[Downloaded free from http://www.urologyannals.com on Tuesday, March 25, 2014, IP: 41.237.218.158] || Click here to download free Android application for this journal

Letter to Editor usage of broad spectrum antibiotics leading to selective survival 2. Steadman R, Topley N. The virulence of Escherichia coli in urinary tract. advantage of pathogens. In: Brumfitt W, Jeremy MT, Hamilton Miller, editors. Urinary tract infections. 1st ed. London: Chapman and Hall; 1998. p. 37‑41. 3. Barton LL, Walentik CW. Citrobacter diversus urinary tract infection. Am J The emergence of this usually rare organism as the third Dis Child 1982;136:467‑8. most common urinary pathogen, which is resistant to 4. Lipsky BA, Hook EW 3rd, Smith AA, Plorde JJ. Citrobacter infections in commonly available antibiotics is alarming. The indiscriminate : experience at Seattle Veterans Administration Medical Centre and review of literature. Rev Infect Dis 1980;2:746‑60. use of antimicrobial agents and frequent genitourinary 5. Whitby JL, Muir GG. Bacteriological studies of urinary tract infection. Br J instrumentation are possibly responsible for this situation. Urol 1961;33:130‑4. Many such infections could be prevented by selective judicious 6. Murray PR, Holmes B, Aucken HM. Citrobacter, Enterobacter, Klebsiella, use of urinary catheters as well as careful attention to underlying Plesiomonas, Serratia, and other members of the . In: Borriello SP, Murray PR, Funke G, editors. Topley and Wilson’s abnormalities in the urinary tract and by continuously Microbiology and Microbial Infections. 10th ed. London: Hodder Arnold; evaluating susceptibility pattern of uropathogens to traditional 2005. p. 1474‑506. as well as new antimicrobials in well‑defined populations and 7. Clinical and Laboratory Standards Institute performance standards for antimicrobial susceptibility testing. Fifteenth informational supplement. limiting inappropriate and injudicious use of antibiotics so as Wayne, PA: CLSI document; 2005. M100‑S15. to prevent further emergence of drug resistance. 8. Gales AC, Jones RN, Gordon A, Sader HS, Wilke WW, Beach ML, et al. Activity and spectrum of 22 antimicrobial agents tested against urinary tract infection pathogens in hospitalized patients in Latin America: Report 1 Basavaraj C. Metri, P. Jyothi, Basavaraj V. Peerapur from the second year of the SENTRY Antimicrobial Surveillance Program Department of Microbiology, BLDEU’s Shri B M Patil Medical (1998). J Antimicrob Chemother 2000;45:295‑303. College, Bijapur, 1Department of Microbiology, RIMS, Raichur, India

Address for correspondence: Access this article online Dr. Basavaraj V. Peerapur, Quick Response Code: Department of Microbiology, Website: RIMS, Raichur, Karnataka, India. www.urologyannals.com E‑mail: [email protected]

REFERENCES DOI: 10.4103/0974-7796.120295 1. Cox CE. Nosocomial urinary tract infections. Urology 1988;32:210‑5.

Commentary

Citrobacter: An emerging health care associated urinary pathogen

Hospital‑acquired urinary tract infection (UTI) is the prevalence of antimicrobial resistance among urinary pathogens commonest health care associated infection (nosocomial has increased worldwide due to uncontrolled and indiscriminate infection) accounting for 35‑40% of the total health care antibiotic usage.[2] Adding to it, certain pathogens which were infections, thus posing a serious health threat.[1] Also, the isolated sporadically have now emerged as prominent health care associated pathogens. Access this article online Quick Response Code: The author reports the emergence of Citrobacter as a common urinary pathogen in hospitalized patients. The Website: Citrobacter was discovered in 1932 by Werkman and Gillen. www.urologyannals.com These organisms are found in , water, intestinal tract of animals, and in clinical samples. Members of the genus Citrobacter are gram‑negative, non‑sporing rods belonging

Urology Annals | Oct - Dec 2013 | Vol 5 | Issue 4 313 [Downloaded free from http://www.urologyannals.com on Tuesday, March 25, 2014, IP: 41.237.218.158] || Click here to download free Android application for this journal

Letter to Editor to family Enterobacteriaceae and, as the name suggests, carbapenemase‑2 (KPC‑2) production and decreased porin usually utilize citrate as a sole carbon source. The genus now expression.[8] Carbapenems are important antibiotics for the consists of 11 genomospecies separable by their biochemical treatment of health care associated infections and have a special characteristics. Out of them, C. koseri has been associated with role in treating infection with ESBL‑producing organisms. The cases of neonatal and brain abscess and C. freundii emergence and spread of resistance to carbapenems will end all with gastroenteritis, neonatal meningitis, and septicemia.[3] the treatment options available for treating multidrug‑resistant It is known to cause health care associated infections of the pathogens. urinary tract, respiratory tract, blood, and other normally sterile sites in the body. The chief cause is a weak and attenuated In conclusion, the emergence of this usually rare organism as immune system and functioning of the body. A frail immune a common nosocomial urinary pathogen is alarming. As the system makes the body more vulnerable and predisposed to drug options are limited in the current scenario, injudicious C. freundii, thus triggering UTI or intestinal infection or and inadequate use of antibiotics should be avoided, at least till meningitis. Hospitalized patients, especially those who have scientists worldwide find some new revolutionary drug which been hospitalized for a prolonged period of time, are more can counter all these drug resistance mechanisms. Till then, vulnerable to C. freundii infections. studies like this should be carried out in different institutes as the prevalence and antibiotic susceptibility patterns vary The authors have conducted a retrospective study and have enormously even in different institutes of the same geographic reported Citrobacter spp. as the third most common urinary area. Infection control practices should be observed strictly and pathogen accounting for 9.4% of the total isolates. The any type of unnecessary instrumentation should be avoided. isolation of this organism was associated with catheterization, genitourinary instrumentation, or obstructive uropathy. Also, the K. P. Ranjan, Neelima Ranjan age group most affected was that of elderly hospitalized patients, Department of Microbiology, G. R. Medical College, especially males. Their finding emphasizes the role of this Gwalior, Madhya Pradesh, India organism as a common health care associated pathogen. Recently, Address for correspondence: a study conducted in Nepal also reported Citrobacter spp. as the Dr. K. P. Ranjan, second most common urinary pathogen in their study.[4] Department of Microbiology, G. R. Medical College, Gwalior, Madhya Pradesh, India. Although Citrobacter spp. are less commonly isolated, they E‑mail: [email protected] are emerging as a common nosocomial multidrug‑resistant REFERENCES pathogen, especially in developing countries. UTI caused by Citrobacter spp. have been seen in 12% patients in 1961, 1. Kalsi J, Arya M, Wilson P, Mundy A. Hospital‑acquired urinary tract infection. and since then, its prevalence has been increasing.[5] Invasive Int J Clin Pract 2003;57:388‑91. 2. Bonadio M, Meini M, Spetaleri P, Gilgi C. Current microbiological and clinical procedures like catheterization or genitourinary instrumentation aspects of urinary tract infections. Eur Urol 2001;40:439‑45. seem to assist the organism in colonization and infection of 3. Murray PR, Holmes B, Aucken HM. Citrobacter, Enterobacter, Klebsiella, urinary tract. Another matter of concern is the emergence Plesiomonas, Serratia, and other members of the enterobacteriaceae. of multidrug‑resistant Citrobacter spp., resulting in reduced Topley and Wilson’s microbiology and microbial infections. 2010, Edward Arnold, London. therapeutic options which further complicate the situation. 4. Baral P, Neupane S, Marasini BP, Ghimire KR, Lekhak B, Shrestha B. The author also reported that most of the isolates were High prevalence of multidrug resistance in bacterial uropathogens from resistant to penicillins, , aminoglycosides, and Kathmandu, Nepal. BMC Res Notes 2012;5:38. fluoroquinolones, which are the commonly prescribed drugs 5. Whitby JL, Muir GG. Bacteriological studies of urinary tract infection. Br J Urol 1961;33:130‑4. in UTI. Resistance to many groups of antibiotics has been 6. Shobha KL, Gowrish Rao S, Rao S, Sreeja CK. Prevalence of extended observed and many mechanisms of drug resistance have been spectrum Beta-Lactamases in urinary isolates of Escherichia coli, Klebsiella demonstrated in Citrobacter spp. In a study concluded by and Citrobacter and their antimicrobial susceptibility pattern in a tertiary care hospital. Indian J Practising Doctor 3:2007-01- 2007-02. Shobha et al., Citrobacter spp. was the third most common 7. Rizvi M, Fatima N, Shukla I, Malik A. Epidemiology of extended spectrum urinary pathogen and 30% of the isolates were extended b‑lactamases in Serratia and Citrobacter species in North India. Indian J spectrum beta lactamase (ESBL) producers.[6] Meher Rizvi et Pathol Microbiol 2010;53:193‑4. al. reported that 62.2% of Citrobacter isolates were producing 8. Zhang R, Yang L, Cai JC, Zhou HW, Chen GX. High‑level carbapenem [7] resistance in a clinical isolate is due to a combination ESBL. High level carbapenem resistance was also reported of KPC‑2 production and decreased porin expression. J Med Microbiol in C. freundii due to combination of Klebsiella pneumoniae 2008;57:332‑7.

314 Urology Annals | Oct - Dec 2013 | Vol 5 | Issue 4