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Original Article
GiriShbabu r.J., PrakaSh r., PraShanth h.V., ChandraShEkar S.C. ABSTRACT Statistical Analysis: The results were analyzed using Background: Asymptomatic bacteriuria is a common
mean, median and Chi-square (χ2) test.
problem in diabetic patients and is associated with risk of
Results: A total of 120 (12%) were positive for significant
septicemia and pyelonephritis if untreated. The diagnosis
bacteriuria. Escherichia coli was the most predominant
is based on urine culture. The incidence of antibiotic
organism fol owed by Klebsiella pneumoniae. Imipenem,
resistance has been steadily increasing over the past few
pipercil in-tazobactum, nitrofurantoin and amikacin were
years resulting in limitation of therapeutic options.
found to be the most effective antibiotics against the urinary
Aims & Objectives: This study was carried out to determine
the prevalence of asymptomatic bacteriuria in diabetic
Conclusion: The prevalence of asymptomatic bacteriuria is
patients and also to isolate, identify and establish the
high in diabetic patients and poor glucose control can be
antimicrobial susceptibility pattern of the pathogens.
considered as a predisposing factor. Routine urine culture is
Materials & Methods: This prospective study includes 1000
recommended, especial y for the detection of asymptomatic
diabetic patients. Isolates were identified by conventional methods
bacteriuria cases in diabetic patients.
and their antibiotic susceptibility pattern was established.
key Words: Asymptomatic bacteriuria, Escherichia coli, Klebsiella pneumoniae, Urinary tract infection, Diabetes mellitus
INTRODUCTION
Medical College and Hospital, Tumkur. A total of 1000 diabetic
Diabetes mellitus has a number of long term effects on the
patients attending various out-patient departments and
genitourinary system. This effect predisposes to bacterial
admitted in wards were taken for the study.
Urinary Tract Infection (UTI) [1]. Risk factors such as age,
Asymptomatic bacteriuria is defined as the “presence of
duration, glycemic control, and complications of diabetes are
actively multiplying bacteria within the urinary tract excluding
the distal urethra”, at the time when the patient has no urinary
It is also a predisposing factor for significant asymptomatic
bacteriuria (ASB). Un-treated asymptomatic bacteriuria
predisposes the individual to recurrent UTI which can cause
1. History of UTI symptoms (dysuria, frequency and urgency,
renal disease (pyelonephritis and gram negative septicemia)
[1,4,5]. UTI is one of the most important cause of morbidity
2. History of antibiotic therapy in the previous two weeks.
ASB is microbial diagnosis based on isolation of specified
4. Known congenital anomalies of the urinary tract.
quantitative count of bacteria in urine from diabetic patients
Urine samples were collected by standard mid-stream “clean
without signs or symptoms of UTI. Escherichia coli were found
catch” method from all the diabetic patients, in a sterile, wide-
to be most prevalent in ASB. The misuse of antibiotics is a
mouthed container that can be covered with a tightly fitted
major factor responsible for bacterial resistance [1, 6].
lid. Microscopic examination of a wet film of uncentrifuged urine was carried out to detect the presence of pus cells,
MATERIALS AND METHODS
erythrocytes, microorganisms, casts etc. The samples were
This study on asymptomatic bacteriuria in diabetes was
processed using standard microbiological procedures. The
carried out in the Department of Microbiology, Sree Siddhartha
specimens were cultured on to dried plates of MacConkey’s agar,
National Journal of Laboratory Medicine. 2013 August, Vol 2(2): 11-13
Girishbabu R.J. et al., Asymptomatic Bacteriuria
Sheep Blood agar with 5-10% CO atmosphere and Cystine
Lactose Electrolyte Deficient agar, by standard loop method and
incubated at 37°C overnight. Culture results were interpreted
as being significant and insignificant, according to the standard
criteria. The organisms were identified by routine methods from
the samples showing significant bacteriuria [8,9].
The standardized Kirby-Bauer disc diffusion test of the
Clinical and Laboratory Standards Institute (formerly NCCLS) was used for antibiotic susceptibility testing and accordingly
interpretations were carried out. The antibiotics tested were:
imipenem, pipercillin-tazobactum, amikacin, gentamicin,
tetracycline, co-trimoxazole and erythromycin [10].
The results were analyzed using mean, median and Chi-
square (χ2) test. p (predictive) value of < 0.05 was considered as a significant association between the variables tested. [Table/Fig-2]: Antibiotic sensitivity pattern of bacterial Isolates
The study shows highest number of culture positive cases among diabetic women (70) when compared to diabetic men (50). People in the age group of 55 yrs and above (24.1%)
DISCUSSION
were affected more when compared to others [Table/Fig-1].
Urinary Tract Infection affects as many as 50% women at
Of the total 1000 samples processed, significant growth
least once during their lifetime. In the present study, it was
was found in 120 (12%) samples, while 880 (88%) samples
observed that the diabetic females (58.3 %) were affected
showed no growth. The commonest isolated organism
more as compared to diabetic males (41.7 %) [11].
being Escherichia coli 50 (41.7%), followed by Klebsiella
In our study significant growth was found in 12% cases and
pneumoniae 25 (20.9%), Staphylococcus aureus 15 (12.5%),
88% samples were sterile. These results were consistent with
Pseudomonas aeruginosa 10 (8.3%), Proteus mirabilis 06
reports of the recent studies [12, 13]. The presence of significant
(5%), Citrobacter koseri 05 (4.1%), Enterococcus faecalis
bacteriuria indicates the significance of microbiological culture
04 (3.3%), Staphylococcus saprophyticus 03 (2.5%) and
to clinch the diagnosis of urinary tract infection.
Streptococcus pyogenes 02 (1.7%).
Bacterial isolates have been changing from time to time
In our study the organisms were sensitive to imipenem (100%),
and from place to place. In our study organisms isolated,
pipercillin-tazobactum (100%), nitrofurantoin (90%), amikacin
correlated with various others studies [3, 4]. In a recent
(85%), ceftazidime (76%), cefotaxime (76%), gentamicin
study, it was noted that increased adherence of Escherichia
(72%), norfloxacin (70%), ciprofloxacin (68%), amoxicillin-
coli with type 1 fimbriae to uroepithelial cells isolated from
clavulanic acid (68%), tetracycline (34%), erythromycin (30%),
the urine of women with diabetes correlated positively with
co-trimoxazole (22%) and ampicillin (18%) [Table/Fig 2].
HbA1C. Poorly controlled patients had a higher adherence of
Escherichia coli. Changes in host defence mechanisms, the
presence of diabetic cystopathy and of microvascular disease
in the kidneys may play a role in the higher incidence of UTI
in diabetic patients. However the other factors like shortness
of female urethra, urethral opening near the anus and vagina,
biologic changes due to menopause in females and prostate
enlargement and neurogenic bladder in men contribute to
asymptomatic bacteriuria [6]. The microorganisms causing
asymptomatic bacteriuria in persons with diabetes mellitus are
similar to those causing bacteriuria in non-diabetic individuals
[Table/Fig-1]: Age & sex wise distribution of diabetics with asymptomatic bacteriuria
The antimicrobial sensitivity and resistance pattern varies from
National Journal of Laboratory Medicine. 2013 August, Vol 2(2): 11-13
Girishbabu R.J. et al., Asymptomatic Bacteriuria
community to community and from hospital to hospital. This
[3] Janifer J, Geethalakshmi S, Satyavani K, Viswanathan V.
Prevalence of lower urinary tract infection in South Indian type 2
is because of emergence of resistant strains as a result of
diabetic subjects. Indian J Nephrol. 2009; 19(3):107–111.
indiscriminate use of antibiotics. In our study isolates showed
[4] Kayima JK, Otieno LS, Twahir A, Njenga E. Asymptomatic
100% sensitivity to imipenem and pipercillin-tazobactum.
bacteriuria among diabetics attending Kenyatta National
Ampicillin was found to be least sensitive (18%). Our
Hospital. East Afr Med J. 1996; 73(8):524-26.
[5] Stapleton A. Urinary tract infections in patients with diabetes.
antibiogram pattern correlates with others studies [3, 4].
Am J Med. 2002; 113(1): 80-84.
Diabetes enhances the progression from asymptomatic to
[6] Girishbabu RJ, Srikrishna R, Ramesh ST. Asymptomatic
symptomatic bacteriuria, which could lead to septicemia,
bacteriuria in pregnancy. Int J Biol Med Res. 2011; 2(3): 740-42.
pyelonephritis and adverse complication which require
[7] Jayalakshmi J, Jayaram VS. Evaluation of various screening
specialized treatment strategies. So routine urine culture is
tests to detect asymptomatic bacteriuria in pregnant women.
recommended, especially for the detection of asymptomatic
Indian J Pathol Microbiol. 2008; 51(3):379-81.
bacteriuria cases in diabetic patients.
[8] Collee JG, Duguid JP, Fraser AG, Marmion BP, Simmons A.
Laboratory strategy in the diagnosis of infective syndromes. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors.
CONCLUSION
Mackie and McCartney, practical medical microbiology. 14th ed.
Asymptomatic bacteriuria is more prevalent among diabetic
Edinburgh: Churchill Livingstone. 1996. p. 84-90.
population than in the non-diabetics, a major public health
[9] Praveen R, Saha SK, Shamshuzzaman SM, Rashid AL,
Chaudhury A, Muazzam N. Detection of uropathogen by using
problem which has to be addressed at the earliest to forestall
chromogenic media (Hicrome UTI agar), CLED agar and other
future complications. So routine urine culture is recommended,
conventional media. Faridpur Med Coll. J. 2011; 6(1):46-50.
especially for the detection of asymptomatic bacteriuria cases
[10] Clinical and Laboratory Standards Institute. Performance
standards for antimicrobial susceptibility testing; 17th informational supplement. CLSI/NCCLS document M100-S17.
Asymptomatic bacteriuria can be ascertained on the basis of
Clinical and Laboratory Standards Institute, Wayne, Pennsylvania;
microscopy and microbial culture. Gram negative organisms
were the commonest organisms isolated. In view of the emerging
[11] Chaudhuri SR, Thakur AR, Nandy P, Samanta S. Urinary Tract
Infection-A Survey of Local Population. Am. J. Infect. Dis. 2008;
drug resistance amongst bacteria, antibiotic therapy should be
advised only after culture and sensitivity has been performed.
[12] Odetoyin WB, Aboderin AO, Ikem RT, Kolawole BA, Oyelese AO.
This would not only help in the proper treatment of the patients
Asymptomatic bacteriuria in patients with diabetes mellitus in Ile-
but also discourages the indiscriminate use of the antibiotics
Ife, South-West, Nigeria. East Afr Med J. 2008; 85(1):18-23.
[13] Alebiosu CO, Osinupebi OA, Olajubu FA. Significant asymptomatic
which prevent further development of bacterial drug resistance.
bacteriuria among Nigerian type 2 diabetics. J Natl Med Assoc. 2003; 95(5):344–49. REFERENCES
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[1] Ophoril EA, Imade P, Johnny EJ. Asymptomatic bacteriuria in
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Assistant Professor, Department of Microbiology,
Sri Siddhartha Medical College, Agalakote, B.H. Road, Tumkur- 572 107, Karnataka, India.
4. Assistant Professor, Department of Microbiology,
Sri Siddhartha Medical College, Tumkur- 572107, Karnataka, India.
National Journal of Laboratory Medicine. 2013 August, Vol 2(2): 11-13
Medical FSA and HSA Expense Eligibility List (IRS Code Section 213 (d) Eligible Expenses) The following is a summary of common expenses claimed against Medical Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs). Due to frequent updates to the regulations governing FSAs and HSAs, this list does not guarantee reimbursement but instead is to be used as a guide for the submiss
Traditions Checklist - from the A.A. Grapevine Service Material from the General Service Office These questions were originally published in the AA Grapevine in conjunction with a series on the Twelve Traditions that began in November 1969 and ran through September 1971. While they were originally intended primarily for individual use, many AA groups have since used them as a basis for wid