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Urinary Tract Infections and Antimicrobial Sensitivity Patterns of
Uropathogens Isolated from Diabetic and Non-diabetic Patients Attending
Some Hospitals in Awka "Urinary Tract Inf...
ArticleinAmerican Journal of Microbiological Research · August 2021
DOI: 10.12691/ajmr-9-3-3
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American Journal of Microbiological Research, 2021, Vol. 9, No. 3, 83-91
Available online at http://pubs.sciepub.com/ajmr/9/3/3
Published by Science and Education Publishing
DOI:10.12691/ajmr-9-3-3
Urinary Tract Infections and Antimicrobial Sensitivity
Patterns of Uropathogens Isolated from Diabetic and
Non-diabetic Patients Attending Some Hospitals in Awka
Ekwealor Chito Clare1,*, Alaribe Oluchi Juliet1, Ogbukagu Chioma Maureen1,
Alaribe James Romeo2, Kyrian-Ogbonna Evelyn Ada1
1Department of Applied Microbiology & Brewing, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
2Department of Microbiology, Federal University of Technology, Owerri, Imo State, Nigeria
*Corresponding author:
Received June 12, 2021; Revised July 19, 2021; Accepted August 02, 2021
Abstract Background: Diabetic patients have been found to be prone to urinary tract infections, and there is a
wide gap of information
in developing countries regarding the prevalence and antibiotic sensitivity of the pathogens
causing this infection. This study
was carried out to determine the prevalence, predisposing factors and antibiotic
sensitivity of organisms causing urinary tract
infections among diabetic patients and non-diabetics in four hospitals
in Awka, Anambra State, Nigeria. Method: A total of four hundred and sixty participants (230 diabetic patients and
230 non-diabetics) were enrolled in a cross-
sectional study design with 249 males (54.13%) and 211 (45.87 %)
females. Clean catch mid-stream urine samples were
collected from all participants in sterile containers and analyzed
macroscopically and microscopically. Each urine specimen
was streaked onto Nutrient agar, MacConkey agar,
Cysteine Lactose Electrolyte Deficient agar and Sabouraud’s Dextrose agar,
incubated at 37°C for 24h and identified
using standard methods. The sensitivity of the isolates to different antibiotics was
tested using Kirby-Bauer disc
diffusion method. Data obtained were analyzed statistically. Result: The overall prevalence of urinary tract
infections among diabetic patients, 63 (27.39%), was significantly higher than
that among non-diabetics, 41 (17.83%)
(p= 0.014). Gender and previous history of UTI were found to have significant
association with urinary tract
infection (0.000). Organisms isolated were Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis,
Pseudomonas aeruginosa, Citrobacter spp, Coagulase negative Staphylococcus, Staphylococcus aureus,
Enterococcus faecalis, and Candida albicans. The isolates were sensitive to tested antibiotics with Gentamicin
(10µg) and
Ceftriaxone (30µg) as most effective against Gram negative bacteria isolates while Ampicillin (10µg)
and Chloramphenicol
(30µg) were most effective against Gram positive bacteria isolates. Conclusion: The
prevalence of UTI is significantly higher in diabetics than in non-diabetics with E. coli being the most
common
isolate.The importance of antibiotic sensitivity testing before treatment is highly recommended.
Keywords: urinary tract infection, diabetics, risk factors of UTI, non-diabetics, antibiotics
Cite This Article: Ekwealor Chito Clare, Alaribe Oluchi Juliet, Ogbukagu Chioma Maureen,
Alaribe James Romeo, and Kyrian-Ogbonna Evelyn Ada, “Urinary Tract Infections and Antimicrobial Sensitivity
Patterns of Uropathogens Isolated from Diabetic and Non-diabetic Patients Attending Some Hospitals in Awka.”
American Journal of Microbiological Research, vol. 9, no. 3 (2021): 83-91. doi: 10.12691/ajmr-9-3-3.
1. Introduction
Diabetes Mellitus (DM) is a group of metabolic
diseases
characterized by hyperglycemia, resulting from
defects in
insulin secretion, insulin action or both [1]. The
prevalence
of diabetes mellitus has increased over the past
decades, and global reports show that it is now
approaching
epidemic proportions [2,3,4]. In 2017, the
global prevalence
of diabetes among adults aged
20-70 years was 8.4% and
was responsible for 10.7% of
all cases of deaths worldwide
[5]. An estimated 463
million adults aged 20–79 years are
living with diabetes
[4]. This represents 9.3% of the world’s population in this
age group. The prevalence is
expected to rise from 135
million in 1995 to 300 million in
the year 2025, 578
million (10.2%) by 2030 and to 700 million (10.9%) by
2045 [4]. According to WHO [3], the
number of people
with diabetes in Africa has increased
from 4 million in
1980 to 25 million in 2014, and the
number is expected to
reach 47.1 million by 2045 [4]. The
disease was
responsible for more than 366,200 deaths in
Africa in
2019 [4]. The estimated prevalence of diabetes is
2.4% in
rural areas, up to 5.9% in urban sub-Sahara Africa
[4]
and
between 8-13% in more developed areas such as
South
Africa [6].
Urinary tract infection (UTI) is the most common
infection
among patients with diabetes mellitus [7,8], with
estimates of diabetics suffering from UTI reaching 10% of
American Journal of Microbiological Research 84
patients visiting hospitals [9]. It is more common among
diabetic patients than non-diabetics [10]. Evidence from
various epidemiological studies showed that UTI is more
common in females with diabetes than in non-diabetic
females [1,12,13].
The chronic hyperglycemia of diabetes is associated
with
long term damage, dysfunction, and failure of various
organs especially the eyes, genitourinary system, nerves,
heart, and blood vessels [14] and low immunity [15], and
these complications predispose diabetics to urinary tract
infections (UTIs) [4]. Other risk factors associated with
increased incidence of urinary tract infections among
diabetic patients include low socioeconomic status,
advancing age, [1], sexual intercourse, and type of
diabetes mellitus [2], metabolic control, and long term
complications [16]. UTI in diabetics is associated with a
number of serious side effects which include carcinoma of
the bladder, gram negative bacteriaemia, sepsis, pyrexia of
unknown origin, end point renal failure, hypertension or
hypotension, increased prematurity, low birth weight and
fetal death [6].
Generally, the common etiologic agents of UTI
include
Escherichia coli, Klebsiella spp., Staphylococcus
aureus,
Pseudomonas aeruginosa, Enterobacter spp.,
Enterococcus spp., Proteus spp., Citrobacter spp.,
Acinetobacter spp. [17], Staphylococcus saprophyticus,
Candida spp. and other pathogenic yeasts [18].
Escherichia coli causes 80-90% of acute uncomplicated
bacterial lower tract infections (cystitis) in young women
[17]
. These agents have also been reported to be
associated
with UTI in diabetic patients [6] [16,19].
Antimicrobial agents commonly used in UTI therapy
include beta-lactam antibiotics: Ampicillin, Amoxicillin;
Fluoroquinolones: Norfloxacin, Ciprofloxacin; third
generation Cephalosporins: Cephalexin, Cotrimoxazole,
Gentamycin and Nitrofurantoin [18,19]. Uropathogens
show wide differences in their susceptibility to these
antimicrobial drugs from place to place and time to time
[19]. Reports show that diabetic patients using antibiotics
experience more intense UTI when compared to those not
using the drugs [20]. This is as a result of the resistance
posed by uncontrolled use of these drugs, thereby
exposing
them to more serious infections. The aim of this
study,
therefore, was to determine the prevalence,
predisposing
factors and antibiotic sensitivity pattern of
the organisms
causing urinary tract infections among
diabetic patients
and non-diabetics in four hospitals in
Awka, Anambra
State, Nigeria.
2. Materials and Methods
2.1. Study Design
The study was a hospital based comparative cross-
sectional study conducted from April 2020 to
September
2020.
2.2. Study Area
The study was conducted in Awka, the capital city of
Anambra State in the South-East geopolitical zone of
Nigeria. It covers a land area of about 522 km2. Awka has
an estimated population of 301,657 as of the 2006
National
population census [21], and over 2.5million by
2018. Four
hospitals, Chukwuemeka Odumegwu Ojukwu
University
Teaching Hospital (COOUTH), Crest
Specialist Hospital,
Regina-Caeli Specialist Hospital and
Nnamdi Azikiwe University Medical Center, all in Awka
South Local
Government Area, were used. The study area
was an
appropriate location as it attends to many patients
from the
nine towns in the Local Government Area and
thus
minimizes sample bias due to the wide area covered.
2.3. Study Population
The study population comprised both adult male and
female diabetic patients and non-diabetics, aged between
20-80 years, attending both outpatients and inpatients of
the selected hospitals, between 8 April 2020 and 30
September 2020.
2.4. Specimen Collection
Socio-demographic data were collected from each
study
participant using a structured questionnaire. A
“clean-catch” midstream urine specimen was collected
following
the method described by [1]. About 20 ml of
urine
specimen collected in a sterile, dry, screw capped
and
wide-mouthed plastic container was labeled with
unique
sample number, date, and time of collection. The
specimens were then transported in ice-pack containers
to
the laboratory of Applied Microbiology and
Brewing,
Nnamdi Azikiwe University, Awka, within 2h of
collection for further studies [22].
2.5. Isolation of Microorganisms
Using a sterile standard calibrated wire loop (0.002ml),
a loopful of each urine specimen was directly inoculated
onto Nutrient agar, Cysteine-lactose-electrolyte-deficient
(CLED) agar and MacConkey agar culture media by
streak plate method. The inoculated plates were incubated
at 37°C for 24h and examined for bacterial growth. The
approximate number of colonies were counted and the
number of bacteria (colony forming units (cfu) per
millimeter of voided urine) was estimated. A colony count
of more than 100,000 (≥105 cfu/ml) was considered a
significant bacterial count for positive urinary tract
infection [23]. Urine specimens inoculated on Sabouraud
Dextrose agar were examined macroscopically for yeast
growth after 48h incubation at 30°C. Significant
candiduria was determined as urine culture growth
≥104CFU/ml
.
2.6. Identification of Bacterial and Fungal
Isolates
A single colony was suspended into Nutrient broth and
streaked onto Nutrient agar plates for further identification
[24]
. The inoculated plates were incubated at 37°C for 24h.
Pure cultures of bacterial isolates were identified using
colony characteristics, Gram reaction and biochemical
reactions following standard procedures [23].The
morphological appearance of the fungal isolates were
noted as presumptive identification. Following standard
85 American Journal of Microbiological Research
procedures, the germ tube test and sugar fermentation tests
were carried out on all yeast isolates [25].
2.7. Antibiotic Sensitivity Tests
Antibiotic sensitivity tests were carried out on pure
cultures of bacterial isolates using Kirby-Bauer disc
diffusion method [24]. The isolates were tested against 13
antibiotics; Ampicillin (AMP) (30µg), Amoxicillin (AMX)
(30µg), Ceftriaxone (CEF) (30µg), Ciprofloxacin (CIP)
(10µg), Norfloxacin (NOR) (5µg), Nitrofurantoin (NIT)
(200µg), Gentamicin (GEN) (10µg), Oxacillin (OX)
(10µg), Tetracycline(TET) (10µg), Doxycycline (DOX)
(10µg), Chloramphenicol (CHL) (30µg), Erythromycin
(ERY) (10µg) and Cotrimoxazole (COT) (25µg). Using
sterile wire loop, colonies of each pure culture was
suspended in 3ml of physiological saline and the
suspension thoroughly mixed. One milliliter of the
suspension was transferred into a bijou bottle and diluted
with peptone water until the optical density of the
suspension matched that of 0.5 McFarland standard
solution [25]. The standardized test inoculum, (test
organism) was inoculated evenly over the entire surface of
Muller-Hinton agar (Oxoid), in triplicates using sterile cell
spreaders. The antibiotic-impregnated discs were placed
on
the surface of the culture media using sterile forceps,
and
after 24h incubation at 37°C, the diameters of the
zones of
growth inhibition were measured to the nearest
whole millimeter using a caliper. The zones of inhibition
were
interpreted as susceptible (S) or resistant (R)
following the
[25]
guideline.
2.8. Statistical Analysis
The data obtained from this study were analyzed using
the
Statistical Package for the Social Sciences (SPSS)
software for windows (version 25). Percentages,
frequencies,
and cross tabulations were used to summarize
descriptive
statistics. Pearson Chi-square test was
employed to
test the existence of association between
discrete variables.
P-value of <0.05 at 95% confidence
interval was
considered to indicate statistically significant
differences.
Odds ratio (OR); Crude Odds Ratio (COR)
and Adjusted
Odds Ratio (AOR) were used in the analysis.
Both
bivariate and multivariate logistic regression analyses
were employed to ascertain the degree of association
between the outcome variable (positive UTI) and
independent variables (socio-demographic characteristics
and
health related risk factors) [26].
3. Results
3.1. Socio-Demographic Characteristics of the
Study Participants
A total of 460 participants (230 diabetic patients and
230
non-diabetics) were included in the study. Of these,
249(54.13%) were males and 211 (45.87%) females. The
participants were aged between 20 to 80 years for both
diabetic and non-diabetic participants. The mean age of
the
diabetic group was 48.8±15.7. One hundred and
twenty-
three (53.48%) diabetic participants were males
while 107
(46.52%) were females. The socio-demographic
characteristics of diabetic and non-diabetic patients are as
shown in Table 1.
3.1.1. Prevalence of Urinary Tract Infection in
Diabetic
Patients and Non-Diabetics
The overall prevalence of UTI was 27.39% among
diabetic
patients and 17.83% among non-diabetic
participants.
There was significant difference between the
prevalence of UTI among diabetic and non-diabetic
participants (P =
0.014). Table 2 shows the prevalence of
UTI according to
socio-demographic characteristics in
diabetic patients and
non-diabetics.
3.1.2. Risk Factors Associated with UTI in Diabetic
Patients.
In the bivariate analysis, the prevalence of UTI was
significantly associated with gender, marital status, place
of residence, occupation, and previous history of UTI. No
significant association was observed betweenage,
educational
level, smoking habit and UTI in diabetic
patients. Inthe
multivariate analysis, the prevalence of UTI
was significantly
associated with gender and previous
history of UTI. The
female diabetic patients had higher
odds of UTI compared
with the males (Table 3). Similarly,
diabetic patients with
previous history of UTI had higher
odds of UTI compared
with those without any previous
history of UTI (Table 3).
However, marital status, place of
residence and occupation
were not significantly associated
with UTI (Table 3).
3.2. Spectrum of Uropathogens Associated
with
Diabetic Patients and Non-Diabetics.
Sixty-three bacteria and forty-one yeasts were recovered
from urine samples of diabetic and non-diabetic
participants,
respectively. Gram-negative bacteria were the
predominant
isolates from urine samples of 38 (60.32%)
diabetic and
21 (51.22%) non-diabetic participants.
Among the diabetic
group, eight bacteria and one yeast
species were isolated
from the urine cultures. The most
prevalent bacterial
isolates were Escherichia coli 25
(39.68%) while the least
isolate was Citrobacter spp. 1
(1.6%). Among the non-
diabetics, six bacteria and one
fungal species were isolated
from urine cultures. The most
prevalent was also
Escherichia coli 17 (41.46%), while the
least was
Enterococcus feacalis (2.44%) and Proteus
mirabilis
(2.44%). The prevalence of organisms isolated
from diabetic
and non-diabetic participants are presented
in Table 4.
3.3. Antibiotic Sensitivity Profile of Bacterial
Isolates
Antimicrobial susceptibility patterns of the bacterial
isolates from diabetic and non-diabetic participants are
presented in Table 5a and Table 5b. Most of the isolates
showed
100% sensitivity to Ceftriaxone, Ciprofloxacin,
Gentamicin and Chloramphenicol while Escherichia coli,
which is the most predominant isolate among the diabetics,
showed high level of resistance to Amoxicillin (76%)
(Table 5a). Predominant gram-positive isolate, Coagulase
negative Staphylococcus (CoNS) showed sensitivity to
Ceftriaxone (83.3%), Nitrofurantoin (83.3%), Doxycycline
American Journal of Microbiological Research 86
(100%) and Erythromycin (100%) but
resisted Ciprofloxacin
(50%) and Oxacillin
(50%). Staphylococcus aureus isolates also showed 100%
sensitivity to Ampicillin,
Nitrofurantoin and
Chloramphenicol (Table 5b).
Table 1. Socio-demographic characteristics of diabetic patients and non-diabetics attending some hospitals
Characteristics
Groups
Diabetics Non-diabetics
Frequency
Percentage
Frequency
Percentage
Age (years)
20-29
34
14.78
34
14.78
30-39 42 18.26 41 17.83
40-49
48
20.87
50
21.74
50-59
43
18.70
51
22.17
60-69 34 14.78 34 14.78
≥ 70
29
12.61
20
8.70
Mean age
48.8
47.4
Gender
Male
123
53.48
126
54.78
Female
107
46.52
104
45.22
Marital status
Single
40
17.39
45
19.57
Married
151
65.65
156
67.83
Divorced
5
2.17
7
3.04
Widowed
34
14.78
22
9.57
Residence
Rural
48
20.87
27
11.74
Urban
182
79.13
203
88.26
Educational status
Informal education
20
8.70
20
8.70
Primary education
35
15.22
26
11.30
Secondary education 59 25.65 58 25.22
Tertiary education
116
50.43
126
54.78
Occupation
Private 43 18.70 58 25.22
Civil servant
60
26.09
74
32.17
Artisan
42
18.26
23
10.00
Trader 31 13.48 27 11.74
Retired
32
13.91
20
8.70
Student
22
9.57
28
12.17
Smoking habit
Smoker
27
11.7
15
6.52
Non-smoker
203
88.3
215
93.48
Previous history of UTI
Yes
43
18.7
45
19.57
No
187
81.3
185
80.43
UTI: urinary tract infection.
Table 2. Prevalence of urinary tract infection by socio-demographic characteristics in diabetic and non-diabetics attending
hospitals
Characteristics
Groups
Diabetics Non-diabetics
No. of
Particpts.
UTI UTI p value No. of
Particpts.
UTI UTI
Positive (%)
Negative (%)
Positive (%)
Negative (%)
Age (years)
20-29
34
8 (23.5)
26 (76.5)
0.000
34
2 (5.9)
32 (94.1)
30-39
42
11 (26.2)
1 (73.8)
41
7 (17.1)
34 (82.9)
40-49 48 26 (54.2) 2 (45.8) 50 17 (34.0) 33 (66.0)
50-59 43 15 (34.9) 8 (65.1) 51 13 (25.5) 38 (74.5)
60-69 34 3 (8.8) 1 (91.2) 34 1 (2.9) 33 (97.1)
≥ 70
29
0 (0.0)
9 (100)
20
1 (5.0)
19 (95.0)
Mean age
48.8
47.4
Gender
Male 123 17 (13.8) 106 (86.2) 0.000 126 12 (9.5) 114 (90.5)
Female 107 46 (43.0) 61 (57.0) 104 29 (27.9) 75 (72.1)
87 American Journal of Microbiological Research
Characteristics
Groups
Diabetics
Non-diabetics
No. of
Particpts.
UTI
UTI
p value No. of
Particpts.
UTI
UTI
Positive (%) Negative (%) Positive (%) Negative (%)
Marital status
Single
40
6 (15.0)
34 (85.0)
0.001
45
4 (8.9)
41 (91.1)
Married 151 53 (35.1) 98 (64.9) 156 32 (20.5) 124 (79.5)
Divorced
5
2 (40.0)
3 (60.0)
7
0 (0.0)
7 (100.0)
Widowed
34
2 (5.9)
32 (94.1)
22
5 (22.7)
17 (77.3)
Residence
Urban
182
58 (31.9)
124 (68.1)
0.003
203
37 (18.2)
166 (81.8)
Rural
48
5 (10.4)
43 (89.6)
27
4 (14.8)
23 (85.2)
Educational status
Informal
20
4 (20.0)
16 (80.0)
0.063
20
2 (10.0)
18 (90.0)
Primary
35
4 (11.4)
31 (88.6)
26
0 (0.0)
26 (100.0)
Secondary
59
16 (27.1)
43 (72.9)
58
14 (24.1)
44 (75.9)
Tertiary
116
39 (33.6)
77 (66.4)
126
25 (19.8)
101 (80.2)
Occupation
Private
43
13 (30.2)
30 (69.8)
0.000
58
13 (22.4)
45 (77.6)
Civil servant
60
28 (46.7)
32 (53.3)
74
18 (24.3)
56 (75.7)
Artisan
42
10 (23.8)
32 (76.2)
23
3 (13.0)
20 (87.0)
Trader
31
7 (22.6)
24 (77.4)
27
4 (14.8)
23 (85.2)
Retired
32
1 (3.1)
31 (96.9)
20
1 (5.0)
19 (95.0)
Student 22 4 (18.2) 18 (81.8) 28 2 (7.1) 26 (92.9)
Smoking habit
Smoker
27
5 (18.5)
22 (81.5)
0.271
15
5 (33.3)
10 (66.7)
Non-smoker 203 58 (28.6) 145 (71.4) 215 36 (16.7) 179 (83.3)
UTI: Urinary tract infection, Particpts: Participants.
Table 3. Risk factors associated with UTI among diabetic patients attending hospitals
Variable
Categories
Bivariate analysis
Multivariate analysis
UTI
UTI
Positive
Cases
Negative
Cases
No (%)
No (%)
COR
95% CI
p-value
AOR
95% CI
p-value
Age (in years)
20 – 29
8 (23.5)
26 (76.5)
…
…
0.998
….
…
0.998
30 – 39
11 (26.2)
31 (73.8)
…
…
0.998
….
…
0.998
40 – 49
26 (54.2)
22 (45.8)
…
…
0.998
….
…
0.998
50 – 59
15 (34.9)
28 (65.1)
…
…
0.998
….
…
0.998
60 – 69
3 (8.8)
31 (91.2)
…
…
0.998
….
…
0.998
≥70
0 (0)
0 (0.0)
…
…
…
…
…
….
Gender
Male
17 (13.8)
106 (86.2)
1
1
1
1
Female
46 (43.0)
61 (57.0)
4.702
2.481 – 8.911
0.000
8.575
3.108 – 23.663
0.000
Marital Status
Single
6 (15.0)
34 (85.0)
2.824
0.531 – 15.022
0.224
1.523
0.099 – 23.41
0.763
Married
53 (35.1)
98 (64.9)
8.653
1.995 – 105.284
0.004
4.209
0.441 – 40.16
0.212
Divorced
2 (40.0)
3 (60.0)
10.667
1.081 – 105.284
0.043
5.881
0.158–219.518
0.337
Widowed
2 (5.9)
32 (94.1)
1
1
1
1
Place of
Residence
Urban
58 (31.9)
124 (68.1)
1
1
1
1
Rural
5 (10.4)
43 (89.6)
0.249
0.094 – 0.660
0.005
0.498
0.100 – 2.495
0.397
Highest level of
Education
Informal
4 (20.0)
16 (80.0)
1
1
1
1
Primary
4 (11.4)
31 (88.6)
0.516
0.114 – 2.340
0.391
1.185
0.103 – 13.592
0.892
Secondary
16 (32.7)
43 (67.3)
1.488
0.432 – 5.127
0.529
1.800
0.244 – 13.266
0.564
Tertiary
39 (33.6)
77 (66.4)
2.026
0.634 – 6.472
0.233
1.900
0.260 – 13.878
0.527
Occupation
Private
13 (30.2)
30 (69.8)
1
1
1
1
Civil servant
28 (46.7)
32 (53.3)
2.019
0.885 – 4.608
0.095
1.375
0.434 – 4.349
0.588
Trader
10 (23.8)
32 (76.2)
0.721
0.275 – 1.889
0.506
0.868
0.175 – 4.293
0.862
Artisan
7 (22.6)
24 (77.4)
0.673
0.232 – 1.951
0.466
0.669
0.127 – 3.520
0.635
Retired
1 (3.1)
31 (96.9)
0.074
0.009 – 0.605
0.015
1.452
0.050 – 41. 85
0.828
Student
4 (18.2)
18 (81.8)
0.513
0.145 - 1.815
0.300
0.228
0.023 – 2.233
0.204
Smoking Habit
Smokers
5 (18.5)
22 (81.5)
0.568
0.205 – 1.572
0.276
1.601
0.387 – 6.616
0.516
Nonsmokers
58 (28.6)
145 (71.4)
1
1
1
1
Previous
history of UTI
Yes
29 (67.4)
14 (32.6)
9.321
4.455 – 19.502
0.000
14.038
4.969 – 39.655
0.000
No
34 (18.2)
153(81.8)
1
1
1
1
FBS Level
<126mg/dl
4 (16.7)
15 (83.3)
0.309
0.069 – 1.386
0.125
0.368
0.045 – 2.984
0.349
≥126mg/dl
37 (17.5)
175 (82.5)
1
1
1
1
COR: Crude Odds Ratio, AOR: Adjusted Odds Ratio, CI: Confidence Interval, FBS: Fasting Blood Sugar.
American Journal of Microbiological Research 88
Table 4. Prevalence of organisms isolated from urine culture of diabetic patients and non-diabetics
Isolates
Number (n = 230)
Total (%)
Diabetic
No (%)
Non-diabetic
No (%)
Gram negative bacteria
Escherichia coli
25 (39.68)
17 (41.46)
42 (40.38)
Klebsiellapneumoniae
5 (7.94)
3 (7.32)
8 (7.69)
Proteus mirabilis
4 (6.34)
1 (2.44)
5 (4.81)
Pseudomonas aeruginosa
3 (4.76)
0 (0)
3 (2.88)
Citrobacterspp.
1 (1.59)
0 (0)
1 (0.96)
Gram positive bacteria
Staphylococcus aureus
9 (14.29)
9 (21.95)
18 (17.31)
CON Staphylococcus
12 (19.05)
7 (17.07)
19 (18.27)
Enterococcus feacalis.
2 (3.17)
1 (2.44)
3 (2.88)
Yeast
Candida albicans
2 (3.17)
3 (7.32)
5 (4.819)
CON – Coagulase negative.
Table 5a. Antimicrobial susceptibility profile of gram negative bacterial isolates from urine of diabetic and non-diabetic
patients attending
hospitals
Isolates from diabetic patients
Isolates from non-diabetic participants
Antibiotics
tested
Pattern
Escherichia coli
(N = 25) (%)
K.. pneumoniae
(N = 5) (%)
P. aeruginosa
(N = 3) (%)
Proteus
mirabilis
(N = 4) (%)
Citrobacter sp.
(N = 1) (%)
Escherichia coli
(N = 17) (%)
K. pneumoniae
(N = 3) (%)
Proteus
mirabilis
(N = 1) (%)
AMX
S
6 (24)
2 (40)
0 (0)
4 (100)
1 (100)
10 (58.8)
2 (66.7)
1 (100)
R
19 (76)
3 (60)
3 (100)
0 (0)
0 (0)
7 (41.2)
1 (33.3)
0 (0)
CEF
S
25 (100)
5 (100)
3 (100)
4 (100)
1 (100)
15 (88.2)
3 (100)
1 (100)
R
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
2 (11.8)
0 (0)
0 (0)
CIP
S
25 (100)
4 (80)
0 (0)
1 (25)
0 (0)
17 (100)
3 (100)
0 (0)
R
0 (0)
1 (20)
3 (100)
3 (75)
1 (100)
0 (0)
0 (0)
1 (100)
TET
S
19 (76)
2 (40)
0 (0)
1 (25)
0 (0)
9 (52.9)
1 (33.3)
0 (0)
R
6 (24)
3 (60)
3 (100)
3 (75)
1 (100)
8 (47.1)
2 (66.7)
1 (100)
GEN
S
25 (100)
5 (100)
3 (100)
4 (100)
1 (100)
17 (100)
2 (66.7)
1 (100)
R
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
1 (33.3)
0 (0)
NIT
S
21 (84)
4 (80)
0 (0)
4 (100)
0 (0)
17 (100)
3 (100)
0 (0)
R
4 (16)
1 (20)
3 (100)
0 (0)
1 (100)
0 (0)
0 (0)
1 (100)
NOR
S
17 (68)
4 (80)
0 (0)
2 (50)
0 (0)
14 (82.4)
3 (100)
0 (0)
R
8 (32)
1 (20)
3 (100)
2 (50)
1 (100)
3 (17.6)
0 (0)
1 (100)
AMP
S
17 (68)
2 (40)
1 (33.3)
4 (100)
0 (0)
13 (76.5)
1 (33.3)
0 (0)
R
8 (32)
3 (60)
2 (66.7)
0 (0)
1 (100)
4 (23.5)
2 (66.7)
1 (100)
CHL
S
25 (100)
4 (80)
0 (0)
3 (75)
0 (0)
15 (88.2)
3 (100)
1 (100)
R
0 (0)
1 (20)
3 (100)
1 (25)
1 (100)
2 (11.8)
0 (0)
0 (0)
S: Sensitivity; R: Resistance; P. aeruginosa: Pseudomonas aeruginosa; K. pneumoniae; Klebsiella pneumoniae; AMP: Ampicillin; AMX: Amoxicillin;
CEF: Ceftriaxone; CIP: Ciprofloxacin; NOR: Norfloxacin; NIT: Nitrofurantoin; GEN: Gentamicin; TET: Tetracycline; CHL: Chloramphenicol.
Table 5b. Antimicrobial susceptibility profile of gram positive bacterial isolates from urine of diabetic and non-diabetic
patients attending
hospitals
Antibiotics
tested
Pattern
S. aureus (N = 9)
(%)
CoNS (N = 12)
(%)
E. feacalis (N = 2)
(%)
S. aureus (N = 9)
(%)
CoNS (N = 7)
(%)
E. feacalis (N = 1)
(%)
AMP
S
9 (100)
NA
2 (100)
9 (100)
NA
1 (100)
R
0 (0)
NA
0 (0)
0 (0)
NA
0 (0)
CEF
S
7 (77.8)
10 (83.3)
2 (100)
8 (88.9)
6 (85.7)
1 (100)
R
2 (22.2)
2 (16.7)
0 (0)
1 (11.1)
1 (14.3)
0 (0)
CIP
S
5 (55.6)
6 (50)
2 (100)
4 (44.4)
5 (71.4)
1 (100)
R
4 (44.4)
6 (50)
0 (0)
5 (55.6)
2 (28.6)
0 (0)
TET
S
3 (33.3)
8 (66.7)
2 (100)
5 (55.6)
6 (85.7)
0 (0)
R
6 (66.7)
4 (33.3)
0 (0)
4 (44.4)
1 (14.3)
1 (100)
DOX
S
5 (55.6)
12 (100)
2 (100)
5 (55.6)
5 (71.4)
1 (100)
R
4 (44.4)
0 (0)
0 (0)
4 (44.4)
2 (28.6)
0 (0)
NIT
S
7 (77.8)
10 (83.3)
1 (50)
9 (100)
7 (100)
1 (100)
R
2 (22.2)
2 (16.7)
1 (50)
0 (0)
0 (0)
0 (0)
ERY
S
5 (55.6)
12 (100)
2 (100)
8 (88.9)
7 (100)
0 (0)
R
4 (44.4)
0 (0)
0 (0)
1 (11.1)
0 (0)
1 (100)
OX
S
4 (44.4)
6 (50)
2 (100)
6 (66.7)
4 (57.1)
1 (100)
R
5 (55.6)
6 (50)
0 (0)
3 (33.3)
3 (42.9)
0 (0)
CHL
S
9 (100)
NA
2 (100)
NA
1 (100)
1 (100)
R
0 (0)
NA
0 (0)
NA
0 (0)
0 (0)
COT
S
3 (33.3)
8 (66.7)
2 (100)
5 (55.6)
7 (100)
1 (100)
R
6 (66.7)
4 (33.3)
0 (0)
4 (44.4)
0 (0)
0 (0)
S: Sensitivity; R: Resistance; S. aureus: Staphylococcus aureus; E. faecalis: Enterococcus faecalis; CoNS: Coagulase negative Staphylococcus,
AMP: Ampicillin; CEF: Ceftriaxone; CIP: Ciprofloxacin; NIT: Nitrofurantoin; OX: Oxacillin; TET: Tetracycline; DOX: Doxycycline;
CHL: Chloramphenicol; ERY: Erythromycin; COT: Cotrimoxazole.
89 American Journal of Microbiological Research
4. Discussion
Studies have demonstrated greater susceptibility of
diabetics than non-diabetics to urinary tract infections [27]
[12]
. The prevalence of urinary tract infections among
diabetic and non-diabetic patients, risk factors associated
with urinary tract infections in diabetics, spectrum of
uropathogens responsible for UTI in diabetic patients and
non-diabetics and the sensitivity patterns of the bacterial
isolates to antibiotics were investigated.
The findings from this study showed that the overall
prevalence of urinary tract infections among diabetic
patients (27.4%) was higher than those of non-diabetic
patients (17.8%). The high prevalence of UTI among
diabetic patients is in line with that of [28], who reported a
prevalence of 32.0% among diabetics and 22.0% in
non-
diabetics. It also agreed with the studies of [29,30],
in
which they recorded 25.2% and 33.8% UTI among
diabetic patients, respectively. In contrast, [2,24],
reported
lower prevalence rates of 19.5% and 13.8%,
respectively
among diabetic patients. Worku et al. [26],
also recorded a
low prevalence of 10.9% among diabetics
and 4.7%
among non-diabetics.
Some other researchers reported higher prevalence of
urinary tract infections among diabetic patients and
non-
diabetics. Prevalence rates of 40% to 50.7% have
been
reported among diabetics [10,11,13,31]. The high
prevalence rate could be attributed to emergence of
antibiotic resistant bacteria that cause urinary tract
infection in diabetics.
There was a significant difference (P < 0.5) in the
prevalence of UTI among diabetic patients when
compared
to non-diabetics and this finding supports the
work of
many other researchers [1,12,27,32].
Among diabetic patients, a significant difference in the
prevalence of UTI was observed among various age
groups. A higher prevalence of UTI was observed among
age group 40-49 years (54.2%) and age group 50-59
(34.9%) (Table 2). This result agrees with those of [33-34],
who observed a high prevalence in age groups 30-49 years
and 51-60 years, respectively. The result obtained is
contrary to that of [35], who observed an increase in UTI
with increasing order of age. The high prevalence of UTI
recorded among the age group 40-49 years could be due to
increased rate of sexual activity in this age group.
The incidence of urinary tract infections was found to
be
significantly higher in female diabetics (43.0%) than in
male patients (13.8%) (P = 0.000) (Table 2). This finding
is in line with the reports of [11,13], who reported higher
prevalence of UTI among female diabetics. A higher
prevalence of UTI was also observed among female
non-
diabetics (27.9%) than male non-diabetics (9.5%)
and this
result supports the works of other researchers
[6,30,36].
Contrary to our findings, [37], reported a higher
prevalence of UTI in male diabetic patients than in
females. The higher prevalence of UTI recorded among
female diabetic and non-diabetic patients may be caused
by decrease in normal vaginal flora (Lactobacilli), less
acidic pH of vaginal surfaces, poor hygienic condition,
short and wider urethra, and proximity to the anus [2].
Table 3 shows the assessment of the association
between
various risk factors and UTI in diabetic patients.
Age was one of the factors considered and the bivariate
logistic
regression analysis showed no significant
association
between age and incidence of UTI in diabetic
patients.
This finding agrees with the work of [24,30,38].
In
contrast to this result, [39], reported a significant
association between age of diabetic patients and UTIs. It
was observed (Table 3) that gender and previous history
of
UTI were associated with high prevalence of UTI in
diabetic patients. There was no significant association
betweeneducational status, smoking habit of patients and
the incidence of UTI in diabetic patients (Table 3).
However, [30] reported a significant association between
drinking habit, high level of glucose and high prevalence
of UTI.
The organisms causing UTI in diabetic patients were
similar to those in non-diabetics but with variations in the
number of isolates obtained (Table 4). This result
corroborates the reports of [40], who studied the impact of
diabetes mellitus on the spectrum of uropathogens in
patients with UTI. The incidence of Pseudomonas
aeruginosa and Citrobacter spp. was found only among
diabetic patients (Table 4). This observation agrees with
the findings by [30]. The results (Table 4) also showed
that
the etiologic agents of UTIs in both diabetics and non-
diabetics were mainly bacterial species, and this is in
accordance with the report of [36]. Most of the isolates
from this study belonged to Gram-negative bacteria, with
Escherichia coli being the most predominant (40.38%).
This finding supports the reports of other researchers
[6,10,22,37,41]. The high incidence of Escherichia coli,
as
suggested by [10], could be attributed to the fact that
they
are commensals of the intestines and that infections
are
most likely to be by faecal contamination due to poor
hygiene. The findings, however, disagree with reports
by
[11] who observed that Coagulase-Negative
Staphylococcus was the most prevalent isolate accounting
for 37.5%.
Escherichia coli was responsible for 39.7% and 41.5%
of
urinary tract infections among the diabetic and
non-diabetic groups respectively, and this is in line with
the reports of [12]. Contrary to our findings, [40] reported
a
prevalence of 67.3% in diabetic patients and 61.8% in
non-
diabetic group. The lower isolation rate of E. coli in
this
study when compared with the findings of [40], could
be
attributed to the smaller sample size examined.
Klebsiella
pneumonia (7.7%) and Proteus mirabilis (4.8%)
were the
second and third most prevalent bacterial
isolates
respectively amongst Gram-negative bacteria.
The
prevalence of Klebsiella pneumoniae among diabetics
(7.94%) and non-diabetics (7.32%) supports the reports
of
[40]
. They isolated 9.3% of Klebsiella pneumoniae
among
diabetics and 7.3% among non-diabetics.
Jagadeeswaran et
al. [37], also isolated 8.6% of the
organism among
diabetics. Obeagu et al. [6], however,
reported a 31.42%
isolation of Klebsiella pneumoniae
among diabetics and
28.57% in non-diabetics. Similarly,
[12], also reported the
high rate of 20.14% of the organism
in diabetics and
19.40% in non-diabetics. The variations in
the isolation
rates may be as a result of the isolation media
used by the
researchers.
Table 4 shows a 6.34% isolation of Proteus mirabilis
among diabetics and 2.44% in non-diabetics, and the
result
is comparable with the report of [2], who isolated
7.65% of
the organism in diabetics. Contrary to our
American Journal of Microbiological Research 90
findings, [12],
recorded a 12.23% of the organism in
diabetics and
10.44% in non-diabetics, while [30], had
9.3% isolation in
diabetics.
As presented in Table 4, Coagulase Negative
Staphylococcus (18.27%) and Staphylococcus aureus
(17.31%) were the second and third most prevalent
Gram
positive bacterial isolates, respectively. This
result
supports the findings of [24] who observed CoNS
(24.2%)
and Staphylococcus aureus (18.2%) to be the
second and
third most common isolates, respectively.
Woldemariam et
al. [42], also reported Coagulase
Negative Staphylococcus
as the second most isolated
bacteria after E. coli. In
contrast, the second most common
isolate in the report by
[36]
, was Enterococcus feacalis
(10.9%). The isolation
rate of Coagulase Negative
Staphylococcus from diabetic
patients (19.04%) and
non-diabetics (17.07%) is as presented in Table 4. This
result is comparable with that of
[30]
. Gram-positive
bacteria are not common uropathogens
[2]
, however, due
to contamination, they have been found
to always invade
the urinary tract infection and cause UTI
[43]
. The
prevalence of Staphylococcus aureus among
diabetics
(14.29%) and non-diabetics (21.95%) (Table 4),
is higher
than that (0.8% in diabetics and 0.6% in non-
diabetics)
reported by [40]. The least isolated gram
positive bacteria
in this study were Enterococcus feacalis,
with a
prevalence rate of 3.17% in diabetics and 2.44% in
non-diabetics. This result agrees with that found by [3].
However, much higher results of 9.3% and 16.2% were
reported by [30] and [42] respectively.
Yeasts, particularly Candida spp. are a common
predisposing factor of UTI in diabetes mellitus patients
[43]
. Candida albicans isolated from diabetics (3.17%)
and non-diabetics (7.32%) are shown in Table 4. The
results obtained are comparable with 2.2% in diabetics
reported by [30]. However, higher rate of 17.9% was
reported by [42]. Mogaka et al. [39], reported an increase
in resistance of isolated bacterial organisms to available
antibiotics among diabetic patients. Tables 5a and
Table 5b show
that, a number of bacterial isolates from
diabetic and non-
diabetic patients were sensitive to the
tested antibiotics.
Most of the gram negative bacterial isolates
from diabetic
patients were sensitive to Beta-lactams,
Quinolones and
Aminoglycosides (Table 5a). Among the
antibiotics tested,
Gentamicin (10µg) and Ceftriaxone
(30µg) were found to be the most effective drugs against
gram negative bacterial
isolates. While this finding agrees
with the report of [2], it
disagrees with that of [44], who
observed quinolones to be
the most effective agents
against isolated gram negative
bacilli. This variation in
susceptibility may be due to
changing trends of
antimicrobial susceptibility pattern of
these urinary tract
pathogens from place to place [36].
In the present study, Tetracycline (10μg), Ampicillin
(30μg) and Amoxicillin(30μg) were the least effective
antimicrobials against gram negative bacterial isolates as
most of the organisms showed high level of resistance to
the antibiotics.
Most of the isolated gram positive organisms were
susceptible to the antibiotics tested (Table 5b). Ampicillin
and Chloramphenicol were found to be the most effective
drugs against gram positive bacterial isolates. While [39],
recorded 50.0% of resistance to Ampicillin and
Ciprofloxacin, [2], reported a lower resistance to
Ampicillin and Ciprofloxacin (20.0%), which is supported
by the result obtained in this study.
5. Conclusions
The prevalence of UTI was significantly higher in
diabetics than in non-diabetics. Gender and previous
history of UTI were observed to be risk factors of
UTI
among diabetic patients. Escherichia coli was
observed to
be the most prevalent bacterial isolate.
Routine urine
cultures and antibiotic sensitivity testing of
samples from
patients is indispensable in the prevention
and treatment of
UTI.
Ethical Consideration
Ethical approval was obtained from the Ethical
Research
Committee of Chukwuemeka Odimegwu
Ojukwu University
Teaching Hospital, Awka before
conducting the study.
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