Health Science Journal

Keywords

Diabetes mellitus; Urinary Tract Infections; Prevalence

Introduction

Worldwide, diabetes mellitus (DM) is considered as one of the most challenging health problems of 21st century. It affects every aspect of patients’ life, including quality of life (QoL), employment and even causing premature death. It is considered as the 5th leading cause of death in developed countries [1,2]. DM country profile of Malaysia showed that the prevalence of DM was 10.2% in males and 9.5% in females and the overall prevalence was 9.8% [3]. DM patients are prone to have various kind of infections more than non-diabetics. This high incidence rate of infections is attributed to altered immune functions like polymorphonuclear leucocyte function, adhesion phagocytosis, chemotaxis and impaired antioxidant system [4,5]. All these changes make diabetic patients prone to have more infections such as UTI, RTI, skin and soft tissue infections (SSTIs). The prevalence of UTI is high among DM patients [6-9]. DM is considered as a risk factor for UTIs. Patients with DM has more chances to get UTIs than non-diabetic. UTIs are five times higher among diabetics than non-diabetics. While Hoepelman et al. found that risk of UTI for diabetic patients was two folds higher than that of non-diabetics. UTIs are more severe and carry worse outcomes in DM patients [10,11]. The prevalence of UTI was 38% among diabetic patients. UTI seen more common in females i.e. 63.16% while male’s contribution was 36.84% among studied subjects. High sugar level is the main cause of prevalence of UTI among the DM patients [7]. Ijaz et al. showed that the prevalence of UTI among diabetic patients was 51%. Furthermore they stated that UTIs are significantly associated with age, it is more common in patient with age more than 55 years and the prevalence of UTI with > 55 years of age was 68.6% [8].

Prevalence of UTI among DM patients was 37%. Female had more UTI (43%) than males (30%) [9]. The prevalence of UTI was higher in patients with uncontrolled glycaemia (78.2%) than patients with controlled glycaemia (21.8%) [6]. Various impairments in the immune system, poor metabolic control and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of UTIs in DM patients [10]. Low urinary concentration of interleukin-8 and interleukin-6 in diabetics have been shown to correlate with lower urinary leucocyte cell count which may contribute to increase incidence and worse outcomes in UTI among DM patients [11,12]. Hyperglycaemia potentially cause nerve damage which effects the ability of urinary bladder to sense the presence of urine in it so it allows urine to stay in bladder for long time thus increasing the probability of getting infection [13]. In diabetic patients, there is an increased adherence of bacteria to uroepithelial cells particularly E. coli expressing type-1 fimbriae which may show increase pathogenesis and prevalence of bacteriuria among diabetic patients [14]. Urine samples with glucose concentration of more than 5.5 mmol/dl showed significant bacterial growth than normal urine [12]. High concentration of urine may act as good media for uropathogens and may enhance the growth of pathogenic bacteria in urinary tract [15]. Generally, urine is considered sterile and germ free. Different studies found that most uropathogens responsible for UTIs colonise the colon and perianal region. Faecal pathogens that ascend with the opening of urethra, stick to the wall of urethra, multiply and move up towards bladder and causing signs and symptoms. Pathogenesis can be ascending or haematogenous rout [16]. Gram negative bacteria are more commonly causing UTIs than gram positive bacteria. Among gram negative bacteria, Escherichia coli (E. coli) is most common uropathogen causing UTIs. E. coli contributes 56% of UTIs followed by Klebsiella pneumonia 35% and Proteus mirabilis [9,17].

Materials and Methods

This cross-sectional study was conducted at a tertiary hospital in Malaysia. The records of patients, more than and equal to age 18 years, who were admitted with diabetes mellitus between Jan 1, 2018 and December 31, 2018 were reviewed. All the aspects and protocols of this study have been reviewed by CRC and MREC. With the permission and approval from committee, the study was started.

Patient’s socio-demographic characteristics (gender, age, ethnicity, smoking status, marital status) and clinical data (Pregnancy status, menopausal status, DM status, UTI status and type of UTI were analyzed by using descriptive statistics. Categorical data was presented as frequency and percentage while continuous data was reported as mean ± standard deviation. Chi-square test was used to find association of glycaemic control with UTI. P-value less than 0.05 were considered statistically significant.

Results

A total of 348 DM patients were studied. Gender distribution is almost equal between male and female with an additional 20 female patients above males. The mean age of the DM patients was 55 (± 14.58) years. There were more non-elderly patients 197 (57%) than elderly 151 (43%). Ethnic distribution showed that majority of the patients were Malays followed by Chinese and Indians. Majority of patients (93.4%) were having T2DM. The studied population was classified according to the glycaemic status; patients with uncontrolled glycaemia (HbA1c ≥ 6.5) and controlled glycaemia (HbA1c < 6.5) as shown in Table 1.

Table 1 Characteristics of the study of DM patients.

Number of DM Patients	348
Mean age (years ± SD)	55 (±14.58)
Gender
Males	164 (47.1%)
Females	184 (52.9%)
Age groups
Elderly	151 (43%)
Non-elderly	197 (57%)
Race
Malay	246 (70.7%)
Chinese	56 (16.1%)
Indians	46 (13.2%)
Type of DM
T1DM	9 (2.6%)
T2DM	325 (93.4%)
GDM	14 (4%)
Duration of diabetes in years
(Mean ± SD)	8.06 (±7.07)
Glycaemic status
Good Control (HbA1C<6.5)	64 (18.4%)
Poor control (HbA1C ≥ 6.5)	284 (81.6%)

Prevalence of UTI among DM patients

As expected there was high prevalence of UTIs among DM patients. In current study out of 348 DM patients 140 (40.2%) patients had UTIs. Prevalence of UTI was higher among females (54.9%) than males (23.8%). Prevalence of UTI among Chinese and Malays was nearly equivalent with slightly higher among Chinese. While Indians had less prevalence than both above mentioned ethnic groups. Cystitis and ASB were most common types of UTI followed by pyelonephritis, urosepsis and prostatitis (Table 2).

Table 2 Characteristics of the study subjects with UTI.

Number of Patients with UTIs	140 (40.2%)
Mean age (years ± SD)	54.33 (±16.42)
Gender
Males (%)	164 (100%)
UTIs	39 (23.80%)
No UTIs	125 (76.2%)
Females (%)	184 (100%)
UTIs	101 (54.9%)
No UTIs	83 (45.10%)
Age groups
Non elderly (%)	197 (100%)
UTIs	81 (41.10%)
No UTIs	116 (58.9%)
Elderly (%)	151 (100%)
UTIs	59 (39.10%)
No UTIs	92 (60.90%)
Ethnic groups
Malay	246 (100%)
UTIs	100 (40.7%)
No UTIs	146 (59.3%)
Chinese	56 (100%)
UTIs	23 (41.10%)
No UTIs	33 (58.90%)
Indians	46 (100%)
UTIs	17 (37%)
No UTIs	29 (63%)
Types of UTIs
Cystitis	61 (43.6%)
ASB	55 (39.3%)
Pyelonephritis	11 (7.9%)
Urosepsis	8 (5.7%)
Prostatitis	5 (3.6%)

Most of the UTI cases in this study (89.3%) were found in DM patients with poorly uncontrolled glycaemia. While 10.7% cases of UTI were found in controlled glycaemic DM patients as shown in Table 3. The association between glycaemia control and risk of getting UTI was determined by Chi-square test. Results showed that there was a significant association between glycaemia control and risk of getting UTI. Those patients with poor glycaemic control have more risk of getting UTI than good glycaemic control patients.

Table 3 Association of controlled and uncontrolled glycaemia with UTI.

Glycaemic status
UTI status	Good Glycaemic control	Poor control	P-value*
With UTI	15 (10.70%)	125 (89.30%)	0.004a
Without UTI	49 (23.50%)	159 (76.50%)

*Chi-Square test ap-value

Discussion

In line with previous studies this study also showed high prevalence (40.2%) of UTI among DM patients. DM attribute various impairments in the immune system (low urinary concentration of interleukin-8 and interleukin-6, lower urinary leucocyte cell count), poor metabolic control and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of UTIs in DM patients [10]. Similar patterns of UTIs was observed in previous studies done by Yadav et al. (38%) and Pargavi et al. (37%) and Sewify et al. (35%). Whereas, there was high prevalence of UTI reported by Ijaz et al. [8] (51%), Hirji et al. (62%). Few studies found less prevalence of UTI than this study. These studies include Gillani et al. (29.2%), Al-Rubeaan et al. (25.2%) and Hamdan et al. (19.5%).

In terms of gender, females are more prone to get UTI than males. Women are vulnerable to UTIs due to their anatomy and reproductive physiology. Short urethra, urethra closer to perirectal area where pathogen colonies easier, absence of bacteriostatic prostatic secretions and sexual intercourse may force bacteria into the female bladder [18]. In line with previous studies, this study results also showed higher prevalence of UTI among females compared to males. Chaudhary et al. [19] found 62.5% prevalence of UTI among females and 37.5% among males. Ijaz et al. [8] showed more similar results to this study. They found 51.37% prevalence of UTI among females while 48.63% in males.

Prevalence among elderly and non- elderly was nearly equal with slightly higher in non-elderly patients. In women there are high chances of UTI during child bearing age that could be due to sexual intercourse or the use of contraception (e.g. diaphragm and spermicides). Whereas in elderly patients loss of estrogen causes a change in the vaginal flora, loss of lactobacilli in the vaginal flora results in periurethral colonization. Decreased bladder capacity and increased urine production, Decreased lower urinary tract sensory threshold and decreased voided volume [20]. Chaudhary et al. [19] assessed age-sex distribution and concluded that 31-40 years’ age group had higher prevalence of UTI followed by 41-50 years’ age group. Njunda et al also found high prevalence of UTI (27.2%) among age group of 41-60 years old DM patients [21]. Unlike this study, Ijaz et al. [8] showed that the prevalence of UTI was higher (68.6%) among patients >55 years of age than 41-55 years’ age group (42.9%) [8].

Expectedly, in this study the prevalence of cystitis was higher than other types of UTI. Bladder is a store house for urine. Uropathogens can enter and colonise in bladder much easier than other parts of urinary tract system. The results of this study showed that majority of patients had cystitis followed by ASB, pyelonephritis, prostatitis and urosepsis. Similarly other studies also reported cystitis as most prevalent type of UTI [14,22].

Most of UTI cases (89.3%) in this study were found in patients with poor glycaemic control. Whereas, only 10.7% cases of UTI were found in patients with good glycaemic control. Those patients with poor glycaemic control had more risk of getting UTI than good glycaemic control patients (P<0.05). Poor metabolic control may suppress immune system. Furthermore high urine glucose concentration shows significant bacterial growth than normal urine. High concentration of sugar in urine may act as good media for the growth of uropathogen [12]. Similarly other studies also stated the high prevalence of UTI in patients with uncontrolled DM [6,23].

Conclusion

UTIs are more frequent and are likely to have a more complicated course in DM patients. Overall, the prevalence of UTI among DM patients was 40.2%. Like other studies the high prevalence of UTI confirms that uncontrolled DM is significantly associated with more UTI. Furthermore, the prevalence among females was higher than males. Cystitis was the most prevalent UTI type.

Conflicts of interest

The authors declare that there is no conflict of interests regarding the publication of this paper.

Registration of study

The study was registered with the National Medical Research Register (NMRR). NMRR ID: NMRR-17-901-35420.

Ethical approval of the study

All the aspects and protocols of this study have been reviewed by CRC and MREC. With the permission and approval from committee, the study was started.

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