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Prevalence of urinary tract infection among patients with diabetes in Bangalore City.

1 INTRODUCTION

Urinary tract infections (UTIs) are the frequent infections observed in clinical practice and results in a significant morbidity and high medical costs. UTI is a common infection observed in diabetic patients. DM alters the genitourinary system where UTI can be a cause of severe complications ranging from dysuria (pain or burning sensation during Urination) organ damage and sometimes even death due to complicated UTI (pyeleonephritis).

UTI is more widespread in women with DM than in non diabetic women as a consequence of debilitated immune system. The risk factors for UTI involve colonization with a different uropathogen in cases of recurrent UTI, glucosuria and impaired granulocyte function [45]. Diabetic patients are at a higher risk developing acute pyelonephritis, renal abscess, abnormalities of bladder scarring and pyelitis. People with diabetes have dysfunctional bladders which contract poorly. Women are prone to UTIs for reasons which are not well understood. [22] Every one woman develops UTI among five women. UTI is uncommon in men and contributes to have larger complications after initial infection. Ninety five percent of UTIs are caused by uropathogens which multiply at the notch of the urethra and migrate towards the bladder. UTI is a result of various factors which may trigger Infection. Recurrent UTI is a nasty infection in sexually active young women and patients with DM. Cystitis or bladder infection is commonly prevalent in women and young adolescent girls. The infection can be brief and acute (Cystitis) with classical symptoms of dysuria. In cases of continuous infection deeper layers of the bladder may be damaged (pyleonephritis). The risk of UTI increases with harmful changes in the immune system which also leads to the easier invasion and colonization in the lining of the bladder by Uropathogens. DM is also a leading a cause of overactive bladder or neurogenic bladder.

It is a serious clinical problem for people with DM. Hospitalization for pyleonephritis occurs 15 times more frequently in diabetic patients. Symptomatic UTI may be present as a severe illness including higher frequency of bacteremia and bilateral renal involvement with pyleonephritis or unusual clinical presentations of emphysematous cystitis. Diabetic patients encounter urinary urgency and incontinence, during night. This condition is often manifested by the shape of painful urination and retention of urine in the bladder. DM also results in abnormalities of the host defense system that may result in a higher risk of developing infection. Immunologic impairments such as defective migration, and phagocytic alterations of chemotaxis in polymorphonuclear leukocytes is well marked in diabetic patients.

2. MATERIAL AND METHODS

2.1. Study Design

Patients Specimen Collection. Clean voided midstream urine samples were collected in sterile uricols with the assistance of laboratory staff at their respective Hospitals and diabetic centers. Urine samples were processed in the laboratory within 2 h of collection. Diabetic patients living in slums were educated about the collection of urine sample to avoid contamination. Urine samples in type 1 diabetic patients(100) were obtained from Janani Diabetic centre located in JPNagar Bangalore. Self prepared questionnaires were given to diabetic subjects to obtain information on age, history of urinary frequency, abdominal pain, Hypertension, Cardiovascular diseases, Lipidemia, and previous infections encountered.

Presumptive Identification of Uropathogens from Urine Samples. All urine samples were plated with 100 [micro]l of urine sample using standard pour plate technique on Hi Chrome UTI Agar (Himedia pvt ltd India) and incubated at 37[degrees]C overnight for visible growth. Urine samples showing colony count more than 10,000Cfu/ml was considered to be significant for UTI [46].UTI isolates were identified following standard biochemical tests [47]. Results were not considered for more than three clinical isolates obtained on isolation and the sample was considered to be contaminated.

Statistical Analysis. The Statistical software SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used for the analysis of the data. Results were calculated on the basis of number and percentages from the higher and Lower socioeconomic groups. P values were calculated using a 2 test. P <0.01 were considered to be statistically significant.

2.2. Results

Diabetic Lower socioeconomic Status Group. Uropathogens were isolated from 140 males and 110 females. UTI isolates in diabetic males and females included E.coli 46 (32.9%) 28 (25.5%) , E.faecalis 44(31.4%), 32(29.1%) P.aeruginosa 2(1.4%) 10 (9.1%), S.aureus 26(18.6%) 22(20%).No UTI was found in 22 males (15.7%) and 18 females (16.4%) in patients with DM respectively. Table 1 shows the Uropathogens isolated urine samples in the diabetic Lower socioeconomic group.

Table 2 shows the prevalence of UTI pathogens in diabetic Higher Socioeconomic group according to the gender in diabetic males and females. Commonly recovered UTI pathogens in males and females with DM included E.coli 18(13.8%) 13(10.8%) E.faecalis 32(24.6%), 36 (30.0%), P.aeruginosa 30(23.1%) S.aureus 13(10%), 24 (20%) respectively. There was no prevalence of UTI found in 28.5% of males and25.8% of females.

Table 3 shows the incidence of Uropathogens (Male and female) in DM type 1.The prevalence of E.coli was 22(44%) in males and 15(30%) in females, E.faecalis 10(20%), 20(40%), S.aureus 14(28%), 8(16%) respectively. 8% of males and 14% of females had no evidence of UTI.

Table 4 shows the comparison of results between the diabetic patients of the lower socioeconomic status and the with non diabetic control groups. The prevalence of E.coli was 74(29.6%) , E.Faecalis 76(30.4%) P.aeruginosa 12(4.8%) S.aureus48 (19.2%) respectively. 40 (16%)of patients had no evidence of UTI. Prevalence of Uropathogens in non diabetic patients was E.coli (19%), E.Faecalis (15.3%) P.aeruginosa (18%), S.aureus (8.7%).44.7% of non diabetic patients showed no evidence of UTI.

Table 5 shows the comparison of results between the diabetic patients of the higher socioeconomic status and the with non diabetic control groups. The prevalence of E.coli was 31 (12.4%), E.Faecalis. 68 (27.2%) P.aeruginosa 46 (18.4%) S.aureus 37 (14.8%) respectively. 68(27.2%) of patients had no UTI. Prevalence of Uropathogens in non diabetic patients was significantly less when compared with diabetic patients E.coli (8.4%), E.Faecalis (20%) There was no prevalence of P.aeruginosa in the non diabetic group. The prevalence of S.aureus was 10.8%).60.8% of non diabetic patients did not indicate any UTI. The results obtained from the two different groups of diabetic patients also suggest that the prevalence of UTI in the lower socioeconomic status was high.

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4. DISCUSSION

Our findings suggest that the relevant clinical epidemiological data which identify the prevalence of UTI in diabetic patients are lacking. Bangalore is fast growing developing city with a dense urban population. Many patients do not undergo regular diagnosis for DM unless they showcase the symptoms. Diabetes goes unnoticed in slums, as a consequence of poor economic status. Limited access to the hospitals in this economically weaker section leads to the Increase in DM. The treatment for DM appears to be costly for slum dwellers. Sometimes the treatment for diabetes such as Insulin Injections does not reach the patients living in slums leading to poor glycemic control. Many diabetic patients in the urban slums face unhygienic conditions, malnutrition and no proper sanitation making the situation worse. Diabetic patients with UTI in slums use over the counter prescriptions which does not eradicate the infection but leads to recurrent Infections. The severe cases of UTI are untreated as a consequence of costly antibiotic treatment.

We found UTI was significantly high in diabetic patients of the Lower socioeconomic status (Table 1) The prevalence of S.aurues was found high in type 2 diabetic females in the Lower socio economic group (20%). The frequency of UTI in diabetic women as a result of S.aureus may also be attributed to frequent sexual activity and close proximity of vagina with Urethra [30]. Among the diabetic patients in the lower socioeconomic status E. coli was isolated from 32.9% diabetic males and 25.5% from female diabetic patients .Pseudomonas spp was prevalent in. 1,4% males and 9.1% females. The incidence of P.aeruginosa in diabetic patients clearly indicates immune suppression by this opportunistic uropathogen which never causes any symptoms of UTI in the non diabetic subjects. The frequent incidence, prevalence, and severity of UTI in diabetic patients squabble for firm antibiotic chemotherapy. We suggest that future Clinical Investigations in DM should focus on how the infection differs from that in patients without DM. We also propose to emphasize on the character of glycosuria and risk of UTI. Diabetic patients with poor glycemic control have a higher tendency of E.coli adherence. [5], [16].

Enterococci could be a consequence of nosocomial UTI [17] Enterococcus feacalis was found to be the cause of 35% of UTI in hospital patients [18], [25]. Our results showed a close similarity with the above study. 31.4% of diabetic male subjects and 29.1% females had UTI as a consequence of Enterococci spp. in the lower socioeconomic status. This also signifies the prevalence of community acquired UTI. The prevalence of uropathogens was considerably less in patients with DM of the higher socioeconomic status Table2.The occurrence of E.coli was high in patients with DM type 1 when compared with the type 2 diabetic results. Patients with DM type 1 have a risk of acquiring bacteremia, with UTI as the most prevalent infection. This also exposes diabetic patients to higher mortality in community acquired infections when compared with patients without DM. This pattern of distribution of uropathogens could be incidental in nature with more confounding factors involved in the pattern of colonization, and additional investigations should be put forward to understand the biodiversity of UTI pathogens in patients with DM type1 and type2.

5. CONCLUSION

UTIs are more frequent and are likely to have a more complicated course in patients with (DM). India is considered to be the diabetic capital of world and many factors contribute to the emergence of Diabetes in developing nations. The mechanisms, which potentially contribute to the greater incidence of UTI in these patients, are malfunctioning in the local urinary cytokine secretions and an increased adherence of bacteria to the cells of the Uroepithelial cells. No confirmation is available on the best possible treatment of acute cystitis and pyelonephritis in patients with DM. Thus we suggest screening of UTI in diabetic patients is imperative.

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Mehvish Saleem, Betty Daniel

Department of Botany (Microbiology Unit)

St. Josephs College PG and Research Centre

Langford road Bangalore India 560027

saleem@gmail.com, joyrachel321@yahoo.co.in
Table I Prevalence of UTI in Diabetic Low Socio-economic status group.

UTI Pathogens   Prevalence of UTI   Prevalence of UTI      Total
                     (Males)            (Females)

                   No       %           No      %       No     %

E.coli             46     32.9         28     25.5      74    29.6
Enterococcus       44     31.4         32     29.1      76    30.4
Faecalis
P.aeruginosa        2      1.4         10      9.1      12    4.8
S.aureus           26     18.6         22     20.0      48    19.2
Patients with      22     15.7         18     16.4      40     16
  no UTI
Total              140    100          110    100       250   100

Table 2. Prevalence of UTI in Diabetic Higher Socio-economic
status group.

UTI pathogens        Prevalence of     Prevalence of     Total
                      UTI Isolates     UTI Isolates
                         (Males)         (Females)

                        No      %        No      %      No      %

E.coli                 18     13.8      13     10.8     31    12.4
Enterococcus           32     24.6      36     30.0     68    27.2
faecalis                --     --        --      --     --     --
P.aeruginosa           30     23.1      16     13.3     46    18.4
S.aureus               13     10.0      24     20.0     37    14.8
Patients with no       37     28.5      31     25.8     68    27.2
  UTI.
Total                 130    100.0      120    100.0    250   100.0

Table 3. Prevalence of UTI pathogens in Type 1 diabetic patients.

UTI pathogens   Prevalence of    Prevalence of     Total
                 UTI Isolates    UTI Isolates
                   (Males)         (Females)

                 No      %        No      %       No      %

E.coli           22      44.0    15      30.0     37    37.0
E.faecalis       10      20.0    20      40.0     30     30
P.aeruginosa      --     --        --     --      --     --
S.aureus         14      28.0     8      16      22    22.0
No UTI            4      8.0      7      14      11    11.0
Total            50       1     50       100     100    100

Table 4 Comparison of Prevalence of organism isolated between
Diabetic and non-diabetic in Lower Socio-economic status:

UTI pathogens     DM group     Non Diabetic Group

                 No      %         No      %

E.coli          74     29.6       19     12.7
E. faecalis     76     30.4       23     15.3
P.aeruginosa     12     4.8       28     18.7
S.aureus        48     19.2        13     8.7
No UTI          40     16.0       67     44.7
Total           250    100.0      150    100.0

UTI pathogens   P value

E.coli          [chi square]=15.086;P<0.001 **
E. faecalis     [chi square]=11.427;P<0.001 **
P.aeruginosa    [chi square]=20.030;P<0.001 **
S.aureus        [chi square]=8.048; P<0.001 **
No UTI          [chi square]=39.318;P<0.001 **
Total                         --

Table 5 Comparison of Prevalence of organism isolated between
Diabetic and non-diabetic in Higher Socio-economic status:

UTI Pathogens    DM Group      Non diabetic Group

                 No      %         No      %

E.coli          31      2.4        21     8.4
E.faecalis      68     27.2       50     20.0
P.aeruginosa    46     18.4        0      0.0
S.aureus        37     14.8       27     10.8
No UTI          68     27.2       152    60.8
Total           250    100.0      250    100.0

UTI Pathogens   P value

E.coli          [chi square]=2.146; P=0.143
E.faecalis      [chi square]=3.594; =0.059+
P.aeruginosa    [chi square]=50.661; 0.001 **
S.aureus        [chi square]=1.792; P=0.181
No UTI          [chi square]=57.273;P<0.001 **
Total                         --
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Author:Saleem, Mehvish; Daniel, Betty
Publication:International Journal of Emerging Sciences
Article Type:Report
Geographic Code:9INDI
Date:Jun 1, 2011
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