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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 164-168

Asymptomatic bacteriuria – Spectrum of organisms and antibiotic resistance pattern in women with type 2 diabetes mellitus


Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission15-Feb-2021
Date of Decision06-Jan-2022
Date of Acceptance08-Feb-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Dr. B S Meghana
#372, Sri Vasu Nilaya, 10th Cross, Avalahalli Bda Layout, Girinagar, Bengaluru - 560 085, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_19_21

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  Abstract 


Background: Diabetes mellitus (DM) is a major health challenge worldwide. It is a risk factor for the development of asymptomatic bacteriuria (ASB) and urinary tract infection. Although the current guidelines do not recommend treatment of ASB among women with type 2 diabetes, it emphasizes the need for therapeutic trials based on culture sensitivity patterns. This study was aimed to determine the spectrum of organisms causing ASB and antibiotic sensitivity patterns. Therefore, we believe that this study would serve as road map to conduct therapeutic trials in subjects with ASB based on antibiotic sensitivity patterns. Methods: Cross-sectional study was conducted including both outpatients and inpatients on 250 Women with T2DM with no symptoms of UTI, were investigated with FBS, PPBS , HbA1C, Urine routine-microscopy and Urine culture- sensitivity. The presence of ASB among women with T2DM was studied, and antibiotic sensitivity pattern was analyzed. Statistical Package for the Social Sciences (SPSS) version 20 was used for statistical analysis. Results: The frequency of ASB in our study was found to be 39 out of 250 diabetic women, that is, 15.6%. The mean HbA1c was higher among diabetic women with ASB (9.63%) than without ASB (8.42%). Escherichia coli (58.97%) was the most common organism. Antibiotic sensitivity showed that most organisms were sensitive to amikacin (64.1%), followed by nitrofurantoin (59.0%). Most organisms were resistant to fluoroquinolone (79.5%). Conclusions: E. coli was the most common organism causing ASB in our study. Antibiotic sensitivity showed that most organisms were resistant to fluoroquinolones and were sensitive to amikacin. Further large-scale studies are required to study the effect of antibiotic sensitivity-directed therapeutic trials to conclude the efficacy of therapy in patients of ASB.

Keywords: Antibiotic sensitivity pattern, asymptomatic bacteriuria, diabetes, HbA1c, organisms isolated


How to cite this article:
Meghana B S, Ravi K. Asymptomatic bacteriuria – Spectrum of organisms and antibiotic resistance pattern in women with type 2 diabetes mellitus. APIK J Int Med 2022;10:164-8

How to cite this URL:
Meghana B S, Ravi K. Asymptomatic bacteriuria – Spectrum of organisms and antibiotic resistance pattern in women with type 2 diabetes mellitus. APIK J Int Med [serial online] 2022 [cited 2022 Nov 28];10:164-8. Available from: https://www.ajim.in/text.asp?2022/10/3/164/350745




  Introduction Top


Diabetes mellitus (DM) has become a major health challenge worldwide. In India alone, the prevalence of diabetes is expected to increase from 31.7 million in 2000 to 79.4 million in 2030.[1] The prevalence of asymptomatic bacteriuria (ASB) in diabetic patients is four times higher than the general population. ASB is also a common precursor to urinary tract infections (UTIs).[2]

ASB is defined as the presence of at least 105 colony-forming units/ml in clean-voided midstream urine sample from an individual without symptoms of UTI such as dysuria, frequency, urgency, abdominal distention, or fever.[1] ASB and UTI are more common in women due to shorter urethra than males. After menopause, a decline in circulating estrogen causes changes in the urinary tract that make women more vulnerable to bacteriuria.[3]

Diagnosis of ASB is considered when a patient who undergoes screening urine culture for a reason unrelated to the genitourinary tract and is incidentally found to have bacteriuria.[4] It has been proposed that transient bacteriuria merely reflects colonization of the bladder without tissue invasion, which clears spontaneously, however, in few susceptible patients, especially with DM, it can progress to symptomatic infection with pyuria over the time.[5]

In general, there is little evidence that routine treatment of positive cultures is required, except during in pregnancy, children, patients for kidney transplantation, and elderly bedridden patients.[5],[6]

It is suggested that in diabetic patients, glycosuria favors the growth of pathogenetic organisms and causes either ASB or symptomatic UTI. ASB has higher risk of becoming complicated UTI and is associated with reduced GFR.[7] Emphysematous pyelonephritis, cystitis, bacteremia, perinephric abscess, and renal papillary necrosis are common in diabetics.[8] Hence, whether ASB requires treatment is still a question, especially in patients with DM.[2],[9]

Current guidelines – IDSA 2019 Clinical Practice Guideline for the Management of ASB does not recommend treatment of ASB among women with type 2 diabetes.[5] However, guidelines states that there is a need for further studies to analyze the effectiveness of treatment among women with type 2 DM (T2DM).

In our study, we aimed to determine the spectrum of organisms causing ASB in diabetics and antibiotic sensitivity patterns which could help to determine the common organisms in the clinical picture and to select the antibiotic group for prophylactic therapy in women with T2DM.


  Methods Top


Study was conducted on 250 women with T2DM (as per WHO criteria) with no symptoms of UTI including both outpatients and inpatients in a tertiary health center. It is a cross-sectional study. Women with T2DM with symptoms of UTI, prior bladder catheterization, surgery of urogenital tract, preexisting renal diseases, renal calculi, or who have received antimicrobial drugs in the last 14 days were excluded from the study. After taking written informed consent, history was taken, and examination was performed. Women with T2DM with no symptoms of UTI were investigated with FBS, PPBS , HbA1C, Urine routine-microscopy and Urine culture- sensitivity. Antibiotic sensitivity testing of the isolated strains was done by Kirby–Bauer's disc diffusion method. The presence of ASB among women with T2DM was studied, and antibiotic sensitivity pattern was analyzed.

Statistical analysis was done by SPSS (Statistical Package for the Social Sciences) version 20. (IBM SPSS statistics [IBM corp. Armonk, NY, USA released 2011]) was used to perform the statistical analysis. Data were entered in the Excel spreadsheet. Descriptive statistics of the explanatory and outcome variables were calculated by mean, standard deviation (SD) for quantitative variables, frequency and proportions for qualitative variables. Inferential statistics such as Chi-square test were used to test the significance between qualitative variables. Unpaired t-test was applied to test the statistical difference between two quantitative variables. The level of significance was set at 5%.


  Results Top


There were 250 participants (women with T2DM) included in the study. Age of the patients ranged from 29 years to 90 years with a mean of 56.2 years [Table 1] and [Table 2]. Predominant group of patients had diabetes for 5–10 years. In the study population, 74% (185) of patients had elevated FBS greater than the target range as per ADA guidelines [Table 1]. Postprandial blood sugar levels were tested, and 88.4% (221) of patients had PPBS greater than target range as per ADA guidelines, that is, more than 180 mg/dl. In our study, 65.6% (164 patients) had HbA1c >7% and 34.4% (86 patients) had HbA1c <7%. The frequency distribution of HbA1c is shown in [Table 1].
Table 1: Baseline characteristics of study population

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Table 2: Mean age distribution of the study subjects with respect to culture

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Urine sample of 17.2% (43 patients) was positive for organisms. On further evaluation, 15.6% (39 patients) had positive bacterial culture [Table 3].
Table 3: Mean Fasting blood sugar, Postprandial blood sugar, and HbA1c distribution of the study subjects with respect to asymptomatic bacteriuria

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Among women with T2DM with ASB, the mean age was 54.51 years; SD was 13.37 with P = 0.366 suggesting no statistically significant difference between ASB-positive and negative cases. There was a significant association of ASB with HbA1c and FBS, but PPBS was not significantly associated with ASB among women with T2DM [Table 4]. Although mean FBS was higher among both the groups of women with T2DM, it was comparatively more elevated with ASB (238.54 mg/dl) than without ASB (194.89 mg/dl); similar results were seen with mean HbA1c was comparatively more elevated among women with type 2 diabetes (9.63%) with ASB than without ASB (8.42%).
Table 4: Distribution of study subjects according to urine culture

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In our study, it was found that 64.1% of ASB-positive cases were sensitive to amikacin, 59.0% showed sensitivity to nitrofurantoin among tested antibiotics. Resistance pattern of organisms was studied which showed that 79.5% of ASB-positive cases were resistant to fluoroquinolones, 71.8% of ASB-positive cases were resistant to both penicillin and cephalosporins [Table 5] and [Table 6].
Table 5: Antibiotic sensitivity pattern among asymptomatic bacteriuria-positive cases

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Table 6: Antibiotic sensitivity pattern among asymptomatic bacteriuria-positive cases

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The frequency of ASB among women with T2DM was 15.6%. It was significantly more common among patients with poor glycemic control (HbA1c >7%). Escherichia coli was the most common organism isolated, followed by Klebsiella [Table 7].
Table 7: Organisms isolated from urine culture among women with Type 2 diabetes with asymptomatic bacteriuria

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  Discussion Top


The prevalence of ASB is ~ 5% among women between ages 20 and 40 years and may be as high as 40%–50% among elderly women and men.[1] In a study done by Dalal et al.[4] the prevalence of ASB varied from 9% to 27%. In a study done by Venkatesan et al.[10] among 100 diabetic patients, the prevalence of ASB was 32%. In a similar study done by Bharti et al.[11] the prevalence of ASB was 21%. In our study, the frequency of ASB was found to be 15.6% (39 among 250 women with type 2 diabetes). Although no definitive comment can be made, high prevalence in few studies could be explained by different inclusion criteria.

ASB in type 2 diabetic women was noted to be an independent risk factor for UTIs.[12]

It has been found that as the duration of diabetes increases, there is an increased risk of both ASB and UTIs.[13] Some studies also suggest to consider ASB as a complication of long-standing diabetes, along with albuminuria and peripheral neuropathy [12],[14]

ASB was significantly more common among patients with poor glycemic control (HbA1c >7%) which was consistent with other studies.[7]

E. coli (n = 23, 58.97%) was most common organism isolated in our study followed by Klebsiella (n = 7, 17.95%). Few studies reported the predominance of Klebsiella pneumonia, coagulase-negative Staphylococcus, and Enterococcus faecalis in their studies as shown in the [Table 8].[11],[15],[16] Antibiotic sensitivity pattern showed that most organisms were sensitive to amikacin and nitrofurantoin, and most organisms were resistant to fluoroquinolones. In view of various factors such as emerging drug resistance, variable drug susceptibility pattern in different geographical areas, and changing prevalence of uropathogens in ASB cases, antibiotic therapeutic trials should be formulated based on the antibiotic susceptibility results.
Table 8: Results from various studies done on asymptomatic bacteriuria

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Although few guidelines do not recommend routine testing of ASB in diabetic patients, however, they do opine lack of good quality data and need of further studies to define subgroup of patients who might benefit from testing and as well as to start on empirical antibiotic therapy.[10],[17]

Certain subpopulations of diabetic patients would benefit from routine treatment of ASB, especially patients in ICU, patients with DKA or patients with significant immunosuppression. Some studies, however, have suggested the use of prophylactic measures such as probiotics may be beneficial in avoiding UTIs and its possible complications.[18]

Therefore, we believe that this study will be road map study for future researchers who would like to conduct therapeutic trials on subjects with ASB and diabetes on the basis of antibiotic sensitivity patterns.[27]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kasper DL, Fauci AS, Hauser S, Longo DL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. 20th ed. New York: McGraw-Hill Professional Publishing; 2015. p. 2399-429.  Back to cited text no. 1
    
2.
Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM, et al. Infectious diseases society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.  Back to cited text no. 2
    
3.
4.
Dalal S, Nicolle L, Marrs CF, Zhang L, Harding G, Foxman B. Long-term Escherichia coli asymptomatic bacteriuria among women with diabetes mellitus. Clin Infect Dis 2009;49:491-7.  Back to cited text no. 4
    
5.
Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the infectious diseases society of America. Clin Infect Dis 2019;68:e83-110.  Back to cited text no. 5
    
6.
Ramos-Ramirez MJ, Surani S. Asymptomatic bacteriuria among hospitalized diabetic patients: Should they be treated? World J Metaanal 2019;7:339-42.  Back to cited text no. 6
    
7.
Harding GK, Zhanel GG, Nicolle LE, Cheang M; Manitoba Diabetes Urinary Tract Infection Study Group. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med 2002;347:1576-83.  Back to cited text no. 7
    
8.
Nicolle LE. Asymptomatic bacteriuria in diabetic women. Diabetes Care 2000;23:722-3.  Back to cited text no. 8
    
9.
Zhanel GG, Harding GK, Nicolle LE. Asymptomatic bacteriuria in patients with diabetes mellitus. Rev Infect Dis 1991;13:150-4.  Back to cited text no. 9
    
10.
Venkatesan KD, Chander S, Loganathan K, Victor K. Study of asymptomatic bacteriuria in diabetic patients. IJCMR 2017;4:480-3.  Back to cited text no. 10
    
11.
Bharti A, Chawla SP, Kumar S, Kaur S, Soin D, Jindal N, et al. Asymptomatic bacteriuria among the patients of type 2 diabetes mellitus. J Family Med Prim Care 2019;8:539-43.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Geerlings SE, Stolk RP, Camps MJ, Netten PM, Collet TJ, Hoepelman AI, et al. Risk factors for symptomatic urinary tract infection in women with diabetes. Diabetes Care 2000;23:1737-41.  Back to cited text no. 12
    
13.
Boyko EJ, Fihn SD, Scholes D, Abraham L, Monsey B. Risk of urinary tract infection and asymptomatic bacteriuria among diabetic and nondiabetic postmenopausal women. Am J Epidemiol 2005;161:557-64.  Back to cited text no. 13
    
14.
Geerlings SE, Stolk RP, Camps MJ, Netten PM, Hoekstra JB, Bouter KP, et al. Asymptomatic bacteriuria may be considered a complication in women with diabetes. Diabetes mellitus women asymptomatic bacteriuria utrecht study group. Diabetes Care 2000;23:744-9.  Back to cited text no. 14
    
15.
Priyadharshini A, Mangaiyarkarasi T, Balasubramaniam VR, Pragash DS, Gopal R. Biofilm production and antibiotic resistance among uropathogens causing bacteriuria in diabetic individuals. Sch J Appl Med Sci 2014;2:568-71.  Back to cited text no. 15
    
16.
Turan H, Serefhanoglu K, Torun AN, Kulaksizoglu S, Kulaksizoglu M, Pamuk B, et al. Frequency, risk factors, and responsible pathogenic microorganisms of asymptomatic bacteriuria in patients with type 2 diabetes mellitus. Jpn J Infect Dis 2008;61:236-8.  Back to cited text no. 16
    
17.
Lin K, Fajardo K; U.S. Preventive Services Task Force. Screening for asymptomatic bacteriuria in adults: Evidence for the U.S. preventive services task force reaffirmation recommendation statement. Ann Intern Med 2008;149:W20-4.  Back to cited text no. 17
    
18.
Ng QX, Peters C, Venkatanarayanan N, Goh YY, Ho CY, Yeo WS. Use of Lactobacillus spp. to prevent recurrent urinary tract infections in females. Med Hypotheses 2018;114:49-54.  Back to cited text no. 18
    
19.
Adhikaree A, Kohli SC, Pokhrel DR, Bhatta D. Asymptomatic bacteriuria in diabetic adults. Journal of Lumbini Medical College. 2015;3(2):25-9. doi: 10.22502/jlmc.v3i2.66.  Back to cited text no. 19
    
20.
Bissong MA, Fon PN, Fritz O, Besong T, Akenji TN. Asymptomatic bacteriuria in diabetes mellitus patients in Southwest Cameroon. African Health Sciences. 2013;13(3):661-6.  Back to cited text no. 20
    
21.
Bonadio M, Costarelli S, Morelli G, Tartaglia T, et al, BMC Infectious Diseases2006, 6:54 doi:10.1186/1471-2334-6-5.  Back to cited text no. 21
    
22.
Bonadio M, Boldrini E, Forotti G, Matteucci E, Vigna A, Mori S, et al. Asymptomatic bacteriuria in women with diabetes: influence of metabolic control. Clin Infect Dis. 2004;38(6):e41-5.  Back to cited text no. 22
    
23.
Meiland R, Geerlings S E, Stolk R P, Netten P M, Schneeberger P M, Hoepelman A L M, et al. Arch Intern Med.2006;166:2222-2227.  Back to cited text no. 23
    
24.
Mohan S, Kathikeyan D, Moinuddin K, Kavitha Y, Jeevithan S, et al. IJMMID 2017;3(4):164-166.  Back to cited text no. 24
    
25.
Renko M, Tapanainen P, Tossavainen P, Pokka T, Uhari M. Meta-analysis of the significance of aymptomatic bacteriuria in diabetes. Diabetic care 2011;34:230-235.  Back to cited text no. 25
    
26.
Rijal M, Neupane B, Bhandari P, Aryal S. (2015) Asymptomatic Bacteriuria in Elderly Patients with Diabetes Attending a Tertiary Care Center. J Trop Dis 3:1662. doi:10.4172/2329-891X.1000162.  Back to cited text no. 26
    
27.
Vishwanath S, Sarda R, D'souza OA, Mukhopadhyay C. Asymptomatic bacteriuria among patients with diabetes mellitus at a tertiary care center. Ntl J of Lab Med. 2013;2(3):16-9.  Back to cited text no. 27
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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