ASYMPTOMATIC BACTERIURIA AMONG PREGNANT WOMEN ATTENDING ANTENATAL CARE AT ABIA STATE UNIVERSITY TEACHING HOSPITAL, ABIA STATE, NIGERIA (ABSUTH)

ABSTRACT

Asymptomatic bacteriuria refers to the presence and multiplication of bacteria in the bladder urine in the absence of symptoms of urinary tract infection. Asymptomatic bacteriuria has been observed to be a strong criterion for urinary tract infection. It is therefore a means of predicting urinary tract infection (UTI). It is common among pregnant women and females. Untreated asymptomatic bacteriuria (ASB) during pregnancy may cause serious complications such as pyelonephritis and delivery of premature or low birth weight infant. This study assessed the prevalence of asymptomatic bacteriuria and the antibiotic susceptibility pattern of the urinary bacterial isolates from pregnant women attending antenatal care clinic at Abia state University Teaching Hospital, Aba, Abia State, Nigeria. Mid-stream urine samples were collected from 100 pregnant women attending antenatal care at Abia state University Teaching Hospital, Aba, Abia State, Nigeria between the ages of 18-49 years. Each specimen was cultured on Cystine Lactose Electrolyte Deficient (CLED) agar using standard bacteriological methods. Identification of suspected colonies and antibiotic sensitivity testing were done. Thirty-eight samples (38) which represent 38.0% showed significant bacteriuria while 62 samples (62.0%) showed no bacteriuria or no significant bacterial growth. Escherichia coli was found to be the most predominant, (36.8%) followed by Proteus spp, (21.1%), Psedomonas aeruginosa (18.4%), Staphylococcus aureus (15.8%) and the least Klebsiella spp. (7.9%). Nitrofurantoin, Ciprofloxacin, Ofloxacin, Gentamicin and Ceftazidime were very effective antimicrobial agents against the isolates while the isolates were highly resistant to Cefexime and Augmentin (Co-amoxiclav). E. coli was the most common bacteria for asymptomatic bacteruria among pregnant women attending antenatal care at Abia state University Teaching Hospital, Aba, Abia State, Nigeria in this study. Education on the importance of inclusion of urine screening in antenatal care should be emphasized.

TABLE OF CONTENTS

Title Page                                                                                                                               i

Certification                                                                                                                          ii

Dedication                                                                                                                             iii

Acknowledgements                                                                                                               iv

Table of Contents                                                                                                                   v

List of Tables                                                                                                                         vi

List of Figures                                                                                                                        vii

Abstract                                                                                                                                  x

CHAPTER ONE

1.0           Introduction                                                                                                                2

1.1                             Aim and objectives                                                                                                     3

1.1.1      Aim                                                                                                                             3

1.1.2    Objectives                                                                                                                   3

CHAPTER TWO

2.0       Literature review                                                                                                        5

2.1       Urinary tract infection (UTI)                                                                                      5

2.2       Asymptomatic bacteriuria                                                                                          7

2.2.1    Historical aspects                                                                                                        8

2.2.2    Causes and pathogenesis of asymptomatic bacteriuria                                              9

2.3       Etiology of urinary tract infection                                                                             10

2.4       Incidence of urinary tract infection                                                                            11

2.5       Epidemiology                                                                                                             12

2.6       Risk factors for asymptomatic bacteriuria                                                                 14

2.7       Prevalence of asymptomatic bacteriuria                                                                    15

2.8       Classification of urinary tract infection                                                                      17

2.8.1    Lower urinary tract infection                                                                                     17

2.8.2    Upper Urinary Tract Infection                                                                                    17

2.8.3    Uncomplicated Urinary Tract Infection                                                                     17

2.8.4    Complicated Urinary Tract Infection                                                                         17

2.9       Outcome of asymptomatic bacteriuria                                                                       18

2.10     Complications                                                                                                            18

2.11     Treatment of asymptomatic bacteriuria                                                                     22

2.12        Pathogenic organisms causing urinary tract infection                                               23

2.12.1 Escherichia coli                                                                                                          24

2.12.2 Staphylococcus aureus                                                                                               24

2.12.3  Klebsiella spp.                                                                                                            24

2.12.4  Pseudomonas spp.                                                                                                      25

CHAPTER THREE

3.0        Materials and method                                                                               26

3.1       Study area                                                                                                       26

3.2       Study population                                                                                             26

3.3           Sample collection                                                                               26

3.4       Media preparation                                                                                          27

3.5           Inoculation and isolation                                                           27          

3.6           Identification and characterization of isolates                                          27

3.6.1    Gram stain technique                                                                                    27

3.7           Biochemical tests                                                                                            28

3.7.1      Catalase test                                                                                                                            28

3.7.2      Oxidase test                                                                                                                28

3.7.3      Coagulase test

3.7.4    Indole test                                                                                                                   28

3.7.4      Citrate utilization test                                                                                                 29

3.7.5      Triple sugar iron agar (TSIA)                                                                                     29

3.8           Antibiotic sensitivity testing                                                                                                                                                  30

CHAPTER FOUR

4.0  Results                                                                                                                        32

CHAPTER FIVE

5.0  Discussion                                                                                                                   37

5.1 conclusion                                                                                                             39

5.2 references

Appendix

LIST OF TABLES

TABLES     TITLE                                                         PAGES

 1            Socio-demographic characteristics of women attending antenatal care at Abia State University Teaching Hospital, Aba, Abia State. Screened for asymptomatic bacteriuria.                33

            2.              Prevalence of bacteria isolated from urine of pregnant women attending Antenatal care at   Abia State University Teaching Hospital, Aba, Abia State.                34

3            Antibiotic susceptibility pattern of bacteria isolates from pregnant women attending antenatal care at Abia State University Teaching Hospital, Aba, Abia State.                  35

LIST OF FIGURES

FIGURE     TITLE                                                                     PAGE

1                      Average percentage susceptibility of different antimicrobial agents against bacteria isolates from urine samples of pregnant women attending antenatal care at Abia State University Teaching Hospital, Aba, Abia State.                                                                                                                                                                                                                           36

CHAPTER ONE

1.0          INTRODUCTION

Bacteriuria is a clinical condition that refers to the presence of one or more bacteria in urine. It is basically a disease condition caused by a wide variety of bacteria. The upper urethra is the most frequent site of infection within the urinary tract, but the entire system is always at risk of invasion by bacteria once one of the parts is infected (Kunin, 1997).

The term 'bacteriuria' means the presence of bacteria in urine. It may results from contamination during or after collection of urine or it may indicate the presence of bacteria in bladder urine.

To distinguish among these possibilities, the term “significant bacteriuria” was introduced which was defined as the occurrence of 10⁵ or more bacteria per ml of voided midstream urine aseptically collected. Bacteriuria can be divided into symptomatic and asymptomatic (Kunin, 1997).

Asymptomatic bacteriuria refers to the presence and multiplication of bacteria in the bladder urine in the absence of symptoms of urinary tract infection while symptoms are present in symptomatic cases.

Bacterial infections of the urinary tract are commonly seen in outpatients, hospitalized patients and apparently healthy populations.

Asymptomatic bacteriuria occurs reliably more frequently in females as compared with males and it is a major criterion of urinary tract infection (UTI) (Nurullaev, 2004). Reasons adduced to this include shorter and wider urethra and its proximity to the anus. Asymptomatic bacteriuria (ASB) accounts for 2-10% pregnancies in developed countries while incidence is much more in developing and under- developed countries.

Asymptomatic bacteriuria is a major risk factor for the development of urinary tract infections (UTIs) during pregnancy resulting in serious medical and obstetrical complications if untreated. In pregnancy, various hormonal and mechanical changes lead to significant alterations in the urinary tract like dilatation, decrease in peristalsis in the ureter and decrease in bladder tone. In addition, the physiological increase in plasma volume during pregnancy, decreases urine concentration leading to decreased ability of the lower urinary tract to resist invading organisms (Belty et al., 1998).These changes have a profound impact on the acquisition and natural history of bacteriuria and lead to an otherwise healthy woman susceptible to serious infection complications. Also a number of conditions like low socioeconomic status, multiparty, illiteracy, medical disorders like diabetes mellitus and sickle cell trait are also associated with increased incidence of asymptomatic bacteriuria in pregnancy.

Symptomatic bacteriuria poses no problems because of its easy diagnosis and treatment due to its overt symptoms but asymptomatic bacteriuria is difficult to diagnose which is more common in pregnant women.

Therefore to prevent untoward complications in the mother and baby that may arise due to asymptomatic bacteriuria; it has been suggested to do routine screening for all pregnant women attending the antenatal clinic even in the absence of symptoms (Maclean, 2001).

Knowledge of the nature, cause and outcome of bacteriuria has obviously been based on the study of the development of symptoms and signs over a period of time. This infection in adult usually leads to the irritation of urethral mucosa, causing frequent painful urination with turbid urine (Kaye and Santoro, 1979). In infants there may be unexplained jaundice or an appearance suggestive of sepsis. In healthy individuals the normal kidney and bladder urine are sterile, but the urethral and introital flora consist largely of non-pathogenic Corynebacterium, Lactobacillus, Staphylococcus epidermis, Gardnerel lavaginalis and non-haemolytic streptococci, while E-coli may be absent or found in small quantities (Farr, 1970).

The state of bacteriuria is detected by qualitative urine culture indicated by finding more than 10⁵ colony forming units (CFU) (Buckley et al., 2000).

Urinary tract infection (UTI) is a common health problem among women compared with men due to shorter urethra, closer proximity of the anus with vagina, and pathogen entry facilitated by sexual activity (Feltosa et al., 2009). It is estimated that one in three women of childbearing age contracts urinary tract infection which may manifest symptoms or remain asymptomatic (Duarte et al., 2008). Pregnant women are more susceptible to urinary tract infection, owing to altered anatomical and physiological state during pregnancy (Abdullah and Al-Moslih, 2005).

In Nigeria and many other developing countries, routine urine culture for detecting asymptomatic bacteriuria is not carried out for antenatal women probably due to cost and delay in obtaining culture result (Imade et al., 2010). Strip urinalysis is often preferred by most clinicians to culture in accessing urine in pregnant women because of speed and simplicity. Though this method can detect presence of protein, nitrite, and leucocytes esterase enzyme which may suggest bacteriuria, its sensitivity is low (Colgan et al., 2006). Moreover, unlike culture, strip urinalysis fails to identify the etiologic agents and the antibiotic sensitivity pattern. This practice will not allow for proper management of urinary tract infection in pregnant women attending antenatal care thus increasing their risk of coming down with complications.

Due to the above reasons, the burden of urinary tract infection in pregnant women and its associated complications in this environment may still be highly underestimated.

1.2                             AIM AND OBJECTIVES

1.2.1      AIM

The broad aim of this research is to determine the prevalence of asymptomatic bacteriuria among pregnant women attending antenatal care at Abia state University Teaching Hospital Aba, Abia State, Nigeria.

1.1.2    OBJECTIVES

1.     To determine the bacterial species in the urine sample of patients.

2.     To determine the antibiotic profiles of the bacterial isolates.

3.     To determine the demographics, those that affect/contribute more to/predispose patients to infection.

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