Are u DIABETIC? Be aware of "URINARY TRACTINFECTION"

           UTI – DIABETES MELLITUS

Urinary tract infection (UTI) is more common in patients with diabetes mellitus. Bacteriuria is more common in females than males with diabetes. UTI is more common in female with diabetes than in non diabetes female as a consequence of debilitated immune system(1). UTI is the most important and most common site of infection in diabetic patients. Diabetic patients are having 5 fold frequency of acute pyelonephritis than nondibetics. In pregnant diabetic women it is 2-4 times more common than normal population. Most UTI in DM patients are asymptomatic. Bacteriuria very often seen in diabetics if unrecognizable and inadequately treated , it lead to low grade foci of inflammation that can ultimately result in serious renal damage.

Bacteriuria	>_ 105 CFU/ml of bacteria
Pyuria	>10 WBC/mm3 /hpf
UTI	Pyuria + bacteriuria
Asymptomatic bacteriuria	With Bacteriuria no signs and symptoms
Symptomatic UTI	Bacteriuria + Genito urinary symptoms symptoms (dysuria , suprapubic pain, or tenderness or urgency)
Uncomplicated UTI	Genitourinary symptoms with pyuria and bacteriuria without urinary tract abnormalities.
Complicated UTI	UTI occurring in a patient with structural or functional urinary tract abnormality

Localization of UTI

ü Infections of upper urinary tract

1.     Acute pyelonephritis
2.     Chronic pyelonephritis

ü Infections of lower urinary tract

1.     Cystitis
2.     Urethritis
3. 
   

Factors influencing resistance to UTI

1.     Hyperglycemia

2.     Ketoacidosis

3.     Neutrophil function

4.     Immune response

5.     Influence of endocrine systems

6.     Vascular insufficiency

7.     Neuropathy

The etiology of urinary tract infection includes

o   shedding of organisms from remote foci in the body  from adjacent sources via

ü Blood stream

ü  Lymph channels

ü Through urinary orifices

o   Urinary tract obstruction by stone or other urinary bladder abnormality due to autonomic neuropathy or after catheterization of the urethra

o   Residual urine in the urinary bladder is a medium favoring the growth of organisms.

Acute UTI is more common in diabetic women due to the short urethra readily accessible to organisms from  the vagina and rectum.

Most common agents of UTI in diabetic patients are:

·        Bacterial

·        Viruses

·        Fungi

·        Tuberculosis

Bacteria

Many organisms infect urinary tract in diabetic patients, but the most common agents are Gram –ve bacilli. E.Coli causes almost 90% of UTI in diabetic and causes 50 % of hospital acquired are UTI. Other organisms that causes are Protease, Klebsiella, Enterobacter, Serrata and Pseudomonas. They account for lower proportion of uncomplicated infections of UTI in diabetics after urologic manipulations such as the placement of catheters for urine retention due to anatomic neuropathy and urinary bladder vasculopathy. Protease and Klebsiella species predisposes to stone formation by urea and extracellular slime, polysaccharide production respectively. Gram positive cocci play a less important role in UTI in diabetic patients. Enterococci and staphylococci aureus can cause bacteremic infection of kidneys and renal damage. A saprophyticus novobiocin resistant coagulase negative staphylococcus had been recognized as an important cause of acute symptomatic UTI in a young diabetic female. Chlamydia trachomatis appears to be an important etiologic agent.

Fungi

Fungal infections of UTI in diabetic patients is important but insignificant. 20 to 90% of all infections are accounted under Torulopsis Globrata of candida species which can cause cystitis, pyelo nephritis , renal or peri renal abscess, fungus ball, and a picture of Gram negative sepsis. In urine >10000 colonies/m2 indicates candida infection.

Bacteriologic criteria for diagnosis of UTI

The most reliable sample is “suprapubic aspiration”.  Midstream urine sample usually recommended. Urine in bladder >4 hours if less gives false negative findings.

§  108/ml from two consecutive midstream urine (MSU) specimens

§  108/ml from one MSU uncentrifuged specimen , leukocyte count 10/mm

§  108/ml from one MSU specimen with symptoms of cystitis or acute pyelonephritis

§  107/ml from one MSU specimen and any number from suprapubic aspiration

Symptomatic women

§  102 coliform organisms/ml urine plus pyuria    or

§  105/ml of any pathogenic organism /ml urine   or

§  Any growth of a pathogenic organism from urine obtained by suprapubic aspiration.

   Symptomatic men

           >103  pathogenic organisms/ml urine

Asymptomatic patients

         >105  pathogenic organisms/ml urine in two consecutive samples

According to Loeb and colleagues, the minimum criteria for initiating antibiotics for UTI in residents without an indwelling urinary catheter include:

ü Acute dysuria alone or

ü Fever (>37.9°C or 1.5°C increase above baseline temperature) and at least 1 of the following:

ü New or worsening

o   Urgency

o   Frequency

o   Suprapubic pain

o   Gross hematuria

o   Costovertebral tenderness (2)

Urinary incontinence4 Clinical symptoms of UTI:

Types of UTI	Typical symptoms and signs
Cystitis	Frequent voiding, suprapubic pain , burning micturition , hematuria, cludy urine, WBC and bacteria on urine microscopy
Pyelonephritis	Fever, chills, flank pain, nausea -vomiting. Costovertebral angle or deep abdominal tenderness, Urine microscopy – pyuria , WBC casts,bacteria and hematuria.
Urosepsis	Fever –chills , shock.

  

  

Treatment

Diagnosis	Antibiotic	Route	Duration
Acute cystits	Cephalexin, 250-500mg every 6 hours	Oral	1-3 days
	Ciprofloxacin, 250-500mg every 12 hours	Oral	1-3 days
	Nitrofurantoin, 100mg every 12 hours	Oral	7days
		Ofloxacin, 200mg for every 12 hours	Oral	1-3 days
		Norfloxacin, 400mg for every 12 hours	Oral	1-3 days
		Ofloxacin, 200 mg every 12 hours	Oral	1-3 days
		Trimethoprim-sulfamethoxazole, 160/800 mg every 2 tablets	Oral	Single dose
Acute pyelonephritis		Ampicillin 1g every 6 hours and gentamicin 1mg/kg every 8 hours	IV	21days
		Ciprofloxacin,750mg every 12 hours	Oral	21 days
		Ofloxacin, 200-300 mg every 12 hours	Oral	21 days
		Trimethoprim-sulfamethoxazole, 160/800 mg every 12 hours	Oral	21 days

1.     Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetics. Infect Dis Clin North Am 1997; 11(3):735-50.

2.     Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol. 2001;22(2):120–4. [PubMed]