{"id":2750,"date":"2015-04-28T07:45:38","date_gmt":"2015-04-28T07:45:38","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=2750"},"modified":"2016-10-05T10:39:32","modified_gmt":"2016-10-05T10:39:32","slug":"spectrum-of-urinary-tract-infections-in-pregnant-women","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol6no2\/spectrum-of-urinary-tract-infections-in-pregnant-women\/","title":{"rendered":"Spectrum of Urinary Tract Infections in Pregnant Women"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Urinary tract infection in women is more prevalent and is one of the most frequently seen medical complication in pregnancy1<\/sup>.\u00a0 Ideal pH, temperature and constituents like glucose present in the urine predispose to bacterial growth2<\/sup>.\u00a0 Moreover during pregnancy, urethral compression at the pelvic brim by the enlarging uterus leads to stasis of urine, incomplete emptying and residual urine which are important factors that initiate the proliferation of microorganisms3<\/sup>.\u00a0 About 6-8% of pregnant women have asymptomtic bacterimia3,4<\/sup>. \u00a0About 23-26% of these women if untreated will develop symptoms late in pregnancy5<\/sup>.<\/p>\n

Klebsiella <\/em>has been the major isolates from the urine of pregnant women in all the reported cases.\u00a0 The detection of bacterimia allows an approach to be made for the prevention of chronic urinary disease in the community and to avoid complications in pregnancy at an early stage4,6,7<\/sup>.\u00a0 In view of this, an attempt was made to evaluate the urinary tract infection in pregnancy and screen out all the high risk.\u00a0 In the present work, an effort is made to determine the clinical significance of bacteriuria in relation to its complications with an intention to negate the untoward impact of the disease on the pregnant women and the growing fetus.<\/p>\n

Materials and Methods<\/strong><\/p>\n

A total of 500 urine samples were collected from women attending the antenatal clinic at KBN Hospital Gulbarga.\u00a0 Subjects from varying ages from 18 year to 35 years and from varying gravida and all the three trimesters were included.<\/p>\n

Collection of Urine<\/strong><\/p>\n

Urine was collected in sterile urine container. Midstream urine sample with complete aseptic precautions was collected.<\/p>\n

Examination of Urine<\/strong><\/p>\n

Macrscopic Examination<\/strong><\/p>\n

Urine was observed for altered colour, presence of turbidity, deposits, etc.<\/p>\n

Microscopic examination<\/strong><\/p>\n

Smears was prepared and gram stained. Presence of at least one organisms per field was considered as significant (\u00de105<\/sup>\/ ml organisms)8<\/sup>.<\/p>\n

For microscopic examination of urine 10 ml of urine was transferred into conical centrifuge tube.\u00a0 The urine was then centrifuged at 1500 rpm for 5 minutes.\u00a0 The supernatant was decanted, to leave a sediment suspended in 1 ml volume of urine.\u00a0 This preparation was examined under low and high power.\u00a0 Several fields were searched to identify and count the number of cells, crystals and casts.\u00a0 3 or more pus cells\/ high power field were considered as significant9<\/sup>.<\/p>\n

Plating of Urine Samples<\/strong><\/p>\n

Standard Loop technique<\/strong><\/p>\n

Plating was done by standard loop technique on blood agar, nutrient agar and McConkey\u2019s agar.<\/p>\n

Method<\/strong><\/p>\n

Flame a calibrated wire loop and allow it to cool without touching any surface.<\/p>\n

Mix the urine thoroughly and remove the top of the container.<\/p>\n

Insert the loop vertically into the urine to allow urine to adhere to the loop.<\/p>\n

Spread the loopful of urine without flaming or re-entering urine, loop is drawn across the entire plate, crossing the 1st<\/sup> inoculum, which is the centre streak numerous times to produce isolated colonies.<\/p>\n

Plates were incubated at 27\u00baC for 18-24 hours.\u00a0 Colonies are counted on each plate.\u00a0 The number of colony formation units (CUFs) is multiplied by 1000 (if 0.001 ml loop is used) or by 100 (if a 0.01 ml loop is used) to determine the number of microorganisms per ml in the specimen10<\/sup>.<\/p>\n

Fermentation of sugars like glucose, mannitol, lactose and sucrose, citrate utilization, urease production, catalase test and coagulase test were other biochemical tests used to identify the organisms.<\/p>\n

The coagulase negative staphylococci were further classified into Staph. epidermis and Staph.saprophyticus with the help of Novobiocin sensitivity disc method.\u00a0 A zone of 22 mm or more indicated a sensitivity zone11<\/sup>.<\/p>\n

Results<\/strong><\/p>\n

The present study has revealed that 52 women were found to be suffering from UTI, giving a prevalence rate of 10.4% (52\/200).<\/p>\n

Table-1 shows the incidence of bacteriuria increased with age among the pregnant women.<\/p>\n

Table 1: Age distribution in pregnant women with bacteriuria<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n
Age in years<\/strong><\/td>\nTotal No. screened<\/strong><\/td>\nCases with bacteriuria<\/strong><\/td>\n<\/tr>\n
Number<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
18-20<\/td>\n89<\/td>\n7<\/td>\n7.86<\/td>\n<\/tr>\n
21-25<\/td>\n203<\/td>\n20<\/td>\n9.85<\/td>\n<\/tr>\n
26-30<\/td>\n166<\/td>\n16<\/td>\n9.64<\/td>\n<\/tr>\n
31-35<\/td>\n38<\/td>\n6<\/td>\n15.78<\/td>\n<\/tr>\n
35 and above<\/td>\n4<\/td>\n3<\/td>\n75.00<\/td>\n<\/tr>\n
Total<\/td>\n500<\/td>\n52<\/td>\n10.40<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Table 2: Relationship of duration of pregnancy and bacteriuria<\/strong><\/p>\n\n\n\n\n\n\n\n\n
Trimester<\/strong><\/td>\nTotal No. screened<\/strong><\/td>\nCases with bacteriuria<\/strong><\/td>\n<\/tr>\n
Number<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
First trimester<\/td>\n55<\/td>\n6<\/td>\n10.90<\/td>\n<\/tr>\n
Second<\/td>\n158<\/td>\n16<\/td>\n10.12<\/td>\n<\/tr>\n
Third<\/td>\n287<\/td>\n30<\/td>\n10.45<\/td>\n<\/tr>\n
Total<\/td>\n500<\/td>\n52<\/td>\n10.40<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Table-2 reveals that significant bacteriuria during pregnancy has a similar incidence during all three trimesters.<\/p>\n

Based on microscopic findings, 3 or more pus cells per field were considered as significant (Table-3).<\/p>\n

Table-4 shows that out of 52 cases, the Gram\u2019s staining was positive in 46 cases indicating a percentage of 88.46%.\u00a0 And standard loop technique was used to inoculate showing growth in all the 52 cases.<\/p>\n

Table 3: Pyuria in bacterimic women<\/strong><\/p>\n\n\n\n\n\n\n
No. of pus cells\/ HPF<\/strong><\/td>\nCases with bacteriuria<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
0-3<\/td>\n18<\/td>\n34.61<\/td>\n<\/tr>\n
More than 3<\/td>\n34<\/td>\n65.38<\/td>\n<\/tr>\n
Total<\/td>\n52<\/td>\n100.00<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Table 4: Gram\u2019s staining positive cases with significant bacteriuria in comparison with standard loop technique<\/strong><\/p>\n\n\n\n\n\n
Technique<\/strong><\/td>\nCases with bacteriuria<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
Standard loop technique<\/td>\n52<\/td>\n100<\/td>\n<\/tr>\n
Gram staining<\/td>\n46<\/td>\n88.46<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Table 5: Organisms isolated<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Organisms<\/strong><\/td>\nNumber<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
Klebsiella<\/td>\n13<\/td>\n25.00<\/td>\n<\/tr>\n
E.coli<\/td>\n12<\/td>\n23.07<\/td>\n<\/tr>\n
Staph.saprophyticus<\/td>\n9<\/td>\n17.30<\/td>\n<\/tr>\n
Staph.aureus<\/td>\n7<\/td>\n13.46<\/td>\n<\/tr>\n
Citrobacter<\/td>\n3<\/td>\n5.76<\/td>\n<\/tr>\n
Pseudomonas<\/td>\n2<\/td>\n3.84<\/td>\n<\/tr>\n
Proteus<\/td>\n2<\/td>\n3.84<\/td>\n<\/tr>\n
Staph.epidermis<\/td>\n2<\/td>\n3.84<\/td>\n<\/tr>\n
Micrococcus<\/td>\n1<\/td>\n1.92<\/td>\n<\/tr>\n
Enterococcus<\/td>\n1<\/td>\n1.92<\/td>\n<\/tr>\n
Total<\/td>\n52<\/td>\n100.00<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Table-5 shows the incidence of organisms isolated in bacteruiric cases.\u00a0 Klebsiella was the major isolate constituting 25%.\u00a0 E.coli was the next major isolate constituting 23.07%, Staph.saprophyticus accounted for 9 cases (17.3%), citrobacter for 3 cases (5.76%), Pseudomonas and proteus for 2 cases each (3.84%).\u00a0 Thus, Gram negative bacilli were responsible for a total of 29 cases (55.76%).\u00a0 Staph.aureus was present in a significant number of 7 cases (13.46%).\u00a0 Staph.epidermis was present in 2 cases (3.84%), Micrococcus was isolated in 1 case and Enterococcus in 1 case.\u00a0 Thus, the total Gram positive isolates were 23 (44.23%).<\/p>\n

Discussion and Conclusion<\/strong><\/p>\n

From this study, the spectrum of UTIs showed a total of 61.51% of Gram negative organisms and 38.44% of Gram positive organisms.<\/p>\n

Bacteriuria during pregnancy ranges from 3-12.8%.\u00a0 This variation is related to the socioeconomic status of the group of women studied which is in accordance with the observations of Turck et al and Kincaid Smith and Butler12,13,14<\/sup>.\u00a0 Therefore early treatment might avoid persistent bacteriuria in these women.<\/p>\n

In this study it is evident from Table-1 & 2 the proportion of bacteriuric cases was found to increase with increasing age and increasing parity, which is in accordance with the observations of Whalley15<\/sup>.<\/p>\n

Apart from influence of age and parity, the role of pregnancy itself in the acquisition of bacterimia must be considered.\u00a0 In Kass study, he has noted that material bacteriuria is usually present by the second month of gestation16<\/sup>.\u00a0 Williams GL found no statistically significant difference in incidence at different periods of pregnancy (3.3% before 13 weeks and 5.9% between 29-32 weeks).\u00a0 In the present study the incidence of bacteriuria in all 3-trimesters was not much different, being 10.9% in 1st<\/sup> trimester, 10.12% and 10.45% in the second and third trimesters respectively17<\/sup>.<\/p>\n

In this study, Gram staining positive cases with significant bacteriuria was seen in 46 cases i.e., (88.46%) and standard loop technique has shown positive results in all 52 cases i.e., 100%.<\/p>\n

Gram positive cocci multiply slowly in the urine as compared to Gram negative bacilli.\u00a0 It has been suggested by Pead et al that 104<\/sup> organisms\/ ml of uncentrifuged urine in cases of Gram positive cocci should be considered consistent with urinary infection instead of 105<\/sup> bacteria\/ ml which is appropriate for Gram negative bacilli.\u00a0 However, those showing 104<\/sup> bacteria\/ ml were repeated18<\/sup>.<\/p>\n

Types of microorganisms isolated from the urine have never been constant.\u00a0 In this study Klebsiella was isolated in 25% of the bacteriuric women.\u00a0 Out of the other members of the coliform group, E.coli was isolated in 23.07% and citrobacter 5.76%.\u00a0 Thus, the total coliform isolates constitute 55.76% (29\/52).<\/p>\n

Gram positive cocci accounted for 38.44% of the total isolates.\u00a0 Coagulase negative staphylococcus was isolated in a significantly high proportion.\u00a0 Staph.saprophyticus 9 cases (17.3%) and Staph.epidermis 2 cases (3.84%) and Micrococcus in 1 case (1.92%) and Enterococcus 1 case (1.92%).<\/p>\n

Two strains of Pseudomonas were isolated and 1 case of Enterococcus was isolated.<\/p>\n

Controlled trials and large-scale studies are required to establish pathogenic potential of the isolates.\u00a0 Many studies have shown that complications during pregnancy are more common in bacteriuric women.\u00a0 This study has revealed the screening for bacterimia during pregnancy is an appropriate investigation and that culture was the most effective means of detecting bacteriuria.<\/p>\n

This study will serve as a reference for researchers interested in the field of urology who may in future take up similar studies to compare and highlight with their findings over the years in combating this disease.<\/p>\n

Acknowledgement<\/strong><\/p>\n

The authors are grateful to the Dean & Principal and the Medical Superintendent of KBN Institute of Medical Sciences and KBN General & Teaching Hospital, Gulbarga for their permission to conduct the study and encouragement.\u00a0 We are thankful to the Head of the Department of Obstetrics & Gynaecology for cooperating timely.\u00a0 We also thank to the technicians and other staff for assisting in collecting data.<\/p>\n

References<\/strong><\/p>\n

    \n
  1. Maclean AB: Urinary tract infection in pregnancy. International Journal of Antimicrobial Agents, (2001); 17,4,279.<\/li>\n
  2. Asscher, AW. Urine as a Medium of bacterial growth Lancet-II (1966); 1037.<\/li>\n
  3. Pritchard JA, MacDonald, PC: Maternal adaptation to pregnancy. Williams obstetrics. 16th<\/sup> Edition Appleton Century Croff\/ New York, (1976): 211.<\/li>\n
  4. Little PJ: The incidence of urinary infection in 5000 pregnant women. (1966); Lancet, 2, 925.<\/li>\n
  5. Little PH: Prevention of Pyelonephritis of pregnancy. (1965): Lancet 1, 567.<\/li>\n
  6. Pritchard JA, MacDonald, PC: Maternal adaptation to pregnancy. Williams obstetrics. 16th<\/sup> Edition Appleton Century Croff\/ New York, (1976): 211.<\/li>\n
  7. Suri PN, Bhaskaran CS: A quantitative bacteriological study of urinary tract infection. The Antiseptic (1975): 72, 157.<\/li>\n
  8. Kas Concept: Textbook of Ananthnarayan & Paniker. 6th<\/sup><\/li>\n
  9. McNeely, Michael. \u00a0 In: Sonnerwith AC, Jarett L (eds.) Gradwohl\u2019s clinical laboratory methods and diagnosis, 8th<\/sup> Edn., Vol. I, B.I. Publications Ltd., New Delhi; 478: 1990.<\/li>\n
  10. Bailey & Scott\u2019s Diagnostic Microbiology, Chapter-60: Infections of the urinary tract, 937: 2002.<\/li>\n
  11. Geary C, Stevens M, Sneath PHA: Construction of data base to identify staph. species. Journal of Clinical Pathology, (1989): 42, 289.<\/li>\n
  12. Turck M, Goffee BS, Petersdorf RG: Bacteriuria of pregnancy- relation to socio-economic factors. New England Journal of Medicine, (1962): 266, 17, 857.<\/li>\n
  13. Kaitz, AL., Hodder EW. (1961): Method for the detection of significant bacteriuria in large groups of patients. Journal of Clinical Pathology, 1964: 17, 498. Quoted by Leigh, DA and Williams JD.<\/li>\n
  14. Kincaid-Smith, P., Bullen M: Bacteriuria in pregnancy (1965): 1, 395.<\/li>\n
  15. Whalley PJ, Martin FG, Peters PC: Significance of asymptomatic bacteriuria detected during pregnancy Journal of American Medical Association (1965): 193, 879.<\/li>\n
  16. Kass EH: Pyelonephritis and bacteriuria, A major problem in preventive Medicine. Annals of Internal Medicine, 1962; 56: 46.<\/li>\n
  17. Williams GL, Campbell H, Davis KG: The influence of age, parity, social class in asymptomatic bacteriuria in pregnancy. Journal of obstetrics and gynecology. British Commonwealth, (1969), 76, 229.<\/li>\n
  18. Pead C, Cump J, Maskell R: Staphylococcus as urinary pathogen. Journal of Clinical Pathology (19770; 30, 427.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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