Introduction
Urinary tract infection (UTI) is one of the most common bacterial infections among men and women, affecting 150 million people each year worldwide.[12] In 2007, it was estimated 10.5 million with UTI symptoms and 2–3 million emergency department visits.[234] The prevalence of UTI varies from 21.8 to 31.3 in various parts of India.[2]
Clinically, UTI is divided into uncomplicated and complicated. When the infection occurs in otherwise healthy and has no structural or neurological urinary tract abnormalities, it is an uncomplicated UTI.[25]
Complicated UTIs are defined as UTIs associated with factors that compromise the urinary tract or host defense, including urinary obstruction, urinary retention caused by neurological disease, immunosuppression, renal failure, renal transplantation, pregnancy, and the presence of foreign bodies such as calculi, indwelling catheters, or other drainage devices.[267]
It is reported that 70–80% of complicated UTIs are attributable to indwelling catheters,[8] accounting for 1 million cases per year in the United States. Risk factors for developing a catheter-associated UTI include prolonged catheterization, female gender, older age, and diabetes.[29]
The symptoms associated with the bladder and kidney infections are contrasting which include painful and frequent urination in case of cystitis as a result of bladder infection whereas conditions such as high fever and flank pain in case of kidney infection.[10]
UTI is regarded as the common hospital-acquired infection.[1112] The infection encompasses a diverse group of clinical syndromes and diseases that differ in epidemiology, etiology, and location severity of the condition.[13] In addition to the above factors, it also varies in symptoms, frequency of recurrence, extent of damage caused, and presence of complicating factors.[14] The occurrence of bladder infection is usually followed by kidney infection, and results in blood-borne infection and in severe circumstances can lead to severe consequences including death. Therefore, UTI is capable of claiming lives under severe circumstances and proper treatment results in quick recovery from the contagion.[10]
In the presence of risk factors such as female sex, diabetes, obstructive uropathy, previous instrumentation, and chronic kidney disease (CKD), the treatment becomes even more challenging.[2] Various studies done worldwide have shown changing pattern in etiology of UTIs.[2] The present trends of the uropathogens and their susceptibility to various antibiotics are essential to formulate guidelines for the empirical treatment of UTIs while awaiting the culture sensitivity.[15] Hence, the present study was an attempt to evaluate the changing clinical presentations and risk factors of UTIs and the etiological agents in complicated and uncomplicated UTIs.
Methodology
This 1-year cross-sectional study was undertaken in the Department of Medicine, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India, attached to Jawaharlal Nehru Medical College, Belgaum, Karnataka, India, from January 2016 to December 2016. Based on universal method, all the cases that are a total of 500 patients admitted with UTI and positive for urinary culture fulfilling the selection criteria were selected for the study. Patients admitted with symptoms of UTIs and UTI confirmed by the positive urinary culture reports were included in the study. Patients aged <18 years were excluded from the study. The ethical clearance was obtained from the Institutional Ethical committee, Jawaharlal Nehru Medical College, Belgaum, before the commencement.
Procedure
Patients fulfilling selection criteria were explained about the nature of the study and a written informed consent was obtained before the enrollment. Demographic data such as age and sex were noted. Patients were interviewed and detailed history was obtained. Physical examination was done followed by systemic examination. These findings were recorded on a predesigned and pretested pro forma. The patients were evaluated for total count, serum creatinine, urine routine and microscopy, urine culture, and imaging. Patients were assessed for clinical signs and symptoms, urine culture to determine causative organism, and diagnosis and history so as to determine the risk factors.
Statistical analysis
The data obtained were coded and entered into Microsoft Excel worksheet. The data were analyzed using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.). The categorical data were expressed in terms of rates, ratios, and proportions, and the continuous data were expressed as mean ± standard deviation.
Results
Most of the patients were males (59.00%) and the male-to-female ratio was 1.43:1 [Graph 1]. The most common age group was 51–60 years (25.40%) [Graph 2]. The mean age was 53.60 ± 17.55 years. The median age was 56 years and ranged between 18 and 90 years. Most of the patients had fever with chills (65.60%), followed by pain abdomen (47.00%), burning and micturition (22.40%), reduced urine output (20.60%), vomiting (15.60%), hematuria and increased frequency of urination (8.20%) each, asymptomatic (2.80%), and dysuria (2.60%) [Graph 3]. Majority (76.80%) of the patients had complicated type of UTI while 23.20% of the patients had uncomplicated UTI [Table 1]. Escherichia coli was the most common organism (56.60%) isolated, followed by Klebsiella (13.00%). The other organisms are as depicted in Table 2. Furthermore, E. coli (40.48%) was the most common organism isolated in patients with nosocomial catheter-related infections and in patients with nosocomial noncatheter-related infections (35.29%). Further, E. coli was the most common organism isolated in patients with complicated (57.03%) and uncomplicated UTI (55.17%). Imaging findings were normal in 33.20% of the patients. In the remaining, obstruction was noted in 32% of the patients, renal parenchymal changes in 13.20%, cystitis and pyelonephritis in 10.4% each, and polycystic kidney disease in 0.8% of the patients. Majority of the patients (88.20%) had community-acquired infection while 8.40% and 3.40% of the patients had catheter-related nosocomial infection and noncatheter nosocomial infection, respectively [Table 3]. The most common risk factor was Type 2 diabetes mellitus (T2DM) (40%) followed by chronic kidney disease (19.2%) and HUN (14.60%). The other risk factors are as depicted in Table 4. The most common clinical presentation was fever with chills in patients with complicated UTI (62.76%) and in patients with uncomplicated UTI (75%). Cystitis and pyelonephritis (15.29% each) were the most common diagnosis among the patients without obstruction while HUN (45%) was the most common diagnosis among the patients with obstruction [Table 5].
Discussion
The etiology, cause, and antimicrobial susceptibility pattern of uropathogens have been changing over years.[11] Effective management of patients suffering from bacterial UTIs commonly relays on the identification of type of organisms that caused the disease. Diagnosis of UTIs is a good example of the need for close cooperation between the clinician and the microbiologist.[12] This study was designed to evaluate the changing clinical presentations and risk factors of UTIs and the etiological agents in complicated and uncomplicated UTIs.
This 1-year cross-sectional study was done under the Department of Medicine, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi. A total of 500 patients with signs and symptoms of UTI and/or with UTI confirmed by urine microscopy in the admitted in the Department of Medicine and Nephrology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, were studied.
It is reported that women are more prone to UTIs than men. The reason behind this high prevalence of UTI in females is due to proximity of the urethral meatus to the anus, shorter and wider urethra, sexual intercourse, incontinence, and less acidic pH of vaginal surface and poor hygienic conditions.[131415] However, in the present study, slight male preponderance was noted as 59.00% of the patients were males and 41.00% of the patients were females with male-female ratio of 1.43:1. In contrast to these observations, other study by Momoh et al.[16] (2011) reported UTIs in 60.2% of the females and 39.8% of males. The male preponderance observed in the present study may be explained by the facts that men's risk for UTI increases with age and prostatic enlargement after 50 years of age, and males are more likely to visit hospital more than females.
The incidence of UTI increases with age.[17] In the present study, age ranged between 18 and 90 years. The most common age group was 51–60 years comprised of 25.40% of the patients and the mean age was 53.60 ± 17.55 years. These findings were consistent with a study by Raval et al.[18] (2015) from Vadodara, India.
UTI usually develops in the lower urinary tract (urethra and bladder), and if not properly treated, they ascend to the upper urinary tract (ureters and kidneys) and cause severe damaged to the kidneys.[17] In the present study, 76.80% of the patients had complicated type of UTI while 23.20% of the patients had uncomplicated UTI. These findings were consistent with a study by Stefaniuk et al.[19] (2016) who reported 37.8% of patients with uncomplicated UTI and 62.2% had a complicated infection.
In the present study, the most common clinical presentation was fever with chills noted in 65.60% of the patients followed by lower abdominal pain which was present in 47.00% of the patients. The other presentations were burning and micturition (22.40%), reduced urine output (20.60%), vomiting (15.60%), hematuria and increased frequency of urination (8.20% each), and dysuria (2.60%). However, 2.80% of the patients were asymptomatic. Further, the most common clinical presentation was fever with chills in patients with complicated UTI (62.92%) and in patients with uncomplicated UTI (75%). Khan et al.[13] in their study also reported that most of the patients with symptomatic UTI complained of mild fever, increased frequency, and burning during micturition along with urgency. A study done by Eshwarappa et al.[20] (2011) demonstrated that fever and dysuria were the most common clinical presentation.
In the present study, the most common risk factor was T2DM (40%) followed by CKD (19.2%), HUN (14.6%), renal calculi (9.20%), pregnancy (4.40%), and benign prostatic hyperplasia (4.20%). In a study by Khan et al.,[13] 52.6% of the patients with diabetes mellitus were diagnosed to have UTI. Another study by Eshwarappa et al.[21] (2011) reported that diabetes was the most common factor associated with complicated UTI which consistent with the present study as 47.13% of the patients with complicated UTI had diabetes mellitus. Nicolle[20] (2000) reported that the risk of developing UTI in diabetic patients is higher and urinary tract is the most common site for infection. In a study by George et al.[22] (2015), the prevalence of UTI was more in diabetics (44.4%) than nondiabetics (29.4%).
In the present study, E. coli was the most common organism isolated in 56.40% of the patients followed by Klebsiella (13%) and Enterococcus (9.60%). Furthermore, E. coli (40.48%) was the most common organism isolated in patients with nosocomial catheter-related infections as well as in patients with nosocomial noncatheter-related infections. Furthermore, E. coli was the most common organism isolated in patients with complicated (57.03%) and uncomplicated UTI (55.17%). These findings suggest that E. coli is the principal pathogen of UTIs. E. coli is a normal inhabitant of the gastrointestinal tract and thus maybe a potential source for the development of UTI.[23]
Stefaniuk et al.[19] (2016) reported that E. coli remains the most common etiologic agent of community-acquired UTI in Poland although its role in etiology differs depending on the type of infection (uncomplicated vs. complicated) and the patient's characteristics.
Ghadage et al.[11] (2016) reported that E. coli (41.3%) was the predominant uropathogen isolated followed by Klebsiella spp. (18.5%) and Enterococcus spp. (12%) which was consistent with the present study. Similar results were observed in other studies also.[2324]
A multicenter study (Antimicrobial Resistance Epidemiological Survey on Cystitis) (2009) on uncomplicated UTIs carried out in nine European countries and Brazil showed that E. coli was responsible for 76.7% of infections, ranging from 68.1% in Austria to 83.8% in France.[25] Among Polish isolates included in this study, E. coli was responsible for 75.6%, which is somewhat lower than that revealed in the present investigation.[19]
Another study by Raval et al.[18] (2015) also reported that E. coil was the most frequently occurring uropathogen in both nosocomial as well as community-acquired UTI. E. coli was found in the urine of 80%–90% of patients with acute uncomplicated cystitis and acute uncomplicated pyelonephritis.
In the present study, majority of the patients (88.20%) had community-acquired infection while 8.40% and 3.40% of the patients had catheter-related nosocomial infection and noncatheter nosocomial infection, respectively. Gould et al.[26] reported that bacteria develop in at least 10%–15% of hospitalized patients with indwelling urethral catheters.[17] Factors associated with an increased risk of catheter-associated UTI include prolonged catheterization, severe underlying illness, disconnection of the catheter and drainage tube, and lack of systemic antimicrobial therapy.
Overall, this study highlights the clinical presentation, risk factors, and etiological agents in complicated and uncomplicated UTIs. This study shows that E. coli is the principal pathogen of UTIs. Regular screening should be done for the presence of symptomatic or asymptomatic bacteriuria in community practice, and specific guidelines should be issued for testing antimicrobial susceptibility.
Conclusion
Based on the findings of this study, it may be concluded that men are also at high risk of developing UTI. The most common clinical presentations of UTI are fever with chills, lower abdominal pain, burning micturition, and reduced urine output. Other uncommon presentations include vomiting, hematuria, increased frequency of urination, and dysuria while few patients with UTI may be asymptomatic. T2DM, CKD, HUN, renal calculi, and benign prostatic hyperplasia are the important risk factors of UTI. The other least common risk factors include malignancy, chronic liver disease, RVD, urethral stricture, and neurogenic bladder while pregnancy and lower segment cesarean section in women. Still, E. coli is the predominant agent in complicated and uncomplicated UTIs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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