Introduction
Diabetes Mellitus (DM) is a chronic metabolic disorder characterized by hyperglycaemia caused by defects in insulin secretion, action, or both. Immune dysfunction is a major issue in the disease course and it can manifest as either autoimmune disease or a poor immune response, the latter of which leads to a higher incidence of infections. Infections most commonly affect the urinary tract in diabetes. Indeed, cystitis is the most common infection in diabetes, outnumbering respiratory tract infections such as acute rhinitis and acute bronchitis, as well as skin infections such as dermatomycoses.1 The link between a higher incidence of urinary tract infections (UTI) and diabetes has been attributed to immune system impairments, poor metabolic control and incomplete bladder emptying due to autonomic neuropathy.2 Age, glycaemic control and long-term complications, primarily diabetic nephropathy and cystopathy were also found to increase the risk of UTI in diabetics.3 Poor glycaemic control may predispose to more severe UTI and greatly increase the risk of complications in UTI.4 Invariably, E. Coli is the most common isolate in UTI in DM. Other pathogens commonly isolated include Klebsiella, Proteus and Staphylococcus aureus.5 The high rates of antibiotic prescription for UTI in these patients may further induce the development of antibiotic-resistant urinary pathogens.6
Objectives
To assess clinical profile of UTI in diabetics, to assess laboratory profile of UTI in diabetics, to assess common causative organisms and their antibiotic sensitivity pattern.
Material and Methods
200 diabetic patients were screened for UTI admitted at Sir T. General Hospital, Bhavnagar over the period of 6 months from 1st November 2021 to 30th April, 2022.
Exclusion criteria
Pregnant and lactating mothers.
Immunocompromised patients (transplant patients, patients on immunosuppressive therapy, HIV patients)
Catheter associated UTI
Diabetic patients who are on SGLT2 inhibitor.
The various measures of central tendencies and graphical representations were used to analyse the data.
Diagnosis of diabetes mellitus was made using the following criteria
Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) or,
Symptoms of diabetes plus random blood glucose concentration ≥11.1 mmol/L (200 mg/dL) or,
Two-hour plasma glucose ≥11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test or,
HbA1C > 6.5%.
A detailed examination of all systems with special emphasis on temperature, pulse rate, blood pressure, suprapubic tenderness, costovertebral angle tenderness, tenderness/ mass on deep abdominal palpation were carried out.
Collection of mid-stream urine. Urine samples were sent to laboratory immediately for routine evaluation and for culture. For culture urine samples were incubated at 37C for 24 to 48 hrs in Blood / Chocolate agar and Mac Conkeys agar plate. Organisms identified were based on colony characteristics, lactose fermentation and biochemical test. Sensitivity to common antibiotics was done in all positive cultures. Other investigations included Complete blood count also done.
Results
In the present study, Majority subjects were from age group of 46 – 60 years 74 (37%) followed by 31-45 years 59 (29.5%), > 60 years was 44 (22%) and 18-30 years was 23 (11.5%) respectively.
In gender wise distribution, it was found that female patients 103 (51.5%) marginally higher than male 97 (48.5%). The ratio of male: female was 1:1.06. Majority of patient’s duration of diabetes between 6 to 10 years comprised 88 (44%).
Duration was less than 5 years in 86 (43%) and more than 10 years in 26 (13%). The least duration of diabetes in the study group was 12 months and the maximum duration was of 18 years. The mean duration of diabetes was 6.67 ± 3.60 years. In the present study, in clinical symptoms fever was found in 182 (91%) patients, Burning micturition in 79 (39.5%), Abdominal pain 38 (19%) and dysuria in 35 (17.5%). In biochemical parameters it was found that abnormal FBS in 163 (81.5%), abnormal PPBS in 171 (85.5%) and abnormal Hb1Ac (%) in 193 (96.5%), anemia in 71 (35.5%) patients, Leukocytosis in 76 (38%) patients respectively.
Predominant bacteria isolated were E. Coli 141 (70.5%) and the next common being Klebsiella 30 (15%). Other organisms isolated were Pseudomonas 12 (6%), Proteus 10 (5%), Candida 4 (2%) and Enterococci 3 (1.5%). Gender based evaluation of the causative organism also showed E. Coli as the most common cause organism in females.
It was found that among all the antibiotics — Imipenem, Meropenem and Colistin were found to be the best drugs to which all the organisms isolated were sensitive and most of the organism’s showed resistance to first line drugs like ciprofloxacin, nitrofurantoin, amikacin and gentamycin except E. Coli.
Table 1
Age wise distribution
|
Age |
No of Patients (N=200) |
|
18-30 |
23 (11.5%) |
|
31-45 |
59 (29.5%) |
|
46-60 |
74 (37%) |
|
>60 |
44 (22%) |
|
Total |
200 (100%) |
|
Mean Age (yrs) |
48.36 ± 13.53 |
Table 2
Gender wise distribution
|
Gender |
No of Patients (N=200) |
|
Female |
103 (51.5%) |
|
Male |
97 (48.5%) |
|
Total |
200 (100%) |
|
M:F ratio |
1:1.06 |
Table 3
Duration of diabetes mallitus
|
Duration of DM (years) |
No of patients (n=200) |
|
<1 |
0 (0%) |
|
1-5 |
86 (43%) |
|
6-10 |
88 (44%) |
|
>10 |
26 (13%) |
|
Total |
200 (100%) |
|
Mean duration of DM (years) |
6.67 ± 3.60 |
Table 4
Clinical symptoms
Table 5
Laboratory parameters
Table 6
Organisms isolated
|
Organism |
No of patients (n=200) |
|
E. Coli |
141 (70.5%) |
|
Klebsiella |
30 (15%) |
|
Pseudomonas |
12 (6%) |
|
Proteus |
10 (5%) |
|
Candida |
4 (2%) |
|
Enterococci |
3 (1.5%) |
|
Total |
200 (100%) |
Table 7
Antibiotic sensitivity to organisms
Discussion
For bacterial infection, urinary tract is the second commonest site after respiratory tract. Diabetes increases the risk of infection and the commonest amongst them are the ones involving the genitourinary tract. 40% of the years of life lost in a diabetic patient on an average can be attributed to nonvascular conditions like cancers, infections, and neurodegenerative disorders.7
In the present study, Majority subjects were from age group of 46-60 years (37%) followed by 31-45 years (29.5%) with mean age was 48.36 ± 13.53 years respectively. Choudhary MK et al have found that the most common age group was 46–55 years in (35%) patients. While it was corresponding with other study by Prakasam KA et al the incidence of UTI in male patients was more in patients with age group of 51-60 (54.28%) and least in the age group of 21-30 (10%), among female patients’ higher prevalence was observed in the age group of 31-40 (27.5%) and 51-60 (26.5%).8, 9 Most urinary tract infections were observed mainly in women because of sexual activity and pregnancy. Prevalence in women is also due to decrease of normal vaginal flora, less acidic pH of vaginal surface, short & wide urethra, proximity of urethra to anus and poor hygienic conditions.10, 11, 12
Majority of patient’s duration of diabetes between 1 to 10 years comprised (87%) then > 10 years in (13%) patients with mean duration of diabetes were 6.67 ± 3.60 years. The similar study by Sylvester SJ et al have observed that patients with duration < 1 year (Newly diagnosed cases) and those with duration > 10 years (Long standing cases) had lower (21% and 17% respectively) than those who had duration of DM between 1-10 years (62%), which is correlated with present study. A study by Abdulla MC et al. 10 observed increased risk of developing UTI, almost 148 (78.4%) patients with duration of diabetes >15 years and the rest had a duration lesser than 15 years (21.6%).
The study by Choudhary MK et al have found that Most of the patient had a fever with rigor (48%) followed by dysuria (22%), suprapubic pain abdomen (20%), increase frequency of urine (18%), flank pain (10%) pyuria (6%), and haematuria (4%).
Study by Abdulla MC et al have found that Gram negative bacilli were isolated from 129 (87.2%) patients which included E. coli in (50.7%), Klebsiella in (20.3%), Pseudomonas species in (8.1%) and Citrobacter in (8.1%) patients. Gram positive cocci were responsible for UTI in (10.1%) subjects including enterococcus (8.9%) and staphylococcus in (1.3%). Candida was isolated from (2.7%) patients.
In present study it was observed that most common isolated bacteria E. Coli was found sensitive against all antibiotics. Other commonly isolated Gram -ve bacteria were found mostly sensitive against Imipenem, Meropenem and Colistin. Similarly, the study by Vignesh PS et al have found that Cefoperazone, sulbactam was found to be highly sensitive antibiotic for gram positive than gram negative microorganisms10, 11 Amikacin was found to be sensitive for both gram positive and gram-negative pathogens followed by nitrofurantoin. Moreover, the study by Abdulla MC et al have found that gram negative bacilli including E. coli, the Klebsiella species, pseudomonas and Citrobacter had good response to piperacillin-tazobactam, cefoperazone-sulbactum, imipenam and amikacin. Our patients with gram negative bacilli UTI had an increased resistance for ampicillin and fluoroquinolones.
Conclusion
UTI was found to be significantly associated with advanced age and poorly controlled Diabetes. The link between a higher incidence of urinary tract infections (UTI) and diabetes has been attributed to immune system impairments, poor metabolic control and incomplete bladder emptying due to autonomic neuropathy.
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