3Department of Microbiology, University of Medical Technology, Yangon 18-Jan-19 BACTERIOLOGICAL PROFILE OF URINARY TRACT INFECTIONS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS Phue Pwint Thynn1, Khin May Oo1, Wah Win Htike1, Mya Mya Aye2, Chaw Chaw Su3 1Department of Microbiology, University of Medicine 1,Yangon 2Department of Bacteriology, Department of Medical Research 3Department of Microbiology, University of Medical Technology, Yangon

INTRODUCTION Type 2 diabetic patients are high risk of infections, especially urinary tract infections Impairment in immune system, poor diabetic control and incomplete bladder emptying contribute to pathogenesis of urinary tract infections (UTIs) (Nitzan et al., 2015)

Estimated annual global incidence of UTIs in developing countries is about 250 million UTI – uncomplicated with normal urinary tract and complicated with abnormal and/or catheterization Asymptomatic or symptomatic bacateriuria can be found in both UTIs (Getenet & Wondewosen, 2011)

Antimicrobial resistance(AMR) threatens effective treatment and prevention of infectious diseases Challenging in developing countries Higher infection rates, malnutrition and poor infection prevention practices Over-the-counter availability and irrational uses of antibiotics (Vila & Pal, 2010)

In Myanmar, Khin-Khin-Wai, 2017 prevalence of uropathogens in nosocomial UTIs was 43.3% (65/150) in medical wards of YGH Thu-Zar-Poe, 2016 significant bacteriuria among catheter-associated UTIs in YGH was 28% (21/75)

Khin-Thawdar-Shein, 2012 113 urine samples in Mandalay General Hospital 67 samples were positive for urine culture 60 Enterobacteriaceae were isolated 51.7% (31/60) were phenotypically confirmed as ESBL producers

In India, 270 urine samples from diabetic patients were studied 43% (118/270) – significant growth (Sharma et al., 2012) In Ethiopia, 240 diabetic patients UTI in diabetic patients was 13.8% (33/240) asymptomatic bacteriuria -- 11.2% symptomatic bacteriuria -- 23.1% (Nigussie & Amsalu, 2017)

Occurrence of uropathogens in type 2 diabetic patients and their antimicrobial susceptibility patterns were studied Helpful in choice of antibiotics in management of UTIs at present moment and also support in future antibiotic guideline policy

AIM AND OBJECTIVES Aim To study bacteriological profile of urinary tract infections in patients with type 2 diabetes mellitus attending to outpatient department of Medical Ward, NYGH

OBJECTIVES To determine the occurrence of urinary tract infections in type 2 diabetic patients To determine the antimicrobial susceptibility pattern of urinary tract infections in type 2 diabetic patients

MATERIAL AND METHODS Hospital and laboratory based cross-sectional descriptive study From January 2018 to October 2018 A total of 208 urine samples from type 2 diabetic patients attending to medical OPD of NYGH Type 2 diabetic patients with known urinary tract abnormalities and patients treated with antibiotics within two weeks were excluded

Clean-catch mid-stream urine samples in a sterile, screw-capped, wide-mouthed container One loopful (0.01ml) of urine sample were inoculated on blood agar and CLED agar Significant bacteriuria - > 104 CFU/ml Identification of bacteria and antimicrobial susceptibility tests --- VITEK 2 Compact System Bacteria with ESBL phenotype detected by VITEK 2 System --- confirmed by combination disc method

VITEK 2 Compact System

Flow chart of the study Urine samples from patients with type 2 diabetes at medical OPD, NYGH Transport in cold box to Microbiology Research Laboratory, UM 1, Yangon Microscopic examination of urine samples Inoculate on Blood agar & CLED agar and incubate at 37oC overnight aerobically Growth No growth (sterile)

Growth Positive urine culture with < 2 species of bacteria Examination of colonial morphology and suspected colony was stained with Gram stain Identification of isolated bacteria with VITEK 2 Compact system (GP and GN cards) Positive urine culture with >2 species of bacteria Discard Antimicrobial susceptibility testing of isolated bacteria with AST GP-67 and AST GN-90 cards Confirmation of ESBL production by combination disc method

RESULTS Out of 208 urine samples, 18 urine samples showed significant bacteriuria Occurrence of significant bacteriuria in type 2 diabetic patients was 8.61%

Age distribution of study population was between 31 to 84 years of age Diabetic patients with significant bacteriuria 51-60 years of age (55.56%, 10/18) Significant bacteriuria --- 3 male diabetic (16.67%) and 15 female (83.33%) diabetic patients

Figure 1. Symptomatic and asymptomatic bacteriuria Figure 1. Symptomatic and asymptomatic bacteriuria in type 2 diabetic patients

Commonest isolated bacteria Escherichia coli (66.67%, 12/18) One isolate (5.56%) Klebsiella pneumoniae Kluyvera intermedia Serratia marcescens Sphingomonas paucimobilis Staphylococcus aureus Micrococcus luteus

Plate 1. CLED agar plate showing the growth of Escherichia coli

Plate 2. Blood agar plate showing the growth of Staphylococcus aureus

Among 16 gram-negative bacteria, 12 isolates (75%) were detected for production of ESBL phenotype by VITEK 2 System Escherichia coli (10 isolates, 83.34%) Klebsiella pneumoniae (1, 8.33%) Serratia marcescens (1, 8.33%) These 12 bacteria were phenotypically confirmed for ESBL production by combination disc method Escherichia coli (5 isolates, 41.67%)

Plate 3. Mueller-Hinton agar plate showing ESBL Plate 3. Mueller-Hinton agar plate showing ESBL production by combination disc method CAZ = Ceftazidime CAZ / CV = Ceftazidime / Clavulanic acid CTX = Cefotaxime CTX / CV = Cefotaxime / Clavulanic acid

Figure 2. Antimicrobial susceptibility patterns of Figure 2. Antimicrobial susceptibility patterns of gram-negative bacteria (n = 16)

Figure 3. Antimicrobial susceptibility pattern of Figure 3. Antimicrobial susceptibility pattern of gram-positive bacteria

DISCUSSION Occurrence of urinary tract infections in type 2 diabetic patients was 8.61% (18/209) Consistent with Nigussie & Amsalu, 2017 Hamdan et al., 2015 But higher prevalence in Chaudhary et al., 2014 Al-Rubeaan et al., 2013

This low occurrence was due to geographic variation & different ethnic groups Higher proportion of asymptomatic UTI and proper aseptic technique of urine sample collection Type 2 diabetic with significant bacteriuria --- highest between 51-60 years (55.56%, 10/18) Similar findings in Hamdan et al., 2015 Than-Than-Aye et al., 2018

Impaired function of urinary tract and dysfunctional immune mechanism in old age urinary incontinence, stasis and reduced urine flow enhance colonization of bacteria in urinary tract resulting in higher chance of urinary tract infections in elder patients

Significant bacteriuria in female diabetic patients was 83% (15/18) In accordance with Shill et al., 2010 Chaudhary et al.,2014 Because of shorter & wider urethra, close proximity to anus and urethral opening in women, decreased of normal vaginal flora and less acidic vaginal pH Others - sexual intercourse, certain types of contraception like diaphragms, poor personal hygiene and menopause

Most frequent causal organism was Escherichia coli (75%, 12/18) due to natural habitat of Escherichia coli is the intestinal tracts of human and animals Uropathogenic Escherichia coli frequently cause urinary tract infections

Among 12 gram-negative bacteria, 5 isolates (41 Among 12 gram-negative bacteria, 5 isolates (41.67%) of Escherichia coli were confirmed for ESBL production by phenotypic confirmatory method Consistent with Khin-Khin-Wai (2017) study out of 22 Enterobacteriaceae, 9 isolates (40.9%) of Escherichia coli were ESBL producers Due to easily accessible antibiotics, self-medication, improper dosage and inadequate duration in taking antibiotics

CONSLUSION As type 2 diabetic patients are at risk of harmful infections, early diagnosis and treatment are essential in prevention of complications Asymptomatic bacteriuria was found Suggest to do urine culture and sensitivity in regular visit to diabetic clinic

Prevalence of ESBL producing bacteria was nearly half of total culture positive cases Important to control the spread of multidrug resistance strains in both hospital and community settings

REFERENCES

Nitzan, O. , Elias, M. , Chazan, B. & Saliba, W. , et al Nitzan, O., Elias, M., Chazan, B. & Saliba, W., et al. Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis and management. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2015; 8: 129-136. Available from: doi:10.2147/DMSO.S51792, accessed 19 June 2018. Getenet, B. & Wondewosen, T. Bacterial uropathogens in urinary tract infection and antibiotic susceptibility patterns in Jimma University Specialized Hospital, Southwest Ethiopia. Ethiop J Health Sci. 2011 July; 21(2): 141-146. Available from: doi:10.4314/ejhs.v21i2.69055, accessed 21 June 2018. Khin-Khin-Wai. Extended spectrum beta-lactamase producing Enterobacteriaceae in nosocomial urinary tract infection in medical ward of Yangon General Hospital. [M.Med.Sc. thesis]. University of Medicine 1: Yangon; 2017. Thu-Zar-Poe. Bacteriological profile of catheter associated urinary tract infection in patients attending Yangon General Hospital. [M.Med.Sc. thesis]. University of Medicine 1: Yangon; 2016. Than-Than-Aye, Poe-Nu-Htay, Thet-Htun-Zaw & Su-Su-Hlaing, et al. Urinary tract infection and pattern of antibiotic sensitivity in hospitalized patients with diabetes mellitus in Myanmar. Archives of Endocrinology and Diabetes Care. 2018; 2(1): 147-153. Available from: http://scientiaricerca.com/srendc/pdf/SRENDC-02-0021.pdf, accessed 5 September 2018.

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