ORIGINAL ARTICLE
Year : 2017 | Volume
: 61 | Issue : 2 | Page : 118--123
Urinary tract infection among pregnant women at a secondary level hospital in Northern India
Shashi Kant1, Ayush Lohiya2, Arti Kapil3, Sanjeev Kumar Gupta1,
1 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Senior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Professor, Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
Correspondence Address:
Shashi Kant
Centre for Community Medicine, All India Institute of Medical Sciences, Room No. 11, Ansari Nagar, New Delhi - 110 029
India
Abstract
Background: Urinary tract infection (UTI) during pregnancy is frequently associated with complications. Currently, in India, there is no regular screening for UTI, and facility for diagnosis of UTI is not available at peripheral government health centers. Objective: To estimate the proportion of pregnant women with UTI among antenatal clinic attendees in rural Haryana. Methods: Eligible participants were pregnant women attending antenatal clinic of secondary care center of rural Haryana from March to May 2015. Consecutive sampling was done to select pregnant women. Interview schedule was administered to the selected women, and midstream urine sample was collected. Urine sample was plated on MacConkey agar, and colony count was done using standard methods. Results: A total of 1253 pregnant women were included in the study. The proportion of women with symptoms of UTI on the basis of history was 33.3% (95% confidence interval [CI] - 30.7, 35.9), and UTI by colony count was 3.3% (95% CI - 2.4, 4.5). The presence of UTI was found to be significantly associated with the presence of any symptom of UTI on multivariate analysis (odds ratio [95% CI] - 7.35 [1.95, 27.77]). Conclusions: The burden of UTI among pregnant women attending antenatal clinic of a sub-district hospital was considerable, more so among the women that presented with symptoms suggestive of UTI. The study suggested that considering the burden of UTI and its complications, diagnosis of UTI at a resource-constrained setting like a secondary care hospital can be done after screening women for symptoms suggestive of UTI.
How to cite this article:
Kant S, Lohiya A, Kapil A, Gupta SK. Urinary tract infection among pregnant women at a secondary level hospital in Northern India.Indian J Public Health 2017;61:118-123
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How to cite this URL:
Kant S, Lohiya A, Kapil A, Gupta SK. Urinary tract infection among pregnant women at a secondary level hospital in Northern India. Indian J Public Health [serial online] 2017 [cited 2023 Mar 27 ];61:118-123
Available from: https://www.ijph.in/text.asp?2017/61/2/118/207410 |
Full Text
Introduction
Urinary tract infections (UTIs) are bacterial infections with a global annual incidence of approximately 150 million cases. The estimated economic burden is more than 6 billion U.S. dollars.[1],[2] About 40% of women and 12% of men experience at least one symptomatic UTI during their lifetime, and as many as 40% of affected women show recurrent UTI.[3],[4],[5],[6]
UTIs are one of the most common medical complications of pregnancy. Increased incidence of UTI during pregnancy is due to the morphological and the physiological changes that take place in the genitourinary tract during pregnancy.[7],[8]
Pregnancy causes numerous hormonal and mechanical changes in the body.[9],[10] Beginning in the 6th week, with peak incidence during 22nd–24th weeks of gestation, 90% of the pregnant women develop ureteric dilatation thereby increasing the risk of urinary stasis and vesicoureteric reflux.[11] In addition, glycosuria and aminoaciduria during pregnancy provide an excellent culture medium for bacteria in areas of urinary stasis.[10] These changes along with already short urethra and difficulty with hygiene due to the distended pregnant belly increase the frequency of UTI in pregnant women.
UTI may present in pregnancy either as asymptomatic bacteriuria or as symptomatic infection. The prevalence of asymptomatic bacteriuria has been estimated to range from 2% to 10% in various studies globally.[12] The prevalence of UTI (including both asymptomatic bacteriuria and symptomatic infection) in pregnant women in India is reported to range from 3% to 24%.[8],[13],[14],[15],[16] Pregnant women with UTI are more likely to develop hypertensive diseases of pregnancy, anemia, chronic renal failure, prematurity, and low birth weight babies.[17],[18],[19] The upper UTIs in particular may lead to significant morbidity for both the mother and the fetus.[13],[20]
An early detection and treatment of asymptomatic bacteriuria may be of considerable importance not only to forestall acute pyelonephritis and chronic renal failure in the mother but also to reduce prematurity and fetal mortality in the offspring.[9],[18] The United States Preventive Services Task Force recommends screening for asymptomatic bacteriuria with urine culture for pregnant women.[21] No regular screening is done for the presence of symptomatic urine infection or asymptomatic bacteriuria during pregnancy in India. The facilities for the microbiological diagnosis of UTI are not available at primary health centers, community health centers, and subdistrict hospitals in India.[22],[23],[24] They are available at district hospitals and tertiary care centers.[25],[26] The nonavailability of diagnostic facilities at peripheral centers of the country may lead to delay in diagnosis and also impose a financial burden on the pocket of the individuals.
There is adequate literature available on the burden of UTI in tertiary care centers and in urban areas of the country, but there is a paucity of literature in rural areas and at primary and secondary care settings. This along with nonavailability of facility for microbiological diagnosis at subdistrict hospital evoked our interest in estimating the burden of UTI and the feasibility of microbiological diagnosis of UTI at a subdistrict hospital. Hence, this study was planned with the objective of estimating the proportion of women with UTI and asymptomatic bacteriuria among pregnant women in secondary care setting in rural Haryana, India.
Materials And Methods
This study was conducted in the subdistrict hospital of Ballabgarh block, district Faridabad, Haryana.[27] This is a secondary level hospital providing specialist services to the local population. The study period was from March 2015 to May 2015. All pregnant women attending antenatal clinic of subdistrict hospital, Ballabgarh, and willing to participate and able to give valid consent were included in the study. Seriously ill pregnant women, patients with previously diagnosed chronic/congenital diseases of kidney and/or urinary tract, and patients with previously diagnosed UTI as confirmed microbiologically were excluded from the study. Assuming 25% of pregnant females have positive urine culture in hospital settings, a relative precision of 10%, and response rate of 90%, the final required sample size was 1300.[14]
Consecutive sampling was done to select pregnant women from the antenatal clinic. Antenatal clinic of subdistrict hospital, Ballabgarh, was held thrice a week in the afternoons. All the women attending clinic that had not been included in the study previously were approached to participate in the study. Willing pregnant women were screened for the eligibility and then informed about the purpose of the study and provided with an information sheet in the local language. An informed written consent was obtained thereafter. On an average, 50 pregnant women per clinic were recruited in the study.
A semi-structured, pretested interview schedule having sociodemographic details, obstetric history, medical history, and symptoms of UTI was administered to the selected pregnant women.
A midstream urine sample was collected from the selected pregnant women in sterile wide mouth bottle, up to three-fourth of its capacity (approximately 10 ml). All the urine samples were plated onto the MacConkey agar within 2 h of collection using standard methods in the laboratory of subdistrict hospital, Ballabgarh. The laboratory was manned with two laboratory technicians and two laboratory assistants. The plates were then kept in incubator at 37°C. Two checks for culture growth were done at 24 h and 48 h. On identification of growth, colony count was done using standard methods. The plates which did not show any growth even after 48 h of incubation were discarded.
Operational definitions
Growth on urine examination
A urine sample was said to have growth on urine examination when there was any visible growth by naked eye within 48 h of incubation on MacConkey agar regardless of the colony count.
Symptoms of urinary tract infection
A pregnant woman was said to have symptoms of UTI when she had one or more of any of the following symptoms on the basis of history: increased frequency of micturition, burning micturition, and painful micturition.
Asymptomatic bacteriuria
A woman was said to have asymptomatic bacteriuria when none of the symptoms of UTI was present, and the colony count in a single culture was 105 or more.[21],[28],[29]
Symptomatic bacteriuria
A woman was said to have symptomatic bacteriuria when any symptom of UTI was present, and the colony count in a single culture was 103 or more.[29]
Urinary tract infection
A woman was said to have UTI when either of asymptomatic bacteriuria or symptomatic bacteriuria was present.
Quality assurance
The laboratory technician of subdistrict hospital, Ballabgarh, had received 2 courses of 4 days each training in Microbiology laboratory of All India Institute of Medical Sciences (AIIMS) on plating and colony counting under supervision of one of the authors, who is a senior microbiologist.
Ethics Committee of AIIMS, New Delhi, provided ethical clearance for the study. Women who were diagnosed as having UTI were given appropriate treatment by the obstetrician.
Data entry was done in Epi Info 7.0.8.3 (Center for Disease Control, United States of America) and cleaned using Microsoft Excel 2013 (Microsoft Corporation, United States of America). The analysis was done in Statistical Package for Social Sciences (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Results of descriptive analysis were presented as proportions or as mean wherever applicable, and of bivariate analysis as odds ratio with P value.
Results
A total of 1253 pregnant women were enrolled in the study. Most (77.9%) of the pregnant women were in the age group 18–25 years. Mean (standard deviation) age of pregnant women was 23.6 (3.4) years. Median (interquartile range [IQR]) duration of marriage was 4 (2.0, 6.5) years. Most (91.7%) of the pregnant women were Hindu by religion. The majority of pregnant women (59.5%) were in the second trimester of pregnancy. Almost one-fourth of pregnant women were in the third trimester of pregnancy.
The majority of pregnant women were unemployed/homemaker by occupation. Almost one-fifth of the pregnant women were illiterate. Similar proportion was educated till 10th standard. Median (IQR) monthly per capita income of the family was Rs. 2000 (1286, 3334). Almost one-third of the pregnant women were primigravida. As many as 14% of pregnant women were gravida 4 or more. The history of abortion was present in one-fourth of the pregnant women.
The proportion of women with symptoms of UTI on the basis of history was 33.3% (95% confidence interval [CI] - 30.7, 35.9). On urine examination, visible growth was present in 10.6% of the samples. Out of the total, 4.7% samples had colony count of 100. Almost 2% of the pregnant women had colony count of 103, 104, and 105, or more each. The proportion of pregnant women attending antenatal outpatient department (OPD) of subdistrict hospital who had UTI was 3.3% (95% CI - 2.4, 4.5). Of all the pregnant women having UTI, two-third, i.e., 2.2% (95% CI - 1.6, 3.2) were symptomatic. The proportion of pregnant women with UTI in the first, second, and third trimester was 1.7, 3.2, and 4.5%, respectively. Of all the pregnant women presenting with symptoms, 6.7% (95% CI - 4.7, 9.5) had laboratory-confirmed UTI. Similarly, out of the asymptomatic pregnant women, 1.7% (95% CI - 1.0, 2.8) had laboratory-confirmed UTI [Table 1].{Table 1}
The presence of UTI was found to be significantly associated with the presence of symptom of increased frequency of micturition (odds ratio [95% CI] - 3.12 [1.63, 5.88]), burning micturition (odds ratio [95% CI] - 2.56 [1.21, 5.55]), and the presence of any one symptom of UTI (odds ratio [95% CI] - 4.22 [2.20, 8.11]). Rest of the variables studied (i.e., age of pregnant women, occupation of pregnant women, education of pregnant women, gravida of pregnant women, history of abortion, and painful micturition) were not found to be significantly associated with the presence of UTI. In multivariate analysis, laboratory-confirmed UTI was found to be significantly associated with the presence of any symptom of UTI (odds ratio [95% CI] - 7.35 [1.95, 27.77]). Other variables included in the analysis were statistically not significantly associated [Table 2].{Table 2}
Discussion
Since UTI is frequently associated with complications, it is necessary to have an estimate of its burden in pregnant women. There were many studies estimating the magnitude of UTI in urban area as well as in tertiary care settings.[8],[14],[15],[30] However, there is a paucity of literature showing burden of UTI in secondary care setting. In this study, we tried to estimate the proportion of women with UTI among pregnant women attending a subdistrict hospital in the rural area of Haryana, India.
The proportion of women with UTI in our study was 3.3% including both asymptomatic bacteriuria and symptomatic bacteriuria. This is comparable with the studies done previously in North India by Sujatha and Nawani and Chandel et al.[31],[32] Previous studies from South India by Jayalakshmi and Jayaram and Lavanya and Jogalakshmi have also reported similar estimates.[8],[15] This finding is comparable to the estimates reported by few studies done outside India as well.[33],[34] Bandyopadhyay et al. and Sabharwal have reported higher proportion of women (25.2% and 24%, respectively) having UTI as compared to this study.[13],[14] This difference could be because of the fact that both these studies were done in tertiary care settings whereas our study was done in secondary care setting.
UTI is frequently associated with both maternal and neonatal complications. Hence, there should be some provision to screen the antenatal women for the presence of UTI, at least at the facility level.[21] This will help in reducing the morbidity associated with undiagnosed and missed cases of UTI.
In this study, one out of every three women attending antenatal OPD had complaints suggestive of UTI. Out of the symptomatic women, 6.7% had microbiologically confirmed UTI as compared to the asymptomatic women, in whom only 1.7% had confirmed UTI. Hence, the chance of having UTI among those who are symptomatic is almost 4 times to that of asymptomatic women. This information can be used for confirmation of UTI in a setting where resources are limited. Only symptomatic pregnant women could be subjected to microbiological examination. This would help in utilizing the resources optimally. However, if the resources are plenty, routine screening of all the pregnant women irrespective of symptoms can be done for laboratory diagnosis of UTI.
Thus, if we screen the antenatal women by symptoms of UTI, then we can diagnose UTI with only one-third burden on the health system. The Indian Public Health Standards guidelines for a subdistrict hospital does not recommend provision for urine culture. As per the guidelines, a laboratory of subdistrict hospital should have 4 laboratory technicians and 2 laboratory attendants. These technicians would be able to confirm the UTI by urine culture method.
Various other tests are also available for screening of UTI including pus cell count and Griess nitrite test.[16] However, these tests are to be done in laboratory. They are time consuming, costly, and require certain level of expertise. On the other hand, screening on the basis of symptom can be easily done at a peripheral level and then the screened pregnant women can be subjected to confirmatory test by urine culture method.
In this study, the proportion of pregnant women with UTI was maximum in the third trimester. This has also been shown in other studies in the past.[35],[36] Hence, if only 1 time screening is affordable, then it should preferably be done in the third trimester.
Currently, in a rural area at a secondary care hospital, pregnant women either are being treated empirically on the basis of symptoms of UTI or are subjected to investigations from the private sector. Treatment solely on the basis of symptoms could lead to overtreatment (93% of women with symptoms in this study did not have UTI). Overtreatment may unnecessarily expose a pregnant woman and her fetus to the antibiotics and also contribute to the development of antibiotic resistance.[37] Alternatively, if every pregnant women is advised urine culture and sensitivity test from private laboratory, then, it is a financial burden on the family as the test costs around Rs. 400–800. Screening for UTI by other methods will also impose the financial burden on the health system and will also increase the burden on the laboratory staff. Hence, initial screening of pregnant women for symptoms, followed by urine culture among symptomatics can be an alternate strategy for diagnosis of UTI. However, the proposed test strategy would result in women with asymptomatic UTI being missed out.
Limitations of the study are that species identification and antibiotic sensitivity of organisms causing UTI could not be done due to nonavailability of reagents required for the confirmation of species and lack of expertise for sensitivity testing at the subdistrict hospital.
Conclusions And Recommendations
The burden of UTI among pregnant women attending the antenatal clinic of a subdistrict hospital was considerable, more so among those that presented with symptoms suggestive of UTI.
The study suggested that considering the burden of UTI and its complications, diagnosis of UTI at a resource-constrained setting like a secondary care hospital can be done after screening women with symptoms suggestive of UTI on the basis of history.
Acknowledgment
We acknowledge the staff members of subdistrict hospital who facilitated data collection. We also acknowledge the help provided by the laboratory personnel from the laboratory of subdistrict hospital, Ballabgarh, for the analysis of urine samples. The project proposal was presented by AL in Indian Association of Preventive and Social Medicine Conference 2013 held at Nagpur, India, and was awarded a ford foundation epidemiological research grant.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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