Multidrug-Resistant Uropathogens in Eastern Nepal: Resistance Patterns Expose Critical Gaps in National UTI Treatment Guidelines

Background Urinary tract infections (UTIs) represent a major public health burden in Nepal, exacerbated by escalating antimicrobial resistance (AMR) that critically limits therapeutic options. The increasing prevalence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) uropathogens necessitates urgent characterization of local resistance patterns to guide empirical treatment. Objectives To determine the distribution of uropathogens and delineate their antibiotic resistance profiles, with a specific focus on MDR and XDR strains, to inform evidence-based local treatment guidelines. Methods We analyzed 2,734 urine cultures collected between June 2024 and April 2025 from patients of Madan Bhandari Hospital and Trauma Center. Bacterial isolation and identification were performed using Blood Agar and MacConkey Agar. Antibiotic susceptibility testing employed the modified Kirby-Bauer disc diffusion method on Mueller-Hinton agar, strictly following Standard Operating Procedures Bacteriology 2024 V. 2.0. MDR and XDR classifications adhered to ECDC/CDC criteria. Results Significant monomicrobial growth occurred in 209 samples (7.64%). Escherichia coli (E. coli) predominated (58.37%), followed by Klebsiella spp. (31.10%). High resistance rates to first-line agents were observed: ampicillin-sulbactam ( E. coli 59.43%, Klebsiella spp. 69.23%, Staphylococcus aureus (S. aureus) 80%), cotrimoxazole ( E. coli 41.96%, Klebsiella spp. 29.03%, S. aureus 85.71%), and ciprofloxacin ( E. coli 43.48%, Klebsiella spp. 46.15%). Overall, 22.96% of isolates were MDR and 7.65% were XDR. Meropenem demonstrated high efficacy ( E. coli 77.57% sensitive, S. aureus 100% sensitive). Doxycycline also showed good activity ( E. coli 78.57%, Klebsiella spp. 63.64%, S. aureus 100% sensitive). Nitrofurantoin was effective against E. coli (81.08% sensitive) but less so against Klebsiella spp. (57.89% resistant). Piperacillin-tazobactam was uniformly effective against S. aureus (100% sensitive) but exhibited low sensitivity against Klebsiella spp. (41.27%). Conclusion This study reveals alarmingly high resistance to first-line antibiotics among predominant uropathogens in Nepal, coupled with a substantial burden of MDR and XDR strains. Significant divergence exists between national empirical treatment protocols and both regional AMR patterns and Nepal’s surveillance data, potentially compromising clinical efficacy. Revising treatment guidelines to integrate local resistance data and strengthening antimicrobial stewardship are critical steps toward optimizing patient outcomes and containing emerging MDR/XDR threats.