September 2013- Version n°23 ANRS - AC 11: RESISTANCE GROUP GENOTYPE INTERPRETATION: NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS Mutations associated with resistance Mutations associated with « possible resistance » • T215Y/F • T215A/C/D/E/G/H/I/L/N/S/V [1, 2, 3, 4] • At least 3 mutations among: M41L, D67N, K70R, L210W, T215A/C/D/E/G/H/I/L/N
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GiriShbabu r.J., PrakaSh r., PraShanth h.V., ChandraShEkar S.C.
Statistical Analysis: The results were analyzed using
Background: Asymptomatic bacteriuria is a common
mean, median and Chi-square (χ2) test.
problem in diabetic patients and is associated with risk of Results: A total of 120 (12%) were positive for significant septicemia and pyelonephritis if untreated. The diagnosis bacteriuria. Escherichia coli was the most predominant is based on urine culture. The incidence of antibiotic organism fol owed by Klebsiella pneumoniae. Imipenem, resistance has been steadily increasing over the past few pipercil in-tazobactum, nitrofurantoin and amikacin were years resulting in limitation of therapeutic options.
found to be the most effective antibiotics against the urinary Aims & Objectives: This study was carried out to determine
the prevalence of asymptomatic bacteriuria in diabetic Conclusion: The prevalence of asymptomatic bacteriuria is
patients and also to isolate, identify and establish the high in diabetic patients and poor glucose control can be antimicrobial susceptibility pattern of the pathogens.
considered as a predisposing factor. Routine urine culture is Materials & Methods: This prospective study includes 1000
recommended, especial y for the detection of asymptomatic diabetic patients. Isolates were identified by conventional methods bacteriuria cases in diabetic patients.
and their antibiotic susceptibility pattern was established.
key Words: Asymptomatic bacteriuria, Escherichia coli, Klebsiella pneumoniae, Urinary tract infection, Diabetes mellitus INTRODUCTION
Medical College and Hospital, Tumkur. A total of 1000 diabetic Diabetes mellitus has a number of long term effects on the patients attending various out-patient departments and genitourinary system. This effect predisposes to bacterial admitted in wards were taken for the study. Urinary Tract Infection (UTI) . Risk factors such as age, Asymptomatic bacteriuria is defined as the “presence of duration, glycemic control, and complications of diabetes are actively multiplying bacteria within the urinary tract excluding the distal urethra”, at the time when the patient has no urinary It is also a predisposing factor for significant asymptomatic bacteriuria (ASB). Un-treated asymptomatic bacteriuria predisposes the individual to recurrent UTI which can cause 1. History of UTI symptoms (dysuria, frequency and urgency, renal disease (pyelonephritis and gram negative septicemia) [1,4,5]. UTI is one of the most important cause of morbidity 2. History of antibiotic therapy in the previous two weeks.
ASB is microbial diagnosis based on isolation of specified 4. Known congenital anomalies of the urinary tract.
quantitative count of bacteria in urine from diabetic patients Urine samples were collected by standard mid-stream “clean without signs or symptoms of UTI. Escherichia coli were found catch” method from all the diabetic patients, in a sterile, wide- to be most prevalent in ASB. The misuse of antibiotics is a mouthed container that can be covered with a tightly fitted major factor responsible for bacterial resistance [1, 6].
lid. Microscopic examination of a wet film of uncentrifuged urine was carried out to detect the presence of pus cells, MATERIALS AND METHODS
erythrocytes, microorganisms, casts etc. The samples were This study on asymptomatic bacteriuria in diabetes was processed using standard microbiological procedures. The carried out in the Department of Microbiology, Sree Siddhartha specimens were cultured on to dried plates of MacConkey’s agar, National Journal of Laboratory Medicine. 2013 August, Vol 2(2): 11-13 Girishbabu R.J. et al., Asymptomatic Bacteriuria Sheep Blood agar with 5-10% CO atmosphere and Cystine Lactose Electrolyte Deficient agar, by standard loop method and incubated at 37°C overnight. Culture results were interpreted as being significant and insignificant, according to the standard criteria. The organisms were identified by routine methods from the samples showing significant bacteriuria [8,9].
The standardized Kirby-Bauer disc diffusion test of the Clinical and Laboratory Standards Institute (formerly NCCLS) was used for antibiotic susceptibility testing and accordingly interpretations were carried out. The antibiotics tested were: imipenem, pipercillin-tazobactum, amikacin, gentamicin, tetracycline, co-trimoxazole and erythromycin .
The results were analyzed using mean, median and Chi- square (χ2) test. p (predictive) value of < 0.05 was considered as a significant association between the variables tested.
[Table/Fig-2]: Antibiotic sensitivity pattern of bacterial Isolates
The study shows highest number of culture positive cases among diabetic women (70) when compared to diabetic men (50). People in the age group of 55 yrs and above (24.1%) DISCUSSION
were affected more when compared to others [Table/Fig-1]. Urinary Tract Infection affects as many as 50% women at Of the total 1000 samples processed, significant growth least once during their lifetime. In the present study, it was was found in 120 (12%) samples, while 880 (88%) samples observed that the diabetic females (58.3 %) were affected showed no growth. The commonest isolated organism more as compared to diabetic males (41.7 %) . being Escherichia coli 50 (41.7%), followed by Klebsiella In our study significant growth was found in 12% cases and pneumoniae 25 (20.9%), Staphylococcus aureus 15 (12.5%), 88% samples were sterile. These results were consistent with Pseudomonas aeruginosa 10 (8.3%), Proteus mirabilis 06 reports of the recent studies [12, 13]. The presence of significant (5%), Citrobacter koseri 05 (4.1%), Enterococcus faecalis bacteriuria indicates the significance of microbiological culture 04 (3.3%), Staphylococcus saprophyticus 03 (2.5%) and to clinch the diagnosis of urinary tract infection. Streptococcus pyogenes 02 (1.7%).
Bacterial isolates have been changing from time to time In our study the organisms were sensitive to imipenem (100%), and from place to place. In our study organisms isolated, pipercillin-tazobactum (100%), nitrofurantoin (90%), amikacin correlated with various others studies [3, 4]. In a recent (85%), ceftazidime (76%), cefotaxime (76%), gentamicin study, it was noted that increased adherence of Escherichia (72%), norfloxacin (70%), ciprofloxacin (68%), amoxicillin- coli with type 1 fimbriae to uroepithelial cells isolated from clavulanic acid (68%), tetracycline (34%), erythromycin (30%), the urine of women with diabetes correlated positively with co-trimoxazole (22%) and ampicillin (18%) [Table/Fig 2].
HbA1C. Poorly controlled patients had a higher adherence of Escherichia coli. Changes in host defence mechanisms, the presence of diabetic cystopathy and of microvascular disease in the kidneys may play a role in the higher incidence of UTI in diabetic patients. However the other factors like shortness of female urethra, urethral opening near the anus and vagina, biologic changes due to menopause in females and prostate enlargement and neurogenic bladder in men contribute to asymptomatic bacteriuria . The microorganisms causing asymptomatic bacteriuria in persons with diabetes mellitus are similar to those causing bacteriuria in non-diabetic individuals [Table/Fig-1]: Age & sex wise distribution of diabetics with
The antimicrobial sensitivity and resistance pattern varies from National Journal of Laboratory Medicine. 2013 August, Vol 2(2): 11-13 Girishbabu R.J. et al., Asymptomatic Bacteriuria community to community and from hospital to hospital. This  Janifer J, Geethalakshmi S, Satyavani K, Viswanathan V. Prevalence of lower urinary tract infection in South Indian type 2 is because of emergence of resistant strains as a result of diabetic subjects. Indian J Nephrol. 2009; 19(3):107–111. indiscriminate use of antibiotics. In our study isolates showed  Kayima JK, Otieno LS, Twahir A, Njenga E. Asymptomatic 100% sensitivity to imipenem and pipercillin-tazobactum. bacteriuria among diabetics attending Kenyatta National Ampicillin was found to be least sensitive (18%). Our Hospital. East Afr Med J. 1996; 73(8):524-26.
 Stapleton A. Urinary tract infections in patients with diabetes. antibiogram pattern correlates with others studies [3, 4]. Am J Med. 2002; 113(1): 80-84.
Diabetes enhances the progression from asymptomatic to  Girishbabu RJ, Srikrishna R, Ramesh ST. Asymptomatic symptomatic bacteriuria, which could lead to septicemia, bacteriuria in pregnancy. Int J Biol Med Res. 2011; 2(3): 740-42.
pyelonephritis and adverse complication which require  Jayalakshmi J, Jayaram VS. Evaluation of various screening specialized treatment strategies. So routine urine culture is tests to detect asymptomatic bacteriuria in pregnant women. recommended, especially for the detection of asymptomatic Indian J Pathol Microbiol. 2008; 51(3):379-81.
bacteriuria cases in diabetic patients.
 Collee JG, Duguid JP, Fraser AG, Marmion BP, Simmons A. Laboratory strategy in the diagnosis of infective syndromes. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. CONCLUSION
Mackie and McCartney, practical medical microbiology. 14th ed. Asymptomatic bacteriuria is more prevalent among diabetic Edinburgh: Churchill Livingstone. 1996. p. 84-90.
population than in the non-diabetics, a major public health  Praveen R, Saha SK, Shamshuzzaman SM, Rashid AL, Chaudhury A, Muazzam N. Detection of uropathogen by using problem which has to be addressed at the earliest to forestall chromogenic media (Hicrome UTI agar), CLED agar and other future complications. So routine urine culture is recommended, conventional media. Faridpur Med Coll. J. 2011; 6(1):46-50.
especially for the detection of asymptomatic bacteriuria cases  Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; 17th informational supplement. CLSI/NCCLS document M100-S17. Asymptomatic bacteriuria can be ascertained on the basis of Clinical and Laboratory Standards Institute, Wayne, Pennsylvania; microscopy and microbial culture. Gram negative organisms were the commonest organisms isolated. In view of the emerging  Chaudhuri SR, Thakur AR, Nandy P, Samanta S. Urinary Tract Infection-A Survey of Local Population. Am. J. Infect. Dis. 2008; drug resistance amongst bacteria, antibiotic therapy should be advised only after culture and sensitivity has been performed.  Odetoyin WB, Aboderin AO, Ikem RT, Kolawole BA, Oyelese AO. This would not only help in the proper treatment of the patients Asymptomatic bacteriuria in patients with diabetes mellitus in Ile- but also discourages the indiscriminate use of the antibiotics Ife, South-West, Nigeria. East Afr Med J. 2008; 85(1):18-23.
 Alebiosu CO, Osinupebi OA, Olajubu FA. Significant asymptomatic which prevent further development of bacterial drug resistance.
bacteriuria among Nigerian type 2 diabetics. J Natl Med Assoc. 2003; 95(5):344–49.
 Makuyana D, Mhlabi D, Chipfupa M, Munyombwe T, Gwanzura  Ophoril EA, Imade P, Johnny EJ. Asymptomatic bacteriuria in L. Asymptomatic bacteriuria among outpatients with diabetes patients with type-2 diabetes mellitus. Journal of Bacteriology mellitus in an urban black population. Cent Afr J Med. 2002;  Das RN, Chandrashekhar TS, Joshi HS, Gurung M, Shrestha  Zhanel GG, Harding GK, Nicolle LE. Asymptomatic bacteriuria in N, Shivananda PG. Frequency and susceptibility profile of patients with diabetes mellitus. Rev Infect Dis. 1991; 13(1): 150- pathogens causing urinary tract infections at a tertiary care hospital in Western Nepal. Singapore Med J. 2006; 47(4):281-85.
Assistant Professor, Department of Microbiology, Sri Siddhartha Medical College, Agalakote, B.H. Road, Tumkur- 572 107, Karnataka, India.
4. Assistant Professor, Department of Microbiology, Sri Siddhartha Medical College, Tumkur- 572107, Karnataka, India.
National Journal of Laboratory Medicine. 2013 August, Vol 2(2): 11-13
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