|Year : 2021 | Volume
| Issue : 2 | Page : 228-231
Recurrent and complicated urinary tract infection in type 2 diabetes: Case series
Rahul R Kotalwar1, Gaurish M Karande1, Vedavati B Purandare1, Hrishikesh S Deshmukh2, Ashootosh M Pakale1, Ambika Gopalakrishnan Unnikrishnan3
1 Department of Clinical Diabetology, Chellaram Diabetes Institute, Pune, Maharashtra, India
2 Department of Urology, Chellaram Diabetes Institute, Pune, Maharashtra, India
3 Department of Clinical Diabetology and Endocrinology, Chellaram Diabetes Institute, Pune, Maharashtra, India
|Date of Submission||02-Jul-2020|
|Date of Decision||10-Sep-2020|
|Date of Acceptance||24-Sep-2020|
|Date of Web Publication||31-Mar-2021|
Dr. Ambika Gopalakrishnan Unnikrishnan
Department of Clinical Diabetology and Endocrinology, Chellaram Diabetes Institute, Lalani Quantum, Pune-Bangalore Highway, Bavdhan Budruk, Pune 411021, Maharashtra.
Source of Support: None, Conflict of Interest: None
Urinary tract infection (UTI) is a common infection in patients with type 2 diabetes (T2DM). We present a case series of recurrent and complicated UTI requiring hospitalization in people with T2DM. Recurrence of UTI, especially when severe or complicated, causes multiple renal and extra renal complications and even death if not intervened early. Recurrent UTI is often caused by resistant pathogens in people with long duration of diabetes and uncontrolled glucose levels. In recurrent and complicated/severe UTI, empirical broad-spectrum antimicrobial therapy and early urological intervention will help early recovery and helps to prevent complications.
Keywords: Recurrent UTI, type 2 diabetes mellitus, pyelonephritis
|How to cite this article:|
Kotalwar RR, Karande GM, Purandare VB, Deshmukh HS, Pakale AM, Unnikrishnan AG. Recurrent and complicated urinary tract infection in type 2 diabetes: Case series. J Diabetol 2021;12:228-31
| Introduction|| |
Urinary tract infection (UTI) is one of the commonly seen infections in patients with type 2 diabetes due to various local and systemic reasons. Recurrent UTI refers to ≥2 infections in 6 months or ≥3 infections in 1 year. Recurrence of UTI causes multiple renal and extra-renal complications and even death if not intervened early. Uncontrolled diabetes, causing glycosuria and immune dysfunction, leads to a recurrence of UTI with pathogens resistant to common antimicrobials. Newer oral antidiabetic drugs like SGLT2 (sodium-glucose cotransporter) Inhibitors lead to therapeutic glycosuria and thus increase the risk of genitourinary infections.
| Patient Information|| |
We searched the Chellaram Diabetes Institute database, a tertiary care diabetes hospital in Pune, Maharashtra, for subjects with type 2 diabetes and recurrent UTI who required hospitalization during the last year. We present data of 10 patients.
| Eligibility Criteria|| |
Subjects with type 2 diabetes having recurrent and complicated UTI who required hospitalization.
| Clinical Characteristics of the Study Population|| |
Clinical characteristics, outcome, and course in hospital are mentioned in [Table 1][Table 2][Table 3].
| Outcome|| |
Mean age in study group was 61.4 years, with 6 male patients and 4 female patients. Seven patients had diabetes for more than 10 yrs. Mean HbA1C value was 8.8% in this study group. All patients had decreased e-GFR ≤60mL/min and five of ten subjects had hypertension along with diabetes. All 10 patients had pyuria and proteinuria. Pyelonephritis was seen on ultrasonography and CT scan in four patients, two of whom had bilateral pyelonephritis. Three of the ten patients had significant post-void residue and three patients had renal calculi as a predisposing factor for complicated UTI with recurrence. Two of the ten patients underwent urological intervention for obstructive ureteric calculi, which could be the cause of recurrence of UTI. CT (computed tomography) abdomen and pelvis of one of the study subject who had pyelonephritis is shown in [Figure 1].
|Figure 1: Noncontrast CT (computed tomography) of abdomen and pelvis, coronal section: it shows perinephric fat stranding suggestive of pyelonephritis|
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Escherichia coli was the most common organism which was isolated in five patients (50%) and was susceptible to meropenem. Blood culture report of one of study patients had Burkholderia pseudomallei (Meliodosis) treated with meropenem for 6 weeks and then cotrimoxazole for 6 months. Urological intervention like cystoscopy and DJ (Double “J”) stenting was done in four cases for pyelonephritis on the same day of admission. One of the patients had meatal stenosis, for which endoscopic dialatation done after control of UTI. For hyperglycemia management the patients were treated with basal bolus insulin and if admitted to the ICU, they received intravenous insulin infusion.
Four of 10 patients had septic shock on admission and required ICU care. Two of the 10 patients were on long-term antibiotic prophylaxis. Kidney function improved in 7 of the 10 patients after adequate treatment of UTI. None of our study subjects were taking sodium-glucose cotransporter inhibitors. Nine of the 10 patients were discharged after recovery. One patient died due to septic shock and acute kidney injury.
| Discussion|| |
In our case series, people with recurrent UTI requiring hospitalization responded to early parenteral antibiotic therapy and appropriate urological intervention. Our case series affirms the role of early antibiotic therapy and urological intervention in these hospitalized subjects. This case series includes only hospitalized subjects and this limited sample size does not reflect the general prevalence of UTI in diabetes.
Recurrent UTI in T2DM increases the risk of kidney injury. The most common pathogens isolated from urine of diabetic patients with UTI are E. coli, other Enterobacteriaceae such as Klebsiella spp., Proteus spp., Enterobacter spp., and Enterococci. Patients with diabetes are more prone to have resistant pathogens causing UTI, including extended-spectrum β-lactamase-producing Enterobacteriaceae, fluoroquinolone-resistant uropathogens, carbapenem-resistant Enterobacteriaceae, and vancomycin-resistant Enterococci. This might be due to several factors, including multiple antibiotics used frequently for asymptomatic or only mildly symptomatic UTI, and increased incidence of hospital-acquired and catheter-associated UTI. Candiduria was not noted in our case series.
Many of the subjects had comorbidities like hypertension and CKD. Ultrasound KUB is essential, but where not contributory, a CT scan should be done. It is advisable to prescribe long-term antibiotic prophylaxis in such patients. When subjects with diabetes and recurrent UTI require hospitalization for a major UTI, in our experience, these patients benefit from early empirical broad-spectrum parenteral antibiotic therapy with meropenem, subsequent transition to culture-specific antibiotics and where pyelonephritis is noted, DJ stenting may be needed. In the DJ stenting procedure a thin, hollow tube placed inside the ureter during surgery to ensure drainage of urine from the kidney into the bladder. J shaped curls are present at both ends to hold the tube in place and prevent migration, hence the description “double J stent.”
| Conclusion|| |
Hyperglycemia increases the risk of complicated UTI. Infection with resistant bacteria is common in diabetes. Hence, early initiation of empirical broad-spectrum antibiotics is recommended in cases of recurrent and complicated UTI till culture reports are obtained. When recurrence occurs with pyelonephritis urological intervention may lead to better outcome. Long-term prophylaxis with antibiotics is important. It is also important to achieve glucose control in these subjects, both during the hospital stay as well as long-term during outpatient follow-up.
Appropriate consent was obtained for the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Patterson JE, Andriole VT Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1997;11:735-50.
Bonkat G, Pickard R, Bartoletti R, Cai T, Bruyère F, Geerling SE, et al
. European Association of Urology (EAU) guidelines on urological infections 2018. Available from: https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urological-Infections-2018-large-text.pdf. [Last accessed on 2020 May 26].
Unnikrishnan AG, Kalra S, Purandare V, Vasnawala H Genital infections with sodium glucose cotransporter-2 inhibitors: Occurrence and management in patients with type 2 diabetes mellitus. Indian J Endocrinol Metab 2018;22:837-42.
Kofteridis DP, Papadimitraki E, Mantadakis E, Maraki S, Papadakis JA, Tzifa G, et al
. Effect of diabetes mellitus on the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis. J Am Geriatr Soc 2009;57:2125-8.
Inns T, Millership S, Teare L, Rice W, Reacher M Service evaluation of selected risk factors for extended-spectrum beta-lactamase Escherichia coli
urinary tract infections: A case-control study. J Hosp Infect 2014;88:116-9.
Wu YH, Chen PL, Hung YP, Ko WC Risk factors and clinical impact of levofloxacin or cefazolin nonsusceptibility or ESBL production among uropathogens in adults with community-onset urinary tract infections. J Microbiol Immunol Infect 2014;47:197-203.
Schechner V, Kotlovsky T, Kazma M, Mishali H, Schwartz D, Navon-Venezia S, et al
. Asymptomatic rectal carriage of blakpc producing carbapenem-resistant Enterobacteriaceae: Who is prone to become clinically infected? Clin Microbiol Infect 2013;19:451-6.
Papadimitriou-Olivgeris M, Drougka E, Fligou F, Kolonitsiou F, Liakopoulos A, Dodou V, et al
. Risk factors for Enterococcal infection and colonization by vancomycin-resistant Enterococci in critically ill patients. Infection 2014;42:1013-22.
Baldwin CM, Lyseng-Williamson KA, Keam SJ Meropenem: A review of its use in the treatment of serious bacterial infections. Drugs 2008;68:803-38.
Shivraj BK, Velmurugan P, Sriram K, Venkat R, Natarajan K Role of minimally invasive urological intervention in acute pyelonephritis: A prospective study. Int J Sci 2018;5:115-20.
[Table 1], [Table 2], [Table 3]