Pakistan Journal of Medical Sciences


ISSN 1681-715X





Volume 23

January - March 2007

Number 1


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Ciprofloxacin resistance among bacterial isolates in a
teaching hospital in Riyadh Saudi Arabia 2001-2005

Hanan Ahmed Habib Babay1


Objective: To present trends of resistance to ciprofloxacin among common organisms isolated at King Khalid University Hospital (KKUH) between 2001-2005.

Methods: Ciprofloxacin susceptibility of all isolates of Gram negative and Gram positive organisms were retrospectively obtained during the period from 2001-2005 in KKUH. Data from intensive care unit (ICU) and non-ICU patients were separately analyzed.

Results: Escherichia coli (E.coli) resistance increased from 10% in 2001 to 22% in 2005. Enterobacter cloacae (Ent.cloacae) resistance decreased from 11-14% in 2003 -2004 to 7% as in 2001 and 2005. Klebsiella pneumoniae ( K.pneumoniae) resistance fluctuated from 6% in 2002 and 2003, 13% in 2004 to 6% in 2005. Pseudomonas aeruginosa ( P.aeruginosa ) resistance ranged from 7% - 8% during this study period while that of Acinetobacter spp. ranged between 45% to 62% and Staphylococcus aureus ( S.aureus) resistance doubled from 18% in 2001 to 39% in 2005. None of Streptococcus pneumoniae (S.pneumoniae) isolates showed resistance to ciprofloxacin. Isolates of E .coli, Acinetobacter spp. and S.aureus from non-ICU patients showed higher resistance to ciprofloxacin than isolates from ICU patients while K.pneumoniae and P.aeruginosa showed higher resistance from ICU patients than isolates from non-ICU patients.

Conclusion: Ciprofloxacin resistance among many Gram negative species and S.aureus is an increasing threat among many Gram negative species and S.aureus in our hospital in both ICU and non-ICU patients.

KEY WORDS: Ciprofloxacin resistance, E.coli, K.pneumoniae, Ent.cloacae, P.aeruginosa, Acinetobacter spp, S.aureus, S.pneumoniae, Intensive care unit, Misuse of antibiotics.

Pak J Med Sci January - March 2007 Vol. 23 No.1  39-42

1. Dr. Hanan Ahmed Habib Babay
Associate Professor, Consultant Medical Microbiologist
Department of Pathology, Microbiology Unit
King Khalid University Hospital
Riyadh, Saudi Arabia

Dr. Hanan A.H.Babay
Department of Pathology,
Microbiology, (32)
King Khalid University Hospital,
PO Box 2925,
Riyadh – 11461,
Saudi Arabia.

* Received for Publication: April 17, 2006
* Accepted: September 14, 2006


Ciprofloxacin is a potent broad spectrum fluoroquinolone antibacterial agent. Prior to its use resistance was rare.1 Since its introduction in the treatment of a broad range of clinical conditions such as the treatment of urinary tract infections and upper respiratory tract infections and as a prophylaxis of neutropenic patients as well as its use in veterinary medicine, resistant strains started to emerge.2,3 A major point of medical concern is the recent emergence of ciprofloxacin resistance among E.coli and other Enterobacteriaceae.1,4,5 Despite being a restricted antimicrobial agent in KKUH we have recently observed an increase in resistance to ciprofloxacin among many Gram negative and Gram positive bacteria in this hospital. In this study we aimed to highlight trends of resistance to ciprofloxacin among common organisms isolated in KKUH between 2001-2005.


This study was conducted at the microbiology laboratory at KKUH, Riyadh, Saudi Arabia. KKUH is a 700 bed hospital which provides a primary, secondary and tertiary health care and has five different ICUs. Ciprofloxacin susceptibility of all commonly isolated Gram negative organisms (E. coli, K.pneumoniae , E. cloacae, P.mirabilis, P.aeruginosa , Acinetobacter spp. ) and Gram positive organisms (S.aureus and S.pneumoniae ) were retrospectively obtained from a hospital computer system during the period from 2001-2005. Repeat isolates from the same patient were excluded. Data from ICU and non-ICU patients were then analyzed separately. Identification and susceptibility testing were carried out by the MicroScan Walk Away 96 system (Dade Behring Inc., West Sacramento, CA95691, USA). Intermediately susceptible strains were considered resistant.


Table-I depicts percentage resistance to ciprofloxacin of Gram negative and Gram positive isolates recovered from specimens at KKUH between 2001-2005. For E.coli, resistance increased from 10% in 2001 to 22% in 2005. Resistance of E.cloacae fluctuated from 11-14% in 2003- 2004 respectively, to 7% in 2005. That of K.pneumoniae changed from 6% in 2002 and 2003 to 13% in 2004 and reduced to 6% in 2005. P.aeruginosa resistance to ciprofloxacin showed gradual increase since 2001 (7%) till 2004 (10%) but decreased to 8% in 2005. A significant rise in resistance of Acinetobacter spp. was observed (45% in 2001 and 62% between 2003 and 2005). S.aureus (both oxacillin sensitive and resistant) resistance to ciprofloxacin doubled from 18% in 2001 to 39% in 2005. None of the S.pneumoniae isolates were resistant to ciprofloxacin during this five year study period. Table-II shows ciprofloxacin resistance from ICU and non-ICU patients. It demonstrates more numbers and higher resistance of E.coli and Acinetobacter spp. from non ICU patients compared to ICU patients. It also showed higher K.pneumoniae and P.aeruginosa resistance was among ICU patients compared to non–ICU Patients. S.aureus resistance was higher among ICU patients during 2002 and 2005 (78% and 51% respectively) compared to 2003 and 2004 (33 and 30% respectively). Most of the ciprofloxacin resistance from ICU was from adult patients during this study. However, there were considerable percentages of resistance to ciprofloxacin among E.coli strains from peadiatric ICU patients in 2002 17(41%).


Ciprofloxacin resistance among E.coli, P.aeruginosa, Acinetobacter spp and S.aureus appears to be increasing in our hospital. This could be due to increasing consumption of ciprofloxacin and other fluoroquinolones.5 Al-Lawati et al estimated a ciprofloxacin consumption equivalent to 33 days per 100 hospital discharges in Oman.6 Increasing ciprofloxacin consumption particularly in ICU leads to selection of resistant mutants among nosocomial pathogens since fluoroquinolones are particularly greater selectors of resistance among aminoglycosides, carbapenems, or other β-lactams and these resistant strains can more easily spread than strains resistant to other drugs.7 Our results showed increasing trend of resistance of E.coli, and Acinetobacter spp as well as S.aureus to ciprofloxacin .These results are comparable with studies from United States, France, Germany, Italy , Spain, Canada and Taiwan.5,7-10 A disturbing trend is development of cross resistance to other fluoroquinolones which are introduced into hospital use.5 In this study, a point of particular importance is that Acinetobacter spp. is becoming a common pathogen isolated from non- ICUs. These organisms showed higher resistance to ciprofloxacin in both ICU and non-ICU patients. There was also cross resistance of these isolates to other agents including: cefepime, carbapenem, piperacillin-tazobactam and aminoglycosides. The importance of these facts could be more clear if linked to the cases in previous studies.7 The percentage of P.aeruginosa resistance in ICU setting increased from 67% in 2002 to 78% in 2005, which is more than the 30% reported by Villegas et al.11 An interesting finding is that there was considerable ciprofloxacin resistance in E.coli among paediatric ICU patients although ciprofloxacin is rarely used in children. This could be explained by acquisition of resistant strains in the gastrointestinal tract via the food chain without exposure to the antibiotic as reported before.5 Furthermore, introduction of quinolones in veterinary medicine in Saudi Arabia has been associated with increase in E.coli resistance in poultry clinical isolates.3 Prevalence of fluoroquinolone resistance among S.pneumoniae was reported to be between 2.6-7% particularly among elderly patients reflecting increased ciprofloxacin use in this age group particularly to treat respiratory infections.9,12 Our S.pneumoniae isolates showed no ciprofloxacin resistance, this may be due to the use of penicillin, third generation cephalosporins and vancomycin for the treatment of pneumococcal infections in our hospital. Ciprofloxacin resistance among our S.aureus isolates (approximately 33%) is comparable to that reported in 2000-2002 from United States 51%, Canada 24.1%, Italy 58.6%, Germany 26.1% and France 40.5% respectively.8 Cohen et al reported strains of methicillin resistant S.aureus minimum inhibitory concentration 128µg/ml to ciprofloxacin, this indicates that ciprofloxacin is becoming less effective for treatment of infections caused by this organism.13 This resistance may be due to more than one resistance mechanisms present in a single strain of S. aureus as reported by Kaatz et al. This can be selected at high frequency.14

In conclusion, ciprofloxacin resistance is a growing threat among many Gram negative species as well as S.aureus in our hospital in both ICU and non-ICU patients. The increasing and promiscuous use of this agent is an important risk factor. The best approach to control the growing resistance is to control the use of ciprofloxacin and other fluoroquinolones use coupled with adherence to infection control measures to prevent spread of such resistant strains among patients. Surveillance of resistance pattern of prevalent strains and reduction of antibiotic consumption are essential for hospital prescribing policy and use of antibiotics.


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2. Chaslus- Dancla E, Martel JL, Carlier C, Lafont JP, Courvalin P. Emergence of aminoglycoside 3- N- acetyltransferase IV in Escherichia coli and Salmonella typhimurium isolated from animals in France. Antimicrob Agents Chemother 1986;29:239-43.

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