Uropathogenic profiles and antibiotic resistance in gynecological cases: a microbial surveillance study from Northeast India

Abstract

Urinary tract infection (UTI) is one of the most common bacterial infections affecting women worldwide. This study investigated bacterial diversity, associated risk factors, and multidrug resistance (MDR) patterns among Gynecological patients in the northeastern region of India. A total of 896 participants were enrolled in the study. Midstream urine specimens were collected and processed using standard microbiological procedures to confirm infection. Antimicrobial susceptibility testing was performed in accordance with Clinical and Laboratory Standards Institute (CLSI) guidelines, 2022. Of the 896 participants, 278 (31.02%) were microbiologically confirmed as UTI-positive. Significant associations were observed between UTI prevalence and several risk factors, including age 18–39 years (OR 2.14, p < 0.001), previous history of UTI (OR 7.81, p < 0.001), hypertension (OR 2.75, p < 0.001), prior antibiotic use (OR 2.99, p < 0.001), and pregnancy (OR 1.96, p < 0.001). The most prevalent pathogens were Escherichia coli (62.5%) and Klebsiella pneumoniae (16.9%). Notably, E. coli, K. pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa demonstrated high resistance to fluoroquinolones, nalidixic acid, ampicillin, and cephalosporins. In contrast, these isolates showed higher susceptibility to fosfomycin, amikacin, gentamicin, ertapenem, and piperacillin/tazobactam. The findings highlight region-specific antimicrobial resistance trends and underscore the need for targeted antibiotic stewardship policies, continuous surveillance, and routine integration of microbiological testing into Gynecological practice to optimize treatment outcomes and curb the spread of resistant pathogens.

Introduction

Urinary tract infections (UTIs) are among the most common bacterial infections worldwide and are associated with significant health complications and increased healthcare expenditures¹. Globally, UTIs account for an estimated 150 million cases annually, are associated with approximately 0.26 million deaths, and impose an annual healthcare burden exceeding US $6 billion^1–3. The prevalence of UTIs is markedly higher in women, with those aged 20–50 years experiencing an approximately 50-fold greater incidence compared with men⁴.The number of UTI cases worldwide increased substantially from about 252.2 million in 1990 to over 404.6 million in 2019⁵. UTIs can lead to several serious complications, including the presence of protein in the urine (proteinuria), elevated blood pressure (hypertension), and kidney impairment due to reduced renal function².

Urinary tract infections are broadly classified into two categories: uncomplicated and complicated^6,7. Uncomplicated UTIs occur in individuals without any prominent urinary tract abnormalities and are also seen in healthy individuals. These infections are further divided into lower UTIs (cystitis), which affect the bladder, and upper UTIs (pyelonephritis), which involve the kidneys^7–10.In contrast, complicated UTIs are associated with conditions that compromise the host’s urinary system or defence mechanisms. These conditions may include urinary obstruction, neurogenic bladder disorders, immunosuppression, chronic kidney disease, renal transplantation, pregnancy, and the presence of foreign bodies, such as kidney stones, indwelling catheters, or other drainage devices^11,12. Such factors not only increase susceptibility to infection but also complicate treatment outcomes.

The global rise of antibiotic-resistant bacteria poses a severe threat to healthcare systems worldwide and is a major contributor to the increasing incidence of UTIs^13,14. The standard clinical approach to managing urinary tract infections (UTIs) relies heavily on antibiotic therapy. However, the effectiveness of this strategy is steadily declining due to the escalating prevalence of antimicrobial resistance among UTI pathogens. Moreover, the extensive and often indiscriminate use of antibiotics for these infections further accelerates the emergence of resistant bacterial strains, complicating treatment outcomes and posing a significant public health challenge^12–15.

Accumulating evidence suggests that the primary etiological agent responsible for both uncomplicated and complicated UTIs is uropathogenicEscherichia coli (UPEC)⁷. In uncomplicated UTIs, UPEC is most frequently isolated, followed by other pathogens such as Klebsiella pneumoniae, Staphylococcus saprophyticus, Enterococcus faecalis, Group B Streptococcus (GBS), Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida species^6,16,17. For complicated UTIs, the spectrum of causative agents expands, with UPEC remaining the most common pathogen, followed by Enterococcus species, K. pneumoniae, Candida spp., S. aureus, P. mirabilis, P. aeruginosa, and GBS^10,18–21.

India has experienced a significant surge in antibiotic resistance among uropathogenicEscherichia coli (UPEC) over the past decade, with resistance patterns emerging across multiple antibiotic classes. These include penicillins, cephalosporins, aminoglycosides, quinolones/fluoroquinolones, and sulfonamides^22–25. However, notable variations in resistance profiles exist within and between regions of the country^22–26.The increasing prevalence of multidrug-resistant (MDR) UPEC strains that produce extended-spectrum β-lactamases (ESBLs), metallo-β-lactamases (MBLs), and AmpC β-lactamases has become a major concern in recent years^27–30.

The Northeast region of India poses a unique context for UTI research due to its diverse population, varied healthcare access, and limited data³¹. Hence, understanding the local bacterial pathogens, AMR patterns, and clinical impacts in Northeast Indian states is crucial for guiding effective management. To date, there are only a few reports that highlight the identification and characterization of the pathogenic strains associated with the UTIs in Northeast India. In Manipur, a study at RIMS Imphal (2007) found E. coli in 72.8% of culture-positive UTIs, followed by Klebsiella spp. (14.4%), with other organisms, such as Pseudomonas and Proteus, accounting for a smaller fraction³². In 2012, a study from Silchar Medical College, Assam, found E. coli in 33.3% of isolates, with significant contributions from Staphylococcus aureus (22.2%) and Klebsiella pneumoniae (11.1%)³³. However, unlike some other regions of India, Northeast India does not yet have a robust, continuous surveillance network focused on UTIs.

The novelty of this study lies in its focused evaluation of antimicrobial resistance patterns and uropathogen diversity among younger women from Northeast India, a geographically and demographically distinct region that remains underrepresented in current epidemiological literature. While several recent studies have examined antimicrobial susceptibility patterns in general adult populations or specific high-risk groups, data specifically addressing younger female patients from Northeast India are limited. This population is epidemiologically significant due to unique sociocultural practices, patterns of healthcare access, climatic conditions, and antibiotic-usagebehaviours that may influence resistance trends. To the best of our knowledge, this is one of the early comprehensive studies from Northeast India investigating the correlation between drug resistance and the diversity of uropathogens among younger women.

Materials and methods

Study design and setting

A cross-sectional study was conducted from April 2024 to March 2025 at the Department of Microbiology, Pratiksha Hospital, Guwahati, Assam, in collaboration with the Department of Medical Laboratory Technology, The Assam Royal Global University, Guwahati. The study aims to evaluate the bacterial diversity and antibiotic resistance patterns of uropathogens in Gynecological cases in Northeast India. The involved female patients exhibited UTI symptoms in gynaecology inpatient Gynecological units, outpatient departments, and maternity wards. The private medical facility operates as a referral centre to offer specialized treatment for patients coming from Northeast India’s urban and rural areas. The study examined 896 women who received UTI diagnoses through clinical symptoms, including dysuria, increased urinary frequency, urgency, suprapubic discomfort, or fever. The study excluded patients with kidney disease, immunosuppressed conditions, or recent antibiotic use to maintain clear microbial results during resistance evaluation (Fig. 1).

Fig. 1.

Flow chart of the study design.

Sample collection and processing

The Midstream clean-catch urine samples (5–10 mL) were collected in sterile, wide-mouthed, screw-capped containers from non-catheterized patients (Fig. 1). Aseptic urine collection from catheterized patients started with cleansing catheter ports using 70% alcohol, followed by drying the area before using a sterile syringe for aspiration. Samples were properly labelled before being transported to the microbiology laboratory for examination. If immediate processing of the specimen was not feasible, the sample was placed in cold storage at 4 °C for no more than 2 h to preventmicrobial growth²⁹.

Initial screening cohort

Women presenting with clinical symptoms indicative of UTIs, such as dysuria, increased urinary frequency, urgency, suprapubic pain, fever, or cloudy/bloody urine with a strong odour, were recruited consecutively. The initial screening cohort comprised 896 symptomatic women, for whom demographic and clinical data, including age and history of UTIs, were recorded at the time of enrolment.

Culture outcomes and eligibility criteria

All urine specimens underwent standard microbiological culture. Among the 896 samples screened, 435 demonstrated significant bacterial growth and were classified as culture-positive, whereas 461 showed no significant growth and were considered culture-negative (Fig. 1). Inclusion in the analytical phase required confirmation of UTI based on significant bacterial growth from urine culture. Eligible participants include community-based patients with documented demographic details (age and gender), clinical history, and characteristic symptoms, including dysuria, increased urinary frequency, and cloudy or bloody urine with a strong odour.Culture-negative cases were excluded from the study. Among the 435 culture-positive samples, 157 were further excluded due to polymicrobial growth, fungal isolates, contamination, paediatric age, or incomplete clinical or laboratory data. After applying these criteria, 278 culture-confirmed monomicrobial bacterial infection cases were retained for final analysis (Fig. 1).

Isolation and identification of bacterial uropathogens

The collected urine samples were cultured on MacConkey and Blood agar (HiMedia, Mumbai, India) using the semi-quantitative streak plate method and incubated aerobically at 37 °C for 18–24 h. We then evaluated bacterial growth and counted the colony-forming units (CFU). We specified significant bacteriuria as having ≥ 10⁵ CFU/mL for midstream urine and ≥ 10³ CFU/mL for catheterized urine, following standard microbiological guidelines. The presumptive identification of bacteria depended on their appearance in culture media, microscopic observation, and Gram-staining results. To confirm accurate species identification, selected isolates were analysed using the VITEK 2 automated system (BioMérieux, France)³⁴.

Antimicrobial susceptibility testing (AST)

AST profiles of the bacterial isolates were conducted for each bacterium identified using the standard Kirby–Bauer disk diffusion method on Mueller–Hinton Agar (MHA) following the Clinical and Laboratory Standards Institute (CLSI) 2022 guidelines. To prepare the suspension, we took 3 to 5 colonies from a pure culture using an inoculation loop. The colonies were then emulsified in nutrient broth and mixed gently. This process was continued until the turbidity of the suspension matched 0.5 McFarland standard. Antibiotic drugs and concentrations were included to determine the antibiogram of the strains. A set of 19 antibiotic discs was selected based on the CLSI recommendations and regional antibiotic usage for gram-negative bacteria (Table 1). Multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) isolates were classified according to Magiorakos et al. based on antimicrobial susceptibility patterns interpreted in accordance with the Clinical and Laboratory Standards Institute (CLSI) M100, 32nd edition (2022)^35,36.

Table 1.

Antibiotic panel used for antimicrobial susceptibility testing of uropathogens isolated from the northeast population.

Antibiotic (disc potency)	Gram-negative Uropathogens	Gram-positive Uropathogens
Ampicillin (10 µg)	+	+
Amoxicillin/clavulanic acid (30 µg)	+	+
Benzylpenicillin (10 µg)	–	+
Oxacillin (1 µg)	–	+
Penicillin (10 µg)	–	+
Gentamicin (30 µg)	+	+
Amikacin (30 µg)	+	+
Ciprofloxacin (5 µg)	+	+
Levofloxacin (5 µg)	+	+
Norfloxacin (10 µg)	+	–
Ofloxacin (5 µg)	+	–
Nalidixic acid (30 µg)	+	–
Nitrofurantoin (300 µg)	+	+
Trimethoprim/sulfamethoxazole (25 µg)	+	+
Ticarcillin (75 µg)	+	–
Piperacillin/tazobactam (100/10 µg)	+	+
Cefalotin (30 µg)	+	–
Cefoxitin (30 µg)	+	+
Cefixime (5 µg)	+	+
Ceftazidime (30 µg)	+	–
Ceftriaxone (30 µg)	+	+
Ertapenem (10 µg)	+	–
Fosfomycin (200 µg)	+	–
Doxycycline (30 µg)	–	+
Vancomycin (30 µg)	–	+
Tigecycline (15 µg)	–	+

Table represents Antibiotic discs (with potency) used for antimicrobialsusceptibility testing (AST) of Gram-negative and Gram-positiveuropathogens isolated from the Northeast population. A total of 19antibiotic discs were selected for Gram-negative bacteria and 20 for Grampositivebacteria in accordance with Clinical and Laboratory StandardsInstitute (CLSI) 2022 guidelines and regional antibiotic usage patterns. ASTwas performed using the standard Kirby–Bauer disk diffusion method onMueller–Hinton Agar (MHA). The symbol “+” indicates antibiotics testedagainst the respective bacterial group, whereas “–” denotes antibiotics notincluded for that group.

Table 6.

Antimicrobial susceptibility pattern of gram positive uropathogens Isolates from urinary tract infections among women Northeast population.

Gram positive bacteria
Antibiotics	Staphylococcus aureus N = 12 (%)			Staphylococcus saprophyticus N = 9 (%)			Enterococcus faecalis N = 23 (%)
	R	I	S	R	I	S	R	I	S
Ampicillin	5 (41.66)	0 (0.00)	7 (58.33)	9 (100)	0 (0.00)	0 (0.00)	4 (17.40)	1 (4.34)	18 (78.26
Amoxicillin/clavulanic acid	5 (41.66)	1 (8.33)	6 (50)	1 (11.11)	0 (0.00)	8 (88.88)	4 (17.39)	3 (13.04)	16 (69.56)
Benzylpenicillin	2 (16.66)	1 (8.33)	9 (75)	9 (100)	0 (0.00)	0 (0.00)	4 (17.39)	2 (8.69)	17 (73.91)
Oxacillin	4 (33.33)	0 (0.00)	8 (66.66)	1 (11.11)	0 (0.00)	8 (88.88)	9 (39.13)	3 (13.04)	11 (47.82)
Gentamicin	3 (25)	2 (16.66)	7 (58.33)	0 (0.00)	0 (0.00)	9 (100)	13 (56.52)	3 (13.04)	7 (30.43)
Ciprofloxacin	5 (41.66)	3 (25)	4 (33.33)	3 (33.33)	1 (11.11)	5 (55.55)	14 (60.86)	2 (8.69)	7 (30.43)
Levofloxacin	5 (41.66)	1 (8.33)	6 (50)	3 (33.33)	0 (0.00)	6 (66.66)	11 (47.82)	2 (8.69)	10 (43.47)
Nitrofurantoin	4 (33.33)	2 (16.66)	6 (50)	0 (0.00)	0 (0.00)	9 (100)	1 (4.34)	2 (8.69)	20 (86.96)
Doxycycline	6 (50)	1 (8.33)	5 (41.66)	1 (11.11)	0 (0.00)	8 (88.88)	4 (17.39)	2 (8.69)	17 (73.91)
Vancomycin	2 (16.66)	1 (8.33)	9 (75)	0 (0.00)	0 (0.00)	9 (100)	3 (13.04)	4 (17.39)	16 (69.56)
Tigecycline	4 (33.33)	0 (0.00)	8 (66.66)	0 (0.00)	0 (0.00)	9 (100)	1 (4.34)	3 (13.04)	19 (82.60)
Trimethoprim/sulfamethoxazole	4 (33.33)	1 (8.33)	7 (58.33)	1 (11.11)	1 (11.11)	7 (77.77)	6 (26.08)	2 (8.69)	15 (65.21)
Piperacillin/tazobactam	4 (33.33)	3 (25)	5 (41.66)	2 (22.22)	1 (11.11)	6 (66.66)	5 (21.73)	2 (8.69)	16 (69.56)
Cefoxitin	7 (58.33)	1 (8.33)	4 (33.33)	3 (33.33)	1 (11.11)	5 (55.55)	11 (47.82)	3 (13.04)	8 (34.78)
Cefixime	6 (50)	2 (16.66)	4 (33.33)	4 (44.44)	0 (0.00)	5 (55.55)	14 (60.86)	4 (17.39)	5 (21.73)
Ceftriaxone	9 (75)	1 (8.33)	2 (16.66)	2 (22.22)	0 (0.00)	7 (77.77)	13 (56.52)	1 (4.34)	9 (39.13)
Amikacin	3 (25)	0 (0.00)	9 (75)	4 (44.44)	1 (11.11)	4 (44.44)	5 (21.73)	3 (13.04)	15 (65.21)
Penicillin	8 (66.66)	1 (8.33)	3 (25)	8 (88.88)	0 (0.00)	1 (11.11)	14 (60.86)	5 (21.73)	4 (17.39)

Table presents the antimicrobial susceptibility patterns of Gram-positivebacterial isolates (Staphylococcus aureus, Staphylococcus saprophyticus,and Enterococcus faecalis) obtained from urine samples of female patientswith urinary tract infections. Data are expressed as the number andpercentage (%) of isolates showing resistance (R), intermediatesusceptibility (I), or full susceptibility (S) to each tested antibiotic. Thefindings indicate a high prevalence of resistance to β-lactams andfluoroquinolones, particularly among S. aureus and E. faecalis, whileantibiotics such as nitrofurantoin, tigecycline, amikacin, and vancomycindemonstrated retained efficacy across all isolates.

A total of 19 antibiotic discs were selected for testing Gram-negative bacteria and 20 antibiotic discs for Gram-positive bacteria, based on CLSI recommendations and regional antibiotic usage patterns. The list of antibiotics is provided in Table 1. The plates were incubated at 37 °C for 18–24 h, and the diameters of the inhibition zones were measured using callipers. The isolates were classified as susceptible (S), intermediate (I), or resistant (R) according to the CLSI 2022 guidelines^29,37.

Quality control assessment

All the bacterial species identification and susceptibility pattern assessment were confirmed with the help of standard reference strains obtained from the American Type Culture Collection (ATCC) used for quality control. The Escherichia coli (ATCC 25922), Klebsiella pneumoniae (ATCC 700603), Pseudomonas aeruginosa(ATCC 27853), Proteus mirabilis (ATCC 29906) for gram-negative bacteria, and Staphylococcus saprophyticus(ATCC BA750), Staphylococcus aureus(ATCC 29213), and Enterococcus faecalis (ATCC 29212) gram-positive bacteria were used as reference strains. These strains were confirmed by clinical isolates to determine the performance of the VITEK 2 system for both detection and antimicrobial susceptibility testing. All test results for control strains were required to fall within established quality control ranges, as recommended by the Clinical and Laboratory Standards Institute (CLSI) guidelines, to ensure the reliability and accuracy of the results^38,39.

Ethical statement

The present study was approved by the Institutional Ethical Committee(IEC) at The Assam Royal Global University, Guwahati. Written informedconsent was obtained from all participants through designed questionnairesand personal interviews.

Statistical analysis

The study employed descriptive statistics to report data results in percentages alongside tables for presentation. All UTI patient data associated with demographic characteristics, UTI status were employed using the chi-square test or Fisher’s exact test. Univariate analysis was performed by calculating odds ratios (ORs) with 95% confidence intervals (CIs) to assess relationships between variables and infection status. Results demonstrated statistical significance (p-value < 0.05) and non-significance (p-value > 0.05). All data analyses were performed using Microsoft Excel (Ver. 2013), MedCalc (Ver. 19.3), and SPSS software version 20.0 (SPSS Inc., Chicago, IL, USA).

Results

Association of sociodemographic and clinical risk factors with UTI prevalence among women in Northeast India

A total of 896 urine samples were collected from women presenting with suspected urinary tract infections in Northeast India. Among these, 435 samples (48.55%) yielded positive bacterial cultures. The remaining samples showed either no significant growth or were culture-negative. From the 435 culture-positive specimens, cases with fungal growth, polymicrobial isolates, contamination, or incomplete clinical or laboratory data were excluded from further evaluation. After applying these exclusion criteria, 278 cases with confirmed significant monomicrobial bacterial infection were retained. These cases constituted the final analytical cohort and were subjected to detailed microbiological characterization and sociodemographic analysis.To identify potential determinants of UTI among Gynecological patients, we considered important sociodemographic and clinical variables, including age, marital status, education level, place of residence, dietary habits, history of UTI, hypertension, antibiotic use, pregnancy status, and presence of burning sensation (Table 2). These variables were evaluated for their potential association with UTI positivity, with odds ratios, 95% confidence intervals, and p-values.

Table 2.

Association of urinary tract infections with sociodemographic features among Gynecological cases in the Northeast population.

Characteristics	Total No. of UTI-positive patients (n = 278), No. (%)	Total No. of UTI-negative patients (n = 461) No. (%)	Odds ratio [95% CI]	p-value
Age in years
18–39	166 (59.71)	210 (45.55)	2. 14 (1.38–3.32	< 0.001*
40–59	77 (27.69)	156 (33.83)	1.33 (0.83–2.15)	0.22
≥ 60	35 (12.58)	95 (20.60)	1.0
Marital status
Unmarried	102 (36.69)	199 (43.16)	0.59 (0.33–1.06)	0.08
Married	151(54.31)	233 (50.54)	0.75 (0.42–1.33)	0.32
Divorced	25 (8.99)	29 (6.29)	1.0
Education
Literate	220 (79.13)	365 (79.17)	1.0
Illiterate	58 (20.86)	96 (20.82)	1.00 (0.69–1.43)	0.98
Place of residence
Urban + semi urban	191 (68.70)	297 (64.42)	1.21 (0.88–1.66)	0.23
Rural	87 (31.29)	164 (35.57)	1.0
Dietary habits
Vegetarian	32 (11.51)	63 (13.66)	1.0
Non-vegetarian	246 (88.48)	398 (86.33)	1.21 (0.77–1.91)	0.39
Previous UTI
Positive	41 (14.74)	10 (2.16)	7.81 (3.84–15.85)	< 0.001*
Negative	237 (85.25)	451 (97.83)	1.0
Hypertension
Positive	59 (21.22)	41 (8.89)	2.75 (1.79–4.24)	< 0.001
Negative	219 (78.77)	420 (91.10)	1.0
Antibiotic use
Yes	73 (26.25)	49 (10.62)	2.99 (2.00–4.46)	< 0.001
No	205 (73.74)	412 (89.37)	1.0
Pregnancy
Yes	238 (85.61)	339 (73.53)	2.14 (1.44–3.17)	< 0.001
No	40 (14.38)	122 (26.46)	1.0
Burning sensation
Yes	263 (94.60)	428 (92.84)	1.35 (0.72–2.53)	0.34
No	15 (5.39)	33 (7.15)	1.0

Table summarizes the distribution of sociodemographic and clinicalvariables among UTI-positive (n = 278) and UTI-negative (n = 461) femalepatients, along with odds ratios (OR), 95% confidence intervals (CI), and pvaluesto indicate statistical associations. Significant risk factors associatedwith UTI positivity included younger age (18–39 years), history of UTI,hypertension, pregnancy, and antibiotic use. Variables such as maritalstatus, education level, place of residence, and dietary habits did not showstatistically significant associations. These findings highlight specificvulnerable subgroups and the need for tailored interventions.

The patients’ age ranged from 18 to 89 years, with a Mean ± SD = 38.02 ± 16.37 years (Table 2) outlines the associations between various sociodemographic and clinical factors with UTI positivity. The prevalence of UTIs was significantly higher among women aged 18–39 years (59.71%), with an odds ratio (OR) of 2.14 (95% CI 1.38–3.32; p < 0.001), indicating that this age group was over twice as likely to develop UTIs compared to those aged 60 and above. The 40–59 years’ group also had an elevated prevalence (27.69%), but this did not reach statistical significance (p = 0.22).

Marital status showed no significant association with UTI prevalence, although unmarried women (36.69%) and married women (54.31%) constituted the majority of UTI-positive cases. Likewise, education level (literate vs. illiterate; p = 0.98) and place of residence (urban/semi-urban vs. rural; p = 0.23) did not significantly influence UTI risk, despite 68.70% of UTI-positive cases residing in urban or semi-urban areas. Similarly, dietary habits (vegetarian vs. non-vegetarian) were not significantly associated with UTI prevalence (p = 0.39), despite the predominance of non-vegetarians in both UTI-positive (88.48%) and UTI-negative (86.33%) groups.

Several clinical risk factors were statistically significantly associated with UTI. A history of UTI was strongly associated with current infection (14.74% vs. 2.16%; OR 7.81, 95% CI 3.84–15.85; p < 0.001), indicating a nearly eight-fold increased risk. Hypertension also emerged as a significant risk factor, with 21.22% of UTI-positive women diagnosed with the condition compared to 8.89% in the UTI-negative group (OR 2.75; p < 0.001). Furthermore, prior antibiotic use was significantly associated with UTI prevalence (26.25% vs. 10.62%; OR 2.99; p < 0.001), suggesting that recent antibiotic exposure may predispose women to infection, potentially by selecting resistant strains.

Pregnancy was another strong correlate, with 85.61% of UTI-positive patients being pregnant, showing a significant association (OR 2.14; p < 0.001) compared to non-pregnant individuals. We observed that among the 739 subjects (including culture-positive and culture-negative individuals), 577 (78.07%) were pregnant. Moreover, a high proportion of both UTI-positive (94.60%) and UTI-negative (92.84%) women reported a burning sensation during urination; however, the difference was not statistically significant (p = 0.34). This finding suggests that, despite urinary discomfort being a commonly reported clinical symptom, its presence alone does not reliably indicate the status of a urinary tract infection.Collectively, these findings indicate that younger age, a history of UTI, hypertension, pregnancy, and antibiotic use are key predictors of UTI among women in this Northeast Indian cohort in present (Table 2).

Microbial spectrum of uropathogens isolated from gynecological patients

Among the 278 culture-positive urine samples obtained from women with clinically suspected urinary tract infections (UTIs), the microbial profile revealed a striking predominance of Gram-negative bacteria. Escherichia coli emerged as the most frequently isolated uropathogen, accounting for 62.58% (n = 174) of the total isolates, thereby reaffirming its established role as the leading etiological agent of community-acquired UTIs in women.

Klebsiella pneumoniae was identified as the second most common Gram-negative isolate, representing 16.90% (n = 47), followed by Pseudomonas aeruginosa (1.79%, n = 5) and Proteus mirabilis (2.87%, n = 8). Together, these Gram-negative organisms comprised a significant majority of the uropathogenic burden. Gram-positive bacteria constituted a smaller but clinically relevant proportion of the isolates. Among them, Enterococcus faecalis was the most prevalent, detected in 8.27% of cases (n = 23). Staphylococcus aureus and Staphylococcus saprophyticus were isolated in 4.31% (n = 12) and 3.23% (n = 9) of samples, respectively. The distribution pattern, illustrated in Fig. 2; Table 3, demonstrates the microbial diversity of uropathogens encountered in Gynecological patients admitted to Pratiksha Hospital.

Fig. 2.

Prevalence of bacteria identified in urine samples among gynecological cases with urinary tract infections.

Table 3.

Prevalence of uropathogensamong the age groups of the Northeast population.

AGE
Name of bacteria (278)	< 40	≥ 40	Odds ratio [95% CI]	p-value
	N = 166 (%)	N = 112 (%)
Gram-negative bacteria
E. coli (n = 174)	109 (65.66)	65 (58.03)	1.00 (0.23–4.34)	0.99
Klebsiella pneumoniae (n = 47)	28 (16.86)	19 (16.96)	0.88 (0.18–4.14)	0.87
Pseudomonas aeruginosa (n = 5)	2 (1.20)	3 (2.67)	0.40 (0.04–3.95)	0.43
Proteus mirabilis (n = 8)	5 (3.01)	3 (2.67)	1.0
Gram-positive bacteria
Enterococcus faecalis (n = 23)	12 (7.22)	11 (9.82)	2.18 (0.43–10.90)	0.34
Staphylococcus aureus (n = 12)	7 (4.21)	5 (4.46)	2.80 (0.46–16.9)	0.26
Staphylococcus saprophyticus (n = 9)	3 (1.80)	6 (5.35)	1.0

Table illustrates the prevalence of Gram-negative and Gram-positiveuropathogens among female UTI patients stratified by age group (<40 yearsand ≥40 years). The data include the number and percentage of isolates,along with odds ratios (OR), 95% confidence intervals (CI), and p-values.Escherichia coli was the most prevalent organism in both age groups, with anumerically higher frequency among women aged <40 years, however, thisassociation was not statistically significant (OR 1.00, 95% CI 0.23–4.34; p= 0.99). Other pathogens, including Klebsiellapneumoniae, Pseudomonasaeruginosa, Proteus mirabilis, Staphylococcus aureus, Staphylococcussaprophyticus, and Enterococcus faecalis, were also distributed withoutstatistically significant differences across age groups

Age-specific distribution of uropathogens among women with UTIs

The comparative distribution of uropathogens across two age groups: women below 40 years old and those aged 40 years or older, who tested positive for 278 UTIs, revealed that E. coli was the most frequently identified pathogen in both age groups (Table 3). E. coli was the most frequently identified uropathogen in both age groups. It was numerically more prevalent among women aged < 40 years (n = 109, 65.66%) than among women aged ≥ 40 years (n = 65, 58.03%). However, this difference was not statistically significant. Klebsiella pneumoniae, the second most frequently isolated Gram-negative bacterium, showed similar prevalence across age groups, at 16.86% among women under 40 years and 16.96% among those aged 40 and above, with no significant statistical association (p = 0.87). Other Gram-negative pathogens, such as Pseudomonas aeruginosa and Proteus mirabilis, were relatively rare in both groups. P. aeruginosa was slightly more common in older women (2.67%) than in younger ones (1.20%), while Proteus mirabilis exhibited a low but uniform prevalence in both age categories (3.01% vs. 2.67%).

Among Gram-positive bacteria, Enterococcus faecalis was more frequently isolated from women aged 40 years and older (9.82%) than from those under 40 (7.22%), although this association was not statistically significant (p = 0.34). Similarly, Staphylococcus aureushad nearly equal prevalence across the two age groups (4.21% vs. 4.46%; p = 0.26). Notably, Staphylococcus saprophyticushad a higher prevalence among older women (5.35%) than among younger women (1.80%), but this difference was not statistically significant.Overall, the data reaffirm E. coli as the leading uropathogen with a distinct age-related pattern favouring younger women.

Multidrug resistance profiles of uropathogens isolated from gynecological patients

To investigate the antimicrobial resistance patterns among Gram-positive and Gram-negative uropathogens, a high prevalence of multidrug resistance (MDR) is observed (Table 4). Escherichia coli (E. coli) demonstrated the highest resistance among Gram-negative bacteria, with 56 (32.18%) isolates exhibiting (≥ R5) multidrug resistance, followed by 67 (38.50%) isolates exhibiting (R4) antibiotic resistance. The MDR profile of Klebsiella pneumoniae isolates showed significant results, as 51.06% of them exhibited resistance to (≥ R5) antibiotics. The five Pseudomonas aeruginosa isolates exhibited full resistance against five different antibiotics. Gram-positive bacteria showed Staphylococcus aureus to have the strongest resistance among them, since 9 out of 12 (75%) isolates demonstrated resistance to (≥ R5) antibiotics. The bacterial strain Enterococcus faecalis exhibited five or more antibiotic resistance properties in 11 (47.82%) clinical isolates. The antibiotic resistance level of Staphylococcus saprophyticus was moderate, based on two (22.22%) isolates showing resistance to (≥ R5) antibiotics.

Table 4.

Antibiotic resistance pattern of gram-positive and gram-negative bacterial isolates from gynecological cases in the Northeast population.

Antibiotic resistance pattern
Bacterial Isolates	Total	R0	R1	R2	R3	R4	≥R5
Antibiotic resistance pattern of Gram-negative bacteria
E. coli	174	6 (3.44)	3 (1.72)	18 (10.34)	24 (13.79)	67 (38.50)	56 (32.18)
Klebsiella pneumoniae	47	0 (00)	0 (00)	2 (4.25)	6 (12.76)	15 (31.91)	24 (51.06)
Pseudomonas aeruginosa	5	0 (00)	0 (00)	0 (00)	0 (00)	0 (00)	5 (100)
Proteus mirabilis	8	0 (00)	0 (00)	0 (00)	2 (25)	3(37.5)	3 (37.5)
Antibiotic resistance pattern of Gram-positive bacteria
Enterococcus faecalis	23	0 (00)	0 (00)	3 (13.04)	3 (13.04)	6 (26.08)	11 (47.83)
Staphylococcus aureus	12	0 (00)	0 (00)	0 (00)	0 (00)	3 (25)	9 (75)
Staphylococcus saprophyticus	9	0 (00)	0 (00)	0 (00)	5 (55.5)	2 (22.22)	2 (22.22)

Table demonstrates theAntibiotic resistance profiles of Gram-negativeand Gram-positive bacterial isolates from urine samples of Gynecologicalpatients with UTIs in Northeast India. Resistance was categorized based onthe number of antibiotics to which each isolate was non-susceptible: R0 (noresistance), R1–R4 (resistance to 1–4 antibiotics), and ≥R5 (resistance tofive or more antibiotics, indicative of multidrug resistance). The tablehighlights a high prevalence of multidrug-resistant strains, particularlyamong Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa,and Staphylococcus aureus, indicating the growing challenge ofantimicrobial resistance in this clinical population.

Multidrug resistance pattern among gram-negative uropathogenic bacteria

The Multidrug resistance pattern of gram-negative uropathogens isolated from women with urinary tract infections (UTIs) is represented in Table 5. Out of the (N = 234) gram-negative isolates,Escherichia coli (E. coli) was the predominant pathogen (n = 174), followed by Klebsiellapneumoniae (n = 47), Pseudomonas aeruginosa (n = 5) and Proteus mirabilis (n = 8). E. coli had a high resistance to norfloxacin (84.27%), nalidixic acid (76.43%), ampicillin (63.21%), cefalotin (63.21%), and ciprofloxacin (61.5%). However, high levels of susceptibility were recorded for fosfomycin (91.37%), amikacin (84.48%), gentamicin (83.90%), ertapenem (85.63%), cefoxitin (72.49%) and piperacillin/Tazobactam (65.52%), respectively, suggesting their continued effectiveness for treating complicated UTIs caused by E. coli.

Table 5.

Antimicrobial pattern of gram negative uropathogens isolates from urinary tract infections among gynaecological cases Northeast population.

Gram negative bacteria
Antibiotics	E. coli (N = 174)			Klebsiellapneumoniae (N = 47 )			Pseudomonas aeruginosa (N = 5 )			Proteus mirabilis (N = 8)
	R	I	S	R	I	S	R	I	S	R	I	S
Ampicillin	110 (63.21)	8 (4.60)	56 (32.18)	24 (51.06)	9 (19.14)	14 (29.78)	5 (100)	0 (0.00)	0 (0.00)	3(37.5)	0 (0.00)	5 (62.5)
Amoxicillin/clavulanic acid	57 (32.76)	15 (8.62)	102 (58.62)	18 (38.29)	5 (10.63)	24 (51.06	2 (40)	0 (0.00)	3 (60)	2 (25)	0 (0.00)	6 (75)
Gentamicin	25 (14.36)	3 (1.72)	146 (83.90)	09 (19.14)	0	38 (80.85)	1 (20)	0 (0.00)	4 (80)	2 (25)	0 (0.00)	6 (75)
Ciprofloxacin	107 (61.50)	24 (13.79)	43 (24.71)	27 (57.44)	2 (4.25)	18 (38.29)	2 (40)	0 (0.00)	3 (60)	2 (25)	2 (25)	4 (50)
Nitrofurantoin	28 (16.09)	25 (14.36)	121 (69.54)	10 (21.27)	16 (34.04)	21 (44.68)	5 (100)	0 (0.00)	0 (00)	5 (62.55)	1 (12.50)	2 (25)
Trimethoprim/sulfamethoxazole	67 (38.50)	3 (1.72)	104 (59.77)	14 (29.78)	1 (2.12)	32 (68.08)	1 (20)	0 (0.00)	4 (80)	3 (37.52)	0 (0.00)	5 (62.50)
Ticarcillin	96 (55.17)	22 (12.64)	56 (32.19)	22 (46.80)	1 (2.12)	24 (51.06)	1 ( 20)	1(20)	3 (60)	2 (25)	1(12.5)	5 (62.5)
Piperacillin/tazobactam	46 (26.43)	14 (8.04)	114 (65.52)	9 (19.14)	1 (2.12)	37 (78.72)	2 (40)	0 (0.00)	3 (60)	2 (25)	0 (0.00)	6 (75)
Cefalotin	110 (63.21)	7 (4.02)	57 (32.76)	32 (68.08)	0 (0.00)	15 (31.91)	2 (40)	0 (0.00)	3 (60)	3 (37.59)	3 (37.51)	2 (25)
Cefoxitin	44 (25.28)	4 (2.29)	126 (72.41)	8 (17.02)	6 (12.76)	33 (70.21)	1 (20)	0 (0.00)	4 (80)	3 (37.54)	0 (0.00)	5 (62.51)
Cefixime	82 (47.12)	12 (6.89)	80 (40.97)	23 (48.93)	6 (12.76)	18 (38.29)	2 ( 40)	0 (0.00)	3 (60)	2 (25)	0 (0.00)	6 (75)
Ceftazidime	55 (31.60)	7 (4. 02)	112 (64.36)	12 (25.53)	8 (17.02)	27 (57.44)	2 (40)	0 (0.00)	3 (60)	3 (37.58)	0 (0.00)	5 (62.51)
Ceftriaxone	92 (52.87)	16 (9.19)	66 (37.93)	20 (42.55)	1 (2.12)	26 (55.31)	4 (80)	0 (0.00)	1 (20)	1 (12.58)	0 (0.00)	7 (87.50)
Ertapenem	10 (5.74)	13 (7.47)	149 (85.63)	3 (6.38)	6 (12.76)	38 (80.85)	1 (20)	1 (20)	3 (60)	1 (12.54)	0 (0.00)	7 (87.50)
Amikacin	22 (12.64)	5 (2.87)	147 (84.48)	4 (8.51)	1 (2.12)	42 (89.36)	1 (20)	0 (0.00)	4 (80)	0 (0.00)	0 (0.00)	8 (100)
Nalidixic acid	133 (76.43)	9 (5.17)	30 (17.24)	28 (59.57)	0	19 (40.42)	4 (80)	0	1 (20)	2 (25)	2 (25)	4 (50)
Norfloxacin	84 (48.27)	34 (19.54)	56 (32.18)	14 (29.78)	10 (21.27)	23 (48.93)	1 (20)	0	4 (80)	3 (37.50)	1 (12.51)	4 (50)
Ofloxacin	62 (35.63)	8 (4.59)	104 (59.77)	20 (42.55)	6 (12.76)	21 (44.68)	2 (40)	2 (40)	1 (20)	2 (25)	0	6 (75)
Fosfomycin	2 (1.15)	12 (6.89)	160 (91.95)	4 (8.51)	3 (6.38)	40 (85.10)	0	0	5 (100)	0	0	8 (100)

Antibiotic resistance and susceptibility profiles of Gram-negativeuropathogens isolated from urine samples of gynaecological patients withUTIs in Northeast India. Data represent the number and percentage ofisolates resistant (R), intermediate (I), or susceptible (S) to individualantibiotics tested. The findings underscore extensive resistance tofluoroquinolones and β-lactams, while maintaining susceptibility toaminoglycosides, carbapenems, and fosfomycin.

In Klebsiella pneumoniae isolates (N = 47), resistance was similar to that of E. coli, with high-level resistance observed against cefalotin (68.08%), ampicillin (51.06%), and nalidixic Acid (59.57%). Moreover, resistance to third-generation cephalosporins, such as cefixime (48.93%) and ceftriaxone (42.55%), was significant. On the contrary, the pathogen remained mostly susceptible to amikacin (89.36%), fosfomycin (85.10%), and gentamicin (80.85%), highlighting the potential role of these agents in managing multidrug-resistant strains. On the other hand, lower resistance was observed for amikacin (8.51%) and ertapenem (6.38%), both of which were among the most effective drugs against this species. The high susceptibility to piperacillin/tazobactam (78.72%) and amoxicillin-clavulanic acid (51.06%) highlights their potential use in empirical therapy, though susceptibility testing remains critical. Pseudomonas aeruginosa (N = 5) isolates, though limited in number, showed moderate to high susceptibility to most of the antibiotics tested, includinggentamicin, trimethoprim/sulfamethoxazole, cefoxitin, amikacin, and norfloxacin. However, this species also demonstrated high resistance to nalidixic Acid (80%), ceftriaxone (80%) and ampicillin (100%), aligning with its intrinsic multidrug resistance mechanisms. While Proteus mirabilis strain (N = 8) displayed a high susceptibility pattern to amikacin and fosfomycin (100%), ceftriaxone and ertapenem (87.5%), suggesting these as potential treatment options. However, the resistance to ampicillin (37.5%) and nitrofurantoin (62.5%) was noteworthy. Although widely effective against UTIs, nitrofurantoin showed reduced activity against Proteus species.

Multidrug resistance pattern among gram-positive uropathogenic bacteria

The multidrug resistance (MDR) patterns and antimicrobial susceptibility profiles of Gram-positive uropathogens isolated from women with urinary tract infections (UTIs) indicate that a total of 44 Gram-positive isolates were identified in this cohort, comprising Staphylococcus aureus (n = 12), Staphylococcus saprophyticus (n = 9), and Enterococcus faecalis (n = 23) (Table 6)Among the Staphylococcus aureus isolates, high resistance rates were observed to commonly used β-lactam antibiotics, with 75% resistant to ceftriaxone, 66.66% to penicillin, and 58.33% to cefoxitin, indicating a significant burden of methicillin-resistant S. aureus (MRSA) strains in the population studied. Despite this, the susceptibility of several antibiotics remained relatively high: 75% of the isolates were sensitive to both amikacin and vancomycin, while 66.66% retained susceptibility to nitrofurantoin and tigecycline, highlighting their potential for treating resistant infections.

Staphylococcus saprophyticus displayed complete (100%) resistance to ampicillin and benzylpenicillin, aligning with its known resistance to β-lactam agents. However, this pathogen was fully susceptible to gentamicin, vancomycin, and tigecycline, and demonstrated 88.88% susceptibility to nitrofurantoin, doxycycline, and amoxicillin/clavulanic acid. These findings suggest that while first-line β-lactams may be ineffective, alternative agents such as nitrofurantoin and glycopeptides remain highly effective for managing infections caused by this species.

Enterococcus faecalis exhibited a distinct resistance pattern, with the highest resistance noted against ciprofloxacin, cefixime, and penicillin (each 60.86%), followed by gentamicin and ceftriaxone (both 56.52%). Nonetheless, the isolates showed excellent susceptibility to nitrofurantoin (91.30%), tigecycline (82.60%), and ampicillin (78.26%). Additionally, vancomycin and piperacillin/tazobactam retained moderate effectiveness, with 69.56% of the isolates susceptible to each. Thus, the results reveal a high prevalence of multidrug resistance among Gram-positive uropathogens, particularly in S. aureus and E. faecalis (Table 5). However, the data also reinforce the continued efficacy of specific antibiotics, such as nitrofurantoin, tigecycline, amikacin, and vancomycin, which may be considered in empirical therapy in light of regional resistance trends.

Discussion

Urinary tract infections (UTIs) remain a significant health problem, primarily affecting women with Gynecological conditions⁴⁰. The present study provides an extensive microbiological and epidemiological assessment of UTIs among women in Northeast India, highlighting key sociodemographic determinants, microbial distribution patterns, and alarming trends in antimicrobial resistance. A significant finding was the higher prevalence of UTIs among women aged 18–39 years (Table 2), with a two-fold higher risk compared to those aged ≥ 60 years (p < 0.001). This trend aligns with earlier studies reporting increased susceptibility among sexually active premenopausal women due to anatomical and hormonal factors⁴¹. Additional clinical risk factors such as a previous history of UTI, hypertension, pregnancy, and antibiotic use were also significantly associated with infection^42,43.

Our findings show that women aged 18–39 years are at significantly increased risk of UTIs compared with women aged ≥ 60 years. Similar findings have been reported in earlier studies, which indicate a higher UTI incidence among reproductive-age women, likely related to sexual behaviour, hormonal changes, and anatomical predisposition^44–46. Considerably, women with a previous history of UTIs had a significantly increased risk of present UTI (p < 0.001)⁴⁷. The robust association supports the present study, demonstrating that recurrent UTI is a main risk factor for several reasons, including partial treatment, identification of uropathogens, and possible host-related immunological responses⁸. Furthermore, we have demonstrated that hypertension emerged as a significant associate (p < 0.001) (Table 2), suggesting a potential relationship among systemic inflammation, compromised immunity, and increased susceptibility to infection⁴⁸. Previous studies suggested that UTIs diagnosed through bacteriuria tests in pregnant women lead to higher risks of hypertension in pregnancy⁴³. Interestingly, we also observed a strong association between pregnancy and UTI positivity. We observed that, in the analysed cohort (n = 739), pregnant women constituted 82.36% of participants. Among UTI-positive cases, 85.61% were pregnant, and pregnancy remained significantly associated with UTI (OR 2.14; p < 0.001), indicating a higher relative burden of infection among pregnant women compared to non-pregnant individuals(Table 2). Also, current antibiotic use was significantly associated with a higher prevalence of UTIs (p < 0.001), potentially due to disruption of the normal microbiota and the development of antimicrobial resistance, which is increasingly recognised as an important factor in UTI pathogenesis⁴⁹.

Microbiological analysisidentified Escherichia coli as the predominant pathogen (62.5%), followed by Klebsiella pneumoniae, Enterococcus faecalis, and Staphylococcus aureus. This finding aligns with previous reports from India and globally identifying E. coli as the leading uropathogen^50–53. Age-wise distribution analysis showed that Gram-negative bacteria, particularly E. coli, predominated in younger women^54,55. Although a numerically higher proportion of E. coli isolates was observed among women aged < 40 years, this difference was not statistically significant in our case. However E. coli predominance was consistent across both age groups in the present cohort (Table 3). In contrast, K. pneumoniae demonstrated a near-equal distribution across age groups, indicating its role as a consistent secondary pathogen independent of age-related physiological factors.

MDR pattern (Table 4) showed that 38.50% of E. coli and 51.06% of K. pneumoniae isolates were resistant to ≥ 4 antibiotics (≥ R5). E. coli, the predominant uropathogen, showed high resistance to ampicillin (63.21%), ciprofloxacin (61.50%), and amoxicillin/clavulanic acid (32.76%). K. pneumoniae demonstrated marked resistance to ampicillin (51.06%), ticarcillin (46.80%), and ceftriaxone (42.55%) (Table 4). However, E. coli remained largely susceptible to gentamicin (83.90%) and nitrofurantoin (69.54%), while K. pneumoniae showed high susceptibility to piperacillin/tazobactam (78.72%) and ertapenem (80.85%), supporting their continued therapeutic value^56,57.Pseudomonas aeruginosa exhibited broad resistance, particularly to ampicillin and piperacillin/tazobactam, yet retained susceptibility to amikacin (84.48%) and ertapenem (80.85%), consistent with previous reports^58,59. Proteus mirabilis demonstrated high susceptibility to amikacin (100%), fosfomycin (100%), ertapenem (87%), and gentamicin (75%), but showed resistance to ampicillin (37.5%) and nitrofurantoin (62.5%), aligning with earlier findings^60–62.

Among Gram-positive isolates, Enterococcus faecalis exhibited high resistance to ciprofloxacin (60.86%) and gentamicin (56.52%) (Table 5), corroborating previous reports⁶³. Moderate resistance to β-lactams was observed in Staphylococcus aureus and S. saprophyticus, consistent with national data on methicillin-resistant strains^64,65. S. aureus showed resistance to ampicillin (66%) and ceftriaxone (75%), with 58.33% cefoxitin resistance indicating a substantial MRSA prevalence, similar to trends reported across India and Asia^64,66–68. In contrast, S. saprophyticus demonstrated 100% susceptibility to gentamicin, nitrofurantoin, vancomycin, and tigecycline, supporting their empirical use⁶⁹.

Despite these findings, this study has certain limitations. Since the study was hospital-based and conducted in a specific region of Northeast India, the results may not fully represent community-level prevalence across the region.Furthermore, although resistance patterns were clearly defined, the lack of molecular characterization for specific resistance genes (such as ESBL or carbapenemase-encoding genes) remains a constraint for understanding the underlying genetic drivers of AMR in this cohort. Future longitudinal studies incorporating molecular typing are required to further elucidate the transmission dynamics of these multidrug-resistant strains.

Conclusion

Our study confirms that women aged 18–39 years in Northeast India are at the highest risk for UTIs, particularly when associated with pregnancy, hypertension, or a history of prior infections. Escherichia coli and Klebsiella pneumoniae remain the most common causes of these infections. While resistance to standard oral antibiotics is now widespread, drugs such as gentamicin, amikacin, and ertapenem remain effective in this population. These findings suggest that regional treatment guidelines should be updated to reflect local resistance patterns. Improving routine surveillance and focusing on patient-specific risk factors will be essential for better management of UTIs in this region.

Author contributions

Conceptualization, R.K., A.D. and J.B.; Methodology, R.K., A.D. and J.B.; Data curation, J.B., V.C., A.L., R.D., R.K.; Writing original draft preparation, R.K., A.D., A.B.; Writing—J.B., V.C., A.L., R.D., R.K.

Funding

The authors declare that no financial support was received for the conduct of this research. This study did not receive any funding from governmental, non-governmental, commercial, academic, or institutional sources. However, limited funds from the university seed money grants from RGU were utilized.

Data availability

The data generated and analyzed during this study can be provided by the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical statement

The present study was approved by the Institutional Ethical Committee (IEC) at The Assam Royal Global University, Guwahati. Written informed consent was obtained from all participants through designed questionnaires and personal interviews.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of The Assam Royal Global University.