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CORRESPONDENCE
Year : 2016  |  Volume : 34  |  Issue : 1  |  Page : 112-113
 

Effect of genitourinary flora on occurrence of recurrent urinary tract infection in females


1 Department of Microbiology, Government Medical College Hospital, Chandigarh, India
2 Department of Obstetrics and Gynaecology, Government Medical College Hospital, Chandigarh, India
3 Department of Medicine, Government Medical College Hospital, Chandigarh, India

Date of Submission20-Jun-2014
Date of Acceptance06-May-2015
Date of Web Publication15-Jan-2016

Correspondence Address:
V Gupta
Department of Microbiology, Government Medical College Hospital, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.167673

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How to cite this article:
Gupta V, Garg R, Huria A, Goel P, Chander J, Cruz S D. Effect of genitourinary flora on occurrence of recurrent urinary tract infection in females. Indian J Med Microbiol 2016;34:112-3

How to cite this URL:
Gupta V, Garg R, Huria A, Goel P, Chander J, Cruz S D. Effect of genitourinary flora on occurrence of recurrent urinary tract infection in females. Indian J Med Microbiol [serial online] 2016 [cited 2019 Sep 22];34:112-3. Available from: http://www.ijmm.org/text.asp?2016/34/1/112/167673


Dear Editor,

Recurrent urinary tract infections (RUTI) are common occurring in up to one-third of women after first-episode UTIs, these days complicated by increasing antibiotic resistance. Risk factors predisposing women to recurrence include sexual intercourse, use of contraception, antimicrobials, oestrogen, genetics and the short distance of the urethra from the anus. Of the various pathogens,  Escherichia More Details coli is the organism most commonly isolated. Recurrences requiring intervention are usually defined as two or more episodes over 6 months or three or more episodes over 1-year. Most uropathogens originate in the rectal flora, colonise the periurethral area and urethra, and then ascend to the bladder. Increasing evidence suggests that alteration of the normal vaginal flora, especially loss of H2O2-producing lactobacilli, may predispose women to introital colonisation with uropathogenic E. coli.[1] The present study was conducted to identify the effect of periurethral and vaginal flora on the development of RUTIs in females and also to determine antimicrobial susceptibility of the isolates bottom of form. This prospective study was conducted over a period of 9 months from September 2012 to May 2013. The study comprised of 25 patients from Gynaecology and Medicine outpatient departments. The patients enrolled were in 18–45 years age group. These included 21 patients having some symptoms of UTI and 4 normal patients. The samples collected were midstream urine, peri-urethral swab, vaginal swabs following standard instructions.[2],[3] All the samples were processed using standard methodologies both aerobically and anaerobically except for urine where semiquantitative aerobic culture was done. Amsel's criterion was defined for every patient based on symptoms and clinical presentation.[4] Gram stain of the vaginal swabs was prepared to get the Nugent scoring.[5] Periurethral and vaginal swab culture were also done. In those patients having active UTI and showing culture positivity, antimicrobial susceptibility testing was performed as recommended by CLSI.[6] Among the 21 UTI patients, on history, taking 19 patients were of RUTI and 2 were of first episode UTI. All the 19 patients, had culture positive urine samples. In culture of periurethral swab, in normal patients we found predominance of lactobacilli, followed by growth of Gram-negative curved anaerobic bacilli and gram variable coccobacilli. Only 2 patients yielded growth of E. coli and that too in lower numbers. While in RUTI patients we were able to isolate E. coli from upto 12 of the patients and growth of lactobacilli and other commensals was decreased significantly. Amsel's score and Nugent scoring of the vaginal washes on Gram's staining are given in [Table 1]. Culture from vaginal washes done aerobically and anaerobically also yielded same organisms as periurethral swabs. The isolates from RUTI were E. coli (15), followed by Klebsiella pneumoniae (1), Enterococcus faecalis (1), Pseudomonas aeruginosa (1) and Staphylococcus saprophyticus (1). While from first episode UTI the isolates were one E. coli and K. pneumoniae each. Antibiotic susceptibility of the isolated E. coli strains in RUTI patients showed resistance to amikacin (73%), norfloxacin (60%), amoxicillin-clavulanate (66%), ceftazidime (53%), ceftriaxone (53%) and cefotaxime (53%). All the isolates showed susceptibility to cefepime and imipenem. As a routine women with RUTI in our country are treated by general practitioners and the repeated use of antibiotics leads to resistance and a proper diagnosis is never established. E. coli is the organism most commonly isolated from RUTI as was seen in our study as well. Out of 19 patients of UTI, E. coli was isolated from 15 patients. Nugent score was abnormal (≥4) in all the 19 patients. This study emphasises that alteration of the normal vaginal flora may predispose women to periurethral colonisation with E. coli which may later lead to RUTI. Furthermore, the absence of lactobacilli may be important in the pathogenesis of RUTI by facilitating E. coli colonisation.[1] The investigations must aim not only to verify the diagnosis of RUTI but also to find any possible cause of the recurrence. We are working further on the hypothesis that the pathological vaginal E. coli colonisation could be eliminated by administration of bacteria normally present in the vaginal flora that is, Lactobacilli.
Table 1: Amsel and Nugent score of patients with UTI

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 ~ References Top

1.
Mohsin R, Siddiqui KM. Recurrent urinary tract infections in females. J Pak Med Assoc 2010;60:55-9.  Back to cited text no. 1
    
2.
Colle JG, Miles RS, Watt B. Tests for identification of bacteria. In: Colle JG, Fraser AG, Marimon BP, Simmon A, editors. Mackie and MacCartney Practical Medical Microbiology. 14th ed. Edinburgh: Churchill Livingstone; 1996. p. 151-79.  Back to cited text no. 2
    
3.
Lidefelt KJ, Bollgren I, Nord CE. Changes in periurethral microflora after antimicrobial drugs. Arch Dis Child 1991;66:683-5.  Back to cited text no. 3
    
4.
Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983;74:14-22.  Back to cited text no. 4
    
5.
Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991;29:297-301.  Back to cited text no. 5
    
6.
CLSI. Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard. M11A8E Standard 2012. 8th ed. Wayne, PA: CLSI; 2012.  Back to cited text no. 6
    



 
 
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