ABSTRACT
INTRODUCTION: Urinary tract infection (UTI) is a common clinical problem and its significance in pregnancy is associated with maternal and foetal morbidity and mortality.
Objectives: To determine the Knowledge and causes of urinary tract infection (UTI) in pregnant women attending the ante-natal clinics at the Edo state University Teaching Hospital.
MATERIALS AND METHODS: The study was a cross sectional study. The participants were enrolled between Dec 2020 and Feb 2021 and were between the ages of 18 and 49 years. Mid-stream urine samples were collected from 421 pregnant women and 229 age-matched non-pregnant female controls in sterile disposable universal bottles. Urine dipsticks using the combined presence of positive nitrite and leucocyte esterase were utilised against urine culture for the diagnosis of UTI. Data was computed and analysed using SPSS version 22 and p-value <0.05 was considered to be statistically significant.
RESULT: The prevalence of UTI in the pregnant women was 18.3%, while in the nonpregnant controls was 8%. The pattern of UTI was asymptomatic bacteriuria in the pregnant women, while the non-pregnant controls manifested with dysuria and or urgency. Risk factors associated with the occurrence of UTI were sexual intercourse (OR=7.01, p=0.01, CI: 2.42-14.20), with-holding urine (OR=7.99, p<0.01, CI: 3.7716.97) and wearing of under-pants the whole day (OR=11.41, p=0.004,CI: 5.71-16.73).
Directional wiping from the front to the back region post micturition appeared to be protective (OR=0.21, p=0.05, CI=0.17- 0.79). There was an association between the level of education and the occurrence of UTI, however, maternal age, parity, trimester and income were not associated with the occurrence of UTI. The predominant bacterial pathogens were Escherichia coli (61%) followed by Enterococcus (19.5%) and Klebsiella pneumonia (6.5%).
The sensitivity, specificity, positive predictive value, negative predictive value, Youden’s index and number needed to diagnose were, 71.6%, 100%, 100%, 95.1%, 170.6 and 0.006 respectively indicating the usefulness of the urine dipsticks in screening for UTI.
CONCLUSION: Urinary tract infection was twice as high in the pregnant women compared with the controls and the pattern was asymptomatic bacteriuria (ASB) in the pregnant women unlike the non-pregnant controls where it was urgency and or dysuria or ASB.
CHAPTER ONE
INTRODUCTION
1.1 Background of Study
Urinary tract infection (UTI) is a common clinical problem and has been ranked as the third most common infection experienced by humans after respiratory and gastrointestinal infections.1,2 It involves the microbial invasion of any of the tissues extending from the urethral orifice to the renal cortex with bacterial infections of the urinary tract accounting for most of the community acquired and nosocomial infections in patients admitted to the hospital in the United States2. Fungal infections of the urinary tract may occur in the setting of immune suppression while the role of viruses cannot be overlooked though they are considered to be rare.
UTI is defined as the presence of at least 100,000 organisms per milliliter of urine in an asymptomatic patient, or greater than 100 organisms per milliliter of urine with accompanying pyuria greater than 5 White blood cells (WBC) per high power field (hpf)
in a symptomatic patient.3,4A diagnosis of urinary tract infection should be supported by a positive culture for a uropathogen particularly in an asymptomatic patient.5
An estimated 50% to 60% of women will experience UTI in their life time.6 In the United States, it is estimated from surveys of office practices, hospital based clinics and emergency departments that UTIs account for over eight million cases annually, and more than one million hospitalizations with an overall annual cost in excess of one billion dollars.7-9
Anatomically, UTI can be divided into upper and lower tract infection and clinically can be categorized into syndromes. Majority of UTIs occur as a result of an ascending infection.10,11 Urinary tract infection is a serious problem affecting millions of people each year and has been reported as the leading causes of morbidity and health care expenditure in persons of all age.12It has been reported to be more prevalent in the females in comparison to the males and this has been attributed to the relatively short length of the urethra and its sheer proximity to the vagina and the rectum in females.13 The presence of the moist environment of the female perineum favours microbial growth and predisposes the female to bladder contamination. Other factors like sexual intercourse, improper cleansing of the perineum, use of sanitary towel and pregnancy contribute to the higher occurrence of UTI in various women.
Pregnancy has been reported to increase the risk of UTI.During pregnancy, the expansion in the plasma volume results in a reduction in urine concentration. Glycosuria and amino-aciduria encourage bacterial growth in the urine. Urinary tract infection (UTI) is a common clinical problem It has been found in as high as 20% of pregnant women and is the most common cause of hospital admission in the obstetric ward.14,15 In pregnancy it may be symptomatic in the form of urethritis, cystitis, or pyelonephritis or it may remain asymtomatic.16 The prevalence of bacteriuria among symptomatic and asymptomatic pregnant women has been reported to be 17.9% and 13% respectively.17 Asymptomatic bacteriuria in pregnancy is a major risk factor for developing cystitis and pyelonephritis in pregnancy.24 Its significance in pregnancy is associated with maternal and foetal morbidity and mortality.18 The prevalence is increased by several risk factors. Poor socioeconomic status has been reported to be a major risk factor with a fivefold increased risk.19 Other risk factors include sickle cell anaemia, older maternal age, high parity, poor perineal hygiene, history of recurrent UTI, diabetes mellitus, neurogenic bladder retention, anatomic or functional urinary tract abnormalities, and increased frequency of sexual intercourse.20 Predisposing determinants of high prevalence of UTI in pregnancy include hormone induced, renal pelvis, ureteral and calyceal dilatation, stasis, reduced immune function ,presence of vesicoureteric reflux and glycosuria.
Urinary tract infection in pregnancy contributes significantly to maternal and perinatal morbidity and mortality. Maternal complications include overt pyelonephritis in 25%- 40% of patients as pregnancy advances among those with asymptomatic bacteriuria, and in 1% -2% in those without asymptomatic bacteriuria. Other complications include maternal anaemia, hypertension, preeclampsia, chronic pyelonephritis and renal failure. The foetus is at risk of prematurity, low birth weight, intra uterine growth retardation and foetal death.21-23
Organisms that cause UTI are those from the normal vaginal, perineal and rectal flora.
They include gram negative bacteria like Escherichia coli accounting for 80% to 90%, Proteus mirabilis, Klebsiella species, Staphylococcus aureus, Staphylococcus faecalis and Streptococcus species among others. These organisms are similar to the causative organisms that occur in non-pregnant females.22,23
There have been reported cases of resistance to antimicrobials by UTI causing organisms. 24 In our locality, the frequent dispensing of antimicrobials without prescription and the inappropriate use of these medications increase the risk of drug resistance. The resistance properties are easily transferred between bacteria of different genera by plasmids.25,26The resistance to antimicrobials are often observed in hospital acquired settings though may occur in community acquired UTI with an increasing occurrence of gram positive cocci like Staphylococcus and gram negative organism like Klebsiella.27
1.2 Statement of problem
In Nigeria, several studies have been carried out on the prevalence and anti- microbial sensitivity pattern of UTI in pregnancy. In Edo state, the commercial capital and one of the most populous and cosmopolitan states in western Nigeria, there is paucity of data related to UTI among pregnant women. Maternal and foetal morbidity and mortality are unacceptably high in developing countries and Nigeria is no exception. This study will be carried out in okada community (LUTH), a tertiary centre that provides medical services to the people of Edo state and its environs. The aim of the study is to determine how much of a problem UTI is in pregnant women attending the antenatal clinics in okada community, Ovia North East, Edo state and to determine the prevalence, the pattern, the causative bacteria and their anti-microbial sensitivity pattern in these women. This will help generate policies that will improve care of pregnant women with UTI and attempt to reduce the occurrence of complications of UTI in pregnancy and subsequently reduce maternal and foetal morbidity and mortality.
1.3 OBJECTIVES
1.3.1 BROAD OBJECTIVES
1)The broad objective is to study the knowledge and causes of UTI in pregnant women in Okada community, Ovia North East, Edo state
1.3.2 SPECIFIC OBJECTIVES
1) To determine the frequency and causative organisms of UTI in the different trimesters of pregnancy.
2) To determine the possible associations between maternal age, gestational age, parity, occupation and social status on the development of UTI in pregnancy
3) To identify the causative organisms and their antimicrobial sensitivity patterns
4) To compare cost benefit analysis between qualitative and quantitative urine analysis using sensitivity, specificity, positive predictive value and negative predictive value.
1.4 Null Hypothesis
1) Urinary tract infection is higher in pregnant women in Edo than in the rest of the world.
2) Urinary tract infection is higher in pregnancy than in non-pregnant females
3) Urinalysis dipstick is comparable to culture in diagnosing urinary tract infection in pregnant women.
1.5 Significance of the study
Maternal deaths have declined globally by almost half from 543,000 in 1990 to 273,465 in 2011.28 In developed countries Maternal mortality rate (MMR) has declined significantly to extremely low rates, 1.5, 4.1, 5.3 and 7.9 maternal deaths per 100,000 live births in Iceland, Ireland, Denmark and Canada respectively.28 This is not the case in developing countries, especially in sub-Saharan Africa with the greatest burden of maternal deaths. MMR still remains one of the key health indicators with the widest gap between developed and developing countries. MMR is about 12 times higher in developing countries and the Millennium Development Goal report shows that 56% of global maternal deaths occurred in sub-Saharan Africa, followed by 29% in South East Asia.28,29. Nigeria is the most populous nation in sub-Saharan Africa with MMR of 525 per 100,000 live births reported in 2013.30 Recent reports indicate that Nigeria is one of the six countries that account for 50% of global maternal deaths.31 A study in Enugu State Teaching Hospital reported an unacceptably high MMR of 840 per thousand live births.32 Infections during pregnancy particularly UTIs rank as one of the top five causes of maternal deaths and complicates about 20% of pregnancies.6 In resource poor countries like Nigeria these rates can be reduced by screening and prompt treatment of the infected women.
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