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- DOI 10.18231/j.ijmmtd.2022.062
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Bacterial urinary tract infection in diabetes patients and evaluation for multidrug resistant organisms
Introduction
The most common and ubiquitous disease-causing agent recognized in clinical practice among all age groups is bacterial urinary tract infections (BUTIs). Urinary tract infection is the epidemic routine and repeated infectious disease involved in the urinary tract, kidneys, cystitis. Urinary tract infection affect 150 million people world-wide annually.[1] Diabetic mellitus is the universal endocrine disorder. Diabetes is constantly increasing metabolic syndrome based on high blood sugar arising from imperfection or deficiency in insulin secretion, action or both. [2] Diabetic mellitus endures for an extended period. It is distinguished by Type 1 and Type 2. Type 1 diabetes is also known as Juvenile diabetes or Insulin dependent diabetes. Type 2 diabetes is also called as diabetes mellitus and adult-onset diabetes. Type 1 diabetes results from the pancreas inability to generate insulin. Insulin resistance in the body's cells causes type 2 diabetes results when the body’s cells resist the normal effect of insulin. [3] Diabetic Mellitus is the highest barrier causing UTI, because of diabetic mellitus there would be weakness or break in cell-mediated immune response, which results in illness microbial infection. Thus person with diabetes are vulnerable to UTI. Various fungi are too in charge for the cause of UTI in diabetic patients. [4] The up-to-date study predict from the global burden of diseases survey rate 462 million single person appeared to be afflicted with diabetic mellitus. Person with diabetes enlarge unhealthy and risky by UTI being the ultimate infection site.[5] Most people visiting health care with diabetes, The physician must enlighten and train the disorder of UTI in diabetic patients could possibly be asymptomatic bacteriuria inflammation of lining the bladder, Kidney infection, Pyelonephritis, Urosepsis, Abdominal pain, recurrent UTI, Perirenal or kidney abscess.[6] Patients with diabetes experience more UTIs than people without diabetes. [7] with more serious UTIs that result in consequences like dysuria which leads to total organ failure can result to trauma, because of complicated UTI. [8] The most regular microorganism isolated in UTI diabetes patients were gram-negative microorganisms like E.coli, Klebsiella pneumonia, Proteus species, Enterobacter, E.faecalis. [9] Diabetes patients are exposed and remain competing resistant pathogens in crisis of UTI [10] incorporate with ESBL positive enteric bacteria, fluroquinolones, proof against resistant pathogens, Carbapenem-resistant Enterobacterales. [11] The scope is to invent and illustrate Antimicrobial resistant connected to medical centre related to infections. [12] The appearance and increase of MDRO’s is comprehensive and far-reaching community health threat. [13] MDRO has more prevalent in antimicrobial resistant infection in addition to nosocomial infection/health care-associated infections, However common occurrence may alter by region. [14] Uropathogens show a wide difference in them of varying levels of resistance to their antimicrobial medicines with time and space. [15] According to reports, diabetic persons who take antibiotics experience more severe UTI than those who don't. [16] This is due to the resistance posed by the medications' unchecked usage, which exposes individuals to more severe infection. The purpose of this study is to compare diabetes patients with non-diabetic patients to ascertain the prevalence, risk factors, and antibiotic sensitivity pattern of the organisms causing UTI.
Materials and Methods
This research is a hospital based investigation and analysis experimentation in adult-diabetic patients and non-diabetic people present at Vydehi research hospital, Whitefield Bangalore.
Ethical permission has been issued from Vydehi Institutional Ethical Committee (VIEC). The analysis is done in VIMS and RC.
Study design
The research design is a prospective study consisting for the duration of 6months (April-September 2022). Ethical approval certificate is issued by VIEC. Informed consent were obtained from all participants. After getting permission from the institution patients the process started for urinalysis. Both male and female patients above 18 years with diabetic and non-diabetic who attended Vydehi hospital were compared in this study, disregarding the presence or absence of urinary tract infection symptoms.
Experimental study design
Urine assessment and culture sensitivity test
Clean-voided midstream urine specimen was obtained from outpatients and inpatients in particular aseptic container for the purpose of microscopic examination of routine urine test and antibiotic susceptibility test for 6months. After giving informed consent form to the person who participates in research subject were enlightened on how to collect sample and be germ free and avoid contaminating. The collected samples was inoculated into a culture media (Agar-media).
Sample size
Calculation of sample size was done using the formula.
n=Z2(1-α/2)P(1-P)d2
Where n=required sample size, Z=Z value (from standard normal distribution) that corresponds to the desired confidence level or level of significance is 5% for 95%
confidence level, P=expected proportion of resistance in the target population, which is =0.04, d=absolute precision, which is =2%.
Diabetic – 247, Non- diabetic - 201
Inclusion standards
Studies that looked at the prevalence of UTIs in diabetes and non-diabetic patients as well as descriptive, cross-sectional, and observational studies were all considered. Patients above 18 years with diabetes and UTI was included. Patients with and without diabetes at all gender above 18 years of age, from OPD and also admitted in General medicine department of VIMS & RC, was included.
Exclusion criteria
Patients with pregnancy, known underlying renal pathology, chronic renal disease, and use of antibiotic medication during the previous month was excluded.
Objectives of research work
To screen and identify bacteria from samples of patients with UTI who are diabetes. To evaluate multidrug resistance in the bacterial isolates.
Methodology
Sample size
A total of 247 diabetic & 201 non diabetic urine samples from out patients and in patients was collected for processing in the microbiology laboratory.
Specimen collection & processing
Informed written consent was taken from case. Patient details was collected in data collection form. Patients. and requested a midstream urine sample. Samples taken with a sterile instrument holder that was delivered to bacteriology lab. Plates was inoculated to 24 hours by 37ᵒC and result is considered based on significant or non-significant growth progress. The presence of 105 CFC of bacteria in pure urine culture is notable and considered by standard calibrated units or colony-forming units.
Bacteria resisting treatment more than one or three antimicrobial classes of antibiotics is called Multidrug Resistant Organisms. Identification of bacteria was done as per CLSI guidelines.
Bacterial culture
According to CLSI guidelines, bacterial isolation and antibiotic susceptibility testing was performed. Vitek2 (Bio-Mereuix) was used. Bacterial identification and susceptibility testing. Bacteria was identified Gram's stain is used in fast tests using VITEK 2 system. VITEK 2 C is an automated analyser that identifies the Gram negative and Gram-positive bacteria in 4-6 hrs and sensitivity in 6-8 hours. VITEK 2 C system work as Advanced Colorimetry, diagnose technique that assist and equip high discrimination between strain and average of different and misidentified or mixed-up species.
Multidrug resistant organism
Resistant to all agents tested within at least three antimicrobial classes, including β-lactams, carbapenems, aminoglycosides, & fluroquinolones. New approaches and techniques applied by scientist to sketch microorganisms as Multidrug resistant organisms according to In-Vitro Antibiotic resistant process finding show three or more antimicrobial categories along with Extended Spectrum Beta Lactamase (ESBL), Methicillin Resistant Staphylococcus Aureus (MRSA), and Vancomycin Resistant Enterococcus (VRE), Carbapenems (CRE). [13]
Results
Significant bacteria was isolated in 90/247 (36%) & 157(63%) of symptomatic & asymptomatic diabetic patients respectively ([Table 2]). Prevalence of bacteria isolated among the symptomatic patients: E.coli (55) (61%) is the most common ([Table 3]). The Prevalence of Multi drug organisms (MDRO) isolated among the symptomatic patients: E.coli (43) (75%) ([Table 4]). Sensitivity to antibiotics patterns of gram negative & gram-positive bacteria segregates showed that E.coli is resistant to I-group (β-lactams), II–group (Carbapenems), III-group (Aminoglycosides), IV-group (Quinolones), SXT. Pseudomonas aeruginosa is resistant to I-group (β-lactams), III–group (Aminoglycosides), IV- group (Quinolones). Klebsiella pneumoniae is resistant to I-group (β-lactams), III - group (Aminoglycosides), IV- group (Quinolones). Enterococcus faecium is resistant to I - group (β-lactams), II – group (Carbapenems), IV- group (Quinolones). Klebsiella aerogenes I - group (β-lactams), IV- group (Quinolones), SXT, NIT ([Table 5]).
Significant bacteria was isolated in 29/201 (14%) & 114(56%) of symptomatic & asymptomatic non-diabetic patients respectively ([Table 6]). Prevalence of bacteria isolated among the symptomatic patients: E.coli (20) (64%) ([Table 7]). The Prevalence of Multi drug organisms (MDRO) isolated among the symptomatic patients: E.coli(2) (66%) klebsiella pneumoniae (1) ([Table 8]). The prevalence of Antibiotic sensitivity profile of MDRO bacterial isolates in non-diabetic patients: E.coli is resistant to I - group (β-lactams)
II – group (Carbapenems), Trimethoprim/sulfamethoxazole. Klebsiella pneumoniae is resistant to I - group (β-lactams), II – group (Carbapenems), III - group (Aminoglycosides), IV- group (Quinolones) ([Table 9]).
|
Isolates |
Diabetic |
Non-diabetic |
Total |
|
|
No(%) |
No(%) |
|
|
Escherichia coli |
55(61%) |
23(79%) |
78 |
|
P. aeruginosa |
6(6.67%) |
- |
6 |
|
K. pneumoniae |
13(14%) |
1(12.9%) |
14 |
|
K. aerogenes |
1(1.1%) |
- |
1 |
|
E. faecium |
2(2.2%) |
- |
2 |
|
E. faecalis |
1(1.1%) |
- |
1 |
|
A. baumanii |
1(1.1%) |
- |
1 |
|
Serratia Maresus |
1(1.1%) |
- |
1 |
|
S. aureus |
- |
1(3.2%) |
1 |
|
Enterobacter cloacae |
- |
2(3.2%) |
2 |
|
Total No. of patients |
Total No. of organisms isolated (%) |
No growth (%) |
|
247 |
90(36%) |
157(63%) |
|
Name of the bacteria |
Total No. of isolate (%) |
|
Escherichia coli |
55 (61%) |
|
Pseudomonas aeruginosa |
6 (6.67%) |
|
Klebsiella pneumoniae |
13(14%) |
|
Klebsiella aerogenes |
1(1.1%) |
|
Enterococcus faecium |
2(2.2%) |
|
Enterococci faecalis |
1(1.1%) |
|
Acinetobacter baumanii |
1(1.1%) |
|
Serratia Maresus |
1(1.1%) |
|
Total |
90 |
|
Name of the bacteria |
No. of MDRO isolates |
|
Escherichia coli |
43(75%) |
|
Pseudomonas aeruginosa |
1 (6.2%) |
|
Klebsiella pneumoniae |
1 (6.2%) |
|
Klebsiella aerogenes |
1(6.2%) |
|
Enterococcus faecium |
1(6.2%) |
|
Total |
48(53%) |
|
Name of the organism |
MDRO antibiotic resistance |
Sensitive antibiotics |
|
1. E.coli |
I - group (β-lactams) |
Fosfomycin |
|
III - group (Aminoglycosides) |
||
|
IV- group (Quinolones), SXT |
||
|
2. E.coli |
I - group (β-lactams) |
III - group (Aminoglycosides) Fosfomycin, Ertapenem, Nitrofurantoin |
|
IV- group (Quinolones), |
||
|
Trimethoprim/sulfamethoxazole |
||
|
3. E.coli |
I - group (β-lactams) |
Fosfomycin, Gentamicin, Nitrofurantoin |
|
IV- group (Quinolones), |
||
|
Trimethoprim/sulfamethoxazole |
|
|
|
4. E.coli |
I - group (β-lactams) |
Fosfomycin, Ertapenem, Nitrofurantoin, Piperacillin-tazobactam |
|
IV- group (Quinolones), |
||
|
Trimethoprim/sulfamethoxazole |
||
|
5. E.coli |
I - group (β-lactams) |
III - group (Aminoglycosides) Fosfomycin, Ertapenem, |
|
II – group (Carbapenems) |
||
|
Trimethoprim/sulfamethoxazole |
Nitrofurantoin |
|
|
6. E.coli |
I - group (β-lactams) |
SXT, Fosfomycin |
|
II – group (Carbapenems) |
||
|
IV- group (Quinolones) |
||
|
7. E.coli |
I - group (β-lactams) |
I - group (β-lactams) III - group (Aminoglycosides) |
|
IV- group (Quinolones), |
||
|
Trimethoprim/sulfamethoxazole |
Nitrofurantoin |
|
|
8. E.coli |
I - group (β-lactams) |
Fosfomycin, Nitrofurantoin, Trimethoprim/sulfamethoxazole |
|
III - group (Aminoglycosides) |
||
|
IV- group (Quinolones) |
|
|
|
9. E.coli |
I - group (β-lactams) |
Fosfomycin |
|
II – group (Carbapenems) |
||
|
III - group (Aminoglycosides) |
||
|
IV- group (Quinolones) |
||
|
10. E.coli |
I - group (β-lactams) |
Amikacin, Fosfomycin, Ertapenem |
|
Nitrofurantoin, |
|
|
|
Trimethoprim/sulfamethoxazole |
||
|
11. E.coli |
I - group (β-lactams) III - group (Aminoglycosides) |
III - group (Aminoglycosides) Piperacillin-tazobactam |
|
IV- group (Quinolones) |
||
|
12. E.coli |
I - group (β-lactams) |
|
|
Nitrofurantoin, |
||
|
Trimethoprim/sulfamethoxazole |
||
|
13. Pseudomonas Aeruginosa |
I - group (β-lactams) |
Cefoxitin, Polymyxin B |
|
III - group (Aminoglycosides) |
||
|
IV- group (Quinolones) |
||
|
14. Klebsiella pneumoniae |
I - group (β-lactams) |
Fosfomycin, Nitrofurantoin |
|
III - group (Aminoglycosides) |
||
|
IV- group (Quinolones) |
||
|
15. Enterococcus faecium |
I - group (β-lactams) |
Trimethoprim/sulfamethoxazole Nitrofurantoin Piperacillin-tazobactam |
|
II – group (Carbapenems) |
||
|
IV- group (Quinolones) |
||
|
16. Klebsiella aerogenes |
I - group (β-lactams) |
Amikacin, Fosfomycin |
|
IV- group (Quinolones), SXT, NIT |
|
Number of patients overall |
Number of Isolates Overall |
No growth (%) |
|
201 |
29(14%) |
114(56%) |
|
Name of organisms |
Total No. of isolated (%) |
|
E.coli |
23(79%) |
|
Enterococcus faecium |
2 (6%) |
|
Klebsiella pneumoniae |
1 (12.9%) |
|
Staphylococcus aureus |
1(3.2%) |
|
Enterobacter cloacae |
2(3.2%) |
|
Total |
29(17%) |
|
Name of the MDRO organisms |
No. of organisms |
|
E.coli |
2 (66%) |
|
Klebsiella pneumoniae |
1 (33%) |
|
Total |
3 |
|
Name of the organism |
MDRO antibiotic resistance |
Sensitive antibiotics |
|
E.coli |
I - group (β-lactams) |
Amikacin, Fosfomycin |
|
II – group (Carbapenems) |
||
|
Trimethoprim/sulfamethoxazole |
||
|
E.coli |
I - group (β-lactams) |
Ertapenem, Fosfomycin, amikacin, Nitrofurantoin |
|
IV- group (Quinolones) |
||
|
Trimethoprim/sulfamethoxazole |
||
|
Klebsiella pneumoniae |
I - group (β-lactams) |
Trimethoprim/sulfamethoxazole |
|
II – group (Carbapenems) |
||
|
III - group (Aminoglycosides) |
|
|
|
IV- group (Quinolones) |
Discussion
The research outcome and findings depicted that many patients encountered Urinary Tract Infection(UTI) long-suffering and short period diabetic cases was considered int his study. Significant bacteria was isolated in 90/247 (36%) & 157(63%) of symptomatic & asymptomatic diabetic patients respectively. The most common cause of UTI is asymptomatic bacteriuria because, in favourable circumstances, colonised bacteria in the urinary system may climb towards the bladder and cause cystitis, which is typically accompanied by the classic UTI symptoms. If an untreated UTI spreads via the ureters to the kidneys, it may result in pyelonephritis, which can cause fatal renal failure and irreparable kidney damage.[17]
The distinctive outcome were described in advance research prevailed no significant variation with recurrence showing up of bacteria in urine considering male and females. In comparison, Geerling’s et al[9] suggested with the purpose that UTI is increased in women.
Comparative research agreement of UTI in people with and without diabetes women unregulated and connected with increasing severity of infectious pathogen. The most commonly isolated pathogen is E.coli.[18] The most prevalent strains of Gram-negative isolate were Klebsiella pnueumoniae, Pseudomonas aeruginosa.
Escherichia coli was the most frequently isolated bacterium, according to several investigations. In this study, individuals with poor glycaemic control accounted for the majority of the 16 UTI cases (84.21%). In patients with adequate glycaemic control, only 3 (15.79%) incidences of UTI were discovered. [9], [19] Among gram positive, Enterococcus represented 6.2% of isolated pathogens further more Staphylococcus aureus 3.2% was found in few cases at most 1% specimens exist to Candida species. Gram-negative infections reveal disturbing resistant to first and second-line agents Ampicillin, Fluroquinolones, Trimethoprim/sulfamethoxazole, Amoxicillin, in this investigation.
In comparison analysis by Bhargava et al[20] exposed remarkably amikacin, gentamycin, cefepime, cefalotin The best treatments for GNB were and imipenem. Vancomycin, chloramphenicol, and nitrofurantoin, on the other hand, were the highest effectual medicine in opposition to Gram negative and Gram-positive bacteria. Various studies published resistant to the β-lactam group of antibiotic drug comparable with investigation of sensitivity pattern is observed.[21] The purpose of the study Daniel, Betty et al estimate the frequency of urethral infections with hose with and without diabetes[22] Whereas our study is to isolate and identify bacteria from samples of people with UTI who are diabetes. To evaluate multidrug resistance in the isolates of bacteria.
Conclusion
Infection of the urinary tract are frequent along with diabetic symptoms. UTI is an enhancing factor which give rise to infection in diabetic patients. The habitual utilize of common antibiotics created particular bacteria resistant’s reaching consequences of antibiotics.
The prolonged case assuming that UTI endures in diabetic patients, later can have dangerous complications. Diabetic people remain on increased risk of infections, with UTI amongst the most chronic situation. Urinary tract infection in diabetic mellitus act as a common intention of mortality and will result in mortality. E.coli is the major recurrent and regular infectious agent in charge between diabetics and non-diabetics of UTI, accompanied by Klebsiella. Examination of bacteriuria (UTI) is high in both diabetes and non-diabetic people. Significant remedy in medical care.
Source of Funding
None.
Conflicts of Interest
There is no conflict of interest.
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