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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 559-564

Prevalence of urinary tract infection in Damietta diabetic patients


1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
2 Department of Community Medicine, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt

Date of Submission06-Jul-2014
Date of Acceptance15-Aug-2014
Date of Web Publication31-Aug-2015

Correspondence Address:
Emad El-Din Mohammed Abd El-Naby
El-Mansoura 35511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163918

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  Abstract 

Aim of the work
The aim of this observational study was to quantify the incidence of urinary tract infections (UTI) among diabetic patients and to compare this risk to patients without diabetes in Damietta hospital.
Patients and methods
This study included one thousand individuals (500 diabetic and 500 nondiabetic) examined for potential infections; assessment of history including age, sex, duration of diabetes, and treatment of diabetes, urine analysis and culture, total leukocyte count, blood sugar, serum creatinine, and glycated hemoglobin A1c was performed for each patient.
Results
The prevalence of UTI was 52.2%/500 diabetic patients, which was significantly higher than the prevalence of UTI in nondiabetic patients (22.4%/500 nondiabetic patients) (P < 0.001). There was a significant difference in the distribution of UTI in the diabetic and the nondiabetic group according to the history of previous UTI and total leukocytic count as diabetic patients had more previous UTI and increased total leukocytic count compared with nondiabetic patients (P < 0.001). In terms of the distribution of uropathogens in diabetic and nondiabetic patients with UTI, Escherichia coli was the most prominent uropathogen in both the diabetic and the nondiabetic group.
Conclusion
UTIs are more prevalent in individuals with diabetes mellitus (DM). The main risk factors for UTI in DM are inadequate glycemic control, duration of DM, diabetic microangiopathy, impaired leukocyte function, and anatomical and functional abnormalities of the urinary tract.

Keywords: diabetes mellitus, urinary tract infection, prevelance


How to cite this article:
Gab-Allah El-Nagar MM, Dawood ADA, Gabr HM, Abd El-Naby EDM. Prevalence of urinary tract infection in Damietta diabetic patients. Menoufia Med J 2015;28:559-64

How to cite this URL:
Gab-Allah El-Nagar MM, Dawood ADA, Gabr HM, Abd El-Naby EDM. Prevalence of urinary tract infection in Damietta diabetic patients. Menoufia Med J [serial online] 2015 [cited 2020 Feb 28];28:559-64. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/559/163918


  Introduction Top


Diabetes mellitus (DM) is a clinical syndrome associated with deficiency of insulin secretion or action. It is considered one of the most major emerging threats to health in the 21st century. It is estimated that by 2025, 380 million individuals will have DM [1] . Urinary tract infections (UTIs) are more prevalent in individuals with DM and may progress to complications and/or serious manifestations. UTI is considered complicated when it is associated with symptoms of upper UTI or if it affects patients with compromised general conditions (including structural abnormalities of the urinary tract, previous pyelonephritis, symptoms lasting more than 14 days, diabetes, pregnancy, or immunosuppression). Episodes may be refractory to therapy, often resulting in relapses and occasionally leading to significant sequelae such as sepsis, metastatic abscesses, and rarely acute renal failure [2] . The gold standard for the diagnosis of a UTI is the detection of the pathogen in the presence of clinical symptoms, many laboratories define 10 5 colony-forming units (CFU)/ml urine as the threshold; there are other recommendations that recommend the diagnosis of UTI from a count of 10 3 CFU/ml [3] . The main risk factors for UTI in DM are inadequate glycemic control, duration of DM, diabetic microangiopathy, impaired leukocyte function, recurrent vaginitis, and anatomical and functional abnormalities of the urinary tract [4] .


  Aim Top


The aim of this observational study was to quantify the incidence of UTIs among diabetic patients and to compare this risk to patients without diabetes in Damietta hospital.


  Patients and methods Top


This study was carried out in Damietta hospital to estimate the prevalence of UTI among diabetic patients in Damietta. This study included one thousand individuals (500 diabetic and 500 nondiabetic).

Inclusion criteria of the diabetic group

  1. Age older than 18 years.
  2. History of diabetes.
  3. Symptoms of diabetes (polyuria, polydipsia, and unexplained weight loss) and random plasma glucose of at least 200 mg/dl OR fasting plasma glucose of at least 126 mg/dl OR 2-h plasma glucose level of at least 200 mg/dl during a 75-g oral glucose tolerance test OR A1C result of at least 6.5%.
  4. No history of chronic renal disease.
  5. No history of chronic liver diseases.
  6. No history of collagen diseases.
  7. No history of pregnancy.
  8. No history of malignancy.


Inclusion criteria of the nondiabetic group

  1. Age older than 18 years.
  2. No history of diabetes.
  3. Random plasma glucose less than 200 mg/dl OR fasting plasma glucose less 100 mg/dl OR 2-h plasma glucose level less than 140 mg/dl.
  4. No history of chronic renal disease.
  5. No history of chronic liver diseases.
  6. No history of collagen diseases.
  7. No history of pregnancy.
  8. No history of malignancy.


The following patients were excluded from our study

  1. Patients with chronic renal disease.
  2. Patients with chronic liver diseases.
  3. Patients with collagen diseases.
  4. Pregnant patients.
  5. Malignancy.


Predesigned questionnaire included data on

  1. Sociodemographic data including age, sex, and residence.
  2. Type, duration, and treatment of DM.
  3. Urinary tract manifestations.
Urine analysis and culture

Urine analysis and culture were carried out to detect the type of organism. Urine samples were processed in the laboratory within 2 h of collection. Patients were provided with sterile wide-mouth universal containers into which a clean catch (midstream urine) of about 10-20 ml urine was collected on the morning of the test. Urine samples were stored at 2-8°C in the refrigerator until culture [5] . Diabetic patients living in slums were instructed on the collection of urine sample and to avoid contamination. A mid stream urine sample was collected for microscopic examination and culture. The samples were cultured in blood agar and MacConkey agar media and incubated at 37°C overnight for visible growth. The growth of 10 5 CFU/ml was considered significant bacteriuria [6] .

Blood samples

  1. Hematological assessment: complete blood count with a total leukocyte count and cell differential was performed for each patient using automated cell counters (CELL-DYN 1700).
  2. Biochemical assessment: blood sugar, serum creatinine, and glycated hemoglobin A1c (HbA1c) were carried out using a HITACHI 912 automatic analyzer (Roche Diagnostics GmbH, Mannheim, Germany).


Statistical analysis

  1. The collected data were summarized, presented, and analyzed using the software SPSS version 20 (Chicago, USA).
  2. Qualitative data were summarized as frequency and percentages.
  3. Data were expressed as mean ± SD for quantitative variables.
  4. P value less than 0.05 was considered statistically significant.
  5. Regression analysis for UTI in diabetic patients and their risk factors was carried out (odds ratio at 95% confidence intervals was calculated).
Ethical considerations

Consent from the ethical committee was obtained before carrying out this study.


  Results Top


It was found that there was no significant difference in the mean age between the diabetic and nondiabetic groups. Also, there was no significant difference in the distribution of the study participants according to sex or residence (P > 0.05).

The incidence of UTI was 52.2% in the diabetic group, which was significantly higher than prevalence of UTI in the nondiabetic group, 22.4% (P < 0.001) [Table 1] and [Figure 1].
Figure 1: Prevalence of urinary tract infection in diabetic and nondiabetic patients

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Table 1 Prevalence of urinary tract infection in diabetic and nondiabetic patients

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Random blood glucose level in diabetic patients with UTI was significantly higher than that in diabetic patients without UTI (P < 0.001) (odds ratio 1.012) [Table 2] and [Table 7].
Table 2 Random blood glucose concentration in diabetic patients with and without urinary tract infection

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There was a significant difference in the distribution of UTI patients in the diabetic and nondiabetic group according to the history of previous UTI. Diabetic patients had a history of previous UTI compared with nondiabetic patients (P < 0.001) [Figure 2].
Figure 2: Distribution of urinary tract infections (UTIs) patients in the diabetic and nondiabetic group according to history of previous UTI

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Diabetic patients had significantly increased total leukocytic count than nondiabetic patients (P < 0.001) [Table 3].
Table 3 Total leukocytic count in urinary tract infection patients in the diabetic and nondiabetic group

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The incidence of type II diabetes was significantly higher than type I diabetes among the diabetic patients with UTI (P < 0.001) [Figure 3].
Figure 3: Distribution of urinary tract infection in diabetic patients according to the type of diabetes mellitus

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In terms of BMI, 69% (n = 180) of diabetic patients with UTI had BMI more than 30 and only 31% (n = 81) had BMI less than 30 (P < 0.001) (odds ratio 0.764) [Table 4] and [Table 7].
Table 4 Distribution of diabetic patients with urinary tract infection according to body mass index

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In terms of duration of DM, 67% of diabetic patients with UTI had a duration of DM more than 10 years and 33% had a duration of DM less than 10 years (P < 0.001) (odds ratio 1.175) [Table 5] and [Table 7] and [Figure 4].
Figure 4: Distribution of diabetic patients with urinary tract infection according to the duration of diabetes mellitus

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Table 5 Distribution of diabetic patients with urinary tract infection according to the duration of diabetes mellitus

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For HBA1c, 58.2% of diabetic patients with UTI had HBA1c more than 8 and 41.8% had HBA1c less than 8 (P < 0.05) (odds ratio 0.985) [Table 7] [Figure 5].
Figure 5: Distribution of diabetic patients with urinary tract infection according to HBA1c%

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Also, serum creatinine in diabetic patients with UTI was significantly higher than that in diabetic patients without UTI (P < 0.001) (odds ratio 6.466) [Table 6] and [Table 7].
Table 6 Serum creatinine in diabetic patients with and without urinary tract infection

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Table 7 Regression analysis of risk factors of urinary tract infection in diabetic patients

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In terms of the distribution of uropathogens in diabetic and nondiabetic patients with UTI, Escherichia coli was the most prominent uropathogen in both the diabetic and the nondiabetic group [Figure 6].
Figure 6: Distribution of uropathogens in diabetic and nondiabetic patients with urinary tract infection

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[Table 7] shows the risk factors of UTI in diabetic patients.

  1. Duration of DM increases the risk of UTI by 1175 times.
  2. Increased creatinine increases the risk of UTI by 6466 times.
  3. Increased blood glucose level increases the risk of UTI by 1012 times.

  Discussion Top


DM is the most common endocrine disease and is associated with organ complications because of microvascular and macrovascular disease. Patients with diabetes also have simple and complicated infections. In DM patients, endothelial dysfunction leads to vasoconstriction instead of the usual local vasodilatation in inflammation. This phenomenon could potentially decrease the ability of phagocytes to leave the blood stream and enter the infected tissues [7] .

UTI is caused by pathogenic invasion of the urinary tract, which leads to an inflammatory response of the urothelium. The clinical manifestation of UTI depends on the portion of the urinary tract involved, the etiologic organism, the severity of the infection, and the patient's ability to mount an immune response to it [8] .

Signs and symptoms include fever, dysuria, and urinary urgency, cloudy, or malodorous urine. UTIs are a common burden in patients with DM. Cystitis, ascending infection leading to pyelonephritis, impaired leukocyte function, recurrent vaginitis, emphysematous complications, and renal/perinephric abscesses are well recognized in this group of patients if glycemic control is poor [9] .

This study was carried out in Damietta hospital to estimate the prevalence of UTI among diabetic patients in Damietta hospital; it included one thousand individuals (500 diabetic and 500 nondiabetic).

The prevalence of UTI was 52.2% in the diabetic group, which was significantly higher than the prevalence of UTI in the nondiabetic group, 22.4%. Findings from this study confirm previously published data reporting associations between diabetes and increased incidence of UTI [10],[11] . Malnutrition, poor hygiene, and low socioeconomic status are associated with UTI and these factors are highly prevalent in a rural setting [12] .

In terms of sex distribution, there was a nonsignificant difference in the distribution of UTIs patients in the diabetic and the nondiabetic group according to sex, but UTI was more prevalent in women than in men. This was in agreement with Arul Prakasam et al. [13] , who observed in their study that the prevalence of UTI was high among the women (65%) than men (35%).

In terms of the distribution of UTIs in patients in the diabetic and the nondiabetic group according to residence, it was found that UTI was higher in diabetic patients, 58.2%, and nondiabetic, 66.1%, patients in rural areas. This was in agreement with Saleem and Daniel [14] , who found that UTI was significantly higher among diabetic patients of lower socioeconomic status.

UTI appears to be multifactorial in patients with diabetes, and various diabetes-related risk factors have been proposed including history of previous UTI, type of diabetes, longer duration of diabetes, and poor glycemic control.

In terms of history of previous UTI, there was a significant difference between the diabetic and the nondiabetic group, where the diabetic patients had a history of UTI, 61.3%, which is more frequent than the nondiabetic patients, 30.3%. This was in agreement with Yismaw et al. [15] , who found that the incidence of UTI was associated strongly with a history of previous UTI.

In terms of the distribution of diabetic patients with UTIs according to the type of DM, the incidence of type II, 60.9%, was significantly higher than that of type I, 39.1%, among the diabetic patients with UTI. Type 2 diabetes is a very common disease, characterized by an asymptomatic phase between the actual onset of diabetic hyperglycemia and clinical diagnosis. This phase has been estimated to last at least 4-7 years and 30-50% cases of type 2 diabetic patients remain undiagnosed; this leads to the development of chronic complications of diabetes, which remain the main problems in diabetic care [16] .

In terms of duration of diabetes, there was a highly significant difference between diabetic patients with UTI according to the duration of diabetes as 67% of patients had diabetes for more than 10 years whereas 33% had diabetes for less than 10 years. This may be because of micturition abnormalities secondary to diabetic neuropathy that occurs in 10-40% of patients with longstanding diabetes and increased residual urine [17] .

In terms of treatment of DM, diabetic patients under insulin treatment showed higher incidence of UTI, 56.3%, than those under oral treatment of diabetes (43.7%). As, insulin injections as treatment of diabetes do not reach all the patients leading to poor glycemic control [14] .

In terms of HBA1c, 58.2% of diabetic patients with UTI were found to have HBA1c more than 8% whereas 41.8% had HBA1c less than 8%. This was in agreement with Hirji et al. [18] , who found that the incidence of UTI was higher among patients with poorly controlled diabetes compared with those with fairly controlled diabetes patients. As glycation of immunoglobulin occurs in patients with diabetes in proportion with the increase in HbA1c, this may adversely affect the biological function of the antibodies. Decreased mobilization of polymorphonuclear leukocytes, chemotaxis, and phagocytic activity may occur during hyperglycemia. The hyperglycemic environment also blocks the antimicrobial function by inhibiting glucose-6-phosphate dehydrogenase, increasing apoptosis of polymorphonuclear leukocytes, and reducing polymorphonuclear leukocyte transmigration through the endothelium [19] .

For BMI, UTI in diabetic patients with BMI more than 30 (69%) was significantly higher than in those with BMI less than 30 (31%). This was in agreement with Janifer et al. [20] , who found that the prevalence of UTI in diabetic women was higher in those with higher BMI.

A previous study in the general population showed that the etiologic agents of UTIs belonged mainly to Gram-negative enteric bacteria [21] . In the present study, E. coli was the most frequent uropathogen in the diabetic (66.3%) and the nondiabetic group (65.1%), Klebsiella spp. in the diabetic (18.4%) and nondiabetic group (17%), and Staphylococcus spp. in the diabetic (15.3%) and nondiabetic group (17.9%). E. coli is a normal intestinal flora found in humans and is therefore expected to be more prevalent in the urinary tract of immunologically suppressed patients [22] .


  Conclusion Top


The prevalence of UTI in the diabetic group was significantly higher than the prevalence of UTI in the nondiabetic group; UTI among diabetic patients was significantly higher in those with type 2 diabetes, those with duration of DM more than 10 years, those with BMI more than 30, and in diabetic patients with poor glycemic control.


  Acknowledgements Top


Conflicts of interest

None declared.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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