A study on the pathogenic microbes and antibiotic-sensitivity patterns in urinary tract infection among diabetes patients at a tertiary care hospital in Central Kerala

Tribeni Goswami; Mathew Samuel Krishnamurthy; Sangeetha Merrin Varghese

doi:10.4103/jcrsm.jcrsm_15_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 8 | Issue : 2 | Page : 140-145

A study on the pathogenic microbes and antibiotic-sensitivity patterns in urinary tract infection among diabetes patients at a tertiary care hospital in Central Kerala

Tribeni Goswami¹, Mathew Samuel Krishnamurthy², Sangeetha Merrin Varghese³
¹ Department of Microbiology, Believers Church Medical College, Thiruvalla, Kerala, India
² Department of Medicine, Believers Church Medical College, Thiruvalla, Kerala, India
³ Department of Community Medicine, Believers Church Medical College, Thiruvalla, Kerala, India

Date of Submission	17-Feb-2022
Date of Decision	01-Apr-2022
Date of Acceptance	13-Apr-2022
Date of Web Publication	23-Dec-2022

Correspondence Address:
Tribeni Goswami
Department of Microbiology, Believers Church Medical College, Thiruvalla - 689 103, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcrsm.jcrsm_15_22

Abstract

Background: Diabetes mellitus (DM) has become a global disease that is affecting millions of people, and currently, India has about 50 million patients. Urinary tract infections (UTIs) have long been recognized as a significant problem in patients with DM. This study aimed to find out the pathogenic microorganisms and antibiotic sensitivity patterns for UTI in diabetes patients.
Methodology: This was a cross-sectional study conducted in the Department of Microbiology at a tertiary care hospital. The duration of the study was for 10 months. Diabetic status was confirmed as per the recommended diagnostic criteria. The identification of the bacterial isolates and antimicrobial sensitivity was carried out by conventional or Vitek-2 compact system. Data were entered in Microsoft Excel and were analyzed using the SPSS version 20. Variables were represented by the frequency and percentage analysis.
Results: There were 59 positive urine cultures in diabetes patients from January 2021 to October 2021, and the highest number of patients belong to the >70 years' age group. Escherichia coli was the predominant organism isolated and was most sensitive to carbapenems.
Conclusions: In our study, the elderly female population were found to be the most vulnerable group. The highest sensitivity was observed in carbapenem which can be used for empirical treatment in admitted patients.

Keywords: Carbapenem, culture and sensitivity, diabetes mellitus, Escherichia coli, urinary tract infection

How to cite this article:
Goswami T, Krishnamurthy MS, Varghese SM. A study on the pathogenic microbes and antibiotic-sensitivity patterns in urinary tract infection among diabetes patients at a tertiary care hospital in Central Kerala. J Curr Res Sci Med 2022;8:140-5

How to cite this URL:
Goswami T, Krishnamurthy MS, Varghese SM. A study on the pathogenic microbes and antibiotic-sensitivity patterns in urinary tract infection among diabetes patients at a tertiary care hospital in Central Kerala. J Curr Res Sci Med [serial online] 2022 [cited 2023 Mar 21];8:140-5. Available from: https://www.jcrsmed.org/text.asp?2022/8/2/140/364494

Introduction

The global prevalence of diabetes and impaired glucose tolerance in adults has been increasing over the recent decades, and it is estimated that there will be 693 million persons with diabetes mellitus (DM) by 2045.^[1] In diabetic patients, there is a tendency to increase the risk of several other diseases caused by macrovascular and microvascular damage and has negative impacts on several organs such as the brain, kidney, heart, and eyes. Diabetic patients are more susceptible to infections due to disruption in host immune response, and infections and diabetic control adversely affect each other.^[2]

It is predicted that there will be an increase in the incidence of people with infectious diseases and related financial burdens, especially in tropical countries due to the increase in the number of diabetics where the prevalence of communicable diseases is high.^[3] People with diabetes are prone to new infections and recurrent urinary tract infections (UTIs), periodontitis, pneumonia, skin, soft-tissue infections, osteomyelitis, and peritonitis due to impaired defenses and disease complications.^[4] The main cause of diabetic individuals' susceptibility to infections is supposed to be due to the defects in innate as well as adaptive immunity. Some microorganisms mainly bacteria, in hyperglycemic conditions are better nourished and become more virulent, whereas also having a better milieu to cause infections.^[5] There is also an increased risk of UTI in diabetic patients.^[6],[7],[8] There are several factors such as immune system disorders, weakening of white blood cells, poor blood supply, and bladder dysfunction due to nephropathy and glycosuria which can cause UTI in Type 2 diabetic patients.^[9] UTI is the most common in women than in men, and about 50%–60% of women suffer from it at least one time during their lifetime.^[10] The spectrum of UTI in diabetic patients ranges from asymptomatic bacteriuria to lower UTI (cystitis), pyelonephritis, and severe urosepsis. The serious complications of UTI, such as emphysematous cystitis and pyelonephritis, renal abscesses, and renal papillary necrosis, are all encountered more frequently in Type 2 diabetes than in the general population.^{[11],[12],[13]} Escherichia coli is the most commonly isolated organism in both diabetic and nondiabetic patients.^[14]

The incidence of Gram-negative bacteria, related to Enterobacteriaceae, causing UTI is higher because of many factors which are responsible for their attachment to the uroepithelium as well as their ability to colonize in the urogenital mucosa with adhesins, pili, fimbriae, and P-1 blood group phenotype receptor.^[15],[16] The treatment of UTI is often started with broad-spectrum antibiotics empirically without performing culture and sensitivity. This inappropriate and nonjudicious usage of antibiotics has resulted in the development of worldwide antibiotic resistance in bacteria, leading to the emergence of multidrug-resistant (MDR) strains of bacterial pathogens.^[17],[18]

The outcome of infections treatment in patients who suffer from diabetes tends to be poor which increases the economic burden on the patient due to the high cost of care, the length of treatment, and related complications. Therefore, it is necessary to investigate the sensitivity of bacterial isolates to antimicrobial agents in diabetic patients as there is an increase in the emergence of MDR strains.

The aims and objectives of this study were to find out the causative pathogenic microorganisms responsible for UTIs and explore the antibiotic sensitivity pattern of diabetes patients admitted to a tertiary care hospital.

Materials and Methods

This was a cross-sectional study conducted in the department of microbiology at a tertiary care hospital in South India. Informed consent was not taken from the participants as their identity was not revealed, and data of the isolates and their antimicrobial sensitivity were analyzed from the laboratory information system of our hospital. The study was presented to the Institutional Research Committee and Institutional Ethical Committee, and a waiver of informed consent was obtained.

Ethical approval for the study was obtained from the Institutional Ethics Committee (IEC No:/2022/02/260).

Inclusion criteria

In this study, all the urine culture samples of patients with diabetes were included in the study.

Exclusion criteria

Pregnancy
Patient on catheter
Urine culture and sensitivity reports with more than one causative organism were excluded from the study.

A total number of 193 patients were studied during a period of 10 months (January 1, 2021–October 30, 2021). DM was diagnosed with per the diagnostic criteria and details of the patients were collected from the medical records. The details of the isolates and their antimicrobial sensitivity were analyzed from the laboratory information system of our hospital.

Sample collection and processing

The samples for urine culture were collected in appropriate sterile containers for bacterial culture and were processed within 2 h. The inoculation was done into MacConkey and cystine lactose electrolyte deficient (CLED) agar using a sterile calibrated platinum loop to deliver 0.001 ml of urine. Plates were kept aerobically for 24 h and colonies were counted on each plate. The number of colony-forming units (CFU) is multiplied by 1,000 as 0.001 ml loop was used to determine the number of microorganisms per ml in the original specimen. Culture with colony counts ≥105/ml was considered significant bacteriuria.^[19]

Samples were processed in the microbiology laboratory as per the standard procedure and identification of the bacterial isolates and antimicrobial sensitivity was carried out by conventional or Vitek-2 compact system.^[20] Data were entered in Microsoft Excel and Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.). Variables were represented by frequency and percentage analysis.

Results

The total number of urine cultures sent for diabetes patients was 193 from January 2021 to October 2021. Out of these patients, 59 (30.56%) showed a significant colony count, whereas 26 (13.47%) patients had an insignificant colony count. No growth was seen in 80 (41.45%) specimens; there were 28 (14.50%) improperly collected specimens (if the colony count was >105 CFU/mL with three different organisms.

Out of these 59 diabetic patients, 35 were female and 24 were male. The maximum number of patients belong to the age group of >70 years, followed by the 61–70 years age group. The least number of patients was seen in the age group below 50 years. Age-and sex-wise distribution of diabetic patients with UTI is shown in [Figure 1].

Figure 1: Age-and sex-wise distribution of urinary tract infection in diabetic patients

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Microorganisms isolated from the urine samples of diabetic patients were E. coli 20 (33.9%) which was the most prevalent, followed by Klebsiella species 12 (20.3%), Pseudomonas species 5 (8.5%), Enterococcus species 5 (8.5%), Staphylococcus species 4 (6.8%), Citrobacter species, 4 (6.8%) Streptococcus species 3 (5.1%), 1 isolate of Morganella morganii and Enterobacter species, and Candida species were isolated in 4 (6.8%) patients. The pattern of organism is shown in [Figure 2].

Figure 2: Microorganisms isolated from patients with urinary tract infection with diabetes in the study

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In our study, isolates of E. coli were sensitive to the following antibiotics in decreasing order: meropenem (90%), imipenem (89%), nitrofurantoin (90%), amikacin (90%), gentamycin (79%), cefoperazone + sulbactam (71%), cefepime (59%), cotrimoxazole (42%), cefotaxime, cefazolin, and cefuroxime (38%), norfloxacin (33%), ciprofloxacin (15), and ampicillin (28%). The isolates of E. coli and Klebsiella species were sensitive to fosfomycin. [Table 1] shows Gram-negative bacteria and their sensitivity to antibiotics.

Table 1: Gram-negative bacteria isolated and their sensitivity to antibiotics

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Enterococcus isolates in our study were found to be 100% sensitive to ampicillin, vancomycin, linezolid, and teicoplanin. Staphylococcus species were 100% sensitive to all antibiotics except erythromycin and ciprofloxacin. In [Table 2], Gram-positive bacteria and their sensitivity to antibiotics are shown.

Table 2: Gram-positive bacteria isolated and their sensitivity to antibiotics in the study

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Discussion

DM is a polygenic disorder that can cause several other health problems worldwide. One of the complications due to DM is UTI. Infectious disease is an important, yet often neglected sequelae of uncontrolled DM.^[21] In the preinsulin era, most deaths among individuals with Type 2 diabetes and Type 1 diabetes occurred as a result of uncontrolled infection, and even today, infections continue to cause significant morbidity and mortality in patients with diabetes, notwithstanding the recent advances in antihyperglycemic and antimicrobial therapeutic options.^[22] Increased blood glucose levels in diabetic patients offer a favorable environment for bacterial growth leading to infection. DM also hampers immunologic functions such as phagocytosis, decrease in antibody production, and failure of T-cells and B-cells to fight against pathogens which ameliorate bacterial growth.^[23]

Abnormalities in the host immune system due to DM such as impaired migration, chemotaxis, phagocytosis, intracellular killing potential of polymorphonuclear cells, and local complications related to neuropathy such as impaired bladder emptying and higher glucose concentration of urine in diabetic patients increase the prevalence of UTI. It is suggested that the increased prevalence of UTI in diabetic patients is not the result of a difference in the bacteria but is due to the changes in the uroepithelial cells leading to increased adherence of E. coli expressing Type 1 fimbriae and hypothetically these changes are in the glycosylation of the infected cells.^[24] There is concern among health-care providers worldwide, including in India, on the high prevalence of diabetes, UTI in persons with diabetes, and antibiotic resistance.^[25] The scenario in low-income countries is challenging because of the high prevalence of infection, irrational uses of antibiotics, over-the-counter availability of antibiotics, and poor infection prevention practices. Therefore, it is essential to retrieve the updated information on the spectrum of uropathogens and their antibiotic resistance patterns in a specific hospital.

In the present study, 59 (30.56%) showed a significant colony count, whereas 26 (13.47%) patients had an insignificant colony count. No growth was seen in 80 (41.45%) specimens; there were 28 (14.50%) improperly collected specimens (if the colony count was >105 CFU/mL with three different organisms). Among them, 35 were female and 24 were male patients and it is correlating with other studies.^{[26],[27],[28]} Different studies have demonstrated that women who are prone to UTI possess epithelial cells with significantly more receptors for uropathogenic bacteria than healthy controls.^[29],[30]

In our study, 59 samples were culture positive from patients with UTIs. We have isolated 33.9% E. coli, 20% Klebsiella species, 8.5% Pseudomonas species, 8.5% Enterococcus species, 6.8% Staphylococcus species, 6.8% Citrobacter species, 6.8% Candida species, 5% Streptococcus species, and 1.7% of M. morganii and Enterobacter species. In our study, E. coli was the predominant organism isolated which is in line with other studies.^{[31],[32],[33]} UTI is caused by coliforms and Enterococcus spp. because of their presence in a higher percentage on the perineum.^[34] The pathogenesis of UTI typically starts with periurethral contamination by a uropathogen residing in the gut, followed by colonization of the urethra and subsequent migration of the pathogen to the bladder which requires appendages such as flagella and pili.

The survival of the uropathogens such as uropathogenic E. coli depends on the invasion of the bladder epithelium which produces toxins and proteases to release nutrients from the host cells and synthesizes siderophores to obtain iron. The uropathogens multiply and overcome host immune surveillance and subsequently ascends to the kidneys attaching through adhesins or pili to colonize the renal epithelium and then producing tissue-damaging toxins.^[35] In the present study, a higher sensitivity pattern for carbapenem, nitrofurantoin, and amikacin was also observed in Gram-negative organisms and the least sensitivity pattern was seen for ampicillin which is similar to some other studies.^{[36],[37],[38]} All the Gram-positive isolates were sensitive to vancomycin, linezolid, teicoplanin, and clindamycin.^[39]

Limitations of the study

The limitations of the study was in the sample size which we got from the diabetic patients and the positivity rate was confined to a small percentage and we need more data to know the prevalence of antimicrobial resistance pattern in a community.

Conclusions

The prevalence of UTI and MDR to commonly used antibiotics among diabetic patients is alarming, and therefore, isolation of uropathogenic bacteria and antimicrobial susceptibility testing is crucial for the treatment of UTIs in persons with diabetes. As diabetic patients have more chances of complications, UTI should be carefully managed in diabetes.

Acknowledgment

The authors would like to thank the technical staff of laboratory medicine for all the support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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