Full Length Research Paper
A
Study about Urinary Tract Infection (UTI) Among Patients Attending Tertiary
Care Hospital, Dewas, Madhya Pradesh
Rinku Padiyal Gehlot1[*], Dr. Sangeeta Gupta2
and Dr. Munish Kumar Sharma3
1PhD Scholar, Department of Microbiology, OPJS
University Churu, Rajasthan, India.
2Associate Professor, Department of Microbiology, OPJS University Churu, Rajasthan, India.
3Associate Professor, Department of
Microbiology, Amaltas Institute of Medical
Science, (AIMS), Dewas, Madhya Pradesh, India.
ARTICLE DETAILS ABSTRACT
1. Introduction
The word Urinary Tract
Infection (UTI) is a combined statement describing any form of infection that
takes part in the urinary tract. This is usually associated with
catheterization or instrumentation of urethra, bladder or kidneys. Urinary
tract infection associated with catheterization is named as catheter associated urinary tract infection (CAUTI).
Infection is caused by E.coli,Klebsiella spp., Proteus spp., Pseudomonas aeruginosa,Stapyloccousaureus
and Candida spp. Infection can be
prevented by strict asepsis during catheterization[1].
E.coli is the
commonest organism responsible for UTI. Most frequent O serotypes of E.coli causing
UTI include 01, 02, 04, 06, 07, 018 and 075. These are also named as nephritogenic strains. Special nephron pathogenic potential
of these strains appears to be due to following factors: Polysaccharides of O
and K-antigens protect the organism from the bactericidal effects of complement
and phagocytes. Strains possessing K1 or K5 antigen appear to be more virulent [1,2]. Fimbriae mediate the adherence of the organism to uro-epithelial cells. The receptor, to which it attaches,
is believed to be a part of the P blood group antigen and therefore it is
termed as P fimbriae[1,3]. E.coli
that causes UTI often originates in the intestinal of the patient. Route of
infection to reach urinary tract is either the ascending route or the
haematogenous route. The ascending route is through faecal flora spreading to
the perineum and from there they ascending into the
bladder [4]. The other commonly encountered bacteria in UTI are klebsiella, Proteus, Citrobacter
and those which rarely produce UIT are Salmonellae,
Edwardsiellae and Enterobacter. The gram positive
organisms that can cause UTI include Staphylococcus
aureus, coagulase negative staphylococci, Str.faecalis, Str.pyogenes, Str.milleri, Str.agalactiae,
other streptococci and anaerobic streptococci. Rarely Gardnerella vaginalis may cause UTI in immune compromised
patients. The hospital-associated infection following instrumentation,
catheterization and other procedure, is mostly caused by Pseudomonas and Proteus[5].
Urinary tract infections
(UTI) known as the propagation of active microorganisms within the urinary
channel and its causes to the environment. UTI was more frequent in women and
frequently present in the bladder or urethra, but extra serious infections
engage the kidney. Back pain, nausea, vomiting and fever of symptoms indicates
microbes causes UTI part kidney (upper urinary tract), likewise pelvic pain,
greater than before urge to urinate, pain with urination and urine with blood
are the symptoms signifying the infection of bladder (lower urinary
tract)[2,6]. UTI can affect lower and sometimes both lower and upper urinary
tracts. The term cystitis has been used to define the lower UTI infection and
is characterized by symptoms such as dysuria, frequency, urgency, and
suprapubic tenderness. The presence of the lower UTI symptoms doesn’t exclude
the upper UTI, which is often present in most of the complicated UTI cases [3,7]. The treatment of UTI can be classified into
uncomplicated and complicated on the basis of their choice of treatment [8].
UTI is more common in females than in males, since the female urethra is
structurally less effective for preventing the bacterial entry [9]. It may be
due to the proximity of the genital tract and urethra [11] and adherence of urothelial mucosa to the mucopolysaccharide
lining [12].
In the case of
uncomplicated UTIs that majorly prevails in healthy persons, and those have no
structural, or neurological abnormalities in the urinary tract [13,14]. These infections are further named as lower UTIs
(cystitis) and upper UTI (pyelonephritis) [13,15]. In
case of cystitis, it remains associated with several risks including sexual
activity, female gender, a prior UTI and vaginal infection, diabetes, obesity
and genetic susceptibility [15,16]. In case of
complicated UTI, they are associated with factors such as compromised urinary
tract or host defense, obstruction in urinary tract, neurological disease based
urinary retention, renal failure, immunosuppression, pregnancy and installation
of foreign material such as calculi, indwelling catheters or any drainage
devices [17,18] In the majority of cases, 70- 80% of
UTIs are linked with indwelling catheters that accounts for 1 million cases per
year [16]. On the basis of symptoms there are two clinical features of UTI,
symptomatic and asymptotic infection. Symptomatic infection is associated with
significant bacteriuria (>105 CFU/ ml
of urine) with symptoms of UTI(8). In the case of Asymptomatic bacteriuria (ABU),
the patient did not represent renal disease or damage. As per studies, patients
undergoing treatment of ABU increases their chances of subsequent symptomatic
UTIs. Therefore, treatment not recommended except in diagnostic and therapeutic
procedures such as entry to the urinary tract with a risk of mucosal damage,
endoscopic urological surgery and transurethral resection of the prostate
[10,19].The increasing antimicrobial resistance among Gram–negative organism
including E.coli
is a growing public health concern in our country. This indicates the need for
continuous monitoring of antimicrobial resistance (AMR) to document any
changing trends in our geographical region.
2. Material and Method:
Study was carried out
for the detection and prevalence of urinary tract infection causing bacteria
from specimens in the microbiology Department of Amaltas
Institute of Medical Science(AIMS), Dewas, (M.P.) from December2019 to December 2021. Total 739
microorganisms were isolated for detection and prevalence of UTI in different
types of specimens such as midstream urine samples, catheter samples and urine
specimens from infants etc. The study design was approved by ethical committee
and the protocol of study was reviewed and approved by the research cell of Amaltas Institute of Medical Science (AIMS),Dewas, (M.P.). Ethical committee
also acquired the ethical approval.
2.1 Laboratory Diagnosis: Physical
examination, Chemical examination, Microscopy andCulture
of the urine is necessary for the identification of the organism and its
antimicrobial susceptibility test.
2.2 Sample Collection:
2.2.1 Midstream Urine Sample (MUS)
For routine urine
examination, the specimen is collected in dry and clean container. For
microbiological examination, a midstream specimen is collected in a sterile
container (to avoid debris and prostatic secretions). The sterile container can
be prepared in the laboratory by sterilizing it in hot air oven at 1600C for 1
hour. The container should be made up of glass with a metal screw cap. It is
better to collect the specimen by catheterization in case of culture. Usually
the female patient is asked to clean the external genitalia before collection.
The first portion of urine adequately flushes out the normal urethral flora.
Urine should be examined within 2 hours and if it cannot be examined promptly,
must be refrigerated.
2.2.1 Catheter sample:
Urine should be
collected directly from catheter and not from the collection bag. The catheter
should not touch the container. Although a catheter specimen yields excellent
results but catheterization to obtain urine is not justified because of risk of
introducing infection.
2.2.1 Urine Specimens from Infants:
A clean catch specimen
after cleansing of genitalia is preferred. Another procedure of collecting
specimen in infants is suprapubic aspiration. This procedure may also be used
in adult women when uncontaminated specimen cannot be obtained by other
methods.
2.2.1 Transport and preservation:
As urine is a good
culture medium, specimens after collection should reach the laboratory with
minimum delay, if this is not possible, the specimen is to be refrigerated at 4*C.
It is better to examine fresh specimen because delay in testing may result in
some undesirable changes, which affect the test results. If there is a delay in
examination, the urine should be refrigerated because it provides
bacteriostatic temperature (2-60C). When bacterial growth is not there, urea
and glucose in urine are unaffected and thus no change in ph.Various
chemicals are used to preserve the urine specimen and are known as
preservatives, e.g. formalin, toluene, HCI, boric acid and thymol,
etc. This preservation is very important to prevent growth of bacteria,
preserving quantity of solutes, and preserving morphology of formed elements.
2.3 Laboratory Methods:
2.3.1 Physical Method:
In physical method,
appearance of urine, volume, order, color, specific gravity, osmolality, pH are included.
2.3.2 Chemical method:
In chemical examination,
different types of chemicals and reducing substances are checked or examined in
patient's urine. These include proteins, glucose, reducing sugars, ketone
bodies, bile pigments, calcium, melanin, chloride, homogentisic
acid, and amino acid.
2.3.3 Microscopy:
The urine is
microscopically examined for cells, casts and crystals. For the microscopic
examination, urine is centrifuged at 2,000 rpm for 5 minutes. The supernatant
is poured off and by flicking the end of tube with finger, re-suspend in a few
drops of urine left. This is placed on the slide and examined. Staining of
urine sediment can also be done. This
makes possible the recognition of cells, particularly for the inexperienced
technicians.
2.3.4 Culture method:
CLED agar is used as a
single urine culture medium. Alternately, Blood agar and MacConkey
agar may also be used. For sensitivity test, Muller Hinton agar is used. Uncentrifuged urine is inoculated on CLED agar alternately,
on blood agar and MacConkey’s agar. Culture plates
are incubated at 37*C for 24 hours. Bacteria isolated on culture are
identified. Most laboratories use a semi quantitative method (standard loop
technique) for culture of urine specimens.
2.3.5 Standard Loop Technique:
A standard calibrated
loop is used to culture a fixed volume of uncentrifuged
urine. CLED agar, Blood agar and MacConkey’s agar are
used and incubated at 37*C for 24 hours. Next day, the number of
colonies obtained is counted and the total count per ml is calculated. The
fixed volume loop is 4mm in diameter and can hold 0.005 ml urine(i.e.200loopfuls
make one ml), the total bacterial count per ml will be number of colonies
multiplied by 200. Single bacterium would form a single colony; therefore, the
number of colonies shall be equal to number of bacteria present. Kass(1996)
gave a criterion of active bacterial infection of urinary tract as follows:
· Count more than 105
bacteria of single species per ml: significant
bacteriuria which indicates active UTI.
· Between 104 to 105
bacteria per ml is of doubtful
significance, specimen should be repeated for culture.
· Less than 104
bacteria per ml: no significant growth
but regarded as contaminant.Contamination is also
considered when three or more bacteria are isolated.
2.3.6 Identification of the Organisms:
The organisms are
identified by colony characteristics, motility, gram staining, biochemical
reaction and serological tests.
3. Results:
Mostly of the 739
samples, 54.94% showed the growth of E.coli. Apart from
this, growth of other microorganisms was seen in remaining 45.06%, like the
growth of Klebsiella
spp. 26.66%, growth of Proteus spp.
13.26%, growth of Pseudomonas aeruginosa2.84%,
growth of Staphylococcus aureusis 1.76%,
while the growth of Candida spp.
0.27% and Enterococcus faecalisgrowth
0.27% were also observed.
Table 1 : Distribution of Micro-organisms isolates from various clinical
samples-midstream urine specimen, catheter specimen, urine specimens from infants,(n=739)
|
Name of
Isolated Microorganisms |
Number of
Isolates |
Percentage
(%) |
|
E.coli |
406 |
54.94 |
|
Klebsiella spp. |
197 |
26.66 |
|
Proteus spp. (P.mirabilis) |
98 |
13.26 |
|
Pseudomonas aeruginosa |
21 |
2.84 |
|
Staphylococcus aureus |
13 |
1.76 |
|
Candida spp. |
02 |
0.27 |
|
Enterococcus faecalis |
02 |
0.27 |
|
Total |
739 |
100% |
Table 2 : Departments wise
distribution of microbial growth. (n=739)
|
Departments |
Total No. of Samples Received |
No. of Specimen with Growth of Microorganisms |
|
Obstetrics
&Gynecology |
623 |
467 |
|
Surgery |
285 |
217 |
|
I.C.U. |
61 |
32 |
|
Casualty |
35 |
20 |
|
N.I.C.U. |
05 |
02 |
|
Orthopedics |
03 |
01 |
|
Total |
1012 |
739 |
Table 3 : Gender wise
distribution of microorganisms isolates. (n=739)
|
Gender |
Total No. of Cases |
Percentage (%) |
|
Female |
496 |
67.12 |
|
Male |
243 |
32.88 |
|
Total |
739 |
100 |
4. Discussion:
This study determined the detection and prevalence of urinary tract
infection causing bacteria from specimens in tertiary care hospital. Our analysis demonstrated that the
prevalence of bacterial urinary tract infection in patients attending amaltas hospital was 739/1012 (73.02%). Out of this
bacterial UTI prevalence, symptomatic and asymptomatic patients contributed to
396/739 (53.5%) and 343/739 (46.4%), respectively. Almost half of the patients
having significant bacteriuria were asymptomatic, and
this situation is of utmost concern since asymptomatic bacteriuria
is a strong predictor of ensuing symptomatic UTIs [22]. The higher prevalence of UTIs in our
study could have been probably due to the inclusion of a number of risk groups
like diabetes,[13,14] elderly, pregnant women,
HIV,[10-12] infants[15,16], and a high number of inpatients who are usually
prone to UTIs. Previous study in Mulago by Mwaka et al. [23] found a much higher prevalence of significant bacteriuria
of 29/40 (72.5%) in asymptomatic patients. The higher proportion in the study
carried out at Mulago is not surprising, since the
study included only adult females who are always at high risk of developing
asymptomatic bacteriuria [20].
Our study demonstrated E.coli as
the most prevalent bacterial uropathogen with
406/739(54.94%). This finding is comparable with other studies elsewhere in
Africa indicating 40–46% of isolation of E. coli [24–27]. The high prevalence of E. coli in the
female gender could be due to the close proximity of the anus to the vagina.
This high possibility of UTIs in females is due to the inherent virulence
of E. coli for urinary tract colonization such as its
abilities to adhere to the urinary tract and also association with other m.o. moving from the perineum areas contaminated with fecal microbes to the moist warmth environment of the
female genitalia [19, 28].
This study demonstrated that age ≤19 years, female gender, married
individuals, genitourinary tract abnormalities, diabetes, hospitalization, catheter, and
increase in duration of catheter were found to bear statistically significant
relationship with UTIs. Age and female gender were found to have statistically
significant relationship with UTIs in similar study carried out by Kabugo et al. in 2016 [20].
The statistically significant association between UTIs and diabetes could be
due to altered immunity in diabetic patients which includes depressed polymorphonuclear leukocyte functions, altered leukocyte
adherence, chemotaxsis, phagocytosis, impaired
bactericidal activity of the antioxidant system [29, 30], and neuropathic complications, such as impaired bladder
emptying. In addition, a higher glucose concentration in the urine may create a
culture medium for pathogenic microorganisms in diabetic patients that may
result into UTIs. Generally, similar reports from elsewhere also indicated that
age, female gender [20, 31], diabetes [21, 31, 32], genitourinary tract abnormalities [13, 14], married individuals [33], hospitalization [17], catheter, and duration of catheter [31] bear statistically significant
relationship with UTIs.
5. Conclusion:
We know that,
UTIs remain a major medical problem occurring frequently and worldwide, the
rate of E.coliis
rising very quickly and becoming most important problem in the part of UTI. E.coli is fastly increasing and now this is the important cause of
trouble among the infectious diseases. Changing pattern of resistant bacterial
infection in UTIs need to be detected as early a
possible to prevent the spread of resistant bacteria and improve the strategies
of treatments. In order to UTIs to emerge in a hospital/health care setup,
various strategies such as applying strict infection control measures,
judicious prescribing of antibiotics, implementation of antibiotics resistant
cycling must be done. Regular monitoring and documentation of urinary tract infection(UTIs) should be done by all microbiology
laboratories.
6. Acknowledgments:
We
are indebted to the department of microbiology, Amaltas Institute of
Medical Science (AIMS) (MP) for the kind cooperation and support.
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