1. 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

2. 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)

3. 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)

4. 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)

5. 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)

6. 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

7. 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 %
symptomatic bacteriuria %
(Nigussie & Amsalu, 2017)

8. 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

9. 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

10. 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

11. 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

12. 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

13. VITEK 2 Compact System

14. 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)

15. 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

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

17. 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 male diabetic (16.67%) and 15 female (83.33%) diabetic patients

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

19. 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

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

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

22. 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%)

23. 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

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

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

26. 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

27. 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 years (55.56%, 10/18)
Similar findings in
Hamdan et al., 2015
Than-Than-Aye et al., 2018

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. REFERENCES

35. 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: Available from: doi: /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 July; 21(2): Available from: doi: /ejhs.v21i , 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): Available from: accessed 5 September 2018.

36. THANK YOU