El-Kashif M. M. L. Urinary Tract Infection among Pregnant Women and its Associated Risk Factors: A Cross-Sectional Study. Biomed Pharmacol J 2019;12(4).

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Manuscript received on :23-09-2019
Manuscript accepted on :13- 11-2019
Published online on: 21-11-2019

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Mirfat Mohamed Labib El-Kashif ^1,2

¹Applied medical science collage, Wadi Addwaser, Prince Sattam Bin Abdulaziz Universivty, Saudi Arabia

²Maternity, obstetrics, and gynecology. nursing department - faculty of nursing- Port Said University, Egypt

Corresponding Author E-mail: drmirfat_k@yahoo.com

DOI : https://dx.doi.org/10.13005/bpj/1832

Abstract

Urinary tract infection is widespread among pregnant women and is accompanying adverse maternal, fetal, and neonatal outcomes. Even so, no data exist regarding this problem in Wadi Addawser to guide specific management and thus to avert the adverse consequences. The study aimed to assess the urinary tract infection among pregnant women and its associated risk factors and to investigate the most common antibacterial agent used by infected pregnant women. A total of 303 pregnant women who attend the obstetrics and gynecology clinic with the inclusion criteria were included.  The sample was collected using a structured interview. The study results showed, 53.5 % of the studied women had positive pathogens in the urine culture. E. coli (37%) followed by Klebsiella pneumonia (27%)  had the highest percentage of the isolated pathogens. Amoxicillin and cefoxitin (40.1% &21.6%, respectively) are the most antibiotics used by infected women, while the lowest used antibiotics are fusidic acid (5.6%). The clinical symptoms such as frequency of micturition, dysuria, lower abdominal pain, urine color change, painful burning sensation, incomplete bladder evacuation were e most common among infected women. Since the symptoms are a good predictor for urinary tract infection during pregnancy, so early screening for pathogens and proper treatment for infected cases should be applied.

Keywords

An antibacterial agent; Pregnant women; Urinary tract infection

Introduction

Pregnancy is associated with, structural, physiological and functional  changes in the  urinary tract  which most often Resulting in ascending of pathogens into the urinary bladder, causing urinary tract infections (UTIs).¹ In the general population, The extent of UTIs among pregnant women is higher than other healthy women.²   Both symptomatic and asymptomatic UTIs are prevalent among pregnant women and are linked with adverse effects to the mother, the fetus, and newborn. ^1,3

The changes in the urinary tract during pregnancy and immune system increase the prevalence of bacteriuria, causing serious risks for both mother and fetus. Parity, Increasing age, sickle cell anemia,   diabetes, urinary tract disorders and history of UTI,  may increase the risk of urinary tract infection in pregnant women . ^4,5

In pregnancy,  urinary tract infection  without antibiotic treatment may be  result in serious  complications such as low birth weight ,  preterm labor,  hypertension , pre-eclampsia, anemia,  pyelonephritis, amnionitis, stillbirths, neonatal deaths , bacteremia and toxic septicaemia.^6,7 Treatment of urinary tract infection may reduce the risk of pregnancy complications. So, screening for early diagnosis and treatment of urinary tract infection in pregnant women is essential to avoid its complications. ⁸

Among pregnant women in Saudi Arabia, the prevalence of UTI  was reported to be 20%  (12% with symptomatic urinary trcat infection and 8% were asymptomatic.⁹ In general, the cases of UTIs are caused by bacteria bathogenes, especially gastrointestinal bathogens, that infects the urethral meatus through contaminating the area that surrounds the rectum and spreading to the bladder. ¹⁰

Approximately the common pathogenic causes of urinary tract infection are “Escherichia coli, Staphylococcus spp., Streptococcus spp., Proteus spp., Klebsiella spp. Corynebacterium, Neisseria, and Pseudomonas spp “. The severity of a urinary tract infection is influenced by the malevolence of the bacteria and the susceptibility of the host.¹¹ Penicillin, Amoxicillin, celtaxidime, norfloxacin, and cefoxitin are the most competent antibiotics for the treatment of the majority  of the urinary tract  pathogens. ⁹

The significance of the present study is that urinary tract infection can be a danger for pregnant women between whom it has been revealed that up to 50% of those with asymptomatic Bacteriuria (ABU) go on to get pyelonephritis. Therefore, women during pregnancy should be assessed for predisposing factor and the causative organism of UTI during their antenatal follow-up.  The urine examination for the presence of pathogens and the suitable antibiotic regimen should be specified for maternal and fetal health safety. The sensitivity for the antibiotics and their adverse reaction related to pregnancy should be considered ¹²

The aim of the study

This study aimed to assess the urinary tract infection among pregnant women and its associated risk factors, and to investigate the most common antibacterial used by infected pregnant women.

Material and Methods

Study design

A cross-sectional descriptive design

Study population and samples

The total subjects of the study sample consisted of 303 pregnant women who attend the antenatal clinic at Wadi Addwaser General Hospital, KSA with the inclusion criteria. The inclusion criteria are pregnant women at the second trimester of pregnancy with suspected clinical symptoms of urinary tract infection. The suspected clinical symptoms of urinary tract infection such as; the frequency of  urination,  fever,  dysuria, painful burning sensation, strangury, incomplete bladder voiding,  lower abdominal pain, flank pain, changed urine color and shaking chills. Exclusion criteria;  sickle cell disease (renal damage), anatomic or functional congenital urinary abnormalities, the pregnant women under antibiotic regimen within 72 hours to the study data collection were excluded because the antibiotic must have inhibited or destroyed the pathogens.   

Sampling

The  data were collected through face to face interview from first October 2018 to end of March 2019 by using  structured questionnaire that inclue;  the socio-demographic characteristics as (age, level of education, occupation, and family income).

Obstetrical history(  number of pregnancies, number of deliveries, abortion, number of children and Previous treatment for UTI during current pregnancy.   Medical history and  health habits  ( regular voiding, drinking enough water,  intake of vitamin C, frequent tea intake ,  soft drinks and coffee ingestion; . Medical history as

previous genital tract infection,  hypertension, anemia , kideney calculi, and   Diabetes Mellitus and clincal symptoms faced by pregnant women. The vaginal swab was taken from the study sample and analyzed to exclude vaginal infection according to the hospital rules.

Urine sample technique

enough clean-catch midstream urine specimen was collected by the pregnant women after given adequate and careful instructions for urine sample collection technique.

The urine sample was inoculated on blood agar- plates- (MacConkey agar). The urine sample plates were put in the incubator under perfectly aerobic conditions at 37°C for 24 hrs.   After 24 hours of inculation, The urine culture plates were examend macroscopically to identify the color,  appearance, morphology,  and the colonies size. The isolated bacteria were diagnosed by using  Gram stain and biochemical test and using microscopic examination. Antimicrobial susceptibility of isolated bacteria was examined to determine the proper antibiotic use. The presence of leukocyte (LE) and nitrate in urine were secreened by using the biochemical reagent strip test (dipstick test). The microscope was used to test  red blood cells (RBCs) and pus cell (pyuria) in urine ¹³

Statistical analysis

The original data were coded and inserted into SPSS system files (SPSS package version 19, Chicago, USA).  The data were analyzed and interpreted. Smirnov test was used to test the distribution of data.    Univariate analyses including ( Mann Whitney test and t-test) were used to test the significance of the quantitative variables results.  Monte Carlo test, Chi-Square test, and Fisher’s Exact test were used to testing the significance of the qualitative variables results.

Results

Out of 303 pregnant women, 162 women (53.5 % )  were positive for urinary tract pathogens. E. coli were the most frequent organism (37%) isolated from a positive pregnant women urine culture, followed by Klebsiella pneumonia (27%) while the lowest was staphylococcus saprophytic (3.7%). The study presented that amoxicillin and cefoxitin (40.1% &21.6%, respectively) are the most used antibiotics by infected women for the treatment of UTI, while the lowest used is the fusidic acid (5.6%) figure 1,2). Table (1): shows that there are statistically significant differences among negative and positive culture women concerning the age, occupation, family income, and previous treatment for UTI during current pregnancy at P≤0.05.  And there were no differences with the number of pregnancies, number of deliveries, abortion and the number of living children.

Table (2) Reveals that there is a statistically significant difference between the presence of pathogens in urine culture in relation to regular bladder voiding, diabetes mellitus, previous urinary tract infection and  regarding clinical manifestation among the pregnant women

Figure 1: The bacteria isolated from the urine culture. Click here to View figure

Figure 2: Antibiotics used by infected pregnant women(n= 162) Click here to View figure

Table 1: The Socio-demographic characteristics and  the obstetric history  of the studied  pregnant women    (n=303)

Q1-Q3: Interquartile range,  Z: Mann Whitney test, X2: Chi-Square test, *significant at P≤0.05, t: Student t-test, MCP: Monte Carlo corrected, P-value, *significant at P≤0.05

Table 2: the  predisposing  factors  and clinical manifestations of the studied pregnant  women (n =303)

X²: Chi-Square test, *significant at P≤0.05

Discussion

The result of the present study revealed the overall prevalence of urinary trcat infection among pregnant women was (53.5%), which is abviousely higher than what was documented earlier in Saudi Arabia (20%). ⁹

In spite of the  advances in medical and health care nowadys . This contrast in prevalence may be due to change in the studied sample and place of data collection. This result is   nearly  similar  with  the result of Worie & Eze., 2010 ¹⁴ but it was lower than the result from Niger (75%) ¹⁵

Regarding bacteria isolated from the urine culture among pregnant women, the present results showed that the highest isolated organisms were E. coli (37%) and Klebsiella pneumonia (27%) while the lowest was staphylococcus saprophytic (3.7%). The previously mentioned result can be explained by the fact that the acidity of urine during pregnancy reaches the percentage that helps E. coli to grow.¹⁶. This finding is most consistent with many of the previous studies which determined that E. coli are the most common urinary tract associated  bacteria.^9,15,17-21. In another study, Staphylococcus aureus is the most prevalent pathogens among asymptomatic pregnant women. ²²

In the current study,  amoxicillin and cefoxitin (40.1% &21.6%, respectively) are the most used antibiotics by infected women for the treatment of UTI, while the lowest used is the fusidic acid (5.6%). In this respect, Faidah et al., 2013 ⁹ reported that amoxicillin, cefoxitin, celtaxidime, norfloxacin, penicillin, and fusidic acid are the highest beneficial antibiotics for treatment of UTI during pregnancy. The effect of these antibiotics lies in these highly expensive drugs and had controlled their attaining and indiscriminate use, therefore facilitating the pathogens susceptible to them.

In this study, there is a statistically significant differences among negative and positive culture women concerning the age, occupation, family income and  previous treatment for UTI during current pregnancy at P≤0.05. In this context,  Eriksson, 2011²³ and Rahiman et al., 2015¹⁶ reported that Urinary tract infection (UTI) is a common in women of all ages but the incidence and prevalence increase with age. Kolawole et al., 2009 ¹⁴stated that socioeconomic rank is a predictor for the presence of bathogens in urine and this result from shortage in housing and drainage system, improper environmental and personal hygiene. From the researcher’s point of view,  this could be attribute to  the association of low socioeconomic status with Improper nutrition and low  immunity especially during pregnancy. This study result is in line with the outcome of Tamalli et al., 2013 ¹⁷ study which revealed that prevalence of bacteriuria in healthy women is found to be 9% and 21% in case of poor pregnant women. It is noticeable that the infection of the urinary system is widespread among working women, and this can be explained that working women do not drink enough water during working hours. Moreover, 66.7% of positive culture women have previous UTI during current pregnancy with P≤0.05. Kearney, 2011  ²⁵ mentioned that during pregnancy, there is a modification in the immune system of the pregnant woman to help implant the egg and the development of the fetus. So, the response of the immune system is modified from a cell-intermediated to a humoral reaction which results in fewer responses to bacterial cell surface proteins and probably facilitate pathogenicity. These modifications allow bacteria  to penetrate, multiply and Settles in the urinary system

The current study results showed that the difference between the presence of bacteria in urine culture in relation to regular bladder voiding, diabetes mellitus, previous urinary tract infection was statistically significant.  Rahiman et al., 2015 ¹⁶  stated that emptying of the bladder is the dominant defense against urinary tract infection so,  complete emptying the bladder during urinating and not ignoring the desire to urinate can help women to be away from urinary tract infections in most cases. Also,  urinary tract infection was significantly associated with pregnant women who have diabetes mellitus and previous UTI. This is maybe attributable to elevate the glucosuria and decrease the immune system host factors prejudice to infection during pregnancy.  Increase blood glucose during pregnancy causes a neutrophil disturbance by excessing calcium inside the levels of the cell and restrict with actin, also diapedesis and phagocytosis. The vaginal candidiasis and vascular disease also have a role in recurrent of infections.  Also, this is due to the stoppage of the urine during pregnancy caused by physiological and anatomical changes in the urinary system, such as uterus compression on the ureters and the effect of the relaxation of progesterone on the urinary tract muscle.²⁶  Moreover, Emiru et al.., 2013 ²⁷ proved that recurrent urinary tract infection and diabetes mellitus are risk factors for UTI, so the frequency and the severity of UTI rise in pregnancy.

The current study results revealed that, a statistically significant difference between presences of bacteria in urine culture in relation to clinical symptoms related to urination. The clinical symptoms such as frequency of micturition, dysuria, lower abdominal pain, urine color change, painful burning sensation, incomplete bladder evacuation. This result consistent with the results of  Almushait et al., 2013 ²⁸  study which found nearly the same results. There is a statistically significant difference between the presence of pathogens in urine in relation to laboratory findings such as pyuria and hematuria P≤0.05 in the present findings. This result is in line with Michelim et al.., 2016 ²⁹, who stated that Pyuria is found in a majority of women with pyelonephritis.

Conclusion

Out of 303 pregnant women, 162 women were positive for utinary tract pathogens. E. coli were the most frequent organism isolated from a positive pregnant women urine culture, followed by Klebsiella pneumonia while the lowest was staphylococcus saprophytic. Amoxicillin and cefoxitin are the most used antibiotics by infected women for the treatment of UTI, while the lowest used is fusidic acid. There was a statistically significant difference between the presence of pathogens in urine culture in relation to regular bladder voiding, diabetes mellitus, previous urinary tract infection, and regarding clinical manifestation among pregnant women. Since the symptoms are a good predictor for urinary tract infection during pregnancy, so early screening for pathogens and proper treatment for infected cases should be applied.

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