THE PREVALENCE OF URINARY TRACT INFECTION IN TYPE 2 DIABETES MELLITUS PATIENTS ATTENDING THE GENERAL OUTPATIENT CLINIC IN THE UNIVERSITY OF PORT HARCOURT TEACHING  HOSPITAL

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THE PREVALENCE OF URINARY TRACT INFECTION IN TYPE 2 DIABETES MELLITUS PATIENTS ATTENDING THE GENERAL OUTPATIENT CLINIC IN THE UNIVERSITY OF PORT HARCOURT TEACHING  HOSPITAL

                                  ABSTRACT

Objectives:  To determine the prevalence of urinary tract infections in type 2 diabetic patients attending the General Out patient clinic at the University of Port Harcourt Teaching Hospital.  Identify the common causative organisms responsible for urinary tract infections in diabetes with a view to forming the basis for empirical antimicrobial therapy and associated risk factors in these patients.

Design: Cross sectional study.

Setting: University of Port Harcourt Teaching Hospital, Port Harcourt.

Patients: Type 2 diabetic and non diabetic adult patients attending the General Outpatient Clinic of the Teaching Hospital between June 1, and December 30, 2005.

Procedures: Clean catch mid stream urine was taken for urinalysis, bacteriological culture and antibiotic sensitivity testing was done on positive cultures. Blood samples were equally collected and sent to the chemical laboratory for fasting blood glucose estimation.

Results: During the seven (7) months period, a total of 600 patients (consisting of diabetics and non diabetics) were evaluated. The mean age for the diabetics was 55.5 ± 8.2 and for the non diabetics was 48.5 ± 8.9.

A prevalence of 25% of asymptomatic bacteriuria was found. The common pathogens isolated were Kleb spp(52%), E.coli(20%), Staph spp(20%). Each of the isolates ( Kleb spp and E.coli ) showed good sensitivity to Nitrofurantoin and Quinolones. Poor metabolic control, females and older subjects were found to have increased bacteriuria.

Conclusion: This study demonstrates that high prevalence of asymptomatic bacteriuria was common among diabetic patients. Also suspected cases of urinary tract infections in diabetics can be managed empirically with nitrofurantoin and quinolones (in the absence of sensitivity testing or while awaiting results of sensitivity).

TABLE OF CONTENTS

Title page ……………………………………………………………………………i

Dissertation submitted to the National Postgraduate Medical College……………..ii

Declaration …………………………………………………………………………iii

Certification…………………………………………………………………………iv Dedication………………………………………………………………………….v

Acknowledgement…………………………………………………………………vi

Table of contents………………………………………………………………….vii-ix

List of tables………………………………………………………………………x-xi

List of figures……………………………………………………………………..xii

List of abbreviations………………………………………………………………..xiii-xiv

Abstract…………………………………………………………………………….xv-xvi

 

CHAPTER ONE

1.1 Introduction………………………………………………………………….1

1.2  Statement of the problem……………………………………………………2

1.3  Relevance of the study………………………………………………………3

1.4  General and Special Objectives………………………………………………4

1.5  Research Question…………………………………………………………..4

1.6  Expected Benefits…………………………………………………………..5  

 

CHAPTER TWO (Literature Review)

2.0 Literature Review …………………………………………………………..6

2.1. General overview of Diabetes mellitus and Urinary tract infections………6

2.1.1.1 Epidemiology of Diabetes mellitus…………………………………….6-7

2.1.1.2 Pathogenesis of Diabetes mellitus ……………………………………..7-8

2.1.1.3 Pathophysiology of Diabetes mellitus………………………………….9

2.1.1.4 Clinical manifestations and diagnosis………………………………… 9-10

2.1.1.5 Management of Diabetes mellitus……………………………………10-13

2.1.2 Urinary Tract Infections (UTI)…………………………………………. 14

2.1.2.1 Epidemiology of UTI.…………………………………………………14

2.1.2.2. Pathogenesis of UTI.…………………………………………………14-15

2.1.2.3 Clinical manifestations and diagnosis……………………………….15-16

2.1.2.4 Treatment of UTI……………………………………………………17

2.1.2.5 Prevention……………………………………………………………17-18

2.2       Asymptomatic bacteriuria in developed countries…………………..19-32

2.3       Asymptomatic bacteriuria in developing countries………………….33-38

 

CHAPTER THREE. (Subject, Materials and Methods)

3.1 Research Design…………………………………………………………..39

3.2 The setting ………………………………………………………………..39

3.3 Duration of study …………………………………………………………39

3.4 Study population …………………………………………………………..40

3.5 Selection (Inclusion and Exclusion criteria)………………………………41

3.6 The Sample size……………………………………………………………41-42

3.7 Sampling method …………………………………………………………43

 

3.8 Data Collection …………………………………………………………….44-47

3.8 Data Handling and Data analysis……………………………………………47-48

3.10 Ethical consideration……………………………………………………….48

 

CHAPTER FOUR. ( Results and Analysis )

4.1 – 4.7 Analysis and Results ……………………………………………………49-79

 

CHAPTER FIVE. ( Discussion)

Discussion …………………………………………………………………………..80-87

Limitation of study…………………………………………………………………..88

Conclusion……………………………………………………………………………89

Recommendation……………………………………………………………………..90

References ……………………………………………………………………………91-101

                                    CHAPTER ONE

INTRODUCTION

 

1.1         BACK  GROUND:

Diabetes mellitus (DM) comprises a group of common metabolic disorders that share the phenotype of hyperglycaemia. Several distinct types of DM exist and are caused by a complex interaction of genetics, environmental factors, and life-style choices1.Depending on the aetiology, factors contributing to hyperglycaemia may include reduced insulin secretion, decreased glucose usage, and increased glucose production. With an increasing incidence world wide, DM will likely continue to be a leading cause of morbidity and mortality1.

There is evidence that diabetic patients are more prone to skin and chest infections than non diabetics2.  Studies have also shown that Urinary Tract Infections are more common in diabetics and tend to have a more complicated course in these patients than in the general population3, 4.  Urinary tract infection (UTI) is said to exist from a microbiologic perspective when pathogenic micro-organisms are detected in the urine, urethra, bladder, kidney or prostate in growth of more than 105 organisms per millilitre from a properly collected mid stream “clean-catch” urine sample5.  Asymptomatic bacteriuria is a significant bacterial count (usually 104 – 106 colony forming organisms per millilitre) of one or two bacterial species in a culture of clean voided mid-stream urine from individuals without symptoms of urinary tract infection6.

The susceptibility to furunculosis, superficial candidal infections, urinary tract infections and vulvovaginitis is increased due to poor glycaemic control as a common denominator in individuals with these infections1, 7 .

1.2         STATEMENT OF THE PROBLEM

 

The metabolic deregulation associated with diabetes mellitus causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.  Type 2 diabetes causes reduced life expectancy on an average of about 5 – 10 years.  It is associated with high morbidity due to complications affecting the heart, kidneys and eyes.  The following complications are increased in Type 2 diabetes in comparison with non – diabetic subjects: stroke (3-fold), myocardial infarction (3-fold), renal failure (17-fold), blindness (15-fold) and amputation (20-fold).  It is a leading cause of end – stage renal disease1.

Netten8 et al, in a study of the consequences of asymptomatic bacteriuria in diabetics seen over 18 month period, found an increased rate of development of symptomatic urinary tract infection with decline in renal function.

 

 

 

 

 

 

 

 

 

1.3       RELEVANCE OF THE STUDY

 

Urinary tract infections (UTI) are a major disease burden for many patients with diabetes mellitus because of the persistent high sugar milieu of the urine in which microorganisms thrive in the presence of reduced immunity1.  Asymptomatic bacteriuria is several folds more common among diabetic women and acute pyelonephritis is five to ten times more common in diabetics of both sexes. These complications (acute pyelonephritis) include acute papillary necrosis, emphysematous pyelonephritis and bacteraemia with metastatic localization to other sites9. Renal involvements even without the presence of symptoms (e.g. subclinical pyelonephritis) are common. Investigating the association between asymptomatic bacteriuria and glycaemic control in patients with diabetes mellitus thus becomes very important10.

A similar study of the prevalence of urinary tract infections and asymptomatic bacteriuria in type

2 diabetic patients has been conducted at University of Calabar Teaching Hospital11 and Olabisi Onabanjo University Teaching Hospital Sagamu12 but no such study here in the University of Port Harcourt Teaching Hospital.

The diabetic patients attending the University of Port Harcourt Teaching Hospital out-patient clinic will benefit from such early detection of asymptomatic bacteriuria. This will reduce the rate of bacteriuria and prevent symptomatic infections and other complications (e.g. structural damage, renal insufficiency, hypertension or mortality) when treated early with appropriate antimicrobials and proper educative counselling.

Easy screening programs for proteinuria, nitrates and leukocytes in the urine of diabetics treated in primary care centres will lead to implementation of specific intervention against overt urinary tract infection and other complications13.

1.4 OBJECTIVES OF THE STUDY

The aim of this study is :

To determine the prevalence of urinary tract infections in type 2 diabetic patients attending the General Out Patient Clinic at the University of Port Harcourt Teaching Hospital. To also identify the common causative organisms responsible for urinary tract infections in diabetes with a view to forming the basis for empirical antimicrobial therapy.

SPECIFIC OBJECTIVES

  1. To determine the prevalence of asymptomatic bacteriuria.
  2. To determine the relationship between glycaemic control and asymptomatic bacteriuria in type 2 diabetic patients.
  3. To determine the common organisms responsible for urinary tract infection in diabetic

patients.

  1. To determine their antimicrobial sensitivity and associated risk factors in these patients.

 

1.5 RESEARCH QUESTIONS

To address the problems highlighted in this study, the following research questions are raised:

  1. What is the prevalence of urinary tract infections in type 2 diabetic patients?
  2. What are the common microbial organisms isolated in the urine cultures?
  3. What is the nature of the antimicrobial sensitivity pattern?
  4. Does glycaemic control have any effect on asymptomatic bacteriuria and are there any risk factors associated with bacteriuria?

 

 

1.6 EXPECTED BENEFITS

In this study, the knowledge of the prevalence of urinary tract infections in diabetic patients will enable the hospital plan and make policies in the hospital that will further enhance the management of patients with diabetes mellitus.

Easy screening of diabetic patients with dip sticks will enhance prompt diagnosis of asymptomatic bacteriuria.

Early institution of antimicrobial agents will prevent the long term renal complications of persistent untreated urinary tract infection.

 

THE PREVALENCE OF URINARY TRACT INFECTION IN TYPE 2 DIABETES MELLITUS PATIENTS ATTENDING THE GENERAL OUTPATIENT CLINIC IN THE UNIVERSITY OF PORT HARCOURT TEACHING  HOSPITAL

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