Molecular Characterisation of nfsA Gene in Nitrofurantoin Resistant Uropathogens

Majority of Urinary Tract Infections (UTI's) are lower UTI's which constitute the real burden in the primary care setting and are usually treated empirically. Nitrofurantoin is an underused antimicrobial for empiric therapy for community-acquired and nosocomial lower UTIs. Nitrofurantoin has a wide spectrum of action against Escherichia coli, Klebsiella pneumonia and Enterococci, which are the frequent causes of nosocomial lower UTIs and also against multidrug-resistant gram-negative organisms including extended spectrum beta lactamase (ESBL) producers, Amp-C producers and Carbapenamase producers. The study was conducted to describe the resistance pattern of nitrofurantoin and to identify the genes responsible for nitrofurantoin resistance (i.e.) nfsA and the type of mutations involved. This study was conducted in a tertiary care hospital for a period of six months which caters to a total of 1200 beds. A total of 115 clinical strains of Escherichia coli and Klebsiella pneumoniae including ESBL and Carbapenemase producing isolates were analysed for susceptibility to commonly used antimicrobials. ESBL producers 65% and 51% of carbapenems resistant strains were susceptible to nitrofurantoin by minimal inhibitory concentration. MIC to nitrofurantoin was determined by E-strip method. Nitroreductase nfsA gene was detected by PCR in 64 of 70 E.coli isolates with reduced susceptibility to nitrofurantoin. Gene sequencing was done using BLAST algorithm and substitution (N=12) and insertion mutation (N=1) were observed in the resistant strains. Nitrofurantoin being an oral antibiotic, its usage in ESBL producers and carbapenamase producers is still warranted. Surprisingly, resistance to nitrofurantoin remains minimal even after extensive use and may be related to the fact that it has multiple mechanisms of action hence may require organisms to develop more than a single mutation to concur resistance.