Skip to main content

Biofilm and hemagglutinin formation: a Hallmark for drug resistant uropathogenic Escherichia coli



Urinary tract infection (UTI) is one of the most frequent disease encounters in pregnant mothers, and the most drug resistant, biofilm and hemagglutinin producer Uropathogenic Escherichia coli (UPEC) is the major etiologic agent. Therefore, the aim of this study was to assess the association between the antimicrobial resistance, and biofilm and hemagglutinin production of Uropathogenic Escherichia coli.


UTI among the study participants was 27.3%; and UPEC was found the major etiologic agent followed by coagulase negative staphylococcus. Risk factors, previous history of catheterization and previous history of UTI were found significantly associated with UTI, recurrent UTI, drug resistance and biofilm formation. Of the tested antibiotics, nitrofurantoin was the most effective drug for UPEC. Nearly 100% of the biofilm producers were resistant to norfloxacin, cotrimoxazole, and gentamicin.


UTI is one of the major bacterial infections worldwide and about 50% of women experience at least one episode during their lifetime [1,2,3]. Nearly 25% [4] and 44% [5] of women develop recurrent UTI within 12 months following acute infection, resulting an estimated prevalence of 150 million cases globally per year [4]. Recurrent UTI contributes significantly to UTI associated morbidity and demands huge resources [4, 5]. For example, in the United States of America (USA), more than 7 million people visit health institutes every year and the costs to manage it reaches approximately over $1 billion every year [6]. Moreover, UTI is among the highest antibiotics prescribed diseases in the health institutions around the worldwide [7, 8].

Though there is no enough and well documented data in developing, a few studies indicated that UTI is one of the top causes of morbidity [9,10,11]. A community based study in Nigeria showed that the prevalence of UTI is about 13%, of which majority of this was due to UPEC [12]. Likewise, in Ethiopia, very limited studies indicated the same trend with other developing countries. A study done at Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia indicated that the overall prevalence of UTI is 23.32%, where E. coli was the major isolate [13, 14]. Other studies at Felge Hiwot Referral Hospital, Bahirdar and Hawassa Referral Hospital, also showed that the prevalence of UTI was 30.2% [14] and 48% [15] respectively. Furthermore, the burden of UTI is not only morbidity, mortality and economic impact at individual and nationwide, but it also incurs a huge antibiotic consumption and hence one of the causes for increasing drug resistance to the commonly prescribed drugs [1].

Over 80% [9, 10] of the etiologic agent of UTI is UPEC [16]. Frequently, the patient’s own intestinal flora is the source of infection [6, 9]. In addition to the ability of UPEC to firmly attach to the urinary bladder and kidney, biofilm formation is also considered another pathogenic determinant, which allows UPEC to persist for a long time in the urinary tract and interfere with bacterial elimination [17]. Biofilms can define as structured bacterial communities embedded in a self-produced exopolysaccharide matrix adherent to any abiotic or biological surface [12, 18]. Currently, antimicrobial resistance is one of major health threats and it is even more in developing countries, where no strict drug monitoring program. The problem is very much significant in UTI; as the major cause (UPEC) is one of the most drug resistant pathogens.

The microbes have evolved a number of mechanisms to evade antimicrobial therapy and the most important way for UPEC is the ability to form the biofilm [19]. Biofilm endows bacteria with several advantages, such as the acquisition of antibiotic tolerance, expression of several virulence factors and increased resistance against phagocytosis and other host defense mechanisms [18]. Studies comparing biofilm positive versus biofilm negative UPEC strains showed that, drug resistance was significantly higher in vitro biofilm formers than non-former [3, 18]. Other studies also indicated that more UPEC drug resistance was observed in strains which produce hemagglutinin [9]. Therefore, the objective of the study was to assess if the very drug resistant nature of UPEC is associated with biofilm formation and hemagglutinin production.

Main text


This cross-sectional study was conducted to assess the association between antimicrobial resistance and biofilm formation and hemagglutinin production of the most eminent drug resistant Uropathogenic pathogens at Mekelle University, College of Health Sciences, Ayder Comprehensive Specialized hospital, Antenatal Care (ANC) Clinics from December 2017 to August 2018. Using a structured questionnaire-based interview, demographic and clinical data were collected from 323 study participants. Training was given to data collectors on how to collect the midstream urine and data. The midstream urine was collected using wide-mouthed and clean container and transported to Mekelle University, College of Health Sciences, Medical Microbiology laboratory within 1 h of collection and cultured to isolate the etiologic agents. The specimen was cultured on CHROMaga, at 37 °C for 24 h aerobically. The bacterial isolates were further identified by standard biochemical tests [1, 2]. On the UPEC isolates, hemagglutination test was performed by mixing one drop of bacterial suspension with one drop of 3% blood group “O” red blood cells in phosphate-buffered saline (PBS) with and without 3% mannose [4, 6]. Biofilm formation was also tested by Congo red agar (CRA) method. The culture media contain brain heart infusion broth 37 g/L, sucrose 50 g/L, agar10 g/L and Congo red 8 g/L. Plates were inoculated and incubated aerobically for 24 h at 37 °C [5, 6].

On Muller Hinton agar, Kirby-Bauer disc diffusion assay was carried out to determine the antimicrobial susceptibility profiles [3]. Based on the frequency of drug prescription in the study area, the following antibiotics (Oxoid UK) were included: amoxicillin: 30 mg, gentamicin: 10 mg, cefotaxime: 30 mg, nalidixic: acid 30 mg, ciprofloxacin: 5 mg, ofloxacin: 5 mg, norfloxacin: 10 mg, erythromycin: 15 mg, oxacillin: 5 mg, vancomycin: 30 mg, nitrofurantoin: 300 mg and tetracycline: 30 mg. Quality control strains; S. aureus (ATCC 25923) and E. coli (ATCC 25922) were used as a quality control for culture and susceptibility testing throughout the study. Data analysis was done by SPSS Ver. 20 and descriptive and multivariate analysis was performed. Those variables which were statistically significant, (p < 0.05) in bivariate logistic regression were moved to multivariate logistic regression.


A total of 323 pregnant women with symptomatic of UTI were included in this study. Median age of the study subjects were 24 ± 5.4 years old and 297 (91.9%) were urban residents (Table 1). Among the study subjects, 283 (87.6%) were married, and about 176 (54.5%) were house wives. Regarding educational status, about 47 (13.2%) and 55 (17%) of them were illiterate and attended college education (Table 1).

Table 1 Socio-demographic characteristics of the study participants in Ayder Comprehensive Specialized Hospital December 2017–August 2018 (n = 323)

Of the total, bacteriuria was detected in 87 (26.9%) of the study participants. In multivariate analysis previous history of UTI (AOR = 7.057, 95% CI (5.269, 18.654), P = 0.002) and previous history of catheterization (AOR = 2.870, 95% CI (1.516, 9.122), P = 0.003) were significantly associated with UTI. Though the number of patients with previous history of catheterization were small 23 (7.1%), it was found significantly associated with UTI (P = 0.03). Variables like marital status, residency, education status, other chronic diseases like diabetic mellitus and previous hospitalization were not showed a significant association with UTI (Table 2).

Table 2 Bivariate and multivariate logistic regression analysis of factors associated with UTI among pregnant women attending ANC clinic of ACSH, December 2017–August 2018

Five bacterial species were isolated and of these with significant bacteriuria, 94.8% were had a single isolate, while the remaining 5.2% were dually infected. Out of the total isolates, E. coli was the major isolated, which is followed by coagulase negative staphylococci (CoNS), S. aureus, and K. pneumonia. Majority of the isolates were gram negative uropathogens and the resistance rate against Ciprofloxacin, Tetracycline, Trimethoprim-Sulfamethoxazole, Ceftriaxone, Amoxacillin-Clavulinic acid, Norfloxacin, Cotrimoxazole, Cefotaxime, Amikacin, Gentamicin; range from 27.0 to 100%. However, all Gram-negative bacterial isolates were showed relatively low level of resistance to nitrofurantoin (3.8%) and ceftazidime (17%).

The leading isolate UPEC, showed high level of resistance to Ampicilin 13 (33.3%) and tetracycline 9 (23.1%). On contrary, 76.5% of the UPEC were relatively sensitive to ceftazidime and norfloxacin each, followed by nitrofurantoin (96.2%). K. pneumoniae isolates were 96% resistant to, Gentamicin, Amoxacillin-Clavulinic acid and Trimethoprim-Sulfamethoxazole. Other drugs like Norfloxacin, Amikacin, Nitrofurantoin, Ciprofloxacin, Ceftriaxone, Cefotaxime, Ceftazidime and Ampicillin were resistant to 60.0% of K. pneumonia isolates. All the UPEC isolates (n = 39) were tested for biofilm formation and hemagglutins production. Of these, hemagglutin and biofilm formation were detected in 38 (97.4%) and 24 (61.5%) respectively. In this study, 23 (96%) of the biofilm producing UCEC isolates were found Multi-drug Resistant (MDR). More interestingly, all biofilm producing UPEC were found 100% resistant to antibiotic like norfloxacin, cotrimoxazole, and gentamicin. However, nitrofurantoin was found to be 98% effective to the biofilm producing UPEC. On multivate analysis biofilm and hemagglutins producing UPEC isolates were significantly associated with being MDR (P = 0.002).


The prevalence of UTI in our study was 27.3% and this in agreement with a study done in Addis Ababa 23.3% (25), Nigeria 25.3% [20], Cameroon 23.5% [11], Bar-Dar (30.0%) and lower than the other studies in Dire Dawa 14.4 [21, 22], Tanzania 14.6% [23] and Brazil (15.7%) [24]. On the contrary, our finding was higher from studies done in Bahir Dar 9.5% [21] and Addis Ababa 11.6% [13]. The difference might be due to geographical difference and sample size effect. In addition, the health care system provision, especially the antenatal services are improving from time to time and hence, the time differences might be also the possible explanation for disparities between our result and the reports earlier reports from Ethiopia. In our study, the predominant etiologic agent of UTI was UPEC and this is in agreement with almost all studies done around the world [3, 19, 24, 25].

Previous history of UTI and history of catheterization were significantly associated with UTI and that is similar to studies reported from Bahir Dar [26], and Pakistan [27]. The possible justification for this may be, due to empirical treatment and overuse of drugs. However, maternal age, residence, educational level, marital status and occupation are variables which did not show a significant association with UTI and this was in agreement with reports from Bahir Dar [26], Gondar [14], Sudan [28] and Tanzania [23].

As a result of absence of appropriate diagnostic tools for diagnosis and drug susceptibility testing plus extensive use empirical treatment, development of drug resistance is vertically raising [18]. In our case drug resistance is defined as; if an isolate is resistant to two or more different chemical classes, then we considered as MDR isolate. In the present study, 76.7% of the isolates were found MDR and this was higher than a study report from Addis Ababa, Tikur Anbesa Specialized Hospital [25] and lower than the findings from Gondar [14] and Dire Dawa [22] and might be justified by the frequent and inappropriate use of antibiotics.

Adhesionis is a crucial and primary step for UPEC to establish and cause disease along the urinary tract and this is mediated by type 1 fimbriae. Adhesion to the epithelial cells is very important to resist the host immune response and ascend to the upper parts of the urinary tract. In our study, UPEC positive for hemagglutinin formation were significantly associated with MDR (p = 0.001) and with recurrent UTI (p = 0.01); and this was in agreement with a study conducted in India [18]. Different studies report that the ability of UPEC to cause recurrent UTI is because of their ability to form biofilm on the epithelial layer of urinary tract and inanimate plastic materials. In our study, biofilm formation was detected in about 61.7% and this is in agreement with studies conducted in India (22), and lower than another study conducted in India [29]. The relationship between being drug resistant and biofilm formation was showed a statistically significant relationship (P = 0.02), and this was in agreement with the studies conducted in India [18]. Moreover, in the present study, biofilm formation was significantly associated with history of catheterization and history of previous UTI, which implies, biofilm could be one of the main factors for UPEC to develop drug resistance. However, UPEC was found uniquely sensitive to nitrofurantoin and hence it could be the best choice of drug for patient suffering from recurrent UTI and for those who failed to respond to the current treatment regimen.


The present study did not address the different serotypes of E. coli.

Availability of data and materials

All generated data are included in this article.



antenatal Care


congo red agar


multi-drug Resistant


phosphate-Buffered Saline


urinary tract infection


uropathogenic Escherichia coli


United States of America


  1. Köves B (2014) The role of bacterial virulence factors in the clinical course of urinary tract infections. Ph.D. Thesis. Department of Microbiology, Immunology and Glycobiology. Institute of Laboratory Medicine. Lund University, Lund, Sweden

  2. Sivick KE, Mobley HL. Waging war against uropathogenic Escherichia coli: winning back the urinary tract. Infect Immun. 2010;78(2):568–85.

    Article  CAS  Google Scholar 

  3. Totsika M, Gomes Moriel D, Idris A, A Rogers B, J Wurpel D, Phan MD, et al. Uropathogenic Escherichia coli mediated urinary tract infection. Curr Drug Targets. 2012;13(11):1386–99.

    Article  CAS  Google Scholar 

  4. O’Hanley P. Prospects for urinary tract infection vaccines. Urinary tract infection: molecular pathogenesis and clinical management. 1996:405–425.

  5. Hilbert DW, Paulish-Miller TE, Tan CK, Carey AJ, Ulett GC, Mordechai E, et al. Clinical Escherichia coli isolates utilize alpha-hemolysin to inhibit in vitro epithelial cytokine production. Microbes Infect. 2012;14(7–8):628–38.

    Article  CAS  Google Scholar 

  6. Langermann S, Möllby R, Burlein JE, Palaszynski SR, Gale Auguste C, DeFusco A, et al. Vaccination with fimh adhesin protects cynomolgus monkeys from colonization and infection by uropathogenic Eschevichia coli. J Infect Dis. 2000;181(2):774–8.

    Article  CAS  Google Scholar 

  7. Wilson ML, Gaido L. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis. 2004;38(8):1150–8.

    Article  Google Scholar 

  8. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002;113(1):5–13.

    Article  Google Scholar 

  9. Momtaz H, Karimian A, Madani M, Dehkordi FS, Ranjbar R, Sarshar M, et al. Uropathogenic Escherichia coli in iran: serogroup distributions, virulence factors and antimicrobial resistance properties. Ann Clin Microbiol Antimicrob. 2013;12(1):8.

    Article  CAS  Google Scholar 

  10. Cusumano CK, Pinkner JS, Han Z, Greene SE, Ford BA, Crowley JR, et al. Treatment and prevention of urinary tract infection with orally active fimh inhibitors. Sci Transl Med. 2011;3(109):109ra115–109ra115.

    Article  Google Scholar 

  11. Gupta K, Hooton TM, Stamm WE. Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections. Ann Intern Med. 2001;135(1):41–50.

    Article  CAS  Google Scholar 

  12. Blango MG, Mulvey MA. Persistence of uropathogenic Escherichia coli in the face of multiple antibiotics. Antimicrob Agents Chemother. 2010;54(5):1855–63.

    Article  CAS  Google Scholar 

  13. Kabew G, Abebe T, Miheret A. A retrospective study on prevalence and antimicrobial susceptibility patterns of bacterial isolates from urinary tract infections in Tikur Anbessa Specialized teaching hospital Addis Ababa, Ethiopia, 2011. Ethiop J Health Dev. 2013;27(2):111–7.

    Google Scholar 

  14. Alemu A, Moges F, Shiferaw Y, Tafess K, Kassu A, Anagaw B, et al. Bacterial profile and drug susceptibility pattern of urinary tract infection in pregnant women at University of Gondar Teaching Hospital, Northwest Ethiopia. BMC Res Notes. 2012;5(1):197.

    Article  Google Scholar 

  15. Gizachew M, Kebede M, Merid Y, Sinshaw Y, Tiruneh M, Alemayehu M, et al. Escherichia coli isolated from patients suspected for urinary tract infections in Hawassa Referral Hospital, Southern Ethiopia: an institution based cross sectional study. J Microbiol Res. 2013;1:9–15.

    Google Scholar 

  16. Totsika M, Kostakioti M, Hannan TJ, Upton M, Beatson SA, Janetka JW, et al. A fimh inhibitor prevents acute bladder infection and treats chronic cystitis caused by multidrug-resistant uropathogenic Escherichia coli st131. J Infect Dis. 2013;208(6):921–8.

    Article  CAS  Google Scholar 

  17. Forbes BA, Sahm DF, Weissfeld AS. Study guide for Bailey and Scott’s diagnostic microbiology-e-book. St Louis: Elsevier Health Sciences; 2016.

    Google Scholar 

  18. Maheswari UB, Palvai S, Anuradha PR, Kammili N. Hemagglutination and biofilm formation as virulence markers of uropathogenic Escherichia coli in acute urinary tract infections and urolithiasis. Indian J Urol. 2013;29(4):277.

    Article  Google Scholar 

  19. Fatima N, Agrawal M, Shukla I, Khan P. Characterization of uropathogenic E. coli in relation to virulence factors. Open Access Scientific reports. 2012.

  20. Iregbu K, Nwajiobi-Princewill P. Urinary tract infections in a tertiary hospital in Abuja, Nigeria. Afr J Clin Exp Microbiol. 2013;14(3):169–73.

    Google Scholar 

  21. Biadglegne F, Abera B. Antimicrobial resistance of bacterial isolates from urinary tract infections at Felge Hiwot Referral Hospital, Ethiopia. Ethiop J Health Dev. 2009;23(3):236–8.

    Google Scholar 

  22. Derese B, Kedir H, Teklemariam Z, Weldegebreal F, Balakrishnan S. Bacterial profile of urinary tract infection and antimicrobial susceptibility pattern among pregnant women attending at antenatal clinic in Dil Chora Referral Hospital, Dire Dawa, Eastern Ethiopia. Ther Clin Risk Manage. 2016;12:251.

    CAS  Google Scholar 

  23. Masinde A, Gumodoka B, Kilonzo A, Mshana S. Prevalence of urinary tract infection among pregnant women at Bugando Medical Centre, Mwanza, Tanzania. Tanzan J Health Res. 2009.

    Article  PubMed  Google Scholar 

  24. de Vasconcelos-Pereira EF, Figueiró-Filho EA, de Oliveira VM, Fernandes ACO, de Moura Fé CS, Coelho LR, et al. Urinary tract infection in high risk pregnant women. Infection. 2013;7(25):27–30.

    Google Scholar 

  25. Assefa A, Asrat D, Woldeamanuel Y, Abdella A, Melesse T. Bacterial profile and drug susceptibility pattern of urinary tract infection in pregnant women at Tikur Anbessa Specialized Hospital Addis Ababa, Ethiopia. Ethiop Med J. 2008;46(3):227–35.

    PubMed  Google Scholar 

  26. Demilie T, Beyene G, Melaku S, Tsegaye W. Urinary bacterial profile and antibiotic susceptibility pattern among pregnant women in North West Ethiopia. Ethiop J Health Sci. 2012;22(2).

  27. Haider G, Zehra N, Munir AA, Haider A. Risk factors of urinary tract infection in pregnancy. J Pak Med Assoc. 2010;60(3):213.

    PubMed  Google Scholar 

  28. Hamdan HZ, Ziad AHM, Ali SK, Adam I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital. Ann Clin Microbiol Antimicrob. 2011;10(1):2.

    Article  Google Scholar 

  29. Mittal S, Sharma M, Chaudhary U. Biofilm and multidrug resistance in uropathogenic Escherichia coli. Pathog Glob Health. 2015;109(1):26–9.

    Article  CAS  Google Scholar 

Download references


We, authors would like to thank the study participants. Furthermore, I would like to profoundly grateful to Medical Microbiology Laboratory technologists, who helped me during laboratory analysis.


This research project is funded by Mekelle University, College of Health Sciences (Grant No. 40,000.00 Eth.Birr) via the small-scale recurrent budget. The funder was not having any role the in study design, data collection, data analysis, interpretation, writing of this manuscripts.

Author information

Authors and Affiliations



DGH: Design the research, perform the research, prepare manuscript and Submit for publication; AAM: Data analysis and Manuscript editing; TAM: sample processing and laboratory analysis; SBG: Consult patient and Participants selection. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Dawit Gebreegziabiher Hagos.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Review Board of Mekelle University, College of Health Sciences; [Project No. CRPO/CHS/SM/010/09]. Permission to carry out the study was also obtained from the hospital medical director office and all were enrolled after they agreed and signed on the informed consent. We were also prepared an assent form, however all the study participants were greater than 18 years. The minimum age of the study participants were 19 years old. All records of patient were kept confidential and anonymous. Filled out questionnaires were carefully handled and access to results was kept strictly.

Consent to publish

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hagos, D.G., Mezgebo, T.A., Berhane, S. et al. Biofilm and hemagglutinin formation: a Hallmark for drug resistant uropathogenic Escherichia coli. BMC Res Notes 12, 358 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: