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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 5-10

Epidemiology and antibiotic sensitivity pattern of asymptomatic bacteriuria during pregnancy: A cross-sectional study


1 Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, Anantapur, Andhra Pradesh, India
2 Department of Obstetrics and Gynecology, Government General Hospital, Anantapur, Andhra Pradesh, India
3 Department of Pharmaceutical Chemistry, Raghavendra Institute of Pharmaceutical Education and Research, Anantapur, Andhra Pradesh, India
4 Department of Pharmaceutical Chemistry, Balaji College of Pharmacy, Anantapur, Andhra Pradesh, India
5 Department of Pharmacy Practice, Balaji College of Pharmacy, Anantapur, Andhra Pradesh, India

Date of Submission14-Feb-2019
Date of Acceptance14-Mar-2019
Date of Web Publication30-Apr-2019

Correspondence Address:
Mr. Narayana Goruntla
Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, K.R. Palli Cross, Anantapur - 515 721, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.jhrr_15_19

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  Abstract 


Background: Asymptomatic bacteriuria (ASB) during pregnancy is associated with significant maternal and fetal complications. Continuous monitoring of antibiotic sensitivity pattern of bacterial isolates is required for appropriate management of ASB. Aims: The study aims to assess the prevalence, risk factors, and antibiotic sensitivity profile of ASB during pregnancy. Materials and Methods: A cross-sectional, hospital-based study was conducted in the pregnant women attending Obstetrics and Gynecology Department of a tertiary care hospital. A suitably designed data collection form was used to collect sociodemographic profile, obstetric history, and illnesses suffering from the participants. Urine specimens of the participants were processed for isolation and identification of bacterial species. Kirby–Bauer disc diffusion test was used to screen antibiotic sensitivity of the isolated bacteria. Statistical Analysis: Descriptive statistics were used to represent the sociodemographic data. Chi-square test was used to associate risk factors for the development of ASB during pregnancy. Results: A total of 1332 women were participated in the study. The prevalence of ASB among pregnant women was 86 (6.4%) and Escherichia coli (58; 67.4%) was the most predominant bacteria. Meropenem, cephalosporin's, and gentamycin were shown higher sensitivity in ASB. Advanced age, illiteracy, rural residency, multigravida, multiparity, history of abortion, and medical illnesses were strongly associated to develop ASB during pregnancy. Conclusion: E. coli were the most predominant isolated uropathogen in ASB. The study observed that there is a wide variation in the antibiotic sensitivity pattern of isolated organisms. Hence, there is a need of routine urine culture sensitivity screening in pregnant women for rational use of antibiotics and to reduce the antibiotic resistance.

Keywords: Antibiotic sensitivity, asymptomatic bacteriuria, pregnant women, urinary tract infection


How to cite this article:
Goruntla N, Jampala S, Mallela V, Bandaru V, Thamineni R, Bhupalam P. Epidemiology and antibiotic sensitivity pattern of asymptomatic bacteriuria during pregnancy: A cross-sectional study. J Health Res Rev 2019;6:5-10

How to cite this URL:
Goruntla N, Jampala S, Mallela V, Bandaru V, Thamineni R, Bhupalam P. Epidemiology and antibiotic sensitivity pattern of asymptomatic bacteriuria during pregnancy: A cross-sectional study. J Health Res Rev [serial online] 2019 [cited 2019 Jul 17];6:5-10. Available from: http://www.jhrr.org/text.asp?2019/6/1/5/257478




  Introduction Top


Urinary tract infection (UTI) is the most common health problem in all age groups, especially in women than men due to the shorter urethra, closer proximity of the anus with vagina, and pathogen entry facilitated by sexual activity.[1],[2] The rate of UTI is more in pregnant women compared to normal women. This is majorly due to the morphological, anatomical, hormonal, and physiological variations in the genitourinary tract.[3] Under normal circumstances, acidic pH, high osmolality, and high urea concentration of urine will act as a bacteriostatic.[4] During pregnancy, reduction in the immunity and physiological increase in plasma volume will decrease the urine concentration. This will decrease the ability of the lower urinary tract to resist the invading organisms and promotes the bacterial growth.[5] Dilatation of the ureter, decrease in the peristalsis, and bladder tone is also observed during pregnancy. This will promote the stagnation of urine in the bladder and reduction in the urine clearance. A good environment for the growth of bacteria will be created during pregnancy and develops UTI.[6]

The UTI during pregnancy will be either symptomatic or asymptomatic. Symptomatic bacteriuria will be diagnosed easily based on symptoms, further, it will be treated and managed well. However, the diagnosis of asymptomatic bacteriuria (ASB) will be ignored due to lack of symptoms. If ASB left untreated, it may lead to various maternal and fetal complications. Maternal complications include anemia, postpartum hypertension, symptomatic cystitis, acute pyelonephritis, and septicemia, which may lead to preterm labor and delivery. Fetal complications include preterm birth, developmental delay, mental retardation, low birth weight, and increased maternal mortality.[7],[8]

ASB is defined as the presence of bacteria in urine with a colony count >105/ml, and the patient does not have symptoms.[9] Globally, it was estimated that 2%–10% of pregnant women will be affected with ASB. The prevalence of ASB in pregnancy fluctuates extensively within and between the countries. For example, the prevalence of ASB in pregnancy was 12.6% in India,[10] 29.5% in Nigeria,[11] 10.0% in Egypt,[2] 21.5% in Kenya,[12] 7.3% in Ghana,[13] 6.0% in Singapore,[14] and 4.3% in Malaysia. This wide variation in the prevalence of ASB in pregnancy was due to the diverse cultural practices established in various countries. Risk factors that are associated with increased incidence of ASB include past UTIs, advanced maternal age, multiparity, lower socioeconomic status, low education level, gestational diabetes mellitus, and poor genital hygiene.[15],[16] Semi-quantitative urine culture is the gold standard method for the diagnosis of ASB, but a routine culture of urine in all pregnant women is not feasible in developing countries. Women associated with above-mentioned risk factors should be advised for urine routine and culture sensitivity screening for early diagnosis and management of ASB, which is a cost-beneficial option.[17]

The most predominant etiological agents for ASB is  Escherichia More Details coli (80%–90%), followed by Klebsiella pneumonia, Proteus mirabilis, and Pseudomonas aeruginosa. Gram-positive bacteria such as Enterococcus faecalis, Streptococcus B, and coagulase-negative staphylococci are less frequent etiological agents for ASB.[18] The antibiotic resistance is a major problem seen in ASB cases. Selection of appropriate empirical antibiotic regimen before culture sensitivity will be determined by using a previous microbial culture sensitivity records.

This study aims to assess the prevalence, risk factors, and antibiotic sensitivity profile of ASB during pregnancy. The study results will aid to develop antibiotic guidelines and to plan preventive strategies for ASB in pregnant women, which will reduce the maternal and fetal complications.


  Materials and Methods Top


Thus, a hospital-based cross-sectional study conducted in Outpatient Obstetrics and Gynaecology Department of Tertiary Care Hospital located in Anantapur, Andhra Pradesh, India. This is a 750-bedded hospital, which provides all types of medical and ancillary services to the public coming from various resource-limited settings of Anantapur district. This study was carried out for 6-month period from July 2017 to December 2017. Due permission was sought from the medical superintendent, and Ethical Clearance (RIPER/IRB/2017/038) obtained from the Institutional Review Board (IRB) before initiation of the study. All pregnant women who came for a first antenatal visit and willing to participate in the study were included. Informed consent were taken from participants before enrolling them in study. Pregnant women having the symptoms of UTI (lower abdominal pain, fever, burning micturition, increased frequency of micturition, and dysuria), pregnancy-induced hypertension, antibiotic therapy within 14 days prior to the study, pyrexia of unknown origin, and known congenital anomalies of the urinary tract were excluded from the study. To determine the number of pregnant women to be enrolled in the study, a single proportion formula was used with a 7.3% of prevalence (p),[19] 20% of relative error (d), 10% nonresponse rate, and 95% confidence level which was calculated as 1332 [Figure 1].
Figure 1: Sample size calculation

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All pregnant women who are attending antenatal visit and met study criteria were included after obtaining informed consent form. Data related to sociodemographic characteristics (age, economic status, and education level), obstetric history (trimester, gravida, parity, and history of previous abortions) and risk factors (past history of UTI, anemia, preeclampsia, and diabetes) were collected by face-to-face interview using a suitably designed prevalidated data collection form.

All participants were instructed to collect clean-catch midstream urine sample (10–20 ml) using wide-mouthed sterile-capped container. The samples were promptly transported to the microbiological laboratory within 1 h and cultured on blood agar, nutrient agar, and Mac-Conkey agar plates. Then, the plates were incubated aerobically at 37°C for 24 h.[20] After the growth of bacteria, colony-forming units (CFUs) were estimated. If the growth was ≥105 CFU/mL of urine was considered as significant bacteriuria, <105 CFU/mL was insignificant, and no growth even after 48 h will be considered as sterile. A colony count of 105 or more pure isolates will be processed for further identification. Suspected bacterial species were characterized by Gram-stain, morphology, microscopy, motility test, and standard biochemical tests.

The standardized Kirby–Bauer disc diffusion test was used for antibiotic susceptibility testing of all isolates according to the Clinical and Laboratory Standards Institute.[21] The culture sensitivity and resistance data regarding samples were obtained from the clinical microbiology department of the hospital. The data were subjected to evaluate the number of isolates sensitive toward various antibiotics such as amoxicillin (AMX), ampicillin (AMP), cefoxitin (CEF), nitrofurantoin (NIT), cotrimoxazole (COT), meropenem (MPM), ceftriaxone (CTR), cefepime (CPM), gentamycin (GM), and cefpodoxime (CPD).

Statistical analysis

Epi Info 7 for Dos version 3.5.1software (Centers for Disease Control and Prevention, Clifton Road Atlanta, USA) was used to analyze collected data from all the study subjects. Descriptive statistics such as mean, standard deviation (SD), frequency, and proportion will be used to represent the sociodemographic characteristics of the study population. Prevalence of ASB in pregnant women and microorganisms associated with the development of ASB their antibiotic sensitivity pattern was represented in proportion.

The association between sociodemographic characteristics and development of ASB in pregnant women was measured by Chi-square test and P < 0.05 was considered as statistically significant.


  Results Top


A total of 1332 women were participated in the study; in these half of the proportion were between the age of 18 and 24 years. The mean age of the women was 24.6 (SD = 4.8) and the majority are illiterate (866; 66.5%), rural residency (793; 59.5%), monthly household income in between 10,000 and 30,000 INR (632; 47.4%), first trimester (626; 47.0%), second gravida (634; 47.6%), and second parity (728; 54.6%). Very less number of women had a history of abortion (26; 1.9%) and medical illnesses such as UTI (43; 3.2%), diabetes (84; 6.3%), anemia (289; 21.7%), and preterm labor (136; 10.2%) [Table 1].
Table 1: Sociodemographics, obstetrics, and clinical profile of the study participants (n=1332)

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Among 1332 women, 86 (6.4%) cases were found to have culture positive and significant bacterial growth. The study estimates a prevalence of 6.4% ASB in pregnant women. Sterile (921; 69.1%), contaminated (187; 14%), and insignificant bacterial growth (138; 10.4%) was observed in urine culture results [Table 2].
Table 2: Result of urine culture (n=1332)

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In 86 isolated bacterial strains from urine, the most predominant bacteria were E. coli (58; 67.4%), followed by Klebsiella species (9; 10.5%), Proteus (6; 6.9%), P. aeruginosa (6; 6.9%), Staphylococcus aureus (4; 4.6%), and Enterococcus species (3; 3.5%). The sensitivity pattern of these organisms toward AMX, AMP, CEF, NIT, COT, MPM, CTR, CPM, GM, and CPD was shown [Table 3].
Table 3: Antibiotic sensitivity pattern of bacterial isolates

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In the enrolled pregnant women, statistically significant association of ASB with age, educational status, residence, gravida, parity, and history of abortion and medical illnesses were observed [Table 4].
Table 4: Association of sociodemographic characteristics with significant asymptomatic bacteriuria (n=1332)

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  Discussion Top


ASB in pregnancy is a chief cause of maternal and perinatal complications.[22] Globally, the prevalence of ASB varies from 4% to 29%. In the present study, the prevalence of ASB was 6.4%, and this is nearly similar to the findings (6.2% and 6% of prevalence) of a study conducted by Khattak et al. in India and Bidin et al. in Malaysia.[14],[23] Similar studies which were conducted by Ankur et al. and Jain et al. in India given the higher prevalence of 8.8% and 10% when compared with our study.[24],[25] The extensive variations in the prevalence of ASB are majorly due to differences in population characteristics such as age, parity, education, socioeconomic status, sexual activity, and health care during pregnancy.[26]

The present study found that 22.6% of ASB cases are in pregnant women bearing age between 30 and 35 years. Pregnancy in advanced age is a major risk factor and having a strong association (χ2 = 115.2 and P < 0.001) for the development of ASB. A similar association was observed in the study conducted by Alghalibi et al.[27]

The study found that ASB in pregnancy was strongly associated with multigravida (χ2 = 25.3 and P < 0.001) and multiparity (χ2 = 45.9; P < 0.001). A similar association was also found in studies of Sujatha and Nawani and Roy et al.[20],[28] Other factors such as rural residency (χ2 = 20.9 and P < 0.001), illiteracy (χ2 = 115.2 and P = 0.005), history of abortion (χ2 = 44.9 and P < 0.001), and medical illnesses (χ2 = 202.5 and P < 0.001) are also strongly linked to developing ASB in pregnancy.

This study will give a clear picture regarding risk factors associated with ASB in pregnancy. Even though the urine culture is the gold standard method to diagnose ASB in pregnant women, but it is very difficult to perform urine culture in all pregnant women due to high cost. This study will guide the practitioners to selectively advise urine routine and culture in pregnant women bearing risk factors.

In this study, the most predominant bacteria were E. coli (67.4%), followed by Klebsiella species (10.5%). Many of the studies conducted in India and abroad are reported E. coli as a predominant urinary pathogen for the development of ASB, which were similar to our study findings.[28],[29]

In the present study, Gram-negative organisms such as E. coli and Klebsiella species are highly sensitive toward MPM (94.8% and 100%). Proteus was shown sensitivity toward all cephalosporin antibiotics such as CTR (100%), CEF (83.3%), CPM (83.3%), and CPD (83.3%). Gram-positive organisms such as P. aeruginosa is highly sensitive toward GM (100%) and S. aureus is sensitive toward CEF (100%), NIT (100%), COT (100%), and CTR (100%). Enterococcus species are more sensitive toward NIT (100%) and COT (100%). This wide variation in the sensitivity pattern of bacteria toward antibiotics was majorly due to irrational use of antibiotics by self-medication for minor infections.

Communication of the current study findings among health-care professionals working in Obstetrics and Gynecology Department, will bring a change in the approach toward pregnant women in terms of screening for risk factors, urine routine, and selection of suitable antibiotic in ASB. Based on antibiotics availability in the hospital, a total of ten antibiotics were only tested for the sensitivity of organisms. The study will give only local prevalence rate of ASB in pregnancy, and its associated risk factors in the region of Anantapur district.


  Conclusion Top


The prevalence of ASB among pregnant women from rural settings of Anantapur district was 6.4%. E. coli was the most predominant uropathogen isolated from the urine samples of pregnant women. Wide variation in antibiotic sensitivity pattern of isolated organisms found in this study suggests that there is a need to conduct a routine urine culture in pregnant women for rational use of antibiotics and to reduce the microbial resistance. It is essential to halt the culture of antimicrobial misuse, and continuous surveillance of multidrug-resistant strains is very important to follow changes in antibiotic susceptibility patterns over time.

Acknowledgment

The authors would like to thank all the participants who are involved in this research study. All the authors are wholeheartedly thankful to the people who are directly or indirectly responsible for the completion of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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