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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 1  |  Page : 22-26

Profile of urinary tract infection in a rural tertiary care hospital: Two-year cross-sectional study


1 Department of Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Community Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
3 Department of Physiology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Web Publication21-May-2019

Correspondence Address:
Dr. Shilpa Bawankule
Department of Medicine, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_87_18

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  Abstract 


Aim: The aim of this study was to study the profile of urinary tract infection (UTI) in patients admitted to the medicine department. Settings and Design: This was a cross-sectional study done in a rural tertiary care hospital conducted for a period of 2 years from September 2016 to September 2018. Materials and Methods: All the patients who were admitted (irrespective of the diagnosis at the time of admission) with onset of fever after 48 h of admission, and patients with catheter-associated UTI (CAUTI) and non-CAUTI were defined using the Centers for Disease Control and Prevention guidelines. Statistical Analysis: Statistical analysis was done using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test, and software used in the analysis were SPSS 22.0 version (IBM, USA) and GraphPad Prism 6.0 version (Graphpad software, Inc. California, USA) and P < 0.05 is considered as level of significance. Results: Eighty-four patients developed UTI, the most common organism causing UTI was Escherichia coli. The risk factors associated with CAUTI were higher age, prolonged duration of catheterization, diabetes, and chronic kidney disease. The risk factors associated with non-CAUTI were higher age and benign prostate hyperplasia. The risk factors associated with mortality were prolonged duration of catheterization and diabetes. Twelve patients (14.28%) with CAUTI succumbed in the ICU to their primary illness. Conclusions: Diabetic and elderly patients are at high risk of developing UTI and patients with CAUTI had higher mortality and morbidity.

Keywords: Etiology, risk factors and mortality, urinary tract infection


How to cite this article:
Bhayani P, Rawekar R, Bawankule S, Kumar S, Acharya S, Gaidhane A, Khatib MN. Profile of urinary tract infection in a rural tertiary care hospital: Two-year cross-sectional study. J Datta Meghe Inst Med Sci Univ 2019;14:22-6

How to cite this URL:
Bhayani P, Rawekar R, Bawankule S, Kumar S, Acharya S, Gaidhane A, Khatib MN. Profile of urinary tract infection in a rural tertiary care hospital: Two-year cross-sectional study. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Dec 11];14:22-6. Available from: http://www.journaldmims.com/text.asp?2019/14/1/22/258664




  Introduction Top


Urinary tract infections (UTIs) are common bacterial infections that affect approximately 150 million people worldwide each year.[1] Serious sequelae such as frequent recurrences, pyelonephritis, renal damage, preterm birth and complications caused by frequent antimicrobial use, such as antibiotic resistance and Clostridium difficile colitis can occur.[1] UTIs are categorized as either uncomplicated or complicated. Uncomplicated UTIs typically affects individuals who are otherwise healthy and have no structural or neurological urinary tract abnormalities.[1] Complicated UTIs are defined as UTIs associated with factors that compromise the urinary tract or host defense, including urinary obstruction, urinary retention caused by neurological disease, immunosuppression, renal failure, renal transplantation, pregnancy, and the presence of foreign bodies such as calculi, indwelling catheters, or other drainage devices.[1] The most common organism causing UTI is uropathogenic  Escherichia More Details coli (UPEC). Uncomplicated UTIs are caused by UPEC followed by Klebsiella pneumoniae, Staphylococcus saprophyticus, Enterococcus faecalis, Group B Streptococcus (GBS), Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida spp. Complicated UTIs are caused by UPEC followed by Enterococcus spp., K. pneumoniae, Candida spp., S. aureus, P. mirabilis, P. aeruginosa, and GBS.[1] Very few studies on the profile of UTI have been carried out in rural India.

Aim

The aim is to study the profile of UTI in patients admitted to the medicine department.

Objectives

The main objectives are as follows:

  1. To determine the etiology and risk factors associated with UTI
  2. To correlate risk factors associated with mortality in UTI.



  Materials and Methods Top


This was a cross-sectional study conducted in a tertiary care rural hospital for a period of 2 years from September 2016 to September 2018. The study was initiated after obtaining permission from the Institutional Ethics Committee. Eighty-four patients were included in the study.

Inclusion criteria

In our study, for catheter-associated UTIs (CAUTIs), most of the patients had the indwelling urinary catheter that had been in place >2 calendar days on date of event. Patient had the following signs and symptoms fever >38°C, suprapubic tenderness, urinary urgency, urinary frequency, and dysuria and patient had urine culture with no more than two species of organisms identified, at least one of which is a bacterium of ≥105 CFU/ml.[2]

Non-CAUTI in any age patient:[2]

Patient must meet 1, 2, and 3 below:

  1. One of the following is true: Patient has/had an indwelling urinary catheter, but it has/had not been in place >2 calendar days on the date of event or patient did not have a urinary catheter in place on the date of event nor the day before the date of event
  2. Patient had at least one of the following signs or symptoms: fever (>38°C) in a patient that is ≤65 years of age, suprapubic tenderness, costovertebral angle pain or tenderness, urinary frequency, urinary urgency, and dysuria
  3. Patient had a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of ≥105 CFU/ml.


Exclusion criteria

  1. Patients having fever on admission
  2. Patients with an indwelling urinary catheter in situ on admission
  3. Age <18 years
  4. Pregnant females
  5. Patients not giving consent for the study.


Data collection

All eligible participants were taken into the study after written and informed consent was obtained from them/relatives. Demographic data and various other parameters were obtained as per pro forma (comorbid conditions such as hypertension, diabetes, alcoholism, ischemic heart disease, chronic kidney disease, benign prostate hyperplasia, neurological impairment, duration of catheterization, duration of hospital stay, medicine ward versus ICU stay, necessary laboratory investigations such as complete blood count, liver function test, kidney function test, urine microscopy, urine culture, and outcome).

Methods

Urine microscopy

For microscopy, midstream urine was collected in a glass bulb and transferred to the department of pathology where the urine was allowed to stand for 1 h and then a drop of urine was placed on the glass slide using a dropper and covered using a coverslip. The sample was then processed under a microscope (OLYMPUS CH20i/OLYMPUS CX21i).

Urine culture

Under all aseptic precautions, midstream urine was collected in urine culture bottle. The culture bottle was then transferred to the Department of Microbiology where the urine was then treated with cysteine-lactose-electrolyte-deficient agar and incubated at 37°C.


  Results Top


Out of 84 patients who developed UTI, 56 patients developed catheter-associated infection and 28 patients developed non-CAUTI.

Out of 56 patients who developed CAUTI, there were 36 male (64%) and 20 female (36%). Twenty-five percent of the patients were in the age group of 18–30 years. Thirty-two percent of the patients were in the age group of 31–59 years and 43% of the patients were 60 years and above. The mean duration of catheterization was 6.21 ± 5.14 days. Patients with chronic kidney disease (27%) and diabetes (21%) were more prone to develop CAUTI.

Out of 28 patients who developed non-CAUTI, there were 17 males (61%) and 11 females (39%). One patient (3.57%) was in the age group of 18–30 years. 42.86% of the patients were in the age group of 31–59 years and 53.57% were 60 years and above. Patients with benign prostate hyperplasia (7%) were more prone to develop non-CAUTI.

In our study, UTI was more common in males as compared to females, but this was statistically not significant. As the age increases, UTI increases. This was statistically significant (P = 0.027). Prolonged catheterization increases UTI (P = 0.0001). Diabetics and patients with Chronic kidney disease were more prone to develop CAUTI (P value <0.05). Benign prostate hyperplasia was more common among patients who developed non-CAUTI as compared to CAUTI (P = 0.014). Hypertension, diabetes, and chronic kidney disease were more common in patients with CAUTI as compared to patients with non-CAUTI. CAUTI was more common among patients admitted in intensive care unit and non-CAUTI was more common among patients admitted in medicine ward (P = 0.018).

Hypertension, ischemic heart disease, and neurological impairment was more common among patients with CAUTI than patients with non-CAUTI, but this was statistically not significant.

Alcoholics were more prone to develop non-CAUTI than CAUTI, but this was statistically not significant [Table 1].
Table 1: Baseline characteristics in participants with catheter-associated urinary tract infection and noncatheter-associated urinary tract infection

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Out of 84 patients who developed UTI, E. coli was the most common organism causing catheter and non-CAUTI. The second most common organism causing CAUTI was Enterococcus (14 patients). The second most common organism causing non-CAUTI was K. pneumoniae (4 patients) [Table 2].
Table 2: Microorganisms cultured in patients with urinary tract infection

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In our study, out of 51 patients who developed UTI in the ICU, 76% of the patients were treated and 24% of the patients succumbed to the primary illness and UTI. Thirty-three patients who developed UTI in the wards were treated.

Out of 56 patients who developed CAUTI, 79% of the patients were treated and 21% of the patients succumbed to the primary disease and UTI. All 28 patients who developed non-CAUTI were treated (P = 0.0001).

Mortality was seen in patients with CAUTI as compared to non-CAUTI [Table 3].
Table 3: Outcome (mortality) of patients with urinary tract infection

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In our study, out of 84 patients who developed UTI, prolonged duration of catheterization (3.75 ± 5.27 days vs. 6.50 ± 3.39 days), and diabetes were significantly associated with mortality (P values were 0.027 and 0.0001).

The mean age was higher among dead patients as compared to those treated, but this was statistically not significant.

UTI in patients with ischemic heart disease was significantly associated with mortality (P = 0.024 and odds ratio = 0.31).

Patients with hypertension and chronic kidney disease who developed UTI were treated. (P = 0.0002 and 0.003, respectively) [Table 4].
Table 4: Risk factors associated with mortality in patients with urinary tract infection

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  Discussion Top


In our study, out of 84 patients who developed UTI, mean age ± standard deviation in years was 53.03 ± 17.45. This finding was similar to the study by Isikgoz Tasbakan et al.[3] UTI was more common in male patients (63%) as compared to female patients (37%). This finding was similar to the study by Tay et al.[4]

Out of 56 patients who developed CAUTI, 43% of the patients were 60 years and above. This finding was similar to the study by Eshwarappa et al.[5] The mean duration of catheterization was 6.21 ± 5.14 days.

This finding was dissimilar to the study by Tay et al. This was because they compared ICU-acquired UTI to non-UTI, and the sample size of patients with ICU-acquired UTI was 35 patients which was comparatively smaller.[4] In our study, 27% of the patients with chronic kidney disease developed CAUTI.

This was because patients with chronic kidney disease are immunocompromised. To strictly monitor the urine output, there was use of an indwelling urethral catheter. It was associated with an increased frequency of symptomatic UTI and bacteremia, and additional morbidity from noninfectious complications. Biofilm formation along the catheter surface is the most important cause of bacteriuria. Biofilm is a complex organic material consisting of microorganisms growing in colonies within an extracellular mucopolysaccharide substance which they produce.[6]

In our study, out of 28 patients who developed non-CAUTI, non-CAUTI was more common in males (61%) as compared to females (39%).

This finding was dissimilar to the study by Marschall et al. because the number of male patients enrolled in the study was less as compared to the females. Out of 183 patients, there were a total of 46 males, of which only 16 males developed non-CAUTI.[7] Hypertension was present in 9 patients (32%). This finding was similar to the study by Kim et al.[8]

In our study, the most common organism causing CAUTI and non-CAUTI in the medicine intensive care unit and medicine ward was E. coli. This finding was similar to the study by Behzadi et al. and Merchant et al.[9],[10]

In our study, out of 84 patients who developed UTI, 12 patients (14.28%) who developed CAUTI, succumbed may be to their primary illness. This finding was similar to the study by Danchaivijitr et al.[11]

Although we were not able to determine the actual cause of death or contributing effect of urinary catheterization, as it was not the objective of our study. In our study, prolonged duration of catheterization (6.50 ± 3.39 days vs. 3.75 ± 5.27 days), diabetes seen in 75% of the patients and ischemic heart disease seen in 16.67% of the patients were significantly associated with mortality. High renal parenchymal glucose levels create a favorable environment for the growth and multiplication of microorganisms, which might be one of the precipitating factors of pyelonephritis and renal complications such as emphysematous pyelonephritis. Various impairments in the immune system, including humoral, cellular, and innate immunity may contribute in the pathogenesis of UTI in diabetic patients. Lower urinary interleukin-6 and -8 levels are found in patients with diabetes. Autonomic neuropathy involving the genitourinary tract results in dysfunctional voiding and urinary retention, decreasing physical bacterial clearance through micturition, thereby facilitating bacterial growth.[12]

Limitations

The actual cause of mortality could not be determined. Fungal infections were not taken in the study, due to lack of diagnostic tools for early detection of candidemia. Pregnant women were not included in the study as UTI is common among them.


  Conclusions Top


Diabetic and elderly patients are at high risk of developing UTI. E. coli was the most common organism causing UTI. Males were more affected than females and patients with CAUTI had higher mortality and morbidity.

Financial support and sponsorship

This study was financially supported by the Department of Medicine, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol 2015;13:269-84.  Back to cited text no. 1
    
2.
Scalise E. Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) Division of Healthcare Quality Promotion (DHQP). Clifton Road Atlanta: GA, USA; 2018. p. 17. Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf.  Back to cited text no. 2
    
3.
Isikgoz Tasbakan M, Durusoy R, Pullukcu H, Sipahi OR, Ulusoy S; 2011 Turkish Nosocomial Urinary Tract Infection Study Group. Hospital-acquired urinary tract infection point prevalence in Turkey: Differences in risk factors among patient groups. Ann Clin Microbiol Antimicrob 2013;12:31.  Back to cited text no. 3
    
4.
Tay MK, Lee JY, Wee IY, Oh HM. Evaluation of intensive care unit-acquired urinary tract infections in Singapore. Ann Acad Med Singapore 2010;39:460-5.  Back to cited text no. 4
    
5.
Eshwarappa M, Dosegowda R, Aprameya IV, Khan MW, Kumar PS, Kempegowda P. Clinico-microbiological profile of urinary tract infection in South India. Indian J Nephrol 2011;21:30-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Nicolle LE. Catheter associated urinary tract infections. Antimicrob Resist Infect Control 2014;3:23.  Back to cited text no. 6
    
7.
Marschall J, Ota KN, Henderson JP, Warren DK. Not all nosocomial Escherichia coli bacteriurias are catheter associated. Infect Control Hosp Epidemiol 2011;32:1140-2.  Back to cited text no. 7
    
8.
Kim B, Pai H, Choi WS, Kim Y, Kweon KT, Kim HA, et al. Current status of indwelling urinary catheter utilization and catheter-associated urinary tract infection throughout hospital wards in Korea: A multicenter prospective observational study. PLoS One 2017;12:e0185369.  Back to cited text no. 8
    
9.
Behzadi P, Behzadi E, Yazdanbod H, Aghapour R, Akbari Cheshmeh M, Salehian Omran D. A survey on urinary tract infections associated with the three most common uropathogenic bacteria. Maedica (Buchar) 2010;5:111-5.  Back to cited text no. 9
    
10.
Merchant S, Sarpong EM, Magee G, Lapointe N, Gundrum J, Zilberberg M. Epidemiology, microbiology and outcomes of catheter-associated urinary tract infection and complicated urinary tract infection in the USA. Open Forum Infect Dis 2017;4 Suppl 1:S348.  Back to cited text no. 10
    
11.
Danchaivijitr S, Dhiraputra C, Cherdrungsi R, Jintanothaitavorn D, Srihapol N. Catheter-associated urinary tract infection. J Med Assoc Thai 2005;88 Suppl 10:S26-30.  Back to cited text no. 11
    
12.
Nitzan O, Elias M, Chazan B, Saliba W. Urinary tract infections in patients with type 2 diabetes mellitus: Review of prevalence, diagnosis, and management. Diabetes Metab Syndr Obes 2015;8:129-36.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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