URINARY TRACT INFECTIONS IN DIABETIC PATIENTS ATTENDING OUTPATIENT DEPARTMENTS AT KASTURBA MEDICAL COLLEGE TEACHING HOSPITAL, MANIPAL, INDIA

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1 WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Gautam R. et al. Volume 2, Issue 3, Research Article ISSN URINARY TRACT INFECTIONS IN DIABETIC PATIENTS ATTENDING OUTPATIENT DEPARTMENTS AT KASTURBA MEDICAL COLLEGE TEACHING HOSPITAL, MANIPAL, INDIA * Gautam R, Acharya A, Nepal HP, Rimal B, Shrestha S Department of Microbiology, Chitwan Medical College (CMC), Chitwan, Nepal. Article Received on 25 February 2013, Revised on 21 March 2013, Accepted on 30 April 2013 *Correspondence for Author: * Mr Rajendra Gautam Assistant Professor, Department of Microbiology, CMC, Chitwan, Nepal gautamrajen@gmail.com, ABSTRACT Urinary tract infection (UTI) is a common infection observed in diabetic patients. We have evaluated urine samples from one hundred diabetic patients suspected of having UTI. All urine samples were processed in the laboratory following standard laboratory protocol. Occurrence of UTI in diabetic patients was found to be 37% and it was more common in diabetic females (43%) than males (30%), with the predominant age group of years. The most common organism isolated was Esherichia coli (56.75%) followed by Klebsiella pneumoniae (38%), Proteus mirabilis (5.4%) and Citrobacter species (2.7%). On performing antibiotic sensitivity testing, Amikacin was found to be the most effective antimicrobial while Ampicillin remained the least effective agent against the isolated urinary pathogens. Keywords: Urinary tract infection, diabetic patients, antibiotic sensitivity. INTRODUCTION Urinary tract infection [UTI] has long been recognized as a significant problem in patients with diabetes mellitus (DM). 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) 1. DM also results in abnormalities of the host defense system that may result in a higher risk of developing infection 1. Immunologic impairments such as defective migration and phagocytic alterations of chemotaxis in polymorphonuclear leukocytes are well marked in diabetic patients. Therefore, UTI acquires enhanced significance in diabetic subjects 2. Hence, we have conducted this study to determine the status of UTI and microbiological profile in diabetic

2 patients attending outpatient departments at Kasturba Medical College Teaching Hospital, Manipal, India. MATERIAL AND METHODS A total of 100 diabetic patients who were suspected of having UTI were included in the study. The study was conducted conducted from May 2006 to February 2007 at Kasturba Medical College, Teaching Hospital, India. Sample collection and microbiological methods Data regarding age, gender, type and duration of diabetes, sign and symptoms of UTI were recorded in specific questionnaire forms. The criteria used to differentiate diabetic patients from non diabetic was done by measuring fasting blood sugar of 126 mg/dl. Individuals with history suggestive of the sexually transmitted infections, vaginitis, tuberculosis, pregnancy, urinary tract obstruction, intake of antibiotics within 15 days, intake of diuretics etc. were excluded from the study. Clean-catch mid stream urine [MSU] was collected in a sterile container after swabbing the genitals with betadine [iodine] solution for routine examination, culture and antibiotic sensitivity. The standard inoculating loop holding 0.01ml of urine was used to inoculate the samples on Blood agar and MacConkey agar. The growth of cfu/ml was considered as a significant bacteriuria for females and cfu/ml for males 3,4. Counts between cfu/ml as one or two predominant species of gram negative rods individually were considered significant only when symptoms or pus cells were present. For each isolates, antibiotic sensitivity testing was performed by Kirby-Bauer disk diffusion method 5 by using High Media antibiotic disks of Ampicillin, Ciprofloxcin, Gentamicin, Nalidixic acid, Norfloxacin, Ofloxacin, Cotrimoxazole, Nitrofurantoin, Amikacin and Cephotaxime. RESULTS Of a total of 100 urine samples that were processed, culture positivity was seen in 37%. The positivity was higher in female patients (43%) than the males (30%) [table 1]

3 Table-1: Gender wise distribution of UTI in diabetic patients Gender No. of cases examined No. of culture positive cases Percentage (%) Female % Male % Total % The most common age group of diabetic patients suffering from UTI were years followed by years [table 2]. Table-2: Age wise distribution of UTI in diabetic patients S. N. Age group Gender Total Female Male Total Single bacterial etiology was detected in all 37 culture positive cases. Escherichia coli was the most common organism isolated (21%) followed by Klebsiella pneumoniae (13%), Proteus mirabilis (2%) and Citrobacter species (1%) [table 3]. Table-3: Distribution of urinary pathogens in diabetic patients. SN Bacteria Total (%) 1 Escherichia coli 21 (21) 2 Klebsiella pneumoniae 13 (13) 3 Proteus mirabilis 2 (2) 4 Citrobacter species 1 (1) Total 37 (37) Antibiotic sensitivity of the urinary pathogens showed Amikacin as the most effective drugs (31/37 isolates sensitive) and Ampicillin as the least effective agent (only 1/37 isolates sensitive) [table 4]

4 Table-4: Antibiotic sensitivity/resistance pattern of the urinary isolates from Diabetic patients Antimicrobials Bacterial isolates E.coli Klebsiella Proteus Citrobacter Total (n=21) pneumoniae (n=13) mirabilis ( n=2) species (n=1) Ampicillin S R Ciprofloxacin S R Gentamicin S R Nalidixic acid S R Norfloxacin S R Ofloxacin S R Cotrimoxazole S R Nitrofurantoin S R Amikacin S R Cephotaxime S R Abbreviations: S-Sensitive, R-Resistant DISCUSSION Urinary tract infection is a serious clinical problem for people with DM 1. Thirty seven percentage of diabetic patients in the present study were associated with UTI. The occurrence of UTI in female diabetic patients in our study (43%) was higher in comparison to that in male (30%), the results being higher than prevalence rate of 14% observed by Andy et al 6 in

5 women with type I diabetes. However, this study agrees with other reports stating high prevalence of UTI in females during youth and adulthood than males 7,8,9,10. The most common organism isolated in our study was Escherichia coli (56.75%) followed by Klebsiella pneumoniae (38%), Proteus mirabilis (5.4%) & Citrobacter species (2.7%). The pattern of isolation of organism in this study is similar to the results from various regions which indicate that gram negative bacterium particularly Escherichia coli is the commonest pathogen isolated in patients with UTI 7,8,11,12. Ebie et al 13 have also reported Escherichia coli as commonly isolated organism (64.3%) followed by staphylococcus aureus (21.4%) & Klebsiella pneumoniae (14.3%). The isolated organisms in our study seem to be members of the enterobacteriaceae family and are normally regarded as inhabitants of the human intestine. Fecal contamination of the urethra, particularly in female due to short urethra and its proximity to anal canal and moreover, impaired immunity in the diabetic patients must have played an important role for predominance of these agents as primary urinary pathogens. While performing antibiotic sensitivity testing, Amikacin was found to be the most effective drug in our study followed by Nalidixic acid, Ofloxacin and Ciprofloxacin against the isolated UTI pathogens. This is in contrary to other reports where Quinolones were found to be the most effective agents against isolated Gram negative bacilli 13,14. This may be due to changing trends of antimicrobial susceptibility pattern of these urinary pathogens from place to place where the clinical use of antibiotic pattern may differ. Moreover, our results also highlight that the isolates exhibited varying frequencies of resistance to almost all clinically used antibiotics and it demands the need to look for newer more effective antimicrobials that can be used safely in the diabetic patients. CONCLUSION UTI is common in diabetic patients. Therefore, periodic screening of UTI in diabetic patients is imperative. The primary etiologic agents are no other than the members of enterobacteriaceae family, the most common being E.coli. The urinary isolates have developed resistance to almost all clinically used antibiotics at varying frequencies. Therefore, judiciary use of antibiotics and institution of infection control practices are crucial to prevent development of resistance by these pathogens

6 REFERENCES 1. Saleem M, Daniel B. Prevalence of urinary tract infection among patients with diabetes in Bangalore city. Int J Emerg Sci. 2011;1(2): Patterson JE, Andriole VT. Bacterial urinary tract Infection in diabetic review. Infec Dis Clin N Am. 1995;9(1): Chhetri PK, Rai SK, Pathak UN et al. Retrospective study on urinary tract infection at Nepal Medical College Teaching Hospital, Kathmandu. Nepal Med Coll J. 2001;3: Wilson ML, Gaido L. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis. 2004;38: Vejlsgaard R. Studies on urinary infection in diabetes. Acta Med Scand. 1966;179: Andy IMH, Ruby M, Suzanne EG. Pathogenesis and management of bacterial urinary tract infections in adult patients with diabetes mellitus. Int J Antimicrob Agents. 2003; 22: 35 / Burbige KA, Retic AB, Colony A, Bauer SB, Lebowitz R. UTI in boys. J Urol. 1984;132: Akinyemi KO, Alabi SA, Taiwo MA, Omonigbehin EA. Antimicrobial susceptibility pattern and plasmid profiles of pathogenic bacteria isolated from subjects with urinary tract infections in Lagos, Nigeria. Niger Qtr J Hosp Med. 1997;1: Cheesbrough M. District Laboratory Practice in Tropical Countries. 2nd ed. Cambridge: Cammbridge University Press; Ibeawuchi R, Mbata TI. Rational and irrational use of antibiotics. Afr Health. 2002;24(2): Okoanafua EE, Okoanafua BN. Incidence and pattern of asymptomatic bacteriuria of pregnancy in Nigerian women. Niger Med Pract. 1989,17: Njoku CO, Ezissi NH and Amadi AN. Observations on bacterial infections of urinary tract patients. Int J Environ Health and Human Development. 2001;2: Ebie M, Kandaki-Olukemi YT, Ayanbadejo J, Tanyigna KB. UTI infections in a Nigerian Military Hospital. Niger J Microbiol. 2001;15(1): Ehinmidu JO. Antibiotics susceptibility pattern of urine bacterial isolates in Zaria, Nigeria. Trop J Pharmaceutical Res. 2003;2(2):

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