2018 Month : July Volume : 5 Issue : 28 Page : 2110-2112
Kothai Gnanamoorthy1, R. Vimal Kumar2, Suthakaran Prasanna Karthik3
1. Associate Professor, Department of General Medicine, ESIC Medical College and PGIMSR, K. K. Nagar, Chennai.
2. Consultant Cardiologist, St. Joseph Hospital, Anna Nagar, Chennai.
3. Associate Professor, Department of General Medicine, Saveetha Medical College and Hospital, Saveetha University, Thandalam, Chennai.
Dr. Prasanna Karthik,
Department of General Medicine,
Saveetha Medical College and Hospital,
Thandalam- 602105, Chennai.
Diabetes mellitus is a major risk factor for urinary tract infections (UTIs) and is also associated with increased risk of complicated UTI. Improved outcomes of these entities may be achieved by early diagnosis, knowledge of common predisposing factors, appropriate clinical and radiological assessment, and prompt management.
MATERIALS AND METHODS
120 diabetic patients were included in the study after fulfilling the inclusion and exclusion criteria. After obtaining consent and history, clinical examination was done; a midstream urine sample was collected in a sterile container and sent for urine culture and sensitivity. Data obtained was recorded and analysed using SPSS version 22.
Data was collected from 120 diabetics and analysed. Urinary tract infection was present among 27.5% diabetics. UTI was independent of the patient’s age and HbA1c levels. Longer the duration of diabetes mellitus, greater is the risk of urinary tract infection. The most common organism isolated was E.coli followed by Klebsiella spp. Most of the organisms showed good sensitivity to amikacin.
The prevalence of UTI among the diabetics is considerably high. Because of the frequency and severity of UTI in diabetic patients, prompt diagnosis and early treatment is necessary to prevent consequent complications.
Urinary tract infections, complicated UTI, pyuria, E.coli, Klebsiella.
Gnanamoorthy K, Vimal Kumar R, Prasanna Karthik S. Clinical and microbiological profile of urinary tract infections in diabetic patients. J. Evid. Based Med. Healthc. 2018; 5(28), 2110-2112. DOI: 10.18410/jebmh/2018/437
Among diabetic patients, the risk of urinary tract infections is usually increased by 60% when compared to other individuals.1 This has been attributed to the changes that occur in the diabetic host defense mechanisms and presence of diabetic nephropathy and cystopathy.2 Diabetes is associated with increased severity of infection and prolonged hospital stay.3 Serious complications of urinary tract infection such as emphysematous cystitis, pyelonephritis, renal or perinephric abscess, bacteraemia and renal papillary necrosis occur more commonly in diabetic patients.4
Increased adherence of bacteria to uroepithelial cells in diabetic women is also one of the causes for increased prevalence of urinary tract infection.5 In a recent study, uropathogenic E.coli which were expressing type-1 fimbriae were more adherent to cells from women with diabetes as compared to cells collected from women without diabetes.6 In this background, the present study was aimed at determining the prevalence of UTI in a cross sectional survey of diabetic patients, and also to determine the antibiotic susceptibility profile of some of the antibiotics routinely used to treat UTI.
MATERIALS AND METHODS
A prospective observational study was conducted at our hospital for a period of 1 year. 120 diabetic patients were included in the study after excluding patients with structural abnormalities of the urinary tract, recent urinary tract infection, pregnancy or history of use of recent antimicrobial agent usage.
After obtaining consent, a detailed history and relevant clinical examination was done. Fasting, post prandial blood sugars and HbA1C levels were estimated. Each individual was explained on the technique of urine collection. Midstream clean voiding urine specimens were collected in a wide mouthed sterile container. All urine samples were
immediately sent to Microbiology laboratory and cultured. Urine culture was performed according to standard procedure. All urine samples were cultured on Nutrient agar, MacConkey and Blood agar to identify organism.
Antibiotic sensitivity was tested by using Muller-Hinton agar plate by Kirby Baur's disc diffusion method. Ciprofloxacin, Norfloxacin, Amikacin, Gentamicin, Erythromycin, Nitrofurantoin, Piperacillin – Tazobactam, Ceftriaxone, Cefotaxime, Cotrimoxazole, Cloxacillin, Vancomycin, Amoxycillin and Ceftazidime were the common drugs used.
Statistical analysis was done using standard statistical packages. Data were analysed by SPSS statistical software version 22 and P value of <0.05 was considered significant. Mean values were reported as mean ± standard deviation.
Out of the 120 patients, 60 were females. The age of the patients ranged from 19 to 93 years with a mean of 53.22 ± 13.86. Majority of study subjects belonged to age group 51 to 60 years which was followed by 41 to 50 years. Age distribution of study group was represented in Figure 1. Duration of diabetes in this group was between within 1 year to 28 years with a mean of 9.09 ± 6.37. Most of them (65%) had diabetes for less than 10 years of duration (Figure 2).
Figure 1. Age Distribution of the Study Patients
Figure 2. Duration of the Diabetes
among Study Patients
Out of the 120 patients, 7 had Type 1 Diabetes and 113 had Type 2 Diabetes Mellitus. Mean values of fasting plasma glucose, postprandial plasma glucose and HbA1c were 165.39±57.95 mg/dL, 258.10±79.53 mg/dL and 7.74±0.90% respectively. Mean values of systolic and diastolic blood pressure were 132.50±7.29 and, 84.63±5.79 mmHg respectively. Mean values of Height, Weight and BMI were 161.16±12.69 cm, 68.88±13.33 Kg, and 26.29±2.36 kg/m².
Symptoms of UTI were present only in 5% patients (n=6) irrespective of their sex and urine culture results. 25% patients (n=30) had pyuria. In this study, 27.5% patients (n=33) were culture positive for UTI. Out of the 33 patients, 24 were female (72.7%) which was statistically significant (p = 0.002). Out of 33 culture positive subjects, only 6 subjects had symptoms of UTI and this difference was statistically significant (p=0.0001).
Figure 3. Organisms Grown in Culture
Out of 33 persons with UTI, 23 subjects had diabetes for duration of more than 10 years which was statistically significant (p value = 0.0001). Among the organisms cultured, Escherichia coli was the most common organism followed by Klebsiella pneumoniae and Pseudomonas species. Figure 3 shows the frequency and percentage of bacterial organisms causing UTI in study population. Most of the organisms (51.51%) showed sensitivity to Amikacin in this study followed by Piperacillin Tazobactam (42.42%). ESBL producing organisms were found in 12.12% (n = 4) of the cultures. Most of the E.coli and Klebsiella strains isolated were sensitive to amikacin. One isolate of Enterobacter species was isolated which showed sensitivity to almost all of the commonly prescribed drugs. Three isolates of Klebsiella oxytoca were sensitive only to amikacin. Four isolates of Pseudomonas species were sensitive only to few (<4) drugs.
In this study, out of 120 subjects with diabetes, 33 subjects (27.5%) had urinary tract infection. The prevalence among females and males was 20% and 7.5% respectively. These results were comparable with previous studies. Alebiosu et al conducted a study in Nigeria among 124 type 2 diabetics (55 males and 69 females) and found that 26.6% of patients (n = 33) had significant bacteriuria.7 Jaspan et al conducted a study among 198 subjects (111 females and 87 males) and found the prevalence of bacteriuria to be 27% among females and 8% among males.8 O’Sullivan et al also conducted a study among 91 female and 59 male diabetics and showed that the prevalence was 19.8% and 3.3% respectively.9
According to this study, age had no significant relation (p value 0.927) with urinary tract infection in diabetic population. This was similar to the findings of Boykyo et al and Boroumand et al.10,11 There was a statistically significant relation between female sex and UTI in diabetics. Various studies done earlier have also showed that the prevalence of UTI was more among female diabetics.8,9,12 In the present study, there was a statistically significant relationship between female sex and asymptomatic UTI (p = 0.016) which is comparable to the findings of Bonadio et al who found that bacteriuria was common among women and they remained mostly asymptomatic.13
There was a statistically significant relation between duration of diabetes and UTI. (p <0.001) which was similar to the findings of Geerlings et al and Janifer et al.14,15 There was no significant relation between HbA1c levels at the time of urine culture and Urinary Tract Infection (p = 0.778) which was comparable with previous published studies.11,14
Like other studies, Escherichia coli was the most common organism (45.5%) isolated from urine culture which is similar to many previous studies.10,15,16 Klebsiella pneumoniae was the second most common organism (18.2%) followed by Pseudomonas species (12.1%) and Klebsiella oxytoca (9.1%).
The study found that female sex and longer duration of diabetes are associated with risk of developing UTI among diabetic patients. Asymptomatic UTI remains very common among females with diabetes. The antimicrobial sensitivity to drugs which were commonly used previously was found to be declining. Frequent irrational usage, inadequate dosage, and non-compliance of patients may be the reason for the emergence of resistance. But further studies by comparing the antibiograms of nondiabetic patients with diabetic patients can shed more light on this matter.