Patients with diabetes are more prone to infection, and the urinary tract being the most common infection site. Many urinary tract infections are asymptomatic and symptomatic urinary tract infections are preceded by asymptomatic bacteriuria. In contrast with men, a higher prevalence of Asymptomatic Bacteriuria has been found in women with diabetes than without the disease. Because more Urinary Tract complications (e.g. Bacteremia, renal abscesses, renal papillary necrosis) are seen in patients with diabetes versus individuals without diabetes and also renal involvement without even the presence of symptoms (eg. Subclinical pyelonephritis) is common , Urinary Tract Infection in patients with Diabetes needs to be always considered.
Various Risk factors of Asymptomatic Bacteriuria with diabetes have been suggested including age, sexual intercourse, duration of metabolic control, and complications of diabetes.
Asymptomatic Bacteriuria is defined as the presence of at least 105 colony forming units/ml of 1 or 2 bacterial species in a culture of clean voided mid stream urine from an individual without symptoms of urinary tract infection.
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Contaminated urine is defined as the presence of at least 3 different micro organisms in 1 urine specimen. On microscopic examination â‰¥ 1 bacterium / oil immension field on gram staining of unspun, freshly voided urine correlated well with â‰¥ 105 colony forming units/ml on culture. â‰¥ 10 leucocytes/mm3 from a clean catch midstream urine sample correlated well with â‰¥ 105 colony forming units/ml on culture.
Asymptomatic bacteriuria is not a separate entity, but an early stage in the course of natural history of urinary tract infection.
Asymptomatic Bacteriuria is common in neonates, preschool children, pregnant women, elderly people, diabetics, catheterized patients, patients with abnormal urinary tracts or renal disease. Specifically asymptomatic bacteriuria occurring in DM can cause serious complications like renal and perirenal abscess, gas forming infections such as emphysematous pyelonephritis, and renal papillary necrosis.
Though there is no consensus on treatment of Asymptomatic Bacteriuria in various population groups, it was recommended to treat asymptomatic bacteriuria in diabetes mellitus, so as to avoid in the future Asymptomatic Bacteriuria going for symptomatic bacteriuria or complications due to Asymptomatic Bacteriuria.
Initially the United States preventive task force recommended periodic testing for asymptomatic bacteriuria in diabetes, pregnant women, pre school children and in persons over age 60 yrs. In general dipsticks combining the leucocyte esterase and nitrite tests should be used to detect Asymptomatic Bacteriuria. However urine culture is a more accurate test than dipstick analysis.
However, recently [IDSA] Infectious Disease Society of America came out with a guide lines with no necessity to screen or treat ASB in diabetes patients.
Aims and Objectives
To study the incidence of Asymptomatic Bacteriuria in Diabetes Mellitus patients presenting to a teaching hospital in Puducherry.
To identify the causative organisms responsible for Asymptomatic Bacteriuria in Diabetes Mellitus Patients.
To detect the organisms by urine culture & grams stain.
To study the precipitating factors for Asymptomatic Bacteriuria
Asmptomatic Bacteriuria in non diabetes individuals.
Comparative study between these two patient groups.
The functional unit of the kidney is the nephron. Each human kidney contains about 0.6 Ã- 106 to 1.4 Ã- 106 nephrons, which contrasts with the approximately 30,000 nephrons in each adult rat kidney. The essential components of the nephron include the renal or malpighian corpuscle (glomerulus and Bowman's capsule), the proximal tubule, the thin limbs, the distal tubule, and the connecting tubule. The origin of the nephron is the metanephric blastema. Although there has not been universal agreement on the origin of the connecting tubule, it is now generally believed to derive from the metanephric blastema. The collecting duct system, which includes the initial collecting tubule, the cortical collecting duct (CCD) in the medullary ray, the outer medullary collecting duct (OMCD), and the inner medullary collecting duct (IMCD), considered part of the nephron because embryologically it arises from the ureteric bud. However, all of the components of the nephron and the collecting duct system are interrelated functionally.
Two main populations of nephrons are recognizable in the kidney: those possessing a short loop of Henle and those with a long loop of Henle . The loop of Henle is composed of the straight portion of the proximal tubule (pars recta), the thin limb segments, and the straight portion of the distal tubule (thick ascending limb, or pars recta). The length of the loop of Henle is generally related to the position of its parent glomerulus in the cortex. Most nephrons originating from superficial and midcortical locations have short loops of Henle that bend within the inner stripe of the outer medulla close to the inner medulla. A few species, including humans, also possess cortical nephrons with extremely short loops that never enter the medulla but turn back within the cortex. Nephrons originating from the juxtamedullary region near the corticomedullary boundary have long loops of Henle with long descending and ascending thin limb segments that enter the inner medulla. Many variations exist, however, between the two basic types of nephrons, depending on their relative position in the cortex. The ratio between long and short loops varies among species. Humans and most rodents have a larger number of short-looped than long-looped nephrons
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TheÂ urinary systemÂ orÂ urinary tractÂ is theÂ organ systemÂ that produces, stores, and eliminatesÂ urine. In humans it includes twoÂ kidneys, twoÂ ureters, theÂ bladderÂ and theÂ urethra. The female and male urinary system are very similar, they differ only in the length of the urethra.
The kidneys are bean-shaped retroperitoneal organs that lie in theÂ posterior abdomen. These organ lie in the extraperitoneal connective tissue and situated lateral to vertebral column , just below theÂ rib cage, surrounded by Peri-nephric fat. AnÂ adrenal gland IS situated on the superior pole of each kidney. The kidneys receive nearly 25% of theÂ cardiac output as theirÂ bloodÂ supply at a rate of 1.25 L/min from the renal arteries branching fromÂ abdominal aorta. Th main role of kidneys is to filterÂ water solubleÂ waste products from the blood. kidneys are attached to theÂ ureters, which lies more medialÂ and runs down to reach theÂ trigone of urinary bladder. The tasks performed by the kidneys are concentrating urine, regulating electrolytes, and maintainingÂ acid-base homeostasis. The kidney excretes and re-absorbsÂ electrolytesÂ likeÂ sodium,Â potassiumÂ and calcium under the influence of local and systemicÂ hormones.Â pHÂ balance is regulated by the excretion of Â bound acidsÂ andÂ ammonium ions. In addition, they als o perform other actions such as removingÂ urea which is aÂ nitrogenousÂ waste product from theÂ metabolismÂ ofÂ amino acids. The end prouct is aÂ hyper osmolar solution carrying waste which is stored in the bladder beforeÂ urination.
HumansÂ produce about 2.9 litres of urine over 24 hours, although this amount may vary according to circumstances. Since the rate of filtration at the kidney isÂ proportionalÂ to theÂ glomerular filtration rate, which is in turn related to the blood flow through the kidney, changes in body fluid status can affect kidney function. Exogenous and endogenous hormones to the kidney alter the amount ofÂ bloodÂ flowing through theÂ glomerulus.Â
Diabetes mellitus, is a group of metabolic disease characterized by highÂ blood sugar, due to either of the factors such as decreased insulin secretion, reduced utilization of glucose, and increased production of glucose.
DM is associated many other pathologic changes in our multiorgan system like ESRD, CAD etc.,
DM is one of the leading cause of morbidity and mortality in the entire world.
Globally, as of 2012, an estimated 346Â million people have typeÂ 2 diabetes
Globally, as of 2010, an estimated 285Â million people had diabetes, with typeÂ 2 making up about 90% of the cases. Its incidence is increasing rapidly, and it is estimated to almost double by the year 2030.Â Diabetes mellitus occurs throughout the world, but is more common in the more developed countries .The International Diabetes Federation says that atleast 438 million individuals will have diabetes at the end of 2030. eventhough the prevalence of both the types 1 & 2 DM is increasing worldwide, the prevalence of type 2 DM is rising much more severely than type 1 because of increasing obesity, reduced physical activity ,change in eating habits and the aging of the population.The increase in incidence in developing countries due to urbanization and change in lifestyle.
India has more diabetics than any other country in the world, according to the International Diabetes Foundation.Â The disease affects nearly 50 million Indians,comprising about 7.1% of the nation's adults and about 1 million deaths a year. The average age of onset is 42.5 years. This high incidence is due to to a combination of factors like genetic susceptibility, adoption of a high-calorie, low-activity lifestyle mainly by India's growing middle class.
Type 1 DM is caused by the pancreatic beta cell destruction and deficiency of insulin due to interactions of genetic, environmental, and immunologic factors . some individuals are develop insulin deficiency by unknown mechanisms. Individuals who have a normal genetic susceptibility initially have a normal beta cell mass at birth but later they begin to lose the beta cells within months to years due to autoimmunity. This autoimmune process is triggered by an infection environmental factors . In most of the individuals, immunologic markers appear before diabetes becomes clinically overt but mainly after the triggering event. Insulin secretion progressively declines due to decrease in size of the beta cell mass. Although the glucose tolerance is maintained at a normal rate. The rate of decline in beta cell mass widely varies among individuals, with some individuals with a tendency to progress rapidly to clinical diabetes while in others it evolves more slowly. In nearly 70-80 percent individuals features of diabetes do not become evident until most of the beta cells are destroyed Though residual functiona of the beta cells exist they are insufficient i to maintain the glucose tolerance. The events such as puberty, infection etc., triggers the conversion from glucose intolerance to overt diabetes which are then associated with increased requirement of insulin.
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Insulin resistance and abnormal insulin secretion are the reasons to the development of type 2 DM. Although there are many controversies in this, most studies favour that insulin resistance precedes an insulin secretory defect, but diabetes develops only when insulin secretion becomes inadequate. Type 2 DM likely holds a range of disorders with common phenotype of hyperglycemia. DM in other ethnic groups like as in Asian, African, and Latin American has a different, but yet undefined, pathophysiology than others. In these groups, DM that is ketosisprone who are often obese or ketosis-resistant who are often lean is commonly seen.
The cause of diabetes depends on the type.
TypeÂ 1 diabetes is partly inherited and triggered by certain infections and environmental factors
The onset of
TypeÂ 1 diabetes is unrelated to lifestyle.
TypeÂ 2 diabetes is primarily due to lifestyle factors and genetics.
* IMMUNE MEDIATED
2. Type II
A. Genetic mutations [ MODY 1 - MODY 6]
* Subunits in ATP sensitive potassium channel
* pro insulin or insulin
B. Genetic defects in insulin action
* Type A insulin resistance
* Rabson-Mendenhall syndrome
* Lipodystrophy syndromes
C. Diseases of the exocrine pancreas
* fibrocalculous pancreatopathy
* mutations in carboxyl ester lipase
D. Drug or chemical-induced
* vacor -a rodenticide
* nicotinic acid
* adrenergic agonists
* protease inhibitors
G. Uncommon forms of immune-mediated diabetes
* anti-insulin receptor antibodies
H. Other genetic syndromes sometimes associated with diabetes
* Wolfram's syndrome
* Down's syndrome
* Turner's syndrome
* Klinefelter's syndrome
* Friedreich's ataxia
* Prader-Willi syndrome
* Huntington's chorea
* myotonic dystrophy
* Laurence-Moon-Biedl syndrome
SIGNS AND SYMPTOMS
The classical symptoms of untreated diabetes are loss of weight,Â polyuriaÂ (frequent urination),Â polydipsiaÂ (increased thirst) andÂ polyphagia(increased hunger).Â Symptoms may develop rapidly (weeks or months) in typeÂ 1 diabetes, while they usually develop much more slowly and may be subtle or absent in typeÂ 2 diabetes.
Other symptoms are
- blurred vision
- peripheral neuropathy
- loss of libido
- hyperpigmentation and skin rashes
Impaired fasting glycaemia
â‰¥ 6.1(â‰¥110) & <7.0(<126)
Impaired glucose tolerance
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:
Fasting plasma glucose level â‰¥Â 7.0Â mmol/l (126Â mg/dl)
Plasma glucoseÂ â‰¥Â 11.1Â mmol/l (200Â mg/dL) two hours after 75Â g oral glucose load as in aÂ glucose tolerance test
Symptoms of hyperglycemia and casual plasma glucose â‰¥Â 11.1Â mmol/l (200Â mg/dl)
Glycated hemoglobinÂ (Hb A1C) â‰¥Â 6.5%
A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat of any of the above methods on a different day.Â According to the current definition, two fasting glucose measurements above 126Â mg/dl (7.0Â mmol/l) is considered diagnostic for diabetes mellitus.
Glycated hemoglobinÂ is better thanÂ fasting glucoseÂ for determining risks of cardiovascular disease and death from any cause.
Diabetes increases the risk of long-term complications. These typically develop after many years nearly 10 - 20 years. It may be the first symptom in some who have not been diagnosed before .
DKA[ diabetic ketoacidosis]
HHS[ hyperglycemic hyperosmolar state]
1.coronary heart disease (CHD)
2. peripheral arterial disease (PAD)
3. cerebrovascular disease
- NON VASCULAR COMPLICATIONS
4. Hearing loss.
5. Sexual dysfunction
8. Periodontal disease
DKA occurs due to relative or absolute insulin deficiency combined with excess counter regulatory hormones like glucagon, catecholamines, cortisol, and growth hormone. Both insulin deficiency and glucagon excess, are necessary for development of DKA.
Hyperglycemic hyperosmolar state
HHS occurs due to relative insulin deficiency or inadequate fluid intake. Insulin deficiency increases hepatic glucose production mainly through glycogenolysis and gluconeogenesis and impairs glucose utilization in skeletal muscle. Hyperglycemia induces an osmotic diuresis that leads to intravascular volume depletion, which is further exacerbated by inadequate fluid replacement. The absence of ketosis in HHS is not understood.
The goals of therapy for type 1 or type 2 DM are to
(1) eliminate symptoms related to hyperglycemia,
(2) reduce or eliminate the long-term microvascular and macrovascular complications of DM, and
(3) allow the patient to achieve as normal a lifestyle as possible.
To reach these goals, the physician should identify a target level of glycemic control for each patient, provide the patient with the educational and pharmacologic resources necessary to reach this level, and monitor/treat DM-related complications.
- oral hypoglycemic agents
URINARY TRACT INFECTIONS
Epidemiologically, urinary tract infections are sub-divided into catheter associated or nosocomial infection or non catheter associated community acquired infections. Infections in either category may be symptomatic or Asymptomatic. Acute community infections are very common and account for more than 7 million Hospital visits annually in the united states. There infections occur in 1-3% of school girls and then increased markedly in incidence with the onset of sexual activity in adolescence. The vast majority of acute infections involve women. Acute symptomatic Urinary Tract Infection's are unusual in men under the young age group of 50 yrs. The development of asymptomatic bacteriuria parallels that of symptomatic infections and in rare among men under 50 years but common among women between 20 and 50 years. Asymptomatic bacteriuria is more among elderly men and women with rates as high as 10-50% in some studies.
Causative organisms of Urinary Tract Infection's are the most common organism are Gram Negative Bacilli
Escherichia coli - 70-80%
Klebsiella - 2-3%
Proteus - 2-4%
Enterococcus - 1-2%
Gram positive cocci
Staphylococcus saprophyticus - 10-15%
More commonly serratia and pseudomonas are known to cause recurrent infections and also in infections which are associated with urological manipulation, calculi or obstruction.
Proteus species and klebsiella species by virtue of urease production and through the production of extracellular slime and polysaccharides, predispose to formation of stone and more frequently in patients with calculi.
Chlamydia trachomatis, Neisseria gonorrhea, and herpes simplex virus are found most frequently in young, sexually active women .
The causative role of non-bacterial pathogens in Urinary Tract Infection's remains poorly defined. Ureaplasma urealyticum has been frequently isolated from t urine of patients with acute dysuria and increased frequency but it is also found in specimens without urinary symptoms.
Mycoplasma hominis have been isolated from prostatic and renal tissues of patients with acute prostatitis and pyelonephritis, and are probably irresponsible for some of the infections as well. Candida and other fungal infection is common and sometimes progressive to symptomatic invasive infection.
Mycobacterial infection of Urinary Tract Infection is also a common cause of Asymptomatic Bacteriuria.
PATHOGENESIS AND SOURCES OF INFECTION
The urinary tract should be viewed as a single anatomic unit that is united by a single column of urine extending from the urethra to the kidney.
Routes of Entry to the urinary tract
Mostly the infections of kidney units from organisms desired from gastrointestinal tract to the urethra and periurethra tissues into the bladder and then by the catheter to renal pelvis with subsequent invasion of renal medulla.
Accounts for less than 3% cases of Urinary Tract Infection and pyelonephritis. The major cases of hematogenous infection are staphylococcus aureus, salmonella species, pseudomonas aeruginosa, Enterococcus faecalis
Spread of infection along the lymphatic channels connecting bowel and urinary tract is possible.
GENDER AND SEXUAL ACTIVITY
In females the urethra is prone for gram negative bacilli infection because it is close to the perineum and its short length and its termination beneath the labia. In addition use of spermicidal compounds with a diaphragm or a cervical cap or of spermicide coated condoms dramatically alters the normal introital bacterial flora and has been associated with marked increase of colonization of E. coli and the risk of Urinary Tract Infection. In males who are a 50 years old and who have no H/o Heterosexual or Homosexual rectal intercourse, Urinary Tract Infection is exceedingly uncommon. Men & women who are infected with HIV are at increased risk of both bacteriuria and Urinary Tract Infection. Lack of circumcision has been identified as a risk factor for Urinary Tract Infection in both neonates & young men.
Pregnancy: 2-9 of Pregnant women 20-30% of pregnant women with Asymptomatic Bacteriuria subsequently develop pyelonephritis. Catheterization during or after delivery causes additional infections.
Obstruction: Any obstruction in free flow of urine tumour, stricture, stone, or prostatic hypertrophy results in increased frequency of Urinary Tract Infection.
NEUROGENIC BLADDER DYSFUNTION
Dysfunction that occurs due to interference with the nerve supply to the bladder which is seen in spinal cord injury, tabes dorsalis, multiple sclerosis. Diabetes and other diseases may be associated with Urinary Tract Infection. Other additional causes due to bone demineralization are from immobilization which lead to hypercalciuria, calculus formation & obstructive uropathy.
Vesicoureteral Reflux: Anatomically impaired vesicoureteral function facilities reflux of bacteria and thus Urinary Tract Infection.
BACTERIAL VIRULENCE FACTORS
Virulence factors of E.coli - surface antigen & toxins
Somatic Polysaccharide surface 0 antigen
Exerts endotoxic activity
Protects bacillus from phagocytosis
Protects bacillus from bactericidal effects of complement.
K antigens or envelop
P fibriae binds specifically to the P blood group substance on human erythrocytes and uroepithelial cells.
The E.coli serotypes commonly responsible for Urinary tract infections are those normally found in the faces, o group 1,2,4,6,7 strains carrying K antigens are more commonly responsible for pyelonephritis.
A maternal History of Urinary Tract Infections is found more among women who have experienced recurrent Urinary Tract Infection's than among controls. It has also been demonstrated that non-secretions of blood group antigens are at increased risk of Urinary Tract Infection.
DEFENSE MECHANISMS OF URINARY TRACT
Normal flora of the vagina
Flushing effect of urine flow and voiding
IgA, IgM, IgG Antibodies
METHOD OF URINE SAMPLE COLLECTION
Collection of midstream specimens of urine.
Suprapubic aspiration of urine
Collection of Midstream Urine collection specimen
Patient must have a full bladder
Retract the fore skin if present
Clean glans penis with swab
Void into toilet with foreskin retracted until half done
Without interrupting stream catch sample in sterile bottle
Patient must have a full bladder
Patient removes underclothing and stands legs either side of toilet
Separate labia with left hand
Cleans vulva front to back with sterile swab
Void downward into toilet until half done
Without interrupting stream catch urine in sterile bottle
The method of urine sample collection is followed because the distal urethra contains bacteria normally so voided urine is contaminated so Midstream Urine collection is done.
SUPRAPUBIC ASPIRATION OF URINE
This method is used when it is impossible to obtain uncontaminated samples or in symptomatic patients with low bacterial counts. This method is not usually followed
Patient must have a full bladder which can be percussed if not percussible or in doubt, give 300ml of water and 20mg of furosemide orally and wait for 1 hr. If still in doubt and especially in obese subjects, localize bladder using ultrasound. When patient supine chose site in midline 2.5cm above symphysis pubis, clean skin with spirit impregnated sterile gauze. Insert a 21 gauge 1.5" needle, attached to a 10ml syringe, directly downwards and aspirate urine. Withdraw needle and collect urine local anesthetics may be used.
It is nearly unnecessary to catheterize patients for collection of urine sample because catheter may introduce infection in the bladder and results in false positive cultures.
Urine being an excellent superfine medium for growth of most bacteria, it must be plated immediately or refrigerated at 4oc. Bacterial counts in refrigerated urine remains constant for as long as 24 hrs.
BD urine culture kit, a urine transport tube containing boric acid, glycerol, sodium formate, preserve bacteria without refrigeration for as long as 24 hrs when greater than 105 CFU/ml were present in initial urine specimen.
SAGE products care of III preservative system also available.
Both above products preserve bacterial inability in urine for 24 hours in the absence of antibodies. A new lyophilized system appears to stabilize microbial population for 24 hrs in the presence of antibiotics. For population of patients from whom colony counts of organisms of less than 105 /ml might be clinically significant, planting within 2 hour collection is recommended. None of the kits have any advantage over refrigeration.
TESTS FOR URINARY TRACT INFECTION
Grams stain method
Earliest least expensive and probably the most sensitive and reliable screening method for identifying urine samples that contain greater than 10 CFU/ ml
A drop of well mixed urine is allowed to dry. The smear is gram stained and examined under oil immersion (1000 x ) . Presence of atleast one organism per oil immersion field, examining 20 fields correlated with significant bacteriuria in 90% cases. The gram stain should not be relied on for detecting polymorphonuclear leucocytes in urine.
GRIESS NITRITE test
The test is based on ;the absence of nitrite in normal urine. The presence of nitrite, Detected by a simple test indicates the presence of nitrate inducing bacteria in urine. A positive test suggests the presence of atleast 105 organisms per ml of urine. This test detects Escherchia coli, klebsiella, proteus, staplylococcus, and pseudomonas species. False negative tests occurs in the presence of yeast, some gram positive cocci, urinary ascorbic acid, frequent voiding, urobilinogen.
This test depends on the generation of oxygen bubbles by catalase produced by the bacteria when hydrogen peroxide is added to the infected urine. False positive results occur in the hematuria.
4. Triphenyl Tetrazolium chloride test
The respiratory activity of growing bacteria, reduce 2,3,5 triphenlytetrazolium chloride to red insoluble triphenyl formogen false positive, false negative results are in the range of 5-10%. This test not used widely.
Glucose oxidase test
Depends on the bacterial metabolism of glucose normally present in urine. In the presence of infection glucose is not detected. False negative tests occur with high urine low rather and frequent voiding, an infected urine must be present in the bladder for some 1 hour before the glucose is metabolized completely. False positive results occur in glycosuric patients.
6.Leucocyte esterase test
This test detects the presence of pyuria by measurement of esterase activity within leucocytes, even in ;the absence of intact neutrophils. On its own it is relatively sensitive. However this test has been combined with griess test sensitivity and ESS-SS-Specificity. On study showed the negative predictive value of the combined tests to be 97.5% therefore if both tests are negative the possibility of a positive urine culture is remote.
7 . Dipslide culture methods
Agar counted slides are immersed in urine or even exposed to the stream of urine during voiding, incubated and growth is estimated by colony counting, by colour change of indications.
Based on detection of adenosine triphosphate (ATP) by measuring light emitted by the reaction of lacifenin luciterase. These tests are expensive and takes time.
9. BAC- T screen bacteriuria detection device
In this method the urine is forced through a filter paper, which retains microorganisms, somatic cells and other particles. A dye is then added to the filter paper to visualize the particulate matter that has adhered. The intensity of colour relates to number of particles. This procedure takes approximately one minute, has been shown to detect greater than 90% of all positive urine specimens even in 102 organisms per ml are consider to be significant.
A manual filtration method using the reagents on ;the Bac-T screen in the filtrate checks out Urinary Tract Infection.
Another promising recently introduced manual system combines filtration with differential media to quantitate and identify presumptively uropathogens with results available within 4 hrs.
None of the screening methods are as sensitive or as reliable on a culture. These tests may have a role in ;the immediate diagnostic. Screening of symptomatic patients and may be if some value in mass screening programs. They are not a substitute for urine culture.
10.NITRITE DIPSTICK TEST
Nitrite dipstick is subject to false-negatives, because 4 to 6 hours is required for bacteria to convert nitrate to nitrite in bladder urine, and some infecting organisms are nitrite negative. In a study of bacteriuria screening in infants ,85% of nitrite tests were false negative compared with culture. A 53% false-negative rate was also reported in an obstetric population with dipstick screening of nitrite.
QUANTITATIVE URINE CULTURE
The quantitative urine culture remains the optimal screening test.
Pour plate dilution technique:
This is an extremely accurate method but time consuming. It is used as a standard of comparison for other methods. Here double dilution series of urine or two fold dilution of urine are spread over the culture plate. The number of colonies in each plate in head in 24 hours and 48 hours and colonies calculated.
Surface culture methods:
Serial 10 fold dilution of urine are plated by surface culture method Number of colonies are calculated at end of 24 hr & 48 hrs.
Both the above methods are too complicated for routine diagnostic ---- for which semi quantitative techniques are more conveniently calibrated bacteriologic loop technique.
Most commonly employed method. In this standard platinum loops or disposable sterile loops are designed to deliver either 0.01 ml or 0.001ml of urine used.
The urine should be mixed thoroughly before plating flame a wire calibrated inoculating loop, allow it to cool without touching any surface if disposable plastic tips are not used. Insert the loop vertically into the urine to allow urine to adhere to the loop spread the loopful of urine to the surface of blood agar loop is touched to the center of the plate, from which the inoculums is spread in a line across the diameter in the plate, without flaming or reentering urine loop in drawn across the entire plate crossing the first inoculums without inflaming insert the loop vertically into the urine again for transfer of a loopful to an indicator medium. Incubate plates for atleast 24 hours at 35o to 37o c in air. The colonies are counted on each plate. The number of colonies CFUs are multiplied by 1000 ( if a 0.001ml loop is used) or by 100 if a 0.01ml of loop was used to determine the number of microorganisms per ml in the original specimen. The former medium gives quantitative measurement of bacteriuria while the later a presumptive diagnosis of the bacterium. The isolated are identified by their properties.
Reincubate plates with no growth or tiny colonies for an additional 24 hours before discarding plates. Since antimicrobial treatment or other factors may inhabit initial growth.
Antibiotic sensitivity test
Antibiotic sensitivity tests may be done directly using the urine samples as inocula and the results confirmed by repeating the tests with individual isolates.
Localization of urinary tract infection
Localisation of urinary tract infection to the bladder or kidney in women and to the bladder, kidney or prostate in men, importantly influences the clinical manifestation, response to treatment likelihood and pattern of recurrent infection and long term prognosis associated with these patients. In diabetic patients with urinary tract infection half of patients have upper urinary tract infection. This stratification of patients by site of infection becomes critical. While an ideal procedure for localization of urinary tract infection does not exist, the following techniques are available.
This method was cystoscopy followed by collection of bladder urine samples for quantitative culture. The bladder is then irrigated, repeatedly to wash out bladder organisms. This is confirmed by collecting further samples at the end of the washout procedure. Catheters are then placed along the ureters and left in the place to collect uretheral urine for quantitative culture. A diagnosis of upper tract infection is based on evidence of a 10 fold increase in bacterial counts in ureteral urine compared with post wash out bladder urine. This technique is invasive, not without morbidity and with considerable urological exploration. This method can identify unilateral Upper Urinary Tract Instrumentation.
Bladder washout technique
This method is now usually considered to be the most acceptable gold standard against which all newer techniques should be compared.
To do the washout test, a triple human catheter is inserted, a specimen is collected for culture and the bladder is emptied of urine. Next 100ml of sterile saline, containing 5mg gentamicin or 2 mg of neomycin and 1,25,000 units of topical streptokinase - stretodornace ( two ampoules of the drug) is injected into the catheter and allowed to remain for 30 min. The bladder is then emptied of urine, washed out with two litres of sterile saline and a post washout culture specimen is obtained. Subsequently, five additional urine specimens are collected 10 min are collected 10 minutes apart and the catheter is withdrawn. After quantitative urine cultures have been done in all specimen patients are classified to have lower tract infection if all post-washout culture specimen or upper tract infection if bacterial count > 102/ml occur in at least 4 of specimen 3 to 7 and there is a long increase in count between specimen 2 and the later specimen.
False positive results occur in those patients who have intermittent shedding of microorganisms from kidney and in patients with vesicoureteric reflux.
NON INVASIVE METHODS
URINARY CONCENTRATING ABILITY
The ability to concentrate urine is used to localize urinary tract infection. Renal infection results in a decreased concentrating ability; but not the bladder infection. Bilateral infection produces greater concentrating defect. Treatment usually produces a return of normal concentrating ability.
MEASUREMENT OF URINARY ENZYMES
Wacker and Dorfman found that urinary lactate dyhydrogenase activity was elevated in upper urinary tractr infection. Recently LDH - iso - enzyme 5 has been investigated as a localization tool.
False positive results occur in the presence of pyuria, haematuria, proteinuria. So that test is insensitive and non specific.
Measurement of urinary Î² glucuronidase activity as a localization tool is suggested by Ronald. In patients with upper urinary tract infection, this enzyme level is high
Vigano and associates suggests measuring the renal tubule cell enzyme N Actyl-Î²-D- Glucosaminidase to localize upper urinary tract infection.
MEASUREMENT OF SERUM OR URINARY ANTIBODIES
Serum levels of antibody directed against the lipopolysaccharide antigen present on bacteria, particularly that of E.Coli are commonly raised in patients with upper tract infection and absent in those with bladder infection. This is most diagnostically useful when an acute increase in antibody titres is demonstrated on serial samples taken over the period of the infection. Sensitivity and specificity of this test is still doubtful.
MEASUREMENT OF C-REACTIVE PROTEIN
Jodal and colleagues reported that consistently elevated level of C - reactive protein in serum, detected by immune diffusion technique were seen in children with pyelonephritis, not with acute cystitis. This test is less sensitive in evaluating adult Urinary Tract Infection.
ANTIBODY COATED BACTERIA ASSAY
Described by Thomas in 1974. This method is widely spread and used now because of its simplicity and apparent reliability.
The test depends upon the demonstration of immunoglobin to somatic or O Antigen on the bacterial cell surface. The presence of immunoglobulins is taken as evidence of invasion of tissues, especially the kidney by bacteria, resulting in an antibody response. IgG, IgM, IgA have all been shown to participate in the antibody coating phenomenon, IgG being predominant. Fluorescein-labelled anti-human immunoglobulin is incubated with infected urine and the number of fluorescent - bacteria present s recorded. Different criterias are used for a positive result. The original criterion of Thomas required 25% of all bacteria seen to be fluorescent to qualify as a positive assay. Subsequent criteria have ranged from 1 to 20 fluorescing bacteria in a search of 200 fields to 2 to 5 fluorescing bacteria in a five minute search.
False positive results occur when vaginal or rectal flora contaminate a urine specimen, proteinuria, prostatitis, haemorrhagic cystitis or bladder infection in the presence of bladder tumors or catheters.
False negative results occur in the range of 16 to 38%, if there is delay in performing the test, particularly if bacterial multiplication continues.
In a first inflection the test may not become positive for 2 weeks.
RESPONSE TO SINGLE DOSE TEATMENT
Described by Robin, using the antibody coated bacteria test in conjunction with single dose therapy, the response to single dose of antibiotics may be used as a localization tool.
Renal scanning with 67Ga citrate has been used to localize infection. A false positive rate of 15% and a false negative rate of 13% have been reported.
MEASUREMENT OF SERUM ANTI TAMM-HORSFALL CLYCOPROTEIN AUTOANTIBODIES
Significant concentration of IgG and IgA anti Tamm-Horsfall glycoprotein antibodies have been observed in patients with acute pyelonephritis, especially in the presence of vesicoureteric reflux. But this is not the case in lower urinary tact infection.
Asymptomatic bacteriuria is common in neonates, preschool children, pregnant women, elderly patients, in diabetics, in catheterized patients and in patients with abnormal urinary tracts or renal disease. Asymptomatic bacteriuria is uncommon in non elderly, non pregnant women and in men.
The patients with diabetes mellitus have many potential reasons to have bacteriuria which in many instances may be asymptomatic, including poor control of blood glucose levels, diabetic neuropathy with neurogenic bladder and chronic urinary retention, impairment of leucocyte function, frequent instrumentation of urinary tract, recurrent vaginitis and diabetic microangiopathy, and large vessel renal vascular disease.
The prevalence of asymptomatic bacteriuria is not significantly influenced by the duration of diabetes or the quality of diabetic control. A recent study that evaluated haemoglobin A1c levels in diabetic patients with and without bacteriuria was unble to relate the risk of bacteriuria to the level of haemoglobin A1c at the time of urine culture, thus concluding that factors other than reversible metabolic derangement place the diabetic at risk of bacteriuria.
The prevalence of asymptomatic bacteriuria increase as diabetic retinopathy becomes more severe, as heart disease and peripheral vascular disease become apparent .
Locaization techniques indicate that approximately half of all diabetic patients with bacteriuria have upper urinary tract involvements. Most of these patients are asymptomatic .
The long term consequences of asymptomatic bacteriuria in patients with diabetes mellitus are poorly documented. These patients are at high risk of developing.
2. Renal corticomedullary abscess
3. Renal carbuncle
4. Emphysematous pyelonephritis
5. Emphysematous cystitis
8. Perinephric abscess
Infectious Diseases Society of America-US Public Health Service Grading System for ranking recommendations
in clinical guidelines.
Category, grade Definition
Strength of recommendation
A Good evidence to support a recommendation for use; should always be offered
B Moderate evidence to support a recommendation for use; should generally be offered
C Poor evidence to support a recommendation; optional.
D Moderate evidence to support a recommendation against use; should generally not be offered.
E Good evidence to support a recommendation against use; should never be offered
Quality of evidence.
I Evidence from â‰¥1 properly randomized, controlled trial.
II Evidence from â‰¥1 well-designed clinical trial, without randomization; from cohort or casecontrolled analytic studies (preferably from 11 center); from multiple time-series; or from dramatic results from uncontrolled experiments.
III Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Recommendations relevant to the diagnosis of urinary tract infections
Diagnosis is based on the results of urine culture with
specimen collected to minimize contamination
For asymptomatic women, two consecutive voided urine
specimens with the same bacterial strain â‰¥105 CFU/mL B-II
For asymptomatic men, a single voided specimen with B-III
â‰¥105 CFU/mL defines bacteriuria
For men or women, a single catheterized urine specimen A-II
with a single species â‰¥102 CFU/mL
Pyuria accompanying bacteriuria is not an indication for A-II
CFU: colony-forming units.
Recommendations for screening for, and treatment of, asymptomatic bacteriuria
(ASB) in selected groups
Pregnant women should be screened for bacteriuria by urine
culture at least once in early pregnancy, and they should A-I
be treated if the results are positive
Screening for, and treatment of, ASB before transurethral A-I
resection of the prostate is recommended
Screening for, and treatment of, ASB is recommended A-III
before other urological procedures for which mucosal
bleeding is anticipated
Recommendations against screening for, and treatment of, asymptomatic
Screening for, and treatment of, asymptomatic bacteriuria is not
1. Premenopausal, nonpregnant women A-I
2. Diabetic women A-I
3. Older people living in the community A-II
4. Elderly, institutionalized people A-I
5. People with spinal-cord injury A-I
6. Patients with indwelling catheters A-I
Subjects and Methods
This was a case control study, which was conducted at the Mahatma Gandhi Medical College and Research Institute Hospital, Puducherry, a rural tertiary care hospital with an annual volume of above 1,00,000 patients over one year period.
The Institutional Medical Ethics Committee approved this study. From January 2011 until April 2012 we enrolled patients between the ages of 14 and 86 years of age.
100 diabetes mellitus patients and 50 healthy non diabetic controls without any urinary complaints viz dysuria, frequency, urgency, strangury, tenesimus, nocturia, nocturnal enuresis, prostatism, incontinence, urethral pain, bladder pain, renal colic, prostatic pain, and who attended Mahatma Gandhi Medical College between August 2010 to July 2012 were enrolled for this study. These patients did not have any previous bladder catheterization, instrumentation of urogenital tract or previous urogenital surgery.
WHO criteria was applied to diagnose diabetes mellitus.
Â WHO criteria for diagnosing diabetes mellitus.
Methods and criteria for diagnosing diabetes mellitus
1. Diabetes symptoms (ie polyuria, polydipsia and unexplained weight loss) plus
a random venous plasma glucose concentrationÂ >Â 11.1 mmol/lÂ
a fasting plasma glucose concentrationÂ >Â 7.0 mmol/l (whole bloodÂ >Â 6.1mmol/l)Â
two hour plasma glucose concentrationÂ >Â 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).
2. without symptoms diagnosis of DM should not be based on a single glucose test but requires confirmatory plasma venous determination . At least two glucose tests result on a another day with a value within the diabetic range is essential. It can be either fasting, random sample or the two hour post glucose test. If the fasting glucose or random glucose values are not diagnostic of DM then the two hour value should be used.
During initial visit relevant facts were elicited from patients regarding history, age, duration of diabetes, absence of urinary symptoms. H/O previous catheterization, instrumentation and surgery of urogenital tract. With regard to female patients, their menstrual history, H/O white discharge. H/O pruritus vulva were elicited.
Then detailed examination of patients carried out particularly with regard to complications of diabetes. In male patients, per rectal examination was carried out to rule out prostatic enlargement routinely. In female patients detailed gynaecological examination carried out to rule out any gynaecological problems, cystocele etc.
After these preliminary examinations, patients not fitting into selection criteria were omitted, and 100 diabetes mellitus patients, and 50 non diabetic control were proceeded to next stage of study.
During subsequent visits, patients and control group random blood sugar levels, blood urea, serum creatinine tests were done. On the same day patients urine samples were collected for culture and microscopic examination . In female patients urine culture sample were collected during their non-menstural periods.
METHODS OF URINE SPECIMEN COLLECTION
Clean catch mid stream urine collection method was adopted.
Patients were explained about the methods of collecting clean catch midstream urine and elderly female patients were provided with nursing assistants for cleaning the external genitalia.
Urine was collected in a sterile wide-mouthed screw cap bottle for culture purpose and microscopic examination. Two consecutive urine specimens were obtained, and refrigerated immediately, because it was not possible to plate all the samples of urine immediately.
One culture of a clean-voide specimen of midstream urine from an individual without symptoms of a UTI with at least 105 cfu/ml of the same single bacterial species was considered adequate to diagnose ASB.
The reason to culture a second time is to discriminate between true bacteriuria and contamination. In most studies ,only the positive cultures are repeated to diagnose.
QUANTITATIVE CULTURE OF URINE
Urine was cultured quantitatively by calibrated loop technique. The culture plates were read at the end of 24 hours and no. of colonies counted in positive cultures. If there was no growth the culture plates were reincubated for another 24 hours and number of colonies calculated if growth was noted.
ANTIBIOTIC SENSITIVITY TESTS
These were done using the standard amounts of ( nitrofurantoin, tetracycline, aminoglycosides, co-trimaxazole,3rd generation cephalosporins, fluroquinolones, Î² lactams and nalidixic acid in all culture positive cases) and report obtained at the end of 48 hours.
It was not possible to estimate HbA1C in all the patients in our set-up.
Written informed consent was obtained from the patients and controls.
We excluded all patients who had factors favouring exclusion criteria and included patients who satisfied inclusion criteria.
All data was entered into a Data Collection Proforma Sheet (Appendix 1) and were entered into Excel (MS Excel 2011). The Sheet had a visual map for marking and divided into indications for both genders. Other biographical details were also collected including date of birth, weight and height.
Statistical analysis was carried out using SPSS version 19.0 (IBM SPSS, US) software with Regression Modules installed.
Statistical methods such as odds ratio and chisquare tests were applied to find the significance between different variables.
Diabetic patients have 11.34 times the risk to develop asymptomatic bacteruria than a non diabetic individual.
X2 = âˆ‘ ( o-e )2 e
df = 1
X2 = 20.564
In this study an attempt was made to determine the incidence of asymptomatic bacteriuria in diabetes mellitus patients with comparison to non diabetic control group, common organisms causing infection and their antibiotic sensitivity.
On reviewing the literature the following studies conducted in similar manner to the present study noted.
Prevalence Rate %
3.5 Fold increase
3 fold rise
Equal to non diabetic male
Very few studies of this type were carried out in our country.
As noted above, most of studies were conducted only in female type II diabetes patients. Prevalence of asymptomatic bacteriuria in female diabetes patients varies from 7.9% to 32%. Comparatively in the present study the incidence of asymtomatic bacteriuria in female Type II patients is 35.38%.
Only few studies were conducted in male Type II patients. Most of the studies showed the prevalence of asymptomatic bacteriuria as equal to non-diabetic men. But in the present study incidence of asymptomatic bacteriuria in male Type II is 20% compared to 0% incidence in non-diabetic control. A study conducted in Type II patients of both sexes showed the prevalence of asymptomatic bacteriuria as 9.3%. In the present study the incidence of asymptomatic bacteriuria in Type II patients is 26.66% (Male 20%; Female 40%).
In the present study incidence of asymptomatic bacteriuria in both female and male diabetic patients are high when compared with non diabetic control group (36% and 20% and 0%)
Both Type II (insulin) and Type II (OHA) patients are equally affected (26.66% and 28.33%).
Percentage of male patients with diabetes mellitus on insulin with
positive culture - 20.00%
Percentage of male patients with diabetes mellitus on OHA with
positive culture - 20.00%
Percentage of female patients with diabetes mellitus on insulin
with positive culture - 40.00%
Percentage of male patients with diabetes mellitus on OHA
with positive culture - 35.00%
Percentage of patients with diabetes mellitus on insulin
with positive culture - 26.66%.
Percentage of patients with diabetes mellitus on
OHA with positive culture - 28.00%
Percentage of male patients with positive culture - 20.00%
Percentage of female patients with positive culture - 36.00%
In control group no. of male patient with positive culture - 0
In control group no. of female patient with positive culture - 3
Percentage - 12.00%
Many studies have found that the commonest organism causing asymptomatic bacteriuria is E. coli 40%, and gram negative bacilli made up 66.7% of the isolates. Comparatively in the present study, the common organism is E.coli (57.14%). Other organisms isolated include Klebsiella (33.33%) Enterococci (4.76%), Proteus (2.38%), acinetobacter (2.38%).
Bacteriuria appears to have no relation to increasing age. In the present study asymptomatic bacteriuria occurred in all age groups. About 55% of culture positive causes are in the age group of 41-60 years.
Bacteruria is common among elderly living in non- instituitional community settings, especially among women, although not as common as among the elderly in institutional settings.
The impression that true bacteruria in the diabetic is mainly confined to elderly diabetic women. Furthermore , the prevalence of bacteriuria among them was significantly greater than that of elderly non diabetic females.
Contaminated urine is defined as the presence of at least 3 different microorganisms in 1 urine specimen.
The prevalence of ASB is increased in women with diabetes [26% vs 6%] and might be added to the list of diabetic complications in women.
Longer the duration of diabetes with the presence of complications seemingly increases the risk of ASB in type 1 diabetic women .
The rate of ASB is not influenced by quality of diabetic control [glycosylated haemoglobin, fasting glucose level] or renal function.
Longer duration of diabetes, but not glucose control, is associated with bacteriuria prevalence. A statistically significant longer diabetes duration was found for diabetic subjects with bacteriuria than without. Prevalence of bacteriuria increases 1.9 - fold times in every 10 years duration of diabetes. However, there was no association between long - term glucose control, as reflected by glycosylated haemoglobin level, and bacteriuria prevalence.
Asymptomatic bacteriuria is common, especially in functionally impaired elderly patients with multiple medical morbidities. If symptoms or signs of infections are absent screening with routine dipstick and subsequent antimicrobial treatment is neither recommended. Early recognition and management of various risk factors of ASB is very important to potentially reduce its occurrence.
Considering all outcomes there is no benefit of screening for and treatment of bacteriuria.
It is difficult to prove that ASB is more frequent among women with diabetes than among those without diabetes[8,12].
Prevalence of ASB is nearly three times higher in patients with diabetes when compared with the control subjects.
Prevalence of bacteriuria was 4.4 times higher among diabetic than non diabetic subjects.
The prevalence of ASB among patients with diabetes is higher than in an apparently healthy group.
The prevalence of bacteriuria in diabetic women is 7% to 13%, about three times higher than non diabetic women.
ASB is unlikely to be a consequence of poor control of diabetes.
Impairment of metabolic control of diabetes as revealed by an increase in HbA1c level increases the risk of developing ASB.
Duration of diabetes, high HbA1c level, glucosuria and pyuria are risk factors for ASB in patients with type 2 diabetes. E.coli and K.pneumoniae are the most frequently isolated bacteria in diabetes patients with ASB. Routine urine culture might be recommended in diabetic patients who show no urinary symptoms but who have one or more of the risk factors mentioned.
The prevalence of ASB and leukocyturia (> 5 cells / high power field) was higher in children and young adults with diabetes than those of control subjects and the spectrum of bacteria in ASB was different from the usual spectrum of UTI. There was a tendency in the decline in renal function in type 1 diabetic women who had ASB.
Asymptomatic urinary infection cannot with certainty be correlated with increasing duration of diabetes. The prevalence rate of asymptomatic bacteriuria increased with longer duration of diabetes. In the present study 30% of positive culture cases had diabetes for 1-3yrs duration. Another 24% cases had diabetes for 5 to 10 yrs. duration. Even 33.33% of newly detected diabetes patients had positive urine culture. Any patient with diabetes can have asymptomatic bacteriuria irrespective of their duration of disease.
The prevalence of asymptomatic bacteriuria is not affected by measures of glucose control. In the present study 40% culture positive cases had random blood sugar value in the range of 201 to 250 mg%. Another 24% had in the range of 151 to 200%. 15% patients had in the range of 251 to 300%. The finding that quality of diabetic control does not affect the prevalence of asymptomatic bacteriuria is confirmed.
The prevalence of asymptomatic bacteriuria increases as diabetic retinopathy becomes more severe, 2 cases of diabetic retinopathy are culture positive in the present study.
Of the 6 patients with diabetic nephropathy 4 cases are culture positive. A cases of diabetic foot in present study not had any urinary tract infection. Of the 4 cases with ischemic heart disease, 2 cases are culture positive.
Certain studies found that isolates were poorly sensitive to regularly available antibiotics - tetracyclines (33% sensitive), cotrimaxazole (33% sensitive). Other antimicrobials with over 80% sensitivity level included aminoglycosides, nitrofurantoin, 3rd generation cepholosporins and fluroquinolones.
All the organisms that are grown in culture in the present study are resistant to commonly used antibiotics like tetracyclines, cotrimaxazole, and nalidixic acid. Almost all isolates are sensitive to quinolone group of drugs. Some are sensitive to aminoglycosides. Most of them were sensitive to nitrofurantoin.
Some of them were even resistant to nitrofurantoin and third generation cephalosporins.
Some of them were only sensitive to extended spectrum Î²-lactam antibiotic.
No benefit was idenitified in continued screening and treatment of asymptomatic bacteriuria. Antimicrobial therapy cleared bacteriuria in the short term, but did not decrease the numbers of symptomatic episodes and hospitalizations during long term follow up,and the high rate of recurrent bacteriuria led to markedly increased use of antimicrobial agents. Increasing antimicrobial resistance is a major concern.
Antimicrobial management of urinary tract infection in diabetic women should focus on the prompt identification and effective treatment of symptomatic episodes.
Isolated E.coli strains were resistant at similar rates to ampicillin, cotrimoxozole, ciprofloxacin and nitrofurantoin in both diabetic and non-diabetic patients. Hence diabetes mellitus could not considered per se a risk factor for the emergence of a non E.coli organism and for antibiotic resistance.
Diabetes has a considerable public health impact on the risk for and prognosis of enterobacterial bacteremia acquired in the community.
Screening for or treatment for ASB is not indicated in women with diabetes and treatment with antibiotics did not delay no