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Journal of A pplied Sciences Res earch, 5(10): 1298-1306, 2009 © 2009, INSInet Publication Synergistic Effect of Antibiotics and Plant Extract to Control Clinical Bacterial Isolates Implicated in Urinary Tract Infections 1 Ghaly, M.F., 2Shalaby, M.A., 3Shash, S.M.S., 3Shehata, M.N. and 3Ayad, A.A. 1 Botany Department, Faculty of Science, Zagazig University, Egypt. Immunology & Microbiology Department, Faculty of Medicine, Zagazig University, Egypt 3 Botany Department, Faculty of Science, Benha University, Egypt. 2 Abs tract: A total 100 u rin e s a mples were collected from patients examinated for urinary tract infection in Zagazig Univers ity hos pitals , Urology Department, Egypt. A pos it ive bacterial growth on CLED, M acConkey's agar and nutrient agar was detected. E. coli was the mos t pre d o min a n t p a t hogen caus ing urinary tract infection in pos itive s amples (40%) followed by Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus saprophyticus and Pseudomonas aeruginosa were pres ent percentage 22, 15, 13 and 10% res pectively. A ntibiotic s ens itivity tes t for Gram-pos itive and negative bacte ria s howed that the antibiotic ofloxacin is more effective agains t clinic a l b acterial is olates (58%) followed by amikacin (54%), chloramphenicol (52%), norfloxa c in (51%) and azithromycin (48%). The effect of medicinal plant extracts agains t highly res is tant b a c t e ria l is olates s howed that, the clove, ros emary, peppermint, hibis icus , thyme and cinnamon s howed s trong inhibitory action agains t tes ted is olates . The combination between ofloxacin and amikacin with clove plant extract s howed that the clearly s ynergis tic effect was obtained agains t tes ted clinical bacterial is olates . The protein band of P. aeruginosa, P. mirabilis and K . p n e u m o n i ae of normal growth (con t ro l) a nd under s tres s of combined of ofloxacin and clove extract s howed new protein bands appeared as res is tant protein to treatment s tres s . The active pure clove s ubs tance s howed antibacterial activity was identified by 1 HNM R and IR as eugenol s tructure. Key words : A ntibiotics , plant extract clinical bacteria urinary tract Infections INTRODUCTION Urinary tract infection (U T I) remains the mos t common reas on for outpatients t o s eek medical care and for inpatients t o d evelop nos ocomial infections . Nos ocomial UTIs account for up to 40% of all hos pital-acquired infe ctions . The as s ociated morbidity and mortality are the major d rain on hos pital re s ources [3 0 ]. Females are however believed to be mo re affected than males except at the extremes of life; this is a res ult of s horter and wider urethra [8] . T h e mos t common caus e of UTI is Gram-negative bacteria that be long to the family Enterobacteriaceae. M embers of th is family include Escherichia coli, Klebsiella, Enterobacter, and P r oteus. A ls o the Gram-pos itive Sta phylococcus saprophyticus plays a role in the bacterial panorama, es pecially among young women. E. coli dominates as caus ative agent in all patient groups . In un complicated UTIs , 80-90% are caus ed by E. coli [2 0 ]. In complicated U TIs , E. coli is les s prominent but s till the major caus ative agent [2 5 ]. Conventional drugs us ually provide effective ant ibiotic therapy for bacterial infections but there is an increas ing problem of antibiotic res is tance and continuing need for n ew s olutions [1 9 ]. The etiology of UTI and the an t ibiotic res is tance of uropathogens have been changing over the pas t years , b o t h in community and nos ocomial infection [2 4 ]. The us e of plant extra c t t o treat infections is a n old practice in a large part of the world , es pecially in develop ing countries , where there is dependence on t raditional medicine for a variety of dis eas es [1 1 ]. Numerous res earches s howed that the es s ential oils and plant extracts have potential in me d ic a l p ro c e d u re s a n d a p p lications in t h e pharmaceutica l, cos metic and food indus try [1 3 ]. Hers ch et al.[1 4 ] found that Cinnamomum verum, Origanum vulgare and Thymus vulgari s extracts , s howed the highes t and broades t antibacterial activities agains t 189 Gram-negativ e and 135 Gram-pos itive pathogenic bacteria is olated from p ediatric patients s howed res is tance to s elected antibiotics . Syzygium aromaticum have many th e ra p eutic us es ; they relieve pain, control naus ea and vomiting improve diges tion, protect agains t internal p a ras ities and act as antimicrobial agents agains t fungi and bacteria caus e uterine contractions and are s trongly antis eptic [6]. A bout four grams of Syzygium aromaticum are boiled in three liters of water until half the water has evaporated. This water, t a ken in draughts , will s low down s evere s ymptoms of cholera [1 8 ]. In general medicine, Syzygium aromaticum Corresponding Author: Ghaly, M .F., Botany Department, Faculty of Science, Zagazig University, Egypt. 1298 J. App. Sci. Res., 5(10): 1298-1306, 2009 is us ed as an agent agains t flatulence, s tomach dis tens ion and gas tro-intes tinal s pam[1 0 ]. Eugenol a main cons tituent of the es s ential oil obtained from commonly cons umed s pecies s uch as Pime n t a r a cemosa, Cinnamomum verum and Syzygium aromaticum is us ed as antis eptic, antibacterial, analges ic agent in traditional me d ical practices [1 2 ]. Eugenol is a phenolic compound, which it is the main component of clo v e plant, with the antimicrob ia l d ata agains t is olated bacterial organis ms . Caryophyllene has als o been s how n to pos s es s antimicrobial properties , which obtained as s econd cons tituents obtained from plant [3]. The aim of th e pres ent s tudy to evaluate the antibiotics action agains t b a c terial pathogens to UTI by us ing different medicinal plant extract combined w it h antibiotics to minimize the dos e and duration of antibiotics us ed. Determination the protein ban d s of bacterial under s tres s of antibiotic combined with the plant e xtract and identified the mos t active s ubs tance purified from active medicinal plant as eugenol. MATERIALS AND METHODS The pres ent s tudy is conduc t e d on 100 urine s amples were taken from patie nts who were examinated for UTIs in Zagazig Univers ity hos pitals (inpatients ) or attending Zagazig Un ivers ity clinics (outpatients ), Urology Department, thes e s amples were collected from A pril 2007 to A u gus t 2007. A pos itive bacterial growth on CLED , M acConkey's agar and nutrient agar, the diagnos is of UTIs in urine s amples was bas ed on the pres ence of $ 105 CFU o f microorganis ms per ml in urine culture [7]. A ls o, pres ence of more than 5 pus cells per high po w e r field in an uns pun urine in male, and more than 10 p u s cells in a female, and is defined as pyuria [2 6 ]. High number of p u s c e lls in urine, or pyuria, us ually indicates infection. Bacterial is olates were identified a c cording to the ke y o f (Be rg e y 's M a n u a l) of Determin a t iv e Bacterio logy [1 5 ]. A ll s trains of bacteria is olated were tes ted for antimicrobial s ens itivity by s tandardized dis c diffus ion technique, which was done as des crib e d by Bauer et a l . [5]. Take one colony from each is olated bacterial is olates by s terile loop th e n inoculated into 5 ml s terile nutrient broth and incubate for 24 h o urs at 37 o C, then make turbidity eq u a l 0.5 M c ferland s tandard s alin (0.05 ml barium chloride + 9.95 ml s ulfuric acid)[4]. Each broth inocula were applied b y s terile s wabs on M uller-Hinton agar plates ; two pla t e s were us ed fo r each is olates in which antibiotics dis cs were applied to the s u rface of plates at cons tant dis tances . The antibiotic s us ed in this experiment were penicillin-G (P.G) (10µg), ampicillin (A M ) (10µg), a zit h romycin (A ZM ) (15µg), norflo xa c in (N O R) (10µg), ofloxacin (O F X ) (5µg), amikacin (A K) (30µg), 1299 chloramphenicol (C) (30µg), cefotaxime s odium (CT X) (30µg). The p la t e s were incubated at 37 o C for 24h. The inhibition zones were meas ured with a millimeter ruler. The entire d ia meter of inhibition zone was meas ured including the diameter of the dis c. The e nd p o int of the reading was taken as complete inhibitio n of the growth to the naked eye [2 9 ]. The antibiotics , ofloxacin, amikacin were s elected according to s ens itivity of different bacterial is olates to determine the M IC and M BC agains t tes ted bacterial is o la t e s n a me ly E. coli, Klebseilla, P r o t e u s , Pseudom o nase and Staphylococcus, according to Lowry,[2 2 ]. The medicinal plant extracts were prepared according to Huang et al.,[1 6 ]. Bacterial protein e xt raction was performed according to Saxena et al.,[2 7 ], w h ere protein content were extracted and d e t e rmined in treated bacteria (combination between M IC of ofloxacin for each tes ted o rg anis ms and extract of Syzygium aromaticum) and control (non-treated) bacteria. Spectros copic analys is of the purified antimicrobial s ubs tances obtained from Syzygium a r omaticum by TLC method was performed by M icroanalytical Center of Cairo Univers ity, Egypt. Th e infra-red (IR) s pectrum of the active fraction wa s d e termined in potas s ium bromide (KBr)[2 1 ]. Infra-red s pectrophotometer is model PYE Unicum SP1100 USA . A ls o, the active frac t ion was determined in Dimethyl s ulfoxide (DM S O ) us ing n u c lear magnetic res onance (H-NM R)[2 8 ]. Nuclear magnetic res onance is model Gemini-200 1 HNM R. RES ULTS AND DIS CUS S ION The urine s amples have been collected from different ages o f males and females . The res ults in Fig. (1) indicated that the number of contaminated urine s amples collected from males an d females were 100 s amples , 40 contaminated with E. c o l i , 22 of Proteus mirabilis, 15 o f Klebsiella pneomoniae, 13 of Staphylococcus saprophyticus and 10 of Pseudomonase aeru g inosa. So the highes t percentage of dis tribution are found in E. coli (40.0%) follo w e d by Proteus mirabilis (22.0%), Klebs i ella pneomoniae (15.0%), S t a p h y l o c o c c u s s a p r o p h y t i c u s (13.0% ) a n d Pseudom o n a s e aeruginos a (10.0%). Out of the (87.0%) of all is olates that belong to Gram-n e g ative organis ms , Enterobacteriaceae cons titute the main grou p (77.0%), while Pseudomonas aeruginosa w as res pons ible for only (10.0%) of the infection. (13.0%) of the is olates belong to the Gram-pos itive cocci; Staphylococcus saprophyticus. M ady and Helmi,[2 3 ] found that 83.1% of all is olates belong to Gram-negative organ is ms . Out of thes e, Enterobacteriaceae c o ns titute the main group (79.0% of all is olates ), while Pseudomonas a e r u ginosa was res p ons ible for only (4.1%) of the infection. J. App. Sci. Res., 5(10): 1298-1306, 2009 Fig. 1: The dis tribution number of pathogenic bacterial is olates from UTI patients . (15.2%) of the is olates belong to the Gra m-pos itive pathogens , and the mos t common was Entero coccus s pp (9.0%). Candida spp. cons tituted only 1.7% of the is olates ; thes e res ults were in agreement wit h our pres ent res ults . The s ens itivity tes t res ults agains t bacterial is olates in Fig. (2) and photos No. (1) s hown t hat the antibiotic ofloxacin is more effective agains t is olated pathogenic bacterial organis ms , which the percentage of s ens itive organis m reach to 58.0% follo wed by amikacin 54.0%, c h lo ra mp h e n ic o l 52.0% , n o rflo xa c i n 5 1.0% , a zithromycin 48.0%, ampicillin 11.0%, cefot a xime s odium 2.0% and penicillin-G 0.0%. The antibiot ic a mikacin s how intermediate effect agains t is olated pathogenic bacterial organis ms , which the percentage of organis m re ach to 27.0% followed by azithromycin 13.0%, cefotaxime s odium 12.0%, chloramp h enicol 10.0%, ofloxacin 7.0%, norfloxacin 5.0%, ampicillin 1.0% and penicillin-G 0.0%. On the other hand, the antibiotic penicillin-G has n't any effect again s t is olated pathogenic bacterial organis ms , which the percentage of res is tance organis m rea c h t o 100.0% followed by a mp ic illin 88.0% , c e fo t a xime s odiu m 86.0% , n o rflo xa c i n 4 4 . 0 % , a z i t h r o m y c i n 3 9 . 0 % , chloramphenicol 38.0%, ofloxacin 35.0% and amikacin 19.0%. A deyemo and s ome colleagues reported that while all urinary is olates were poorly s us ceptible to t rimethoprim-s ulphamethoxazole and ampicillin, they exhibited good s us c e p t ib ilit y t o nalidixic acid, nitrofurnation and ofloxacin [2]. The pres ent s tudy s howed that the s us ceptibility rat e of urinary is olates was highes t for meronem (76.19%), followed by amikacin (70.27%), nitrofurantion (66.60%), norfloxacin (64.28%) and gentamicin (58.33%)[1]. Thes e res ults go in line with our res ult s , where it des cribed that all urinary is olates were poorly s us ceptible to ampicillin, b ut exhibited good s us ceptibility to ofloxacin, amikacin and norfloxacin. Fifteen bacterial is olates and The mos t two effective ant ib iotics were chos en to perform M IC and M BC tes t, where the res u lt s in Table (1) indicated that 1300 the maximum M BC w e re obtained at ofloxacin antibiotic which recorded 250 µg/ml agains t P. aeruginosa number 96 & 42, K. pneumoniae number 93 and Proteus mirabilis number 43 & 55, and the lowes t M BC were obtained 31.25 µg/ ml at E. coli number 7 and Staphylococcus sapr ophyticus number 76. M BC equal to M IC which recorded 250 µg/ml & 125 µg/ml o f o floxacin agains t P. aeruginosa number 42 & E. coli number 65 res pect iv e ly. The res ults indicated that t h e ma ximum M BC were obtained at amikacin antibiotic which recorded 250 µg /ml agains t E. c o l i n u mber 24, 65 & 72, P. aeruginosa number 42, K. pneumo n i a e number 93 and Proteus mirabilis number 47 & 55, and the lowes t M BC were obtained 62.5 µg / ml at E. coli number 7 and Staphylococcus saprophyt i c u s number 9 & 76. M BC equal to M IC which recorded 250 µg/ml of a mikacin agains t E. coli n u mber 24, K. pneumoniae number 93 followed by P. aeruginosa number 96, Pro t eus mirabilis number 43 & 45 and E. coli number 69 which re corded 125 µg/ml followed by Staphylococcus saprophyticus number 9 & 76 which recorded 62.5 µg/ml. A n attempt was made to tes t the antagonis tic effect of different medicin a l plant extracts (ros emary, orange peel, ga rlic, lemon gras s , peppermint, s pearmint, h ib is c u s , ma rjoram, thyme, tilia, clove, fennel, cinnamon, cas tor plant, ginger a n d chamomile), as cold water extract, boiled water extract and a lc o h olic extract agains t fifteen c lin ical bacterial is olates . The res ults in Fig. (3) and photos No. (2) illus trated that ros emary, le mon gras s , peppermint, hibis cus , clove, marjoram, thyme, cinnamon, cas tor plant and chamomile were mos t effective plants extracts agains t s elected pathogens (Escherchia coli, Klebsi e l la pneumoniae, Proteus m i r a b i l is, Pseu d o mo n a se a eru g in o s a a n d Staphyloccocus saprophyticus). However in three cas es (cold water, boiled w a ter and alcohol extract), ginger was the lowes t effective plant extracts . Orange peel and fe n nel were mos t effective only in cas e of alco h o l extract, low effective in cas e of boiled w a t e r extract, a n d n o t effective in cas e of cold water extract. M ore over J. App. Sci. Res., 5(10): 1298-1306, 2009 Fig. 2: The s ens itivity tes t of pathogenic bacterial is olates agains t different antibiotics drugs . Photos No. 1: A ntibiotic s us ceptibility of bacterial is olates by dis c diffus ion method. A K = amikacin; PG = penicillin -G; CTX = cefotaxime s odium; OFX = ofloxacin; NOR = norfloxacin; A M = ampicillin; A ZE = azithromycin & C = chloramphenicol. M i n i mum inhibitory concentrations (MICs) (µg/ml) and minimum bactericidal concentrations (MBCs) of ofloxacin and ami k aci n antibiotics. Parameters Ofloxacin Amikacin --------------------------------------------------------------------------------------Bacterial isolates No. (MIC) (µg/ml) (MBC) (µg/ml) (MIC) (µg/ml) (MBC) (µg/ml) E. coli 7 7.82 31.25 31.25 62.5 S. saprophyticus 9 7.82 62.5 62.5 62.5 E. coli 24 62.5 125 250 250 P. aeruginosa 42 250 250 125 250 P. mirabilis 43 125 250 125 125 P. mirabilis 45 62.5 125 125 125 P. mirabilis 47 62.5 125 125 250 P. mirabilis 55 125 250 125 250 E. coli 65 125 125 125 250 E. coli 69 62.5 125 125 125 E. coli 72 62.5 125 125 250 S. saprophyticus 76 7.82 31.25 62.5 62.5 P. mirabilis 85 15.63 62.5 62.5 125 K. pneomoniae 93 125 250 250 250 P. aeruginosa 96 125 250 125 125 Table 1: garlic was the mo s t effective in cas e of cold water and alcohol extract, a n d n ot effective in cas e of boiled water extract. Spearmint and tilia haven't any effect a g a in s t bacteria. However in three cas es (cold water, boiled water and alco h o l e xtract). The pres ent s tudy illus trates that thyme, ro s e mary, 1301 caraway and dianthus are mos t effectiv e plant extracts agains t s elected pat h ogens (E. coli, K. aerogense, P. aeruginosa). In two c a s e s , water and a lc o hol extract. Clove extract had potent a n t imicrobial activity agains t the entire Gramnegative J. App. Sci. Res., 5(10): 1298-1306, 2009 Fig. 3: Sens itivity of bacterial is olates agains t cold water, boiled water and alcoholic plant extracts . Photos No. 2: Sens itivity of bacterial is olates agains t cold water, boiled water and alcoholic plant extracts . 1- Ros emary, 2- Chamomile, 3- Thyme, 4- Cinnamon, 5- Ginger, 6- Orange pe e l, 7- Peppermint, 8- M a rjo ra m, 9- Fennel, 10- Lemon gras s , 11- Cas tor plant, 12- Hibis cus , 13- Tilia, 14- Spearmint, 15- Garlic, 16- Clove. 1302 J. App. Sci. Res., 5(10): 1298-1306, 2009 and Gra m-pos itive organis ms tes ted (S. aureus, Enterococcus cloacae, Salmonella paratyphi, Klebsiella pneumoniae, E. coli, C i t robacter spp, and Candida albicans [3]. The res ults in Tables (2 and 3) and photos No. (3, 4) illus trated that there is s ynergis m between the combination of clove extract and antibiotics (ofloxacin and amikacin), but there is n't s ynergis m between the combination of garlic extract and antibiotics (ofloxacin and amikacin). This s tudy with agree with our s tudy where it illus trated that clove extract s how s ynergis m with ofloxacin but no s yn e rg is m between garlic extract and ofloxacin [1 7 ]. The clinical bact e ria l is olates P. aeruginosa 42, P. mirabilis 55, K. pneumoniae 93 we re g row on nutrient a g a r as control and on nutrient agar with antibio t ic ofloxacin with concentrations (125, 62.5 & 62.5) µg/ml res pectively combined with clove extract (boiled water extract) to determine protein band at control and treated bacteria, the res ults in photo (5) indicated that there are many protein bands induced a n d other dis appeared if compared with control. The res ults obtained from s pectrum analys is 1 HNM R of compound s howed s ignals at 3.8(d, 2H, CH2 ), 5(t, 2H, =CH2 ), 6(m, 1H, -CH=), 6.5-6.8(m, 3H, A r H's ) and at 8.6(S, 1H, OH); as illus trated in Fig. (4). IR of compound s howed broa d band at 3500 cm-1 corres ponding to –OH gro u p and band at 1518 cm-1 corres ponding to C=C, in addition to O-C band a b s o rp tion at 1099 cm-1 ; as illus trated in Fig. (5). Thes e data corres ponding to eugenol s tructure. Table 2: Combination effect between different medicinal plant extracts and MICs of ofloxacin against bacterial isolates Bacterial isolates No. Ofloxacin MICs Diameter of inhibition zones (mm) of medicinal plant extracts ----------------------------------------------------------------------------------------------------------------------------------------Rosemary Garlic Clove Castor plant Peppermint Hibiscus µg/ml IZ IZ IZ IZ IZ IZ IZ E. coli 7 7.8125 12 14 12 13 12 12 12 S. saprophyticus 9 7.8125 12 10 11 15 ND ND 15 E. coli 24 62.5 12 15 ND 18 13 14 15 P. aeruginosa 42 250 15 17 15 18 11 15 17 P. mirabilis 43 125 15 15 12 23 ND 25 20 P. mirabilis 45 62.5 12 22 15 20 ND 17 20 P. mirabilis 47 62.5 12 ND 12 18 12 13 16 P. mirabilis 55 125 15 15 12 20 11 20 22 E. coli 65 125 14 17 12 15 14 13 18 E. coli 69 62.5 11 15 ND 19 ND 15 14 E. coli 72 62.5 15 ND 16 17 11 10 12 S. saprophyticus 76 7.8125 15 15 18 18 17 11 23 P. mirabilis 85 15.625 15 10 12 20 ND 10 20 K. pneomoniae 93 125 13 23 10 20 23 21 20 P. aeruginosa 96 62.5 12 14 12 18 10 15 14 Table 3: Combination effect between different medicinal plant extracts and MICs of amikacin against bacterial isolates. Bacterial isolates No. Amikacin MICs Diameter of inhibition zones (mm) of medicinal plant extracts ------------------------------------------------------------------------------------------------------------------------------------------Rosemary Garlic Clove Castor plant Peppermint Hibiscus µg/ml IZ IZ IZ IZ IZ IZ IZ E. coli 7 31.25 12 12 16 15 12 12 14 S. saprophyticus 9 62.5 12 15 10 16 12 14 13 E. coli 24 250 12 11 11 20 13 14 13 P. aeruginosa 42 125 10 14 12 15 11 14 18 P. mirabilis 43 125 12 15 12 19 19 14 13 P. mirabilis 45 125 10 12 14 15 13 12 15 P. mirabilis 47 125 11 12 11 18 13 14 22 P. mirabilis 55 125 13 13 10 18 22 15 12 E. coli 65 125 13 16 ND 15 17 15 15 E. coli 69 125 10 13 ND 17 10 12 20 E. coli 72 125 12 15 ND 15 ND 10 14 S. saprophyticus 76 62.5 13 22 26 25 15 20 27 P. mirabilis 85 62.5 10 14 10 18 ND 12 17 K. pneomoniae 93 250 13 15 ND 16 15 12 20 P. aeruginosa 96 125 15 18 12 19 13 12 21 T he pres ent s tudy illus trates that the compound res pons ible for the clove aroma is eugenol. It is the main component in the es s ential oil extracted from 1303 cloves , compris ing 72-90%. Eugenol h a s pronounced antis eptic, antimicrobial and anaes thetic properties [9]. J. App. Sci. Res., 5(10): 1298-1306, 2009 Photos No. 3: Combina t io n b e t w e en medicinal plants extracts and ofloxacin antibiotic s us ceptibility of bacterial is olated by dis c diffus ion method. Photos No. 4: Combination between medicin a l p la n t s e xtracts and amikacin antibiotic s us ceptibility of bacterial is olated by dis c diffus ion method. 1- Garlic, 2- Clove, 3- Ros emary, 4- Peppermint, 5- H ib is cus , 6- Cas tor plant, 7- M IC of ofloxacin or amikacin. Photos No. 5: Protein analys is for clinical bacterial is o la t e s b e fo re a n d after s tres s by comination between ofloxacin and clove extract 1- M arker. 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