when describing results: "Most of the blaSHV genes… …we found, were negative.". A gene itself cannot be negative, but an ESBL producing isolate can be negative for the blaSHV gene. This is a recurring theme in this results section that needs to be addressed. Similarly, on line 217 "highest numbers of negatives for all the encoding genes" needs to be rephrased to say highest numbers of genotype negative but phenotype positive isolates" and so on. The discussion provides some thoughtful insights but lacks detail in places. Line 277-278: explain why regular screening would be important. Line 284-286: why would we do genotypic testing when you have shown in your work that these are poor predictors of the ESBL resistant phenotype? The Conclusion section largely repeats what has already been said in the discussion so both are not needed. I would recommend replacing parts of the text from the discussion section with that of the conclusion section. Minor comments: Please ensure consistent formatting/capitalisation of "extended-spectrum beta-lactamase". Sometimes there are hyphens, sometimes there are not (e.g. lines 1, 64), sometimes the symbol for beta and sometimes the word beta is used. The best way to avoid this would be to make use of the acronym once it has been defined on line 55 of the manuscript. Line 28: "We conducted a cross-sectional study", missing "a". Please italicise "bla" in all gene names: lines 32, 35, 36, 139. Please ensure to italicise all species names: lines 33, 34, 116, 261. Please capitalise Gram on lines 54 and 115 (Gram-negative, Gram staining) Line 56: typo "therapies". Line 60: odd reference formatting, please fix. Line 63: change "population" to "populations". Line 74: please provide further details on what an increase is. I.e. changed from X to Y or provide a percentage increase value for a specified time period. Line 93: think a word is missing here - two months/weeks prior maybe? Line 142: temperature. Line 148: Reformat oC to °C. Line 177: "Most participants" is an overstatement (only 27.9%). Please change this. Line 184: how have you defined the ESBL producing organisms? If it is phenotypic characterisation, please state method, e.g. combined disk test. Line 187-188: please unitalicized "species" (x2) Line 188: please change to "the least frequent ESBL producing organism was Proteus mirabilis". Line 206: please add number "(n = 101)" for number of ESBL producing bacteria for clarity. Tables 2, 3, and 4: unitalicize "species" after Klebsiella. Add 'species' after Morganella and Providencia for consistency. Line 216: missing word "were the most common ESBL producing" Line 229-231: please explain the referenced findings (provide numerical information and state what 'variations in percentages' were exactly). Line 235: please add quantitative measure for "high resistance". Line 246-247: this statement seems to contradict the findings shown in Figure 3 - were the most common genes not blaTEM followed by blaCTX-M? (looking at the gene positive counts). Please check this. Line 276: please correct double .. Line 287: "resistant genes" should be "resistance genes". The abbreviations DHO, FRC, REC, and WHO (lines 322-329) are stated but not used in the manuscript so please remove these. E. coli does also not need to be listed here. CDT should be added.
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Poor
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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