Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq

Abstract

Background: Urinary tract infections (UTIs) are the most common type of infection during pregnancy. UTI include a spectrum of disorders, ranging from those affecting the lower urinary tract, like asymptomatic bacteriuria and cystitis, to those affecting the kidney, such as pyelonephritis. In pregnancy UTI can lead to preterm labor, anemia and septicemia. Escherichia coli is the most common pathogenic microorganisms associated with UTI and counting up to 60–80% of all UTIs. Objective: The aim of this study is to determine the prevalence of urinary tract infection (UTI) among pregnant women in wasit province. Materials and Methods: Mid-stream urine samples from 100 pregnant women who attending to Al- Shaheed Fairuz hospital and private clinics in wasit province between the periods of March 2024 to July 2024 with the age range of (16-35) years. The urine samples were cultured on MacConkey and blood agars then examined by Macroscopic and Microscopic examination by Gram's stain. The colonies were examined by biochemical tests (Oxidase, catalase, manitol salt agar, novobiocin tests, IMViC) and confirmatory tests (API 20E and API Staph) for isolates. Results: The results showed that the percentage of bacterial growth culture among the pregnant women was 33%. Gram negative bacteria were the higher percentage with (73%). Eschirishia coli bacteria were the most frequently isolated organism (40%) while, the lower percentage for Streptococcus spp. (3%). UTI in pregnant women was commonest in the age group 20-24 years (42%). According to trimesters of pregnancy, the highest percentage of UTI was in third trimester (43%) followed by second trimester (39%), while the the first trimest was the the lowest percentage with (18%). Conclusions: Urinary tract infections (UTIs) are common during pregnancy. Untreated UTIs can lead to complications such as preterm labor, low birth weight and sepsis. E.coli is the predominant pathogen presently causing urinary tract infections at all stages of pregnancy. Urine culture and sensitivity tests are mandatory for all pregnant women during the different trimesters.

Full text

513 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in
Wasit Province in Iraq
Hayder Abdullah Kadhim Al-Sarray1
1Department of Medical Laboratory Technologies, Middle Technical University, Iraq. E. mail: Karraralattaby@mtu.edu.iq
KEYWORDS
Pregnancy, Urinary
tract infection (UTI),
Eschirishia coli,
Gram negative
bacteria, Trimester
ABSTRACT
Background: Urinary tract infections (UTIs) are the most common type of infection during pregnancy. UTI
include a spectrum of disorders, ranging from those affecting the lower urinary tract, like asymptomatic
bacteriuria and cystitis, to those affecting the kidney, such as pyelonephritis. In pregnancy UTI can lead to
preterm labor, anemia and septicemia. Escherichia coli is the most common pathogenic microorganisms
associated with UTI and counting up to 60–80% of all UTIs.
Objective: The aim of this study is to determine the prevalence of urinary tract infection (UTI) among
pregnant women in wasit province.
Materials and Methods: Mid-stream urine samples from 100 pregnant women who attending to Al-
Shaheed Fairuz hospital and private clinics in wasit province between the periods of March 2024 to July
2024 with the age range of (16-35) years. The urine samples were cultured on MacConkey and blood agars
then examined by Macroscopic and Microscopic examination by Gram's stain. The colonies were
examined by biochemical tests (Oxidase, catalase, manitol salt agar, novobiocin tests, IMViC) and
confirmatory tests (API 20E and API Staph) for isolates.
Results: The results showed that the percentage of bacterial growth culture among the pregnant women
was 33%. Gram negative bacteria were the higher percentage with (73%). Eschirishia coli bacteria were the
most frequently isolated organism (40%) while, the lower percentage for Streptococcus spp. (3%). UTI in
pregnant women was commonest in the age group 20-24 years (42%). According to trimesters of
pregnancy, the highest percentage of UTI was in third trimester (43%) followed by second trimester (39%),
while the the first trimest was the the lowest percentage with (18%).
Conclusions: Urinary tract infections (UTIs) are common during pregnancy. Untreated UTIs can lead to
complications such as preterm labor, low birth weight and sepsis. E.coli is the predominant pathogen
presently causing urinary tract infections at all stages of pregnancy. Urine culture and sensitivity tests are
mandatory for all pregnant women during the different trimesters.
1. Introduction
Urinary tract infections (UTIs) are the second most common medical condition complicated
pregnancy after anemia and it's the most common type of infection during pregnancy (1). About 5-
10% of women develop some type of UTI during pregnancy (2) which can lead to important
complications in new-born of such mothers in case of inappropriate diagnosis and treatment (3).
In pregnancy, Urinary tract infections include a spectrum of disorders ranging from those affecting
the lower urinary tract, like asymptomatic bacteriuria and cystitis to those affecting the kidney such
as pyelonephritis (4). Asymptomatic bacteriuria is usually benign in non pregnant women, but the
risk of developing pyelonephritis increases during pregnancy (5). Pyelonephritis in pregnancy can
lead to anemia, septicemia, preterm labor, respiratory insufficiency and rarely maternal death (6,7,8).
UTIs in pregnancy are also associated with pre-eclampsia and birth defects (9,10,11).
The prevalence of UTIs in pregnancy may ranges from (13-33%) with asymptomatic bacteriuria
occurring in (2-10%) (12). The majority of urinary tract infection among pregnant women is well-
known in age group 26-30 years, followed by 21-25 and 31-35 years. The youngest among those
studied was 18 years and oldest 45 years (13).
Escherichia coli (E.coli) is the most common pathogenic microorganisms associated with UTI and
counting up to (60–80%) of all UTIs (14). Other microorganisms also included in UTI in pregnant
women such as Staphylococcus saprophyticus (5% to 15%) of cases (15), Gardnerella vaginalis,
Chlamydia trachomatis, Klebsiella pneumoniae, Proteus spp., Pseudomonas aeruginosa,
Enterococcus spp. (5% to 10%) (16).
2. Methodology

514 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
Mid-stream urine samples from 100 pregnant women who attending to Al- Shaheed Fairuz hospital
and private clinics in wasit province between the periods of March 2024 to July 2024 with the age
range of (16-35) years were collected in sterile containers and then transported to the laboratory for
bacterial analysis. Pregnant women who had been receiving antibiotics the day before admission
were excluded because of the possibility of affecting the urine culture results. The urine samples
were cultured on plates of MacConkey medium and blood agars were aseptically inoculated with 2-3
drops of the urine and then incubated for 24-48 hours.
The positive growth samples were examined by Macroscopic characteristics of the colonies and
Microscopic examination by Gram stain. Then, the colonies were examined by using standard
biochemical tests (i.e., Oxidase, catalase, manitol salt agar, novobiocin tests, IMVIC) and
confirmatory tests (i.e., API 20 E and API Staph) systems for isolates.
Ethical Considerations: This study carried out with the moral standards set forth in the Declaration of
Helsinki. Before a sample was taken, it was done with the patient’s informed consent.
Statistical analysis
The data were statistically analyzed by using SPSS/PC version 20 software (SPSS, Chicago). Chi
square test was used to reveal the significant comparison among percentages in this study. Where
similar letters refers to non significant difference (P>0.05) between groups while different letters
refers to significant difference (P<0.05).
3. Results and discussion
The results of the present study shown that the percentage of bacterial growth culture among the
pregnant women was 33%, while the negative growth culture was 67% as shown in figure (1).
Figure (1): The percentage of bacterial UTI growth in this study.
This study shown that the higher percentage were for gram negative bacteria with (73%), while lower
percentage were for the gram positive bacteria with (27%). The results demonstrated that there was a
significant increase (P<0.05) for gram negative than gram positive bacteria as shown in figure (2).
33%
67%
Positive Bacterial Growth

515 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
Figure (2): Percentage of bacteria isolates according to gram stain.
*Different letters refer to significant difference (P<0.05).
Eschirishia coli bacteria was the most frequently isolated organism (40%) followed by
Staphylococcus spp. and Klebsiella spp. (15%), the percentage of Enterococcus spp. was (9%), while
the lower percentage was for Proteus spp. and Streptococcus spp. with (6%) and (3%) respectively.
Eschirishia coli appeared a significant increase (P<0.05) than other species that isolated from
pregnant women. While, Streptococcus spp. appeared a significant decrease (P<0.05) than other
species except Enterococcus spp and Proteus spp. The results shown that there was non significant
differences (P>0.05) among the species of Proteus spp., Pseudomonas spp., Klebsiella spp.,
Staphylococcus spp. and Enterococcus spp., as shown in figure (3).
Figure (3): Percentage of bacterial isolates from urine of the pregnant women.
*Different letters refer to significant difference (P<0.05).
Gram Positive Bacteria Gram Negative Bacteria
Series1 27% 73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
E. Coli Proteus
spp.
Pseudo
monas
Spp.
Klebsiell
a spp.
Staphylo
coccus
spp.
Streptoc
occus
Spp.
Enteroco
ccus spp.
Series1 40% 6% 12% 15% 15% 3% 9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
a
b
a
bc
b
b
b
c
bc
a
B

516 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
Figure (4): A: E.coli on macConkey agr, B: klebsiella Oxytoca on macConkey agar C: Enterococcus
Faecalis on blood agar, D: Proteus Mirabilis on blood agar
According to the age group, the UTI in pregnant women was commonest in the age group 20-24
years (42%) followed by age group of 25-29 years with (27%), the age group of 30-35 years was
(18%), while the lower percentage was in age group 20> with (12%).
The age group 20-24 years shown a significant increase (P<0.05) in UTI than age groups (20>) and
(30-35) years while, there was non significant differences (P>0.05) when comparing it with age
group 25-29 years. Also, the results appeared that there was non significant differences (P>0.05)
between age group of (20>) and (30-35) years as shown in figure (5).
Figure (5): Distribution of UTI in pregnancy according to age group.
*Different letters refer to significant difference (P<0.05).
According to trimesters of pregnancy, the highest percentage of UTI was in third trimester (43%)
followed by second trimester (39%), while the the first trimest was the the lowest percentage with
(18%). The first trimester shown a significant decrease (P<0.05) in UTI when comparing it with third
and second trimesters, while there was non significant difference (P>0.05) between third and second
trimesters as shown in figure (6).
20> 20-24 25-29 30-35
Series1 12% 42% 27% 18%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
a
b
bc
ac
A
C
D

517 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
Figure (6): Urinary tract infection according to trimesters of pregnancy.
*Different letters refer to significant difference (P<0.05).
Discussion
The results of the present study shown that the percentage of bacterial growth culture among the
pregnant women was 33%.This study similar to Al-Dujiaily et al. study in Iraq with 38% and to
studies in other regions such as in Yemen by Al-Haddad study it was 30% and in Pakistan by Sheikh
et al. study 28.5% (17,18,19). Also this study different from other studies that show the bacterial
growth culture was about 8% and 7.7% (20). According to Obeagu et al. the risk factors associated
with urinary tract infections during pregnancy including; the age, education level, socio-economic
factors and obstetric factors play significant role in the occurrence of UTI during pregnancy (12).
This study shown that the higher percentage for gram negative bacteria were (73%), while lower
percentage were for the gram positive bacteria with (27%). When comparing with other studies this
result agree with the study done by Hussein et al. who found that the gram-negative bacteria were
80.95%, while gram-positive bacteria were 19.05% (21). On the other hand, the results disagree with
the results reported by Naji and Awadh, who found Gram-positive bacteria were the predominant
cause of UTI 66.7%, while Gram-negative bacteria were found 33.3% (22).
Regarding etiologic prevalence, the most frequent germ in this study was E. coli (40%) this finding
agree with results of other researchers such as Al-Haddad study who reported that the most
frequently isolated germ was E. coli 41.5% and to those reported by Balachandran et al. who reports
E. coli isolates was 40% (18,23), While this results disagree with some studies as Al-Saadi et al. and
Abd Al-Amir et al. who reported that staphylococcus aureus was the most frequently isolated germ
in UTI in pregnant women (24,25). E. coli was considered as the most prominent urinary pathogenic
bacteria due to a number of virulence factors specific for colonization and invasion of the urinary
epithelium (26).
This study appeared that, the UTI in pregnant women was commonest in the age group 20-24 years
(42%). This result agree with some studies that shown the age from 21-25 recorded the highest
percentage of UTI in pregnancy such as studies of Tamalli et al. and Bandyopadhyay et al. (27,28).
This can be explained by the fact that women’s reproductive activity increases during this period;
therefore, they are most prone to sexual activity which predisposes them to the introduction of
microorganisms to the urinary tract and infection (29).
4. Conclusion and future scope
Third trimester Second trimester First trimester
Series1 43% 39% 18%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
b
b
a

518 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
Urinary tract infections (UTIs) are common during pregnancy and can have significant implications
for both the mother and the developing fetus due to physiological and hormonal changes that affect
the urinary tract. Untreated UTIs can lead to complications such as preterm labor, low birth weight
and sepsis. Eschirishia coli is the predominant pathogen presently causing urinary tract infections at
all stages of pregnancy. Urine culture and sensitivity tests are mandatory for all pregnant women
during the different trimesters. Health education with regular antenatal care plays a significant role in
reducing the incidence of this infection.
Reference
[1]
Amiri M, Lavasani Z, Norouzirad R, Najibpour R, Mohamadpour M, Nikpoor AR, Raeisi M, Zare Marzouni H.
Prevalence of urinary tract infection among pregnant women and its complications in their newborns during the birth in
the hospitals of Dezful City, Iran, 2012–2013. Iran Red Crescent Med J, 2015, 17, e26946.
[2]
Souza RB, Trevisol DJ, Schuelter-Trevisol F. Bacterial sensitivity to fosfomycin in pregnant women with urinary
infection. Braz J Infect Dis, 2015, 19, 319-323.
[3]
Nwosu DC, Obeagu EI, Amajioyi O, et al. Prevalence Of Bacterial and Parasitic Urinary Tract Infections In Female
Students of Imo State University. World J Pharm Pharm Sci. 2015;4 (5):152-67.
[4]
Stein G, Fünfstück R: [Asymptomatic bacteriuria] . Med Klin (Munich). 2000, 95:195-200. 10.1007/pl00002106
[5]
Whalley P. Bacteriuria of pregnancy. Am J Obstet Gynecol. 1967;97:723-38. https://doi.org/10.1016/0002-
9378(67)90458-9
[6]
Hill JB, Sheffield JS, McIntire DD, Wendel GDJ: Acute pyelonephritis in pregnancy. Obstet Gynecol. 2005;105:18–23.
[PubMed: 15625136]
[7]
Jolley JA, Kim S, Wing DA: Acute pyelonephritis and associated complications during pregnancy in 2006 in U.S.
hospitals. J Matern Fetal Neonatal Med. 2012;25:2494–2498. [PubMed: 22725624]
[8]
Wing DA, Fassett MJ, Getahun D: Acute pyelonephritis in pregnancy: an 18-year retrospective analysis. Am J Obstet
Gynecol. 2014;10:219.e211–219.e216.
[9]
Feldkamp ML, Arnold KE, Krikov S, et al.: Risk of gastroschisis with maternal genitourinary infections: the US National
Birth Defects Prevention Study 1997–2011. BMJ Open. 2019;9:e026297.
[10]
Easter SR, Cantonwine DE, Zera CA, Lim KH, Parry SI, McElrath TF: Urinary tract infection during pregnancy,
angiogenic factor profiles, and risk of preeclampsia. Am J Obstet Gynecol. 2016;214:387.e381–387.e387. [PubMed:
26450405]
[11]
Howley MM, Feldkamp ML, Papadopoulos EA, et al.: Maternal genitourinary infections and risk of birth defects in the
National Birth Defects Prevention Study. Birth Defects Res. 2018;110:1443–1454. [PubMed: 30402975]
[12]
Obeagu EI, Ofodile AC, Okwuanaso CB. A review of urinary tract infections in pregnant women: Risks factors. J Pub
Health Nutri. 2023;6(1):137
[13]
Care A, Alrass C, Qassim A, et al. The Prevalence of Urinary Tract Infection among Pregnant Women Attending
Antenatal Clinic at, 2016;5(5):23-7.
[14]
M.A. Belete, & M. A. "Saravanan, Systematic Review on Drug Resistant Urinary Tract Infection Among Pregnant
Women in Developing Countries in Africa and Asia; 2005-2016" . Infect Drug Resist, vol. 18(13),pp.1465-1477, 2020.
[15]
Mittal P, Wing DA. Urinary tract infections in pregnancy. Clin Perinatol.2005, 32: 749-764.
[16]
Amer H, Almasri A. Urinary Tract Infections among Pregnant Women at Tripoli. Int Arch Med Microbiol.2023, 5:019.
doi.org/10.23937/2643-4008/1710019
[17]
Al-Dujiaily AA et al. Urinary tract infection during pregnancy in Tikrit. Medical Journal of Tikrit, 2000, 6:220–4.
[18]
Al-Haddad AM. Urinary tract infection among pregnant women in Al-Mukalla district, Yemen. Eastern Mediterranean
Health J, 2005, 11(3):505-511.
[19]
Sheikh MA et al. Incidence of urinary tract infection during pregnancy. Eastern Mediterranean health journal, 2000,
6(2–3):265–71.
[20]
Mikhail MS, Anyaegbunam A. Lower urinary tract dysfunction in pregnancy: a review. Obstet. Gynecol Surv.1995, 50:
675-683.

519 | P a g
e
Prevalence of Bacterial Urinary Tract Infection among Pregnant Women in Wasit Province in Iraq.
SEEJPH 2024 Posted: 24-07-2024
[21]
Hussein, Tahsein, M., Al-fattah, Munther, N., Thamir, T., Ibrahim, Radhwan, H., & Ibrahim, Radhwan, H. Assessment
of Nursing Students’ Knowledge toward Preventive Measures of Urinary Tract Infections in Mosul Teaching Hospitals.
Medico-Legal Update.2021, 21(1), 1070–1074.
[22]
Safa A. Naji and Halah A. Awadh. A Study of Urinary Tract Infections Prevalence, Antibiotics Resistance, and Biofilm
Formation Capability of the Bacterial Causal Agents”, Tikrit Journal of Pure Science, 2022, 27(6), pp. 11–17.
[23]
Balachandran L, Jacob L, Al Awadhi R, et al. Urinary Tract Infection in Pregnancy and Its Effects on Maternal and
Perinatal Outcome: A Retrospective Study. Cureus, 2022, 14(1): e21500. DOI 10.7759/cureus.21500
[24]
M. A.Al-Saadi, N. M.Al-Hilli, &N. A.Sheriff, "Association of TLR4 Polymorphisms with Susceptibility to Urinary Tract
Infection Caused by Gram Positive Bacteria in Pregnant Women". Indian Journal of Public Health, vol.11,pp. (2),
1941,2020.
[25]
Abd Al-Amir H Tamarah and Mousa M Hind. Bacterial Infections in Urinary Tract among Pregnant Women in
Nassiriyah City, Iraq. UTsci, 2023, 10 (1): 116-121.
[26]
Lavigne JP, Boutet-Dubois A, Laouini D, Combescure C, Bouziges N, Mares P, and Sotto A. Virulence potential of E.
coli strains causing asymptomatic bacteriuria during pregnancy. J ClinMicrobiol, 2011. 2011;49(11):3950–3.
[27]
Tamalli M., Alghazal M. A., Bioprabhu S. Urinary tract infection during pregnancy at Al-khoms, Libya. International
Journal of Medicine and Medical Sciences. 2013;3(5):455–459.
[28]
Bandyopadhyay, S., Thakur, J. S., Ray P., Kumar, R. High prevalence of bacteriuria in pregnancy and its screening
methods in North India. J Indian Med Assoc;2005, 103: 259-262, 266.
[29]
Tütüncü L, Ardıç N, et al. Urinary Tract Infection in Pregnancy. Perinatal J. 2005;13(4):47.