Original Article
ShaShIDhar VIShWanath, raDhIKa SarDa, annet OlInDa D’SOuza, ChIranjay MuKhOpaDhyay ABSTRACT
out of the four patients with asymptomatic bacteriuria had Objective: Patients with diabetes mel itus have a higher
associated complications of diabetes mel itus. Enterococcus prevalence of asymptomatic bacteriuria and incidence faecalis (2,50%), Staphylococcus saprophyticus (1, 25%) and of urinary tract infections compared to patients without Escherichia coli (1, 25%) were the organisms isolated from diabetes mel itus. A prospective pilot study was conducted patients with asymptomatic bacteriuria. Staphylococcus to determine the frequency of association of asymptomatic saprophyticus isolate was mostly sensitive to antimicrobials bacteriuria among patients with diabetes mel itus in tested. Enterococcus faecalis was sensitive to ampicil in. comparison to control group without diabetes mel itus. Escherichia coli isolate was multi-drug resistant. Methods: Urine specimens were processed by microscopy
Conclusion: Asymptomatic bacteriuria was more common
and culture fol owing standard guidelines. The spectrum of among patients with diabetes mel itus than in healthy uro-pathogens causing asymptomatic bacteriuria and their control subjects. Further, long term studies investigating the antibiotic susceptibility profile were noted. occurrence of complications secondary to asymptomatic Results: Asymptomatic bacteriuria was seen more
bacteriuria in patients with diabetes mel itus and randomized commonly in patients with diabetes mel itus (4%) than in control studies for studying the efficacy of antimicrobial healthy control subjects. Asymptomatic bacteriuria was not therapy in preventing further complications in diabetes seen in the non-diabetic individuals under control group. Three mel itus patients in Indian setups are needed.
Key Words: Bacteriuria, Diabetes Mellitus, Enterococcus faecalis, Escherichia coli, Staphylococcus saprophyticus INTRODUCTION
However, reports on the incidence of ASB among diabetes Diabetes mellitus has become a major health challenge mellitus patients from India are scarce. Hence, there is a need worldwide. In India alone, the prevalence of diabetes is for studying the impact of ASB in patients with diabetes mellitus expected to increase from 31.7 million in 2000 to 79.4 million in Indian setups. A prospective pilot study was conducted to in 2030 [1]. As the prevalence of diabetes mellitus increases assess the frequency of occurrence of ASB among patients worldwide, complications associated with it also assume equal importance. Patients with diabetes mellitus have a higher prevalence of asymptomatic bacteriuria (ASB) and MATeRIAl & MeThODS
incidence of urinary tract infections (UTIs) compared with A prospective case-control study was conducted, in a patients without diabetes mellitus [2]. Presence of ASB in tertiary care hospital attached to a teaching Institution, to patients with Type 2 diabetes is a predictor of subsequent study the frequency of occurrence of ASB among patients development of a symptomatic UTI [3]. Complications of UTIs with diabetes mellitus. This study was approved by our such as emphysematous cystitis, pyelonephritis and renal Institutional Ethical Committee. Following informed consent, papillary necrosis occur more commonly in subjects with Type one hundred randomly selected adult patients (18-65 years) diagnosed with diabetes mellitus and presenting to hospital with ailments other than urinary tract infection were included The reported prevalence rate of ASB in diabetic patients are in the present study. Pregnant females, individuals who had 9-29% among females and 0.7-11% among males [5]. There received antimicrobial drugs during the previous 2 weeks, are reports of symptomatic UTI in patients with diabetes those with urinary catheterization, symptomatic urinary tract mellitus and ASB in pregnant women from Indian setups. National Journal of Laboratory Medicine. 2013 Sep, Vol 2(3): 16-19 11 Shashidhar Vishwanath et al., Asymptomatic Bacteriuria among Patients with Diabetes Mellitus at a Tertiary Care Center infection and renal failure were excluded from the study. One hundred healthy, non-diabetic age and sex matched controls Of the 100 patients with diabetes mellitus, 62 were males and 38 were females (M:F::1.6:1; Range 35 – 65 years). Majority of Sample Collection & processing: Clean-voided, mid-stream the individuals were between the age group of 51 - 60 years urine samples were collected in wide mouth sterile containers (50%). All patients (100%) in the study group had diabetes from both case and control groups. All specimens were mellitus – Type 2. Of the 100 patients with diabetes mellitus in transported within 2 hours to the microbiology laboratory study group, four (4%) had asymptomatic bacteriuria (males – for immediate processing. The specimens were processed 3.2% and females – 5.3%). Of the four patients with ASB, two following standard guidelines [6]. Urine wet mount and gram (50%) were males and two (50%) were females. All patients stain examination were done for presence of pus cells and with ASB had uncontrolled diabetes mellitus status. None bacteria. Presence of >5 polymorphonuclear leukocytes/ of the healthy controls without diabetes mellitus had ASB. high power field (which correlates with WBC excretion rate Presence of other complications of diabetes mellitus (diabetic of >400,000 WBC/hr) indicated pyuria which is evidence of retinopathy, neuropathy, nephropathy) was seen in three (75%) an inflammatory response in the urinary tract [6,7] and; one out of the four patients with ASB [Table/Fig-2].
organism per oil-immersion field in gram stain of uncentrifuged Enterococcus faecalis (2, 50%), Escherichia coli (1, 25%) urine would suggest bacteriuria with a colony count of ≥ 105 and Staphylococcus saprophyticus (1, 25%) were the CFU/ml of urine [6]. Specimens were inoculated onto blood organisms isolated. S. saprophyticus was sensitive to most agar and MacConkey agar by standard loop method for semi- of the antibiotics tested. However CLSI does not recommend quantitative culture [8]. The inoculated media were incubated routine sensitivity testing of urine isolates of S. saprophyticus aerobically for 24 hrs at 37°C. A diagnosis of asymptomatic because infections respond to concentrations achieved in bacteriuria in female patients was made, if two consecutive urine of antimicrobial agents commonly used to treat acute, clean-voided midstream urine specimens yielded the same non-complicated urinary tract infections [10]. Both isolates bacterial strain in quantitative counts of ≥105 CFU/mL in the of Enterococcus spp. were sensitive to Ampicillin (100%). E. absence of symptoms referable to urinary infection. In male coli isolate was multi-drug resistant, resistant to most of first patients, asymptomatic bacteriuria was diagnosed if one line drugs except for the aminoglycoside, Gentamicin. The bacterial species was isolated from a single, clean-voided isolate was sensitive to Meropenem and Beta lactam-Beta midstream urine specimen in a quantitative count ≥105 CFU/ lactamase inhibitor (BL-BLIs) drugs, Ticarcillin-clavulanate mL in the absence of symptoms referable to urinary infection and Piperacillin-tazobactam. Quinolones, the commonly Key Words: Bacteriuria, Diabetes Mellitus, Enterococcus faecalis, Escherichia [9]. In those cases with significant bacteriuria, the isolates were used antibiotics for urinary tract infections were found to be coli, Staphylococcus saprophyticus identified by biochemical reactions using standard methods ineffective against all the four isolates [Table/Fig-3].
[8]. Antibiotic susceptibility testing of the isolated strains was done by Kirby-Bauer’s disc diffusion method following Clinical DISCUSSION
Laboratory Standards Institute (CLSI) guidelines [10].
A prospective case-control study was done to detect the presence of asymptomatic bacteriuria in patients with diabetes mellitus. The present study showed that, ASB was present in four (4%) out of 100 patients with type-2 diabetes mellitus. This is lower compared to the reported rates of 36.15% (Ophori EA et al., Nigeria, 2010) [11], 26% (Geerlings SE et al., Utrecht, 2001) [12], 17.5% (Bonadio M et al., Italy, 2004) [13] and 17% [Table/Fig-1]: Showing the occurrence of asymptomatic
(Meiland R et al., Utrecht, 2006) [14]. However, Karunajeewa bacteriuria among patients with diabetes mellitus and control group H et al. [15], (2005, Australia) found a lower rate of 7.3% of [Table/Fig-2]: Showing the clinical profile of patients with asymptomatic bacteriuria among the study group
*DM: Diabetes mellitus
National Journal of Laboratory Medicine. 2013 Sep, Vol 2(3): 16-19 Shashidhar Vishwanath et al., Asymptomatic Bacteriuria among Patients with Diabetes Mellitus at a Tertiary Care Center [Table/Fig-3]: Showing the sensitivity pattern of organisms isolated from asymptomatic bacteriuria
Ap: Ampicillin (10 µg), Ac: Amoxicillin–Clavulanic acid (20/10 µg), Cf: Cefazolin (30 µg), Cr: Cefuroxime (30 µg), Fr: Ceftriaxone (30 µg), Nf: Norfloxacin (10 µg), Ct:
Trimethoprim-Sulfomethaxazole (23.75/1.25 µg), Er: Erythromycin (15 µg), Cm: Clindamycin (2 µg), Te: Tetracycline (30 µg), Ak: Amikacin (30 µg), Gm: Gentamicin
(10 µg), Tim: Ticarcillin-Clavulanate (75/10µg), Tzp: Piperacillin-Tazobactum: (100/10 µg), Ipm: Imipenem (10 µg), NT: Not tested
diabetic patients having ASB. Low incidence of ASB (4%) in None of the control subjects with normal glucose tolerance the present study is probably due to more number of male had ASB. It is reported that ASB is found in 2-5% of healthy subjects (62%) in the present study.
adult women and is quite unusual in healthy men [19]. Renko M et al., [19] in their meta-analysis of 22 studies found that Various risk factors for ASB in women with diabetes have ASB was present in 12.2% of patients with diabetes and in been suggested including age, disease duration, renal 4.5% of healthy controls. Point prevalence of ASB was higher microangiopathy (proteinuria, albuminuria), UTI in the previous in both women (14.2% vs 5.1%) and men (2.3% vs 0.8%) with year, sexual activity, lower body mass index and status diabetes than in health control subjects [19].
of diabetic complications (retinopathy, nephropathy and neuropathy) [3, 5, 13]. There are differences of opinion by However, the important clinical concerns of ASB in diabetic different investigators regarding these predisposing factors. [5] individuals are its contribution to morbidity, either the short- Three patients with ASB in the present study had associated term risk of developing a symptomatic urinary infection and complications of diabetes mellitus [Table/Fig-2]. None of its more serious complications or the longer-term risks of the four patients with ASB had prior history of UTI, urinary developing serious diabetic complications (e.g, nephropathy) catherization or genito-urinary surgery. Poor metabolic control [18]. In the present study, the patients with ASB were not though not a risk factor for developing ASB, was seen in treated with any antibiotics. The identification and treatment of most of the study subjects. [5] Considering the small number ASB would be appropriate if doing so prevents symptomatic of patients with ASB among diabetic individuals, statistical infection, especially pyelonephritis or complications of urinary analysis of significance of presence of risk factors could not tract infection in diabetes. Antimicrobial therapy for ASB is also beneficial in some patient populations like pregnant women and individuals undergoing traumatic genitourinary E. coli, E. faecalis and S. saprophyticus were the organisms interventions [3]. Not many randomized control studies are isolated in the present study. These are among the most performed to determine the efficacy of treating ASB in diabetic common organisms isolated from diabetic subjects with ASB individuals to prevent the occurrence of complications and the and those with symptomatic UTI in other studies [11, 16]. E. dilemma of treatment versus not treating patients with ASB coli was the most common organism isolated in the studies persists. Harding GKM et al., [20] (2002) in their study on of Nicolle LE et al. [17] and Ophori EA et al. [11] In the present 55 patients with ASB found that treatment does not reduce study, E. faecalis was the most commonly isolated bacteria. complications. They recommended against treatment of ASB. Quinolones, the commonly used antibiotics for urinary tract Also, in the absence of valid reason to treat, unnecessary infections were found to be ineffective against all the four antibiotic exposure risks the development of resistance to isolates. Janifer J et al., [16] have reported 62% of gram- negative bacilli and 33% of gram-positive cocci in their study to be sensitive to Ciprofloxacin. Rising rates of drug resistance The limitation of the present study was the lack of follow- among both gram-positive & gram-negative pathogens is a up of patients with ASB. This need has to be addressed in future studies. Further, studies in Indian setups including larger population based study group to assess the true Only two (50%) of the four patients with ASB had pyuria. incidence of ASB among diabetic individuals across various Nicolle LE [18] in their study found that the prevalence of pyuria age groups and in both sexes; clinical progression of ASB among diabetic women with ASB was relatively low (68% of cases into symptomatic UTI, pyelonephritis and; other long women with Type 2 diabetes and with positive cultures). It has term complications of ASB in diabetic patients are needed. been speculated that the low leukocyte count is a marker for a Also randomized control studies for studying the efficacy of dampened inflammatory response that promotes persistence antimicrobial therapy in preventing further complications in of bacteriuria and contributes to the observed increased diabetes mellitus patients may be planned. This would provide prevalence of bacteriuria in diabetic patients [18].
National Journal of Laboratory Medicine. 2013 Sep, Vol 2(3): 16-19 Shashidhar Vishwanath et al., Asymptomatic Bacteriuria among Patients with Diabetes Mellitus at a Tertiary Care Center guidelines for screening or treating ASB among patients with [11] Ophori EA, Imade P, Johnny EJ. Asymptomatic bacteriuria in patients with type-2 diabetes mellitus. Journal of Bacteriology Research. 2010; 2:14-7.
[12] Geerlings SE, Stolk RP, Camps MJ, Netten PM, Collet JT, Schneeberger PM et al. Consequences of asymptomatic [1] Mehta SR, Kashyap AS, Das S. Diabetes Mellitus in India: The bacteriuria in women with diabetes mellitus. Arch Intern Med. Modern Scourge. MJAFI. 2009;65: 50-4.
[2] Geerlings SE. Urinary tract infections in patients with diabetes [13] Bonadio M, Boldrini E, Forotti G, Matteucci E, Vigna A, Mori S et mellitus: epidemiology, pathogenesis and treatment. Int J al. Asyptomatic Bacteriuria in women with Diabetes: Influence of Antimicrob Agents. 2008; 31:S54-7.
Metabolic Control. Clin Infect Dis. 2004;38:e41-5.
[3] Ooi S, Frazee LA, Gardner WG. Management of Asymptomatic [14] Meiland R, Geerlings SE, Stolk RP, Netten PM, Schneeberger bacteriuria in patients with diabetes mellitus. Ann Pharmacother. PM, Hoepelman AI. Asymptomatic bacteriuria in women with diabetes mellitus: effect on renal function after 6 years of follow- [4] Papazafiropoulou A, Daniil L, Sotiropoulos A et al. Prevalence of up. Arch Intern Med. 2006;166:2222-7.
asymptomatic bacteriuria in Type 2 diabetic subjects with and [15] Karunajeewa H, McGechie D, Stuccio G, Stingemore N, Davis without microalbuminuria. BMC Research Notes. 2010; 3: 169- WA, Davis TME. Asymptomatic bacteriuria as a predictor of subsequent hospitalisation with urinary tract infection in diabetic [5] Zhanel GG, Harding GK, Nicolle LE. Asymptomatic bacteriuria in adults: The Fremantle Diabetes Study. Diabetologia. 2005; 48: patients with diabetes mellitus. Rev Infect Dis. 1991;13:150-4.
[6] Winn WC Jr, Allen S, Janda W, Koneman E, Procop G, [16] Janifer J, Geethalakshmi S, Satyavani K, Viswanathan V. Schreckenberger P, et al. Koneman’s color atlas and textbook of Prevalence of lower urinary tract infection in South Indian Type 2 diagnostic microbiology. 6th ed. Philadelphia: Lippincott Williams diabetic subjects. Indian J Nephrol. 2009;19:107-11.
[17] Nicolle LE, Zhanel GG, Harding GKM. Microbiological outcomes [7] Isenberg, H. D. Clinical microbiology procedures handbook. in women with diabetes and untreated asymptomatic bacteriuria. Washington, D.C: American Society for Microbiology; 1992.
[8] Collee JG, Miles RS, Watt B. Tests for identification of bacteria. [18] Nicolle LE. Asymptomatic bacteriuria in diabetic women. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Mackie and McCartney Practical Medical Microbiology. 14th ed, [19] Renko M, Tapanainen P, Tossavainen P, Pokka T, Uhari M. Meta- New York. Churchill Livingstone; 2006.
Analysis of the Significance of Asymptomatic Bacteriuria in [9] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton Diabetes. Diabetes Care. 2011;34:230-5.
TM. Infectious Diseases Society of America Guidelines for the [20] Harding GKM, Zhanel GG, Nicolle LE, Cheang M. Antimicrobial Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. treatment in diabetic women with asymptomatic bacteriuria. N Clin Infect Dis. 2005;40:643-54.
Engl J Med. 2002; 347:1576-83.
[10] Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. Twenty-first informational supplement. M100-S21. Wayne, Pennsylvania: Clinical and Laboratory Standards Institute; 2011.
Associate Professor, Department of Microbiology, Kasturba Medical College, Manipal University,Manipal-576104, Karnataka, India.
1. Associate Professor, Department of Microbiology, Ph: + 91 9886075904, Fax: + 91 820 2571927 Kasturba Medical College, Manipal University, Manipal, India.
2. Graduate Student, Kasturba Medical College, Manipal 3. Assistant Professor, Department of Microbiology, Yenepoya Medical College, Mangalore, India.
4. Professor and Head, Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, India.
National Journal of Laboratory Medicine. 2013 Sep, Vol 2(3): 16-19

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