European Journal of Cardiovascular Medicine

Diabetes Mellitus is the most common endocrine condition, affecting practically every system in the body. It is a syndrome characterized by metabolic imbalances that result in long-term consequences affecting the nerves, blood vessels, and kidney. A large body of research suggests that diabetes mellitus has a diverse etiology, clinical presentation, and therapeutic response. Diabetics who are untreated or poorly treated are more likely to develop a number of complications that cause increased morbidity and mortality. Diabetes Mellitus has several long-term impacts on the genitourinary system.

These consequences make diabetic people more likely to develop bacterial urinary tract infections. Urinary tract infections have long been recognized as a serious concern in Diabetes Mellitus patients due to a combination of host and local factors. Complications from an upper urinary tract infection are also more likely in this population. Diabetes and urinary tract infection have a wide range of clinical bacteriological manifestations, including asymptomatic bacteriuria, cystitis, pyelonephritis, renal corticomedullary abscess, renal carbuncle, and some uncommon complicated urinary tract infections such as emphysematous pyelonephritis, emphysematous cystitis, fungal infections, and xanthogranulomatous pyelonephritis. Despite the availability of multiple strong antibacterial medicines, morbidity and death from urinary tract infection at all ages remain very high.

Diabetes produces various anomalies in the host system, raising the risk of urinary tract infections. This includes immunologic impairments such as poor migration and phagocytic chemotaxis in polymorphonuclear leukocytes. Subjects with diabetes mellitus may be at risk of developing asymptomatic bacteriuria due to a variety of factors such as poor blood glucose control, diabetic neuropathy with neurogenic blader, hyperglycemia-induced leukocyte dysfunction, urinary tract instrumentation, and diabetic microangiopathy. It is still debated if diabetes mellitus is connected with an increased incidence of urinary tract infections. The prevalence of symptomatic urinary tract infection and/or asymptomatic bacteriuria in diabetic patients has been found to be either increased or unaltered when compared to non-diabetic subjects.

Aims and Objectives

• To study the clinical profile of genitourinary tract infection in diabetes.
• Yield of urine culture, discharge culture and microscopic examination in UTI in diabetics & the common causative organism and their antibiotic sensitivity pattern.
• To study the relationship of duration and control status of diabetes mellitus to the complications of UTI.

This was a hospital based study conducted among 344 patients who were screened for genitourinary tract infection by culture of urine and discharge, in the Department of Medicine with the assistance of Department of Microbiology at VIMSAR, Burla, over a period of two years from December 2015 to November 2017, after obtaining clearance from Institutional Ethics Committee and written informed consent from the study participants.

 Inclusion Criteria

All the patients of diabetes mellitus with symptomatology of genitourinary tract infection admitted to medical ward were included in this study. Diabetes mellitus was diagnosed as per the diagnostic criteria.

 Exclusion Criteria

1. Gestational diabetes mellitus
2. Congenital renal anatomocal abnormalities.
3. Immunocompromised state: HIV, patient on steroid, malignancy, transplant receipients.

 Statistical Methods

Data was entered in MS Excel and analyzed using SPSS software. Results were resented as tables.

Nephropathy was found to in maximum no. of cases (64%) followed by retinopathy and neuropathy.

Urinary tract complications were found to be cystitis and pyelonephritis (31%).

1. Coli was isolated in highest no. of cases (33%) followed by Klebsiella (25%).

Amp-ampicillin, Nal-nalidixic acid, Nitro- nitrofurantoin, Cip-ciprofloxacin, Ctx-cotrimoxazole, Nor-norfloxacin, Gen-gentamicin, Cefo-cefotaxime, Ami-amikasin.

Nitrofurantoin and Amikasin are found to be having highest sensitivity among the antibiotic tested and cefotaxime and cotrimoxazole having least sensitivity.

The prevalence of urinary tract infection in male was 43%(65 out of 150) and in female 75.2% (146 out of 194). J Janifer, S Geethalakshmi et al found that women (47.9%) had a significantly higher prevalence of UTI than men (34.1%)(¹) .May Sewify and Shinu Nair et al found that females showed much higher prevalence of UTI than males in both glycemic groups (88.5% and 11.5%, respectively). These studies also agree that the prevalence in female is more than male.

The percentage of UTI was found to be more in T2 DM 81.5% (172 out of 211) than T1 DM 12.7%(27 out of 211) similar to observation made by Zhanel G.G and Kayima J.K in their study. (62,63) Zhanel G.G found the prevalence in IDDM 22.4% and in NIDDM 75.3% and 2% in gestational diabetics. However gestational diabetes are not included in our study. But in our study we found 5.6%(12 out of 211) of FCPD have UTI.  

Analysing the duration of Diabetes Mellitus with UTI in present study, it was found that most of the patients have duration of 6-10 years of Diabetes Mellitus, however no relation of prevalence of UTI with duration of diabetes as observed in other studies also. Still some studies by  Sara M. Lenherr, J. Quentin Clemens et al found that  urinary tract infection is associated with poor glycemic control in women with type 1 diabetes. This relationship is independent of other well-described risk factors for UTI and suggests that factors directly related to glycemic control may affect UTIs.(²⁾ Srinivas M Aswani, 1 UK Chandrashekar et al (2014) found that duration of diabetes was less than one year in 33 (18%) patients, 1 to 10 years in 109 (60 %) patients and greater than 10 years in 39 (22 %) patients.

The age of patients of U.T.I. ranges from 15-85 years and the average age was 55 year. Maximum number of patients 55-65 years, but female patients has wide range of age distribution (15-65 year) as compared to male (45-65 year). Manik C. Shill and Naz H. Huda et al  found that in the diabetic group of patients, the age range of infected females (26-83 years) was also much broader compared to that of males (43-70 years).(³⁾

In this study we found that most common presenting symptoms of urinary tract infections is dysuria( 75.3%), followed by increase frequency of mircturition(66%), fever(61%).Srinivas M Aswani, 1 UK Chandrashekar et al (2014) found that fever was the most common presenting symptoms (57.4), followed by dysuria(41.4%), increase  frequency of mircturition(27.3%).(66)

56. Brauner, U.Flodin et al reported long term complications like retinopathy in 50%, neuropathy 52%, proteinuria 34%, hypertension 45% and foot ulcer in 24% of cases of bacteriuric patients and comparing with nonbacteriuric group they suggested that it is similar to the prevalence of complications with bacteriuric group.(⁴⁾ In the present study we have found that neuropathy 56.8% (120 out of 211) ,retinopathy 59.2%(125 out of 211) almost similar to above mentioned study. Foot ulcer 14.2% (30 out of 211) and nephropathy 64%(135 out of 211) was observed. In our study nephropathy was most common complication associated with UTI in diabetes. However in the study by Zhanel G. G. And Lindsay E. Nicollee et al, it was observed that percentage of retinopathy 25.9, neuropathy 34.1%, renal disease 5.9%, peripheral vascular disease 10.6% and of heart disease was 10.6% in bacteriuric women. Compared with the non-bacteriuric women this was 19% retinopathy, 25.6% neuropathy, 6.5% renal diaease, 7.2% peripheral vascular disease and 3.7% heart disease. In the same study they found that the prevalence of neuropathy and heart disease was more associated with in bacteriuric than the non-bacteriuric group.(⁵⁾

Renal complications associated with urinary tract infections in our study includes cystitis 31.2%(66 out of 211), pyelonephritis 30.8%(65 out of 211) emphysematous pyelonephritis 7.1%(15 out of 211), xanthogranulomatous pyelonephritis 5%(10 out of 211).

Most common genital infection in male was found to be balanitis and in female vulvovaginal candidiasis.

Gram negative organisms were most commonly isolated from the patients in present study. The contribution of E.Coli was 33.6%(71 out of 211), Klesiella species25.1%(53 out of 211) Pseudomonas 13.5% (30 out of 211), Staphylococcus(16 out of 211), Streptococcus (6 out of 211), Candida species 17.6%(39 out of 211). Manik C. Shill and  Naz H. Huda et al found that  E. Coli infections (78.8%) whereas Streptococcus sp. (9.4%) which was the second highest causative pathogen. The proportion of Acinetobacter and Klebsiella were 3.5% and 2.4% respectively while of the other pathogens accounted for 5.9% of infections.(65) J Janifer, S Geethalakshmi et al found that  about 533 pathogens were isolated from 495 subjects with UTI, out of which, 362 were gram negative bacilli, 100 were gram positive cocci, and 71 were of the Candida spp. Percentage-wise distribution of gram negative bacilli in which 258 (71.3%) of the patients had E. coli, 49 patients (13.5%) had Klebsiella spp., and 32 patients (8.8%) had Pseudomonas spp.Among the specimens containing Candida, 57 (80.3%) were Candida spp. and 14 (19.7%) were Candida albicans.

Antibiotic sensitivity pattern of organisms isolated showed that Nitrofurantoin and Amikasin having highest sensitivity, 73.4% and 66.3% respectively.Least sensitive antibiotic was found to be Cotrimoxazole. Srinivas M Aswani, 1 UK Chandrashekar et al (2014)  found that antimicrobial resistance profile of the uropathogens,  observed that the isolated E. coli strains were resistant  to ampicillin, cotrimoxazole, norfloxacin and cephalosporins  in diabetic and non-diabetic patients.  The antimicrobial susceptibility of E. coli showed an increased sensitivity to carbapenems in both diabetics (93.8 per cent) and non-diabetics (95.1 per cent) and decreased susceptibility to ampicillin (diabetics 16.7 per cent vs non-diabetics 17 per cent).(⁶⁾ Manik C. Shill and Naz H. Huda et al found that  the most effective antibiotic overall is meropenem followed by amikacin. Antibiotics such as amoxicillin, ciprofloxacin, cephradine showed most resistance with 78.0%, 62.8%, 60.4% resistance respectively and cephalosporins such as cefixime, cefepime and ceftriaxone showed around 50% resistance.

Bacterial UTI are common problem in patients with diabetes mellitus. Bacteriuria is more common in diabetic women than in nondiabetic. Upper urinary tract infection complications occur more frequently in diabetics. Thus a abdominal imaging is recommended as a screening in a patient with diabetes mellitus presenting with systemic signs of diabetes.

The fact that antibiotic sensitivity changes with time; therefore, knowledge of bacteria involved and their current sensitivity pattern will help us not only providing best initial empirical therapy but also preventing long term morbidity.

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