Clinico-Microbiological Profile of Urinary Tract Infections in Diabetic Patients in a Tertiary Centre in Kerala

Abstract

Objectives: Primary Objective: To study the role of blood C- reactive protein in distinguishing upper & lower urinary tract infections in Diabetic Patients. Secondary Objective: (1) To study the clinical spectrum of urinary tract infections in Diabetic patients including common organisms involved in UTI in diabetic patients & their antibiotic sensitivity & resistance pattern. (2) To assess correlation between (a) duration of diabetes & UTI, (b) Hba1c values & UTI
Methods: A Cross sectional study was done on 73 cases of Diabetic patients with UTI at Amrita Institute of Medical Sciences, Edappally, Kochi from a period from December 2013 to January 2015. The subjects were included based on specific inclusion criteria. They were divided in 2 groups - Upper and Lower UTI. Detailed history and examination was done on all patients. CRP value was measured on presentation and compared among 2 groups. Along with that, the clinical spectrum, urine culture and antibiotic sensitivity of all the cases were studied. The correlation between duration of Diabetes with UTI and control of diabetes with UTI was also done.
Results:In our study we evaluated 73 cases of Diabetic patients with UTI at Amrita Institute of Medical Sciences, Edapally, Kochi for a period from December 2013 to January 2015. The patients were divided in 2 groups, upper and lower UTI. Demographically both groups were comparable in all aspects. CRP at the time of presentation in both the groups was compared. We found out that the mean CRP value in case of Diabetic upper UTI was 216.80mg/L which was very high compared to the mean CRP in lower UTI diabetics which was only 26.71mg/L, with a significant P value <0.0001. Also in our study clinical spectrum including symptoms was studied and it was found out that in case of upper UTI the predominant symptoms were fever and abdominal or flank pain followed by vomiting, while in case of lower UTI the predominant symptom were fever and dysuria. Also we studied the major organisms isolated in upper and lower UTI in diabetics and found that gram negative bacilli were the predominant isolate in both groups. Among gram negative bacilli, E coli (61% lower UTI and 68% in upper UTI) and Klebsiella (24 % in lower UTI and16% in upper UTI) were the major organism isolated in both the groups. Also we studied the sensitivity and resistance pattern of the organisms isolated from both groups in our institution and found out very high resistance pattern to most of the commonly used first line medications for UTI such as fluoroquinolones, aminoglycosides and nitrofurantoin. As the secondary objective the correlation between duration of Diabetes and risk of getting upper and lower UTI was studied. The mean duration of Diabetes in lower UTI was 8.55yrs and mean duration of Diabetes in upper UTI was 11.47 yrs, but however P value was found to be insignificant (0.070). The correlation between control of diabetes and risk of getting upper and lower UTI was also studied by comparing the HbA1c levels and the mean Hba1c was 7.63 in lower UTI and in case of upper UTI the mean Hba1c was 9.40, showing significant statistical difference (p value <0.0001).
Conclusion: A cross sectional study was done at Amrita Institute of Medical Sciences, Edapally, Kochi in which 73 cases of Diabetic patients UTI were studied. The patients were included in the study according to the inclusion and exclusion criteria mentioned in the methodology. The Patients were divided into 2 groups - Upper and lower UTI. We found out that the CRP levels in Diabetic patients with upper UTI was significantly high compared to the lower UTI (p value <0.0001), suggesting that CRP can be used as an excellent bio- marker for distinguishing upper and lower UTI in diabetic individuals at the time of presentation itself along with clinical features. The clinical features of diabetic patients with UTI were the same as non- diabetic patients. Our study showed that gram negative bacilli were the predominant organism isolated in both the groups with E coli and Klebsiella being the predominant isolate among them. The culture sensitivity and resistance pattern showed that there was very high resistance pattern in the organisms isolated from patients when compared to any studies so far, suggesting antibiotics such as Piperacillin-Tazobactum or Cefoperazone sulbactam should be started empirically for treating Diabetic patients UTI. We also proved in our study that there was no relation between duration of Diabetes and risk of getting upper or lower UTI, but it was the control of Diabetes which was important, as patients with uncontrolled diabetes were more prone to upper UTI (p value < 0001).