March 201628 THE ANTISEPTIC

“when I woke up just after dawn on sept 28, 1928, I certainly didn’t plan to revolutionize all medicine by discovering the world’s first antibiotic ,or bacteria killer,”…. “But I guess that was exactly what I did”

------Alexander Fleming.INTRODUCTION:

Leading cause of morbidity and health care expenditure in persons of all ages.

Urinary tract infection is the second most common infection next to respiratory tract infection. UTI in pregnancy is commonly presented as urinary frequency, dysuria, fever with chills and rigor, suprapubic tenderness and associated with preterm contractions sometimes due to release of prostaglandin. Symptomatic UTI occurs in 1-2% of all pregnancies.UTI in pregnancy can be categorized as follows:

1. Lower UTI-affecting urethera and bladder

2. Upper UTI-affecting kidney.Symptomatic bacteriuria is more than 100 organism/ml of urine with accompanying pyuria (>7 WBC/ml).

Organisms responsible for UTI

1. Bacterial: Gram Negative: E.coli (80%), proteus

M i r a b i l i s , k l e b s i e l l a pneumoniae, gardenella vaginalis

Ureaplasma urealyticum, pseudomonas aeroginosa

A Clinical Study on Symptomatic Urinary Tract Infection During PregnancyMITALI MAHAPATRA

Dr. Mitali Mahapatra, MBBS., MS., Senior consultant, Department of Obstetrics & Gynaecology, Christian Hospital, Behrampur.

Specially Contributed to "The Antiseptic" Vol. 113 No. 3 & P : 28 - 31

Gram positive: Mycoplasma, Group B Streptococcus,staph aureus,staph epidermidis,staph saprophyticus,gonococcous chlamydia.

2. Viral: Adenovirus, CMV3. Fungal: candida albicans UTI Commonin Pregnancy..Why?

1. P r e g n a n c y i n c r e a s e s susceptibility to certain organisms.

2. Ureteral dilation during pregnancy causing stasis of urine in the urinary tract leading to more chance of infection

3. Increase in plasma volume during pregnancy leads to decrease in urine concentration.

4. Most of the pregnant women develop glycosuria which favours bacterial growth.

5. Increased bladder volume and decreased bladder tone and decreased ureteral tone lead to increased urinary stasis and ureterovesical reflux.

Aims and Objectives

i) To find out the obstetric outcome in symptomatic urinary tract infections during Pregnancies

ii) Type of organisms responsible for symptomatic UTI and response to treatment in those patients.

Materials and Methods

This study was conducted in O&G Dept of Hi-Tech Medical College, Bhubaneshwar,

Orissa from 2012 september to Jan 2014. All patients with symptomatic

UTI during

Pregnancy have been thoroughly studied regarding the organism isolated from urine culture as well as their sensitivity pattern to antiobiotics.

It is to be noted that the safe antibiotic during pregnancy was implicated for that patient in a standard regimen & its response was observed.

As a matter of fact, within one wk. of completion of antibiotic course, the pregnant woman was advised for urine culture & sensitivity .

Even after taking a course of antibiotic if

She was found to be uncured of symptoms and bacteriological pathogenesis was noted then repeat urine culture was done and according to sensitivity the repeat antibiotic was given.

Unfortunately, within one wk of completion of 2nd course of antibiotic if she was found to be uncured, she was subjected for reculture and retreatment both symptomatically and bacteriologically.

Method Adopted: Standard Loop Method

Inoculating loop of standard dimension is used to take a small, approximately fixed and known volume of mixed uncentrifuged urine and spread it over a plate of agar medium, commonly on CLED medium.

Theplateisincubatedat37˚Cfor 24-48 hr, the number of colonies counted or estimated.And this number is used to calculate the number of viable bacteria per ml of urine.

29 THE ANTISEPTIC March 2016

The fixed volume loop is 4 mm in diameter and can hold 0.005 ml urine, the total bacterial count /ml will be the no. of colonies multiplied by 200.

Single bacterium would form a single colony. Count more than 10*5 bacteria of single species

per ml : significant bacteriuria.

Observations:

By age group: out of 100 cases of pregnant women with symptomatic UTI

83% are between 21-30 yrs,12% cases <21yrs and 5%>30 yrs.

Colonies of Escherichia Coli on Nutrient Agar

Total Number of Cases Studied = 100Inclusion Criteria

All pregnant patients with symptomatic UTI.Exclusion Criteria:

Non cooperative patients.Not giving informed consent. Asymptomatic UTI.

By gravida: Symptomatic uti is in 66% primi gravidaGravida No.of Cases % Primi 66 66% 2nd 14 14% 3rd 17 17% >3rd 3 3%

Literacy Wise

literacy No. of cases % literate 47 47% lilliterate 53 53%

Colonies of staph aureus on blood agar

March 201630 THE ANTISEPTIC

Antepartum ComplicationsSymptoms No.of Cases %

Frequency 87 87%

Dysuria 81 81%

Fever with Chill and Rigor 51 51%

Fasting Blood Sugar

FBS(mg/dl) No of cases %

60-70 7 7

71-80 11 11

81-90 18 18

91-100 26 26

101-110 36 36

>110 2 2

Uterine Activity at Ist Presentation

Status of Ist No of Presentation Cases %

Not in Labor 85 85%

Without Preterm Contraction 63 63%

With Preterm Contraction 22 22%

In Labor 15 15%

Organism Isolated

Organisms No of Cases %

E.Coli 69 69

S. Aureus 18 18

Candida Albicans 2 2

Proteus 2 2

Klebsiella 3 3

Pseudomonas 4 4

No Growth 2 2

Postpartum Complications

Sensitivity to Antibiotic

SensitivityStudied Clinically No .of Cases Cured %

Nitrofurantoin 87 72 82.8

Cefuroxime 4 3 75

Fluconazole 2 2 100

Amoxicillin 5 4 80

Amoxicillin+ Clavulinic Acid 17 16 94.1

Piperacillin+ Tazobactum 1 1 100

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Name of E.Coli Klebsiella Psmonaseudo Proteus Candida Anti Microbial Agent Nitrofurantoin MS WS R WS NA Amoxicillin MS SS R SS NA Cefuroxime MS SS MS WS NA Amoxicillin + Clavulunic Acid SS SS SS SS NA Fluconazole NA NA NA NA SS Piperacillin + Tazobactum SS SS SS SS NA

Sensitivity to Antimicrobials

E.COLI is strongly sensitive (SS) to amoxicillin + CLAVULANIC ACID & piperacillin + tazobactum & moderately sensitive to nitrofurantoin, amoxicillin and cefuroxime and rest as given in the table.All the klebsiella and proteus were treatedBy amoxicillin as 1st line of treatment and

reculture and retreatment required in one case All pseudomonas were treated with cefuroxime

out of which one needed re-culture and retreatment with piperacillin +tazobactum.

Single dose treatment Amoxicillin 3 gm, ampicillin 2gm, cephalosporin

2gm, NFT 200mg 3 day course Amoxicillin 500 mg tds Ampicillin 250 mg qid Cephalosporin 2 gmqid Ciprofloxacin 250 mg bd Levofloxacin 250 mg bd NFT 50-100 MG BD Other NFT 100MG QID 10 DAYS Treatment Failure NFT 100MG at Bed Time for 21 Days CONCLUSION

During the study it was found out that as per age group 21-30 yrs i.e about 83% more prone to UTI, 67% cases booked category, E.COLI was the causative organism in majority of cases i.e 69%.

E.Coli was SS to amoxocillin + clavulinic acid and piperacillin + tazobactum.

Klebsiella is SS to amoxicillin, cefuroxime, amoxicillin + clavulinic acid / pip + tazobactum

These all data are similar to study done by Dr. Md.Talukdar, Khatoon in july 2010.

Symptomatic UTI INFECTION during pregnancy causes PROM, oligohydraminos, PPH, anaemia, Puerperal pyrexia, breast complication, preterm contraction, early labor last but not the least pyelonephritis.

The fetal complication encountered in the current study are prematurity, intrapartum asphyxia. LBW, IUGR.

SO, ANY EVIDENCE OF symptomatic uti should be diagnosed as early as possible by urine culture.

Take Home Message

Cranberry juice should be advised to uti patient. Clean catch midstream urine should be sent for

culture and sensitivity. Screening for all pregnant women should be

done at their first prenatal visit. NITROFURANTOIN causes nausea and vomiting

and should be given after meal. REFERENCES

Clinical pharmacy and therapeutics by Roger Walker, Clive Edwards; 3rd edition; page 503 – 511.

Patterson TF Androl VT,Infect.Dis clin North Am , Bacteriuria in pregnancy 1987,1:807-22 and co.

Hooton, Scholes, et al. A prospective study of risk factors for symptomatic urinary tract infections in young women. N Engl J Med 1996; 335:468.

Hooton, Besser, et al. Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. Clinic Infect Dis 2004; 39:75.

Stamm, Hooton. Management of urinary tract infections in adults. N Engl J Med 1993; 329:1328.