Urinary Tract Infections in Diabetics-Libya

Urinary Tract Infections in Diabetics and non-Diabetics in Tripoli-Libya: associated uropathogens and their

susceptibility to antimicrobials.

Einass El-Kateb, Khalifa Sifaw Ghenghesh, Nuri Berbash, Amal Rahouma,

Nadia Saifnasser, Taher Belreesh, Mohamed Abdulwahab Elgabroun

Faculty of Science and Faculty of Medicine, Tripoli University; Tripoli Diabetic Center;

and Alkhadra Hospital; Tripoli, Libya

Introduction

• Urinary tract infections (UTIs) are a serious health problem and are second only to respiratory infections as the most common type of infections in Human beings.

• Escherichia coli is the most common cause of uncomplicated UTIs.

• Several investigators have observed that infections including UTIs are more frequently reported among patients with diabetes mellitus (DM) than the general population, although this is not universally accepted.

• It has been suggested by various epidemiologic studies that bacteriuria and UTIs are more common in women with diabetes than among non-diabetic women.

• Studies on UTIs in diabetic patients in developing countries are few and mainly in asymptomatic patients.

• Worldwide, there is great concern due to high rates of resistance to antimicrobials used in the treatment of infections caused by E. coli.

• In developing countries, there is dearth of information on the antimicrobial susceptibility testing of E. coli from diabetics with UTIs to the newly available drugs including the fluoroquinolones and third generation cephalosporins.

Introduction

Objectives of the Study

• To determine the causative organisms of UTIs in diabetic patients in Tripoli, Libya, compared with non-diabetic patients.

• To determine the susceptibility of the isolated organism to the commonly used antimicrobial agents.

• To determine the influence of age, gender, marital status and education level on the species and frequency of isolation of organisms from diabetics compared with non-diabetics.

Materials and Methods

• Urine specimens from 135 diabetic and 164 non-diabetic patients both with clinically diagnosed UTIs (D-UTIs and ND-UTIs, respectively), attending attending Elkhadra Hospital and the Diabetic Center in Tripoli, were examined for different uropathogens using standard microbiological procedures.

• The study was carried out between July 2005 and June 2006.

• The commonly isolated uropathogens were tested for their susceptibility to different antimicrobials using the disc diffusion method.

Results• Uropathogens were isolated from 57% (77/135) of D-UTIs and

from 67.1% of (110/164) ND-UTIs (P>0.05).

• Of isolated uropathogens, Escherichia coli was isolated from 13.3% and 17.7%, Klebsiella sp. from 13.3% and 14%, and Staphylococcus aureus from 8.9% and 7.3% of D-UTIs and ND-UTIs respectively.

• These differences are not statistically significant (P>0.05).

• Age, gender, education level and marital status had no significant influence on the isolation rates of different organisms from D-UTI when compared with ND-UTI.

• Multiple drug resistance (>3 antibiotics) was common among the commonly isolated uropathogens, however, no significant differences in the resistance rates of uropathogens isolated from D-UTIs and ND-UTIs to different antimicrobials were observed (P>0.05).

Table 1. Uropathogens isolated from diabetic and non-diabetic patients with urinary tract infections

Organism

No (%) positive for:

Diabetics with UTIs(n=135)

Non-diabetics with UTIs(n=164)

Total(n=299)

Escherichia coli 18 (13) 29 (18) 47 (16)

Klebsiella spp. 18 (13) 23 (14) 41 (14)

Proteus spp. 2 (1.5) 9 (5.5) 11 (4)

Enterobacter spp. 7 (5) 7 (4) 14 (5)

Citrobacter spp. 2 (1.5) 4 (2) 6 (2)

Serratia spp. 0 (0.0) 3 (2) 3 (1)

Pseudomonas spp. 6 (4) 7 (4) 13 (4)

Staphylococcus aureus 12 (9) 12 (7) 24 (8)

S. saprophyticus 1 (1) 2 (1) 3 (1)

Candida albicans 10 (7) 9 (5.5) 19 (6)

Total 77 (57) 110 (67) 187 (62.5)

No organism identified 58 (43) 54 (33) 112 (37.5)

Table 2. Antimicrobial resistance of Escherichia coli isolated from diabetic and non-diabetic patients with urinary tract

infections.

Antimicrobial agentNo (%) resistant to:

Diabetic(n=19)1

Non-Diabetic(n=29)

Ampicillin 12 (63) 17 (59)

Amoxicillin + clavulanic acid

8 (42) 9 (31)

Cephalothin 9 (47) 19 (66)

Cefotaxime 1 (5) 1 (3.5)

Chloramphenicol 2 (11) 6 (21)

Gentamicin 2 (11) 3 (10)

Nalidixic acid 6 (32) 8 (28)

Ciprofloxacin 6 (32) 4 (14)

Streptomycin 6 (32) 14 (48)

Trimethoprim- sulphamethoxazole

6 (32) 7 (24)

1Two different isolates from one patient

Total(n=48)

29 (60)

17 (35)

28 (58)

2 (4)

8 (17)

5 (10)

14 (29)

10 (21)

20 (42)

13 (27)

Table 3. Antimicrobial resistance of Klebsiella spp. isolated from diabetic and non-diabetic patients with urinary tract

infections.


Diabetic(n=18)

Non-Diabetic(n=23)

Ampicillin 18 (100) 23 (100)


8 (44) 21 (91)

Cephalothin 10 (56) 17 (74)

Cefotaxime 4 (22) 7 (30)


Gentamicin 6 (33) 9 (39)

Nalidixic acid 8 (44) 10 (44)

Ciprofloxacin 4 (22) 8 (35)


3 (17) 2 (9)

Total(n=41)

41 (100)

29 (71)

27 (66)

11 (27)

10 (24)

15 (37)

18 (44)

12 (29)

5 (12)

Table 4. Antimicrobial resistance of Staphylococcus aureus isolated from diabetic and non-diabetic patients with urinary

tract infections.


Diabetic(n=12)

Non-Diabetic(n=12)

Ampicillin 8 (67) 7 (58)


1 (8) 4 (33)

Cefotaxime 1 (8) 4 (33)


Gentamicin 0 (0.0) 4 (33)

Ciprofloxacin 0 (0.0) 1 (8)


0 (0.0) 0 (0.0)

Tetracycline 5 (42) 7 (58)

Methicillin 1 (8) 4 (33)

Fusidic acid 3 (25) 4 (33)

Vancomycin 0 (0.0) 0 (0.0)

Total(n=24)

15 (63)

5 (21)

5 (21)

3 (13)

4 (17)

1 (4)

0 (0.0)

12 (50)

5 (21)

7 (29)

0 (0.0)

Conclusions

• In the population studied diabetes is not a significant factor that may influence the type, rates of isolation or antibiotic resistance of uropathogens that cause UTIs in diabetics when compared with those from non-diabetics.

• Our findings and those of other investigators suggest that diabetes mellitus per se is not associated with an increase in antimicrobial resistance.

• However, all classes of isolated uropathogens in the present work, regardless of their source, showed high rates of multiple-antimicrobial resistance, particularly to some of the commonly used drugs for treatment of UTI with more than 20% of E. coli and Klebsiella spp. isolates were resistant to ciprofloxacin.

• The high rates of multiple-drug resistance among uropathogens observed in our study no doubt will limit the choices of drugs available for clinicians involved in the treatment and management of UTI in diabetics in our region.

• Ciprofloxacin and cefotaxime were observed to be the most appropriate agents in the population studied. However, treatment should be tailored to local resistance patterns, and the most likely causative agent in the individual patient.

• Studies are needed on the molecular level to determine whether the uropathogens isolated from both groups are similarly virulent or not.

Conclusions

Health & Medicine

Urinary Tract Infections in Diabetics-Libya