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Year : 2019 | Volume : 7 | Issue : 2 | Page : 36 - 40  


Original Articles
A prospective study of clinical presentation, need for hospitalisation, microbiology and outcome of urinary tract infections in diabetes mellitus

Sandeep Patil1 Aadil Beigh2*, Satish Balan1, Praveen Murlidharan1, Sagar Jethwa1, Rajalakshmi A3

1Department of Nephrology, 3Department of Infectious diseases, Kerala Institute of Medical Sciences, Anayara PO, Thiruvananthapuram, Kerala, India

2 Department of Nephrology, Indraprastha Apollo hospital New Delhi, India

*Corresponding author:

Dr. Aadil Beigh,                                                                                                                                   

E-mail: aadilbeigh@gmail.com                                                                                                        

Abstract:

Background: Diabetics are more prone to infections than their non diabetic counterparts. The urinary tract is the most common site of infection in diabetes mellitus patients. Urinary tract infections (UTIs) most of the time in diabetic patients are relatively asymptomatic, which can lead to renal failure and severe kidney damage. A combination of local risk factors and host factors in diabetes mellitus lead to bacteriuria commonly compared to non diabetics.

Objective: To evaluate clinical presentation, need for hospitalisation, microbiology and outcome of UTI in diabetes mellitus.

Methods: This prospective, descriptive study was conducted at Kerala Institute of Medical Sciences, a tertiary level multispecialty hospital in South India to study the clinical profile of UTI (clinical presentation, need for hospitalisation, microbiological profile and outcome) in Diabetes mellitus; also to find out reasons for hospitalisation and for UTI in Diabetes mellitus.

Results: Among study population, 24% patients were in age group of 30 to 50 years, 52% patients were in age group of 51 to 70 year, 13% were in 71 to 80 year group. 32% (32patients) had growth of E. coli in urine, 14% (14 patients) had growth of k. pneumonia, 10%(10 patients) had growth of proteus , 9% (9 patients) had growth of S. aureus, 5%(5 patients) had growth of C. perfringens, 5% (5 patients) had growth of candida, 4% (4 patients) had growth of pseudomonas and Enterococcus. 52% (52 patients) had sepsis as the reason for hospitalization, 32% (32 patients) had fever as the reason, and 14% (14 patients) had flank pain as the reason and 1 patient each had pelvic pain and vomiting as the reason for hospitalisation. 18% (18 patients) had renal dysfunction and 32% (32 patients) had proteinuria.

Conclusion: UTI requiring hospitalization in Diabetes mellitus was more common after 50 years of age and equal in men and women. Diabetics are at risk of an increased susceptibility to infections of the urinary tract and occur with increased frequency and severity, and complications are more common.

Key words: clinical presentation, hospitalisation,, microbiology, outcome , urinary tract infections , diabetes mellitus

Introduction:

Among the most common infectious diseases, Urinary Tract Infections (UTIs) are commonly encountered diseases by clinicians in developing countries with an estimated annual global incidence of at least 250 million. 1 In Indian population Urinary Tract Infection is one of the common causes of morbidity and mortality, affecting all age groups across the life span. 2 There is increased risk of Urinary Tract Infections in infants, pregnant women, the elderly, patients with spinal cord injuries and/or catheters, patients with Diabetes mellitus or multiple sclerosis, acquired immunodeficiency disease syndrome/human immunodeficiency virus patients, and in patients with abnormalities of the genitourinary tract. 3 

Epidemiological studies suggest an association between Diabetes mellitus and           an increased susceptibility to infections of the urinary tract. It occurs with increased frequency and severity in diabetics, and complications are more common. 4 Host factors which are generally associated with increased risk of infection in Diabetic patients include age, metabolic control, duration of Diabetes mellitus, micro vascular complications, urinary incontinence, and cerebrovascular disease or dementia. Each specific variable which are contributing to the increased incidence and severity of Urinary Tract Infection 5, 6

The different types of presentations of urinary tract infections are asymptomatic bacteriuria, acute uncomplicated urinary tract infections (acute cystitis or acute non obstructive pyelonephritis), and complicated urinary tract infection in men or women with presence of abnormalities of the genitourinary tract and, acute or chronic bacterial prostatitis in men. Infection is often recurrent; either as are infection with new organisms introduced into the genitourinary tract or relapses when an organism persists within the genitourinary tract and often recurs after treatment. 7

In patients with Diabetes there is a disturbance in complement factor 4, abnormal cytokine response; it has been also observed that there is defect in cellular immunity leading to decreased function of neutrophils and macrophages/monocytes compared to controls. The cellular functions can be improved with strict control of the Diabetes mellitus (DM). Some microorganisms become more virulent in a high glucose environment. 8, 9  

There is high risk   for intra renal abscess, with a spectrum of disease ranging from acute focal bacterial pyelonephritis to renal cortico medullary abscess, to the renal carbuncle in diabetics. 10

Diabetic patients should be watched for Urinary Tract Infections which would enable bacteriuria to be properly treated, and avoid development of the most dreaded complications of Urinary Tract Infections, including mortality. There are lot of controversies with respect to incidence, prevalence and microbiological features of UTI between Diabetes mellitus patients and non Diabetes mellitus patients. 11

Studies showed significant increase in the prevalence of UTI as well as renal scarring in females, when compared to male Diabetes mellitus patients. 12

We performed this prospective descriptive study in a tertiary care hospital in North India to study the clinical profile of UTI in patients with Diabetes mellitus. 

METHODS:

Study design and Objectives.

This  prospective, descriptive study was conducted at, Kerala Institute of Medical Sciences, a tertiary level multispecialty hospital in south India to study the clinical profile of UTI ( clinical presentation, need for hospitalisation, microbiological profile and outcome) in Diabetes mellitus; also to find out reasons for hospitalisation and for UTI in Diabetes mellitus. Study population included Urinary tract infection patients total 100 in number, which are clinically confirmed by a Nephrologists and lab confirmed Urinary tract infection patients admitted in wards and ICU from May 2015 to May 2017. Informed consent was taken. Demographic data like gender and age was obtained. Patients were interviewed and history pertaining to Diabetes mellitus along with other relevant history was recorded. Patients were subjected to general physical examination and systemic examination. A freshly voided midstream urine sample was collected for urine routine and culture prior to initiating antimicrobial therapy for every patient presenting with Urinary tract infection. When such a specimen cannot be collected, such as in patients with altered sensorium or neurologic/urologic defects that hamper the ability to void, a culture was obtained through a sterile urinary catheter inserted by strict aseptic technique, or by supra pubic aspiration. In patients with long-term indwelling catheters, the preferred method of obtaining a urine specimen for culture was replacing the catheter and collecting a specimen from the freshly placed catheter, due to formation of bio film on the catheter. 

Inclusion criteria:

All clinically & laboratory confirmed cases of Urinary Tract Infections in Diabetes mellitus individuals. Inpatients admitted to medical wards and ICU, who give informed consent constitute the study population. 

Exclusion criteria:

Patients who are already on antibiotics for Urinary Tract Infection in Diabetes mellitus, patients who are not willing to participate, pregnant Women and patients with congenital genitourinary system abnormality.

The following diagnostic criteria were used for different presentations,

Uncomplicated cystitis: Genitourinary symptoms (i.e., dysuria, supra pubic pain or tenderness, frequency, or urgency) with evidence of pyuria plus bacteriuria in a structurally normal urinary tract. Pyuria: >10 white blood cells (WBC)/mm 3 per high-power field (HPF), bacteriuria when urinary pathogen of ≥10 5 colony-forming units (cfu) per ml. 12

Acute pyelonephritis was said to be present when patient complained of fever with chills and rigors, flank pain, nausea, and vomiting and following imaging findings.

  1. a) Ultrasound imaging studies were done and were considered to be suggestive of pyelonephritis if there was a combination of enlarged kidney, presence of collection and or perinephric stranding. 13
  2. B) Computed tomography was diagnostic of pyelonephritis if single or multiple hypo dense areas were evidenced after contrast medium injection.

Papillary necrosis was said to be present when patient complained of fever with chills and rigors, frequency, flank pain, nausea, and vomiting and imaging CECT depicted contrast material-filled clefts in the renal medulla, and no enhanced lesions surrounded by rings of excreted contrast material. 14

Emphysematous pyelonephritis was said to be present when patient complained of fever with chills and rigors, flank pain, nausea, and vomiting   and following imaging findings. a. On the basis of CT scan patients were classified into the following, Class 1: Gas in the collecting system only Class 2: Gas in the renal parenchyma without extension to the extra renal space Class 3A; Extension of gas or abscess to the peri nephric space Class 3B: Extension of gas or abscess to the para renal space Class 4: Bilateral emphysematous pyelonephritis or solitary kidney with emphysematous pyelonephritis. 15 

Statistical methods

The data were entered in MS EXCEL and analysis was done using the statistical software SPSS version 22.0. Quantitative variables were described by mean, standard deviation, minimum, maximum, median and interquartile range. Qualitative variables were described by proportion. Comparison of quantitative variables between two groups were analysed by independent sample t test. Comparison of quantitative variables among more than two groups were analysed by ANOVA. Association between qualitative variables were analysed by chi-square test. Variables which were significantly associated with outcome were subjected to multivariate analysis of binary logistic regression. A p value of <0.05 was considered statistically significant. 

RESULTS:

Description of study variable

Among study population, 24% patients were in age group of 30 to 50 years, 52% patients were in age group of 51 to 70 year, 13% were in 71 to 80 year group. Male and female formed 50% of study population respectively. Mean age of females was 60.4 ±10.0 years and that of males was 56.8 ±12.2 years. 6% of males and females were between 31-40 years,10% males and 28% females were between 41-50 years,34% males and 26% females were between 51-60  years,36% males and 28% females were between 61-70 years, and 14% males,12%  females were >70 years age. 

Table 1 Comparison between males and females with clinical presentations 

Clinical presentation

Sex

Total

χ2

Df

P

Male

Female

 

 

 

N

%

N

%

N

%

 

 

 

Dysuria

28

56

32

64

60

60

0.667

1

0.414

Frequency

37

74

37

74

74

74

0.000

1

1.000

Hematuria

15

30

8

16

23

23

2.767

1

0.096

Fever

40

80

34

68

74

74

1.871

1

0.171

Vomiting

36

72

33

66

69

69

0.421

1

0.517

Flank pain

37

74

27

54

64

64

4.340

1

0.037

Sepsis

29

58

23

46

52

52

1.442

1

0.230

EPN

8

16

10

20

18

18

0.271

1

0.603

Cystitis

12

24

10

20

22

22

0.233

1

0.629

XGP

1

2

1

2

2

2

0.000

1

1.000

Renal abscess

7

14

2

4

9

9

3.053

1

0.081

RPN

5

10

2

4

7

7

1.382

1

0.240

Renal dysfunction

6

12

12

24

18

18

2.439

1

0.118

Acute pyelonephritis

16

32

16

32

32

32

0.000

1

1.000

32% (32 patients) had growth of E. coli in urine, 14% (14 patients) had growth of k. pneumonia, 10% (10 patients) had growth of proteus, 9% (9 patients) had growth of S. aureus, 5% (5 patients) had growth of C. perfringens, 5% (5 patients) had growth of candida, 4%(4 patients) had growth of pseudomonas and Enterococcus. (Figure 1)

31% (31 patients) had > 20 years of diabetes mellitus, 27% (27 patients) had 16-20 years, 16% (16 patients) had 11-15 years, 15% (15 patients) had 6-10 years and 11% (11 patients) had < 5 years of diabetes mellitus. Mean duration of diabetes of males was 11.9±6.1 years and that of females was

13.1±6.5 years and the median duration of diabetes among males were 12 years and that of females was 13 years.

52% (52 patients) had sepsis as the reason for hospitalization, 32% (32 patients) had fever as the reason, and 14% (14 patients) had flank pain as the reason and 1 patient each had pelvic pain and vomiting as the reason for hospitalisation. 18% (18 patients) had renal dysfunction and 32% (32 patients) had proteinuria. Mean S. Creatinine of males was 1.5±0.8 mg/dl and that of females was 1.7±1.3 mg/dl and the median creatinine among males was 1.3 mg/dl and that of females was 1.15 mg/dl. Mean HbA1C level of males was 7.92±0.78 and that of females was 8.29±1.15 which was statistically not significant (p>0.05). 

DISCUSSION:

Urinary tract infection in Diabetes mellitus is a major health problem with high incidence and prevalence worldwide. These patients are at increased risk of infections, with the urinary tract being the most frequent infection. They are found to have an increase in the risk of Urinary Tract Infection (UTI) by 60%, with the involvement of upper tract in 80%, bilateral in most cases and are more prone for developing complications.

Diabetes mellitus has long been considered to be a predisposing factor for Urinary tract infection (UTI) and the urinary tract is the principle site of the infection in diabetics with increased risk of complications of UTI. Diabetes mellitus is associated with many complications and in the long run it has some major effects on the genitourinary system which makes diabetic patients more liable to UTI, particularly to upper urinary tract infections.

A higher glucose concentration in the urine acts as a favourable culture medium for pathogenic bacteria and promotes rapid bacterial colonization and growth. The spectrum of organisms causing UTI and their sensitivity patterns have changed over a period of time due to indiscriminate use of broad spectrum antibiotics. The need for hospitalisation in urinary tract infections in diabetes mellitus and outcome is limited. Thus in this study, we intend to know the spectrum of organisms, reasons for hospitalization and outcome of UTI in Diabetes mellitus.

During the study period in all patients with Diabetes mellitus with features of urinary tract infection a freshly voided midstream urine samples were collected for urine routine and culture prior to initiating antimicrobial therapy. Depending on the condition of patient need for hospitalisation was decided. Empirical antibiotics was started and changed according to urine culture and sensitivity report. Complete blood count, Renal function tests, fasting blood sugar, post prandial blood sugar, Hba1c, were sent in the meantime. Ultrasound abdomen and CT abdomen was done and depending on the findings, course of antibiotics was decided. After a course of antibiotics for 10 to 14 days patient was assessed clinically and confirmed by laboratory tests about the response to treatment.

In this study most of the patients were more than 45 years and as the age increases there is increase in the risk of UTI in type 2 diabetics. We found 18% of emphysematous pyelonephritis in diabetes Mellitus. In a Canadian report, women with diabetes mellitus were 6 - 15 times more frequently hospitalized for acute pyelonephritis when compared to diabetic men (3.4- 17 times), but in our study men and women had equal incidence of acute pyelonephritis.

In Diabetes mellitus patients the prevalence of Urinary tract infection (UTI) is high, compared to non-diabetics they have a distinctly high risk of complications. Complicated forms of UTI are described as severe pyelonephritis and renal abscesses, emphysematous pyelitis and pyelonephritis, renal papillary necrosis. 17

In this study the most common clinical presentation was acute pyelonephritis, followed by cystitis, emphysematous pyelonephritis, renal abscess and renal papillary necrosis. In this study 32% (32patients) had growth of E. coli in urine, 14% (14 patients)  had growth of k. pneumonia, 10% (10 patients) had growth of proteus , 9% (9 patients) had growth of S. aureus, 5% (5 patients) had growth of C. perfringens, 5% (5 patients) Had growth of candida,4% (4patients) had growth of pseudomonas and Enterococcus.

Also this study showed the most common organism isolated was E. coli, followed by k. pneumonia, proteus, and S. aureus, C. perfringens, Candida and pseudomonas. In contrast in other studies most common organism isolated was E. coli but differed with respect to other organisms.

In this study 52% (52patients)had sepsis as the reason for  hospitalization, 32% (32 patients) had fever as the reason,14%(14 patients) had flank  pain as the reason and 1 patient each had pelvic pain and vomiting as the reason for  hospitalisation.  54% (54 patients) had long hospital stay because of bacteremia, emphysematous pyelonephritis, renal abscess, azotemia and septic shock.

Hamdanet al​ 18 conducted study at Sudan in 2013 among 200 diabetic patients  found that overall prevalence of UTI was 39%. Among the total population, 17.1% and 20.9% had symptomatic and asymptomatic bacteriuria respectively. According to multivariate logistic regression, none of the risk factors (age, sex, type of DM and duration) were associated with UTI. In contrast to this study in our study the risk of UTI was more with respect to age, sex, and duration of Diabetes mellitus

Jennifer et al (​19) conducted a study in 2009 on the prevalence of lower urinary  tract infection in South Indian type 2 Diabetic patients found that poor glycemic  control was significantly associated with UTI in both sexes. As in our study also poor blood sugar level increased the risk of UTI. 

Strengths of our study 

1) Larger sample size 

2) Previous studies demonstrated about clinical presentations and microbiological profile of UTI in diabetes mellitus, but in our study reasons for hospitalisation and outcome of UTI in diabetes mellitus was also included as there few studies about reasons for hospitalization and outcome of UTI.

Limitations

  1. Only admitted patients with UTI were included and no follow up was done.
  2. There was no comparison with non-diabetics.
  3. Imaging studies were limited with only USG and CT-abdomen. 

CONCLUSION: 

UTI requiring hospitalization in Diabetes mellitus was more common after 50 years of   age and equal in men and women. Diabetics are at risk of an increased susceptibility to infections of the urinary tract and occur with increased frequency and severity, and complications are more common. The most common organism isolated from urine culture is E. Coli with good recover after two weeks of antibiotics and more sick patients had prolonged hospital stay which adds burden to heath cost. Diabetic patients should be watched for Urinary Tract Infections which would enable bacteriuria to be properly treated, and avoid development of the most dreaded complications of Urinary Tract Infections, including mortality. 

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Figure 1: Distribution of study population according to Urine Culture





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