catheter associated urinary tract infections among

(1)

A dissertation submitted in partial fulfilment of the rules and regulations for MD General Medicine examination of the Tamil Nadu Dr. M.G.R. Medical University, Chennai, to be held in April 2016.

Vaginal lactobacilli and

catheter associated urinary tract infections among

inpatients admitted in medical wards and medical ICU in a

tertiary hospital in South

India.

(2)

1

DECLARATION

This is to declare that this dissertation titled

“Vaginal lactobacilli and catheter associated urinary tract infections among inpatients admitted in medical wards and medical ICU in a tertiary hospital in South India.”

is my original work done in partial fulfilment of rules and

regulations for MD General Medicine examination of the Tamil Nadu Dr. M.G.R. Medical University, Chennai to be held in April 2016.

CANDIDATE Ashwin Rajenesh

Post graduate Registrar General Medicine

Christian Medical College Vellore- 632 004

(3)

2

CERTIFICATE

This is to certify that the dissertation entitled,

“Vaginal lactobacilli and catheter associated urinary tract infections among inpatients admitted in medical wards and medical ICU in a tertiary hospital in South India.”

is a bona fide work of Dr. Ashwin Rajenesh

towards the partial fulfilment of rules and regulations for MD General Medicine degree examination of the Tamil Nadu

Dr. M.G.R. Medical University, to be conducted in April 2016.

GUIDE

Dr. Thambu David

Professor and Head of Unit

Dept. Of Medicine II and Clinical Epidemiology Christian Medical College

Vellore-632 004

(4)

3

CERTIFICATE

This is to certify that the dissertation entitled, “Vaginal

lactobacilli and catheter associated urinary tract infections among inpatients admitted in medical wards and medical ICU in a tertiary hospital in South India.” is a bona fide work

Dr. Ashwin Rajenesh

towards the partial fulfilment of rules and regulations for MD General Medicine degree examination of the Tamil Nadu

Dr. M.G.R. Medical University, to be conducted in April 2016.

PRINCIPAL HEAD OF THE DEPARTEMENT Dr. Alfred Job Daniel Dr. Anand Zachariah Professor Professor and Head Dept. of Orthopaedics Department of Medicine Christian Medical College Christian Medical College Vellore Vellore

(5)

4

ANTI - PLAGIARISM CERTIFIACTION

(6)

5

APPROVAL OF THE INSTITUTIONAL

REVEIW BOARD (IRB)

(7)

6

(8)

7

(9)

8

(10)

9

(11)

10

ACKNOWLEDGEMENT

This dissertation would be incomplete without expressing my gratitude to the people involved in its conceptualisation and completion; without which this would not be possible.

First and foremost I would like to thank with utmost gratitude, my guide Dr. Thambu David, Professor and Head of Medicine, for the mentorship and guidance throughout this process, since its

conception to its completion and for effectively inculcating the principles and ethics of research. I thank him for all the patience and kindness with which he dealt with me and every difficulty faced.

My gratitude to Dr. Anand Zachariah, Professor and Head of the department of General Medicine, for his guidance and oversight.

I thank the hard work, dedication and guidance of Dr. Rani Diana Sahni, Associate Professor, Department of Microbiology.

I thank Dr. J.V. Peter, Head of Medical ICU, Dr. Abhilash K.P.P;

Ag. Head of Accident and Emergency Medicine, Dr. Sudha Jasmine for their valuable input and guidance in designing the study. I also thank the other faculty of Medicine.

(12)

11 I thank Dr. Renu George, Head of Dermatology and Mrs. Sheeba Tennyson for their assistance in this thesis.

I would like to thank Dr. Jayaprakash Muliyil and Dr. Prasanna Samuel, Department of Biostatistics for their assistance in statistical analysis.

I thank my co-investigator Dr. Anjali Sarah George for her never ending encouragement and her assistance in sam ple collection.

My colleagues and interns in the department of medicine for their assistance in recruitment. I also thank the staff nurses in casualty, medical wards and ICU for their assistance and co -operation.

I thank the patients and their relatives for consenting to participate in this study.

I thank my wife, Jinju and my daughter Amaeya for supporting me in ways that cannot be described and for making everything worth it. I cannot thank them enough for putting up with me and all difficulties through my course. I also thank my parents and my in- laws for their constant support and encouragement.

(13)

12

SYMPTOMATICURINARYTRACTINFECTION 111 CATHETERASSOCIATEDURINARYTRACTINFECTION 112 ASSOCIATIONWITHVAGINALLACTOBACILLI 114 CORELATIONWITHBASELINECHARACTERISTICS 116 CO-RELATIONWITHCO-MORBIDILLNESS 117 CO-RELATIONWITHURO-GYNECOLOGICALVARIABLES 118 CO-RELATIONWITHCATHERIZATIONVARIABLES 119 CO-RELATIONWITHNUGENTSCORINGSYSTEM 120

BASELINEURINECUTLURE 121

LIMITATIONS 122

CONCLUSION 123

REFERENCES 125

LIST OF ANNEXURES 134

ANNEXURE 1: PATIENT INFORMATION SHEET 135

ANNEXURE 2: PATIENT CONSENT FORMS 142

ANNEXURE 3: DATA ABSTRACTION SHEET 144

ANNEXURE 4: DATA WORKSHEET 148

ANNEXURE 5: FLUID RESEARCH GRANT APPROVAL 153

ANNEXURE 6: APPLICATION FOR THE INSTITUTIONAL REVIEW BOARD APPROVAL OF OBSERVATIONAL STUDIES 155

(17)

16

INDEX OF TABLES AND FIGURES

TABLE 1: RISK FACTORS FOR CAUTI 28

FIGURE 1: STUDY ALGORITHM 60

TABLE 2: NUGENT SCORING SYSTEM; 71

TABLE 3: INCIDENCE OF SYMPTOMATIC URINARY TRACT INFECTION 78

FIGURE 2: SYMPTOMATIC URINARY TRACT INFECTION 79

FIGURE 3: TIME PLOT TO EVENT OF SYMPTOMATIC URINARY TRACT

INFECTION 79

TABLE 4: INCIDENCE OF SYMPTOMATIC URINARY TRACT INFECTION IN RELATION TO VAGINAL LACTOBACILLI 80

FIGURE 5: STROBE 81

TABLE 5: BASELINE DEMOGRAPHIC CHARACTERISTICS 85

FIGURE 6: AGE OF PATIENTS 86

FIGURE 7: MARITAL STATUS 86

(18)

17

FIGURE 8: PARITY SCORE OF PATIENTS 87

FIGURE 9: MENOPAUSAL STATUS 87

TABLE 6: PROFILE OF CO-MORBID ILLNESS 88

TABLE 7(A): URO-GYNECOLOGICAL DETAILS 89

TABLE 7(B): CONTRACEPTION METHOD 89

TABLE 8: INDICATION FOR URINARY CATHERIZATION 90

TABLE 9(A): CATHETERIZATION VARIABLES 92

TABLE 9(B): CATHETERIZATION VARIABLES 91

TABLE 10 (A) BASELINE URINE CULTURE 93

TABLE 10 (B) BASELINE URINE CULTURE 94

FIGURE 10(A): BASELINE URINE CULTURE 94

FIGURE 10 (B): MICROBIOLOGY WITH QUANTIFICATION 95

TABLE 11: INCIDENCE OF SUTI COMPARED WITH DEMOGRAPHIC

DATA 97

FIGURE 11: RELATIONSHIP OF MARITAL STATUS AND INCIDENCE OF

SUTI 97

(19)

18

FIGURE 12: RELATIONSHIP OF PARITY WITH INCIDENCE OF SUTI 98

FIGURE 13: RELATIONSHIP OF MENOPAUSAL STATUS WITH

INCIDENCE OF SUTI 98

TABLE 12: INCIDENCE OF SUTI COMPARED WITH CO-MORBID ILLNESS 100

TABLE 13: INCIDENCE OF SUTI IN RELATION TO METHOD OF

CONTRACEPTION 101

FIGURE 14: INCIDENCE OF SUTI IN RELATION TO METHOD OF

CONTRACEPTION 101

TABLE 14: INCIDENCE OF SUTI IN RELATION TO URO-

GYNECOLOGICAL PARAMETERS 102

TABLE 15: INCIDENCE OF SUTI IN RELATION TO CATHETERIZATION

INDICATIONS 103

TABLE 16: INCIDENCE OF SUTI IN RELATION TO CATHERIZATION

DETAILS 105

TABLE 17: INCIDENCE OF SUTI IN RELATION TO NUGENT’S SCORE AND

ITS COMPONENTS 106

FIGURE 15: INCIDENCE OF SUTI IN RELATION TO NUGENT’S SCORE 107

(20)

19

FIGURE 16: INCIDENCE OF SUTI IN RELATION TO LACTOBACILLI

SCORE 108

FIGURE 17: INCIDENCE OF SUTI IN RELATION TO GARDENELLA SCORE 108

FIGURE 18: INCIDENCE OF SUTI IN RELATION TO GRAM VARIABLE

SCORE 109

FIGURE 19: MICROSCOPIC PHOTOGRAPH OF GRAM STAIN OF

VAGINAL SWAB (HPF 1000X) SHOWING HIGH LACTOBACILLI. 115

FIGURE 20: MICROSCOPIC PHOTOGRAPH OF GRAM STAIN OF

VAGINAL SWAB (HPF 1000X) SHOWING ABSENT LACTOBACILLI WITH HIGH GARDENELLA AND GRAM VARIABLE ORGANISMS 120

INTRODUCTION

Urinary catheterization is a frequently indicated procedure among inpatients in medical wards and ICUs. Approximately 25% patients who are hospitalized have an indwelling urinary catheter placed at some time during their hospital stay(1,2) and nosocomial urinary

(21)

20 tract infections develop in 5% per day of catheterization.

Bacteriuria in patients with indwelling urinary catheters occ urs at a rate of approximately 3 to 10 % per day of catheterization. Of those with bacteriuria, 10 to 25 % develop symptoms of urinary infection and a further 5% develop bacteremia(3).

Urinary tract infections (UTI) are one of the most common health care acquired infections accounting for up to 40% of nosocomial infections and urinary catheter associated infections (CA -UTI) accounts for most nosocomial UTI(3). catheter associated urinary tract infection is classified as a complicated UTI. Data has shown significant associated increased mortality and morbidity and increases the length of hospital stay. (4), and is a leading cause of secondary blood stream infection. It results in the increased

antimicrobial use thereby leading to drug resistant organisms and increasing the cost of treatment significantly.

It is noted in clinical practice that few patients on follow-up develop symptomatic urinary tract infection following discharge

(22)

21 even after catheter removal. These are outside the time limits

defined by CDC for catheter associated urinary tract infections (5).

These have not been studied previously and incidence data

unavailable on extensive literature search. It was noted that they are most common in the first weeks following catherization and thereafter decreases. We attempt to also study these symptomatic urinary tract infections which occur follow after catheter removal to capture the community impact of CAUTI following discharge from hospital and avoid reliance on submission and

microbiological analysis of urine specimens.

.

Catheter associated urinary tract infections have been shown to occur more frequently in women with a relative risk for bactiuria 1.7 and relative risk for infection of 2.0 among them (3).

Organisms implicated are often from perineal microbiota.

Lactobacilli present in the vaginal microflora have been shown to regulate the microbiota thus preventing colonization with

uropathogens. Depletion of lactobacilli may be associated with increased risk of colonization with uropathogenic organisms and

(23)

22 thus could lead to increased incidence of catheter associated

urinary tract infections. This study attempts to study the association between symptomatic urinary tract infections and

vaginal lactobacilli. If found to be significant it may suggest a role for probiotic lactobacilli in preventing catheter associated urinary tract infections.

(24)

23

AIM

To understand the risk factors for a symptomatic urinary tract infection and its association with vaginal microbiota and study the protective properties of vaginal lactobacilli in female inpatients following the insertion of an indwelling urinary catheter while admitted in wards or Medical Intensive Care Unit and Medical High Dependency Unit under the Department of General Medicine at Christian Medical College, a tertiary care hospital in South India.

(25)

24

OBJECTIVIES

1. To study the incidence of symptomatic urinary tract infections developing within 30 days of urethral

catherization in women admitted in a general medical ward and medical ICU.

2. To correlate the vaginal lactobacilli measured by Nugent score on vaginal smear at the time of Catherization with the development of symptomatic urinary tract infection.

(26)

25

REVIEW OF LITERATURE EPIDEMIOLOGY

Urinary tract infections are one of the most common health care acquired infections accounting for up to 40% of nosocomial infections and urinary catheter associated infections accounts for most nosocomial UTI worldwide(3). US data has shown urinary tract infections made up the highest number of nosocomial

infections (> 560,000) and with significant associated increased mortality and morbidity resulting in an estimated 13,000 deaths annually with a mortality rate of 2.3% (6,7). Morbidity data showed a catheter associated UTI increases the length of stay by a median 2 to 4 days(4), and is a leading cause of secondary blood stream infection(8) and the resultant antimicrobial use. Also to mention the additional cost to healthcare by 400 to 500 million dollars per year nationally(9).

In a large cohort of 69,248 admissions followed for 371,452 days in ICUs in 10 countries including India. A catheter associated

(27)

26 urinary tract infection prolonged length of ICU stay by mean of 1.59 days (95% CI: 0.58, 2.59 days), and increased mortality by 15% (95% CI: 3, 28%)

Indian data have shown the catheter-associated urinary tract infection (CA-UTI) rate was 1.41 per 1000 catheter-days(10) in a survey of tertiary centres in 7 Indian cities by the Internation al Nosocomial Infection Control Consortium. The number of symptomatic urinary tract infection episodes was found to be 73 (10.75%) among the studied ICU patients who had indwelling urinary catheter. In addition, for 1 year incidence of CAUTI was calculated as 9.08 per 1000 catheter days(11). In a recent study in a tertiary health care institute in eastern Indian, nosocomial Urinary tract infection incidence of 7.44/1000 catheter days was noted (12).

In a study published in 2010 from new Delhi(13) 22.4% of patients developed a symptomatic urinary tract infection during the period of follow up (up to 48 hours of catheter removal). All these

patients also had a bacterial colonization on Foley's catheters, which revealed the same organisms as the ones isolated from their urine culture. Another 30.4% patients had developed just an

(28)

27 asymptomatic colonization of their urinary catheters d uring the period of catheterization. Amongst all patients developing a bacterial colonization, E. coli was the most frequent organism isolated 59.1%. Other organisms isolated were Klebsiella spp.

(13/66), Staphylococcus spp. (10/66) and Enterococcus spp.(4 /66).

In previous dissertation done by Dr. Divya Bala in Medicine Unit 2 in Christian Medical College, Vellore; (manuscript under

preparation) she studied 76 patients and followed them up for 2 months. 37 (~50%) patients had urine samples on Day 3 which had significant bacteria. On 2 month follow up 4 (5.3%) of patients developed symptomatic UTI (telephonically).

(29)

28

RISK FACTORS FOR CAUTI

Table 1: Risk factors for CAUTI

Risk factors for catheter-associated urinary tract infection, based on prospective studies and use of multivariable statistical

modelling (7,14,15).

Factor Relative risk

Prolonged catheterization >6 days 5.1-6.8

Female gender 2.5-3.7

Catheter insertion outside operating room 2.0-5.3

Urology service 2.0-4.0

Other active sites of infection 2.3-2.4

Diabetes 2.2-2.3

Malnutrition 2.4

Azotemia (creatinine >2.0 mg/dL) 2.1-2.6

Ureteral stent 2.5

Monitoring of urine output 2.0

Drainage tube below level of bladder and above collection bag

1.9

Antimicrobial-drug therapy 0.1-0.4

(30)

29

DEFENITIONS

Indwelling urinary catheter: An indwelling urinary catheter is a drainage tube that is inserted through the urethra into the urinary bladder, is left in place, and is connected to a closed collection system.

This does not include straight in-and-out catheters or suprapubic, condom, catheters.

This definition includes indwelling urethral catheters that are used for intermittent or continuous irrigation.

Catheter associated urinary tract infection (CA-UTI) (Adapted from CDC guidelines(16) and IDSA guidelines(17))

A UTI in a patient where an indwelling urinary catheter which has been in place for at least 48 hours; which is insitu, or was in place until 1 calendar day prior to when all elements of the UTI as mentioned below in either of the criterion were first present together:

 With indwelling CBD insitu:

(31)

30 Fever (>38°C); rigors, costovertebral angle pain or tenderness, suprapubic tenderness, acute hematuria and otherwise unexplained systemic symptoms such as delirium or altered mental status, hypotension, or evidence of a systemic inflammatory response syndrome.

And either:

A positive urine culture of ≥ 1,00,000 colony-forming units (CFU)/ml with no more than 2 species of microorganisms.

Elements of the criterion must occur within a timeframe that does not exceed 24 hours.

-- or –

A positive urine culture of ≥ 1,000 but < 1,00,000cfu/mL with a positive finding on urinalysis (ie, pyuria, leukocyte esterase, nitrite)(18) (19).

 If within 48 hours of CBD removal

Fever (>38°C); rigors, urgency; frequency; dysuria;

costovertebral angle pain or tenderness; suprapubic tenderness; and otherwise unexplained systemic symptoms such as hypotension, altered mental status, or evidence of a systemic inflammatory response syndrome.

and

(32)

31 A positive urine culture of ≥ 1,00,000 colony-forming units (CFU)/ml with no more than 2 species of microorganisms.

All the elements of the criterion must occur within a timeframe that does not exceed 24 hours.

*With no other recognized cause

Symptomatic urinary tract infection (S-UTI)

Patient who did not have an indwelling urinary catheter in place at the time of , or 48 hours before all elements of this criterion were first present together and has at least 1 of the following signs or symptoms : fever (>38 °C); urgency ; frequency ; dysuria ; costovertebral angle pain or tenderness; suprapubic tenderness ; and at least 1 of the following findings:

 positive dipstick for leukocyte esterase and/or nitrite

 pyuria (urine specimen with ≥10 WBC/mm 3 of unspun urine or >5 WBC/high power field of spun urine

 microorganisms seen on Gram stain of unspun urine and

(33)

32 a positive urine culture of ≥ 1,000 and < 1,00,000 CFU/ml with no more than 2 species of microorganisms .

Elements of the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day.

Catheter associated Asymptomatic bacteriuria (CA-ASB)

A patient where an indwelling urinary catheter is in place or was in place until 48 hours prior; and in the absence of symptoms

compatible with UTI in a patient with indwelling urethral catheter has positive urine culture growth of ≥ 1,00,000 colony forming units per mL of more than one or more species of uropathogenic bacteria.

Asymptomatic bacteriuria (ASB)

Patient who did not have an indwelling urinary catheter in place at the time of; and in the absence of symptoms compatible referable to urinary infection; the isolation of a specified quantitative count of bacteria in an appropriately collected urine speci men.

(34)

33 Recurrent urinary tract infection (R-UTI)

Patient who has had three separate symptomatic urinary tract infection episodes with three positive urine cultures within a 12 - month period or two infections in the previous six months

(35)

34

PATHOGENESIS AND MICROBIO

L

OGY

The source of microorganisms causing catheter associated urinary tract infection can be endogenous, typically through meatal, rectal or vaginal colonization, or exogenous, from contamination form health-care personnel during catheter insertion or during

manipulation of the collection system(17).

Organisms may gain access in one of two ways. Extra luminal contamination occurs early, either by direct inoculation when the catheter is being inserted, or later, by organism’s ascension from the perineum by capillary action in the thin mucous biofilm whi ch is contiguous to the external surface of the urinary catheter via migration along the outside of the catheter in the periurethral mucous sheath. Intraluminal contamination may occur due to reflux or from microorganisms which gain access to the catheter inner lumen from failure of the closed drainage system or

contamination of urine in the collection bag and formation of an internal biofilm(7).

(36)

35 The relative contribution of either route in the pathogenesis of

catheter associated urinary tract infection is not certain. The marked reduction in risk of bacteriuria following the introduction of sterile, closed urinary drainage system(20) have suggested the importance of the intraluminal route in the pathogenesis. However, even with the closed drainage system in place, bacteriuria

inevitably occurs over time either via defects in the sterile system or via the extraluminal route. (21)

Studies have shown that catheter associated urinary tract infections most frequently originate from microorganisms that gain access to the bladder extra luminally, but both routes are of importance in the pathogenesis of catheter associated UTIs(21). Some studies have suggested that the extra luminal route may be of particular importance in women due to the short urethra and due to its close proximity to the anus(22). Investigators have found that antecedent heavy peri-urethral cutaneous microbial colonization is an

consistent risk factor for Catheter associated urinary tract infections in both men and women(23,24).

(37)

36 Biofilms are a microbially derived sessile community which

consists of cells which are attached to each other or to an interface, and are embedded in a polymeric extracellular matrix which is produced by the colonizing microbes which occurs almost

universally with prolonged catheterization(25). The biofilm often demonstrates altered phenotype which is associated with

differential gene expression which often leads to drug resistance(26). The biofilm offers not only a synergistic

opportunity for survival and for the evasion of host defences, but also ability to resist host defence and exogenous antimicrobial use, allowing the development of recurrent infection and virtually

impossible to eradicate without the removal of the catheter.

The daily risk of bacteriuria with urinary catheterization is 3% to 10% per day (27) and approaching 100% after 30 days (28).

The most frequently implicated pathogens associated with catheter associated urinary tract infection (combining both ASB and SUTI)

(38)

37 in a surveillance study between 2006-07 were Escherichia coli

(21.4%) and Candida spp. (21.0%), followed by Enterococcus spp.

(15.1%), Pseudomonas aeruginosa (9.9%), Klebsiella pneumonia (7.7%), and Enterobacter spp. (4.1%). A small proportion was caused by other gram negative bacilli and Staphylococcus spp.

In an Indian study done in a tertiary health care institute in

Nagpur, by Bagchi Indranil et al. the most frequent pathogens were E.coli (34.85%), Klebsiella spp. (19.7%), Pseudomonas spp.

(12.12%), Candida spp. (10.6%), Enterococcus spp. (6.06%), CONS (6.06%), Staphylococcus aureus (4.55%), Citrobacter spp. (3.03%),

& Proteus spp (3.03%).

(39)

38

THE SCIENTIFIC BASIS FOR PROBIOTIC PROPERTIES OF LACTOBACILLUS

Genitourinary infections in women are often preceded by an alteration in the local flora, with a transformation from a

predominant lactobacilli to coliform pathogens, due to multiple factors. Lactobacilli are the predominant bacteria of the vaginal flora(29) in healthy women and has antimicrobial properties that regulate the urogenital microbiota and plays a major role in

preventing illnesses, including bacterial vaginosis and urinary tract infections(30).

One antibacterial property of lactobacilli is the ability to maintain an acidic pH <4.5, which is conducive to lactobacilli replication and their subsequent production of antibacterial metabolites such as bacteriocin and hydrogen peroxide(31). They also produce biosurfactant which decrease adhesion of uropathogenic organisms(32). Furthermore, the ability of lactobacilli to co -

aggregate with urinary pathogens allows them to block the ability of pathogens to adhere(33) and kills the pathogens through the

(40)

39 production of inhibitors of uropathogen growth by competitive

exclusion (34,35) and immune modulation via H2O2, G-CSF, defensins and IL-8 neutrophil recruitment. Incomplete cure of urinary infection and recurrent genitourinary infections may result in a shift in the perineal flora from a predominant lactobacilli to coliforms and other uro-pathogens and hence predisposes to a urinary tract infection.

The concept of using Lactobacillus sp. for disease treatment and prevention as well as health restoration and maintenance is not new(36). However, in recent times, there has been a renewal of interest in the use of probiotics. Probiotic lactobacilli species, interact with the microbial biofilms of the intestine and urogenital tract and restore normal flora and maintain health. Recent

advances in the study of biofilms, such as use of confocal microscopy and the discovery of cell-to-cell signaling, will provide useful road maps for investigating the interactions between lactobacilli and intestinal and urogenital biofilms.

(41)

40 The important properties for lactobacilli to be effective probiotic organisms (37). These include the ability to:

a. adhere to cells;

b. exclude or reduce pathogenic adherence;

c. persist and multiply;

d. produce acids, hydrogen peroxide, and bacteriocins antagonistic to pathogen growth;

e. safe. i.e. noninvasive, noncarcinogenic, and nonpathogenic;

f. coaggregate and form a normal, balanced flora.

Firmicute organisms, primarily Lactobacillus spp, dominate in healthy premenopausal women, followed by Proteoba cteria such as Escherichia coli , then Actinobacteria such as Gardenerella and Bifidobacteria , then Fusobacteria and Bacteroidetes. (38)

In a study published by Kirjavainen et al, the microbiota of UTI - prone women was shown to be characterized by a diminished

(42)

41 lactobacillus morphotypes, with an abnormally high (>3) mean

Nugent score of 4.6 as compared to 1.7 for the controls(39).

In a study done on postmenopausal women(40) a relative depletion of vaginal lactobacilli and were present in only 62% of the women.

And it was significantly more prevalent among women who had been receiving hormone replacement therapy. Vaginal Escherichia coli and enterococci spp. were each present in 38% of women and were significantly more frequent in women with a history of

recurrent urinary tract infection. Heavy growth of lactobacilli was found to be associated with a lower frequency of vaginal

colonization with pathogenic strains of Escherichia coli.

Culture-based methods among women living mostly in

industrialized countries first suggested that a healthy vagi - nal flora was dominated by four species: Lactobacillus fermentum;

Lactobacillus brevis; Lactobacillus jensenii ; and Lactobacillus casei (41).

(43)

42 The predominant species seen in the vaginal mucosa of most

reproductive age women worldwide are Lactobacillus crispatus, Lactobacillus iners and Lactobacillus gasseri (42).

In Indian women differ from those reported from other countries;

the predominant species isolated being Lactobacilli reuteri present in 26 (32.5%) women, Lactobacillus reuteri present in 26 (32.5%) women, Lactobacillus reuteri Lactobacillus fermentum in 20

(25%), and Lactobacillus salivarius in 13 (16.25%) women (43) in a study done in New Delhi.

Another recent Indian study done in Southern India showed he common lactobacilli species found in this sample include d Lactobacillus crispatus(39.6 %), Lactobacillus gasseri(45.8 %), and Lactobacillus jensenii(14.6 %)(44).

A cross sectional study done in Indian and US population showed instead that the vaginal Lactobacillus species in both groups were similar, with Lactobacillus Jensenii and Lactobacillus crispatus

(44)

43 dominating all other species in healthy women in the reproductive age group (45).

(45)

44

CLINICAL TRIALS OF LACTOBACILLI FOR THE PREVENTION OF URINARY TRACT INFECTIONS

In a study done in Seattle, by Gupta et al, vaginal introital cultures were obtained from 140 women, 65 with recurrent UTI (case -

patients) and 75 without (controls). Vaginal E. coli colonization was significantly more frequent in case-patients than controls (35% vs. 11%) and in women without peroxidase producing lactobacilli than in women with (odds ratio 4.0). Hence it was shown that women with recurrent urinary tract infection often demonstrate persistent vaginal colonization with Escherichia coli.

Since strains of lactobacilli that produce hydrogen peroxide inhibit the growth of E. coli, the absence of these strains may predispose to E. coli colonization and to UTI. It was also noted in the study that external application of spermicides depleted the lactobacilli population and increased risk to recurrent UTIs which was

reversed on discontinuation of the same.(46)

On review of literature, three randomized trials aimed at the prevention of recurrent uro-genital infections with the use of

(46)

45 lactobacillus were identified. These studies used definitions from the Infectious Diseases Society of America of urinary tract

infections as defined by CDC surveillance guidelines (5).

Diagnostic criteria for UTI included the presence of classic signs

& symptoms, and evidence of bacteriuria (>100 CFU/mL). Cure was evaluated based on the improvement in clinical findings.

Baerheim et al (47) conducted a randomized, double- blind,

placebo-controlled study of Lactobacillus vaginal suppositories for the prevention of recurrent UTI in 47 women. Patients inserted vaginal suppositories containing either live Lactobacillus casei or placebo twice weekly for 26 weeks. Study participants were

between the ages of reproductive age group with a history of recurrent UTI, and had been symptom free and received no antibiotic treatment for 3 weeks before initiation of the study.

Recurrence was assessed at followup visits 2 weeks after study inclusion and monthly thereafter for 6 months. There was no significant difference in the monthly incidence of symptomatic lower UTIs between the Lactobacillus casei group and the placebo group (0.21 and 0.15, respectively); the observed incidence rate

(47)

46 ratio over 26 weeks was 1.41 (95% CI, 0.88–1.98). Colonization of lactobacilli, as assessed in periurethral samples, did not differ significantly between patients with and without a UTI.

Enterococci, E. coli, and undefined gram-positive cocci were the most commonly isolated causative organisms in the group treated with Lactobacillus casei, in 16%, 24%, and 44% of identified pathogens respectively. There were no dropouts during treatment, and treatment was generally well tolerated.

In a multicentre, randomized, active-controlled, blinded study, Reid et al (48) evaluated rates of recurrent UTI with a short course of antimicrobial therapy followed by Lactobacillus vaginal

suppositories in 41 premenopausal women. After positive results on tests for bacteriuria (> 1,00,000 CFU/mL) in a fresh midstream urine specimen and sensitivity to norfloxacin and TMP/SMX, participants received a 3-day supply of either oral norfloxacin or TMP/SMX 160/800 mg to be taken once daily. On the final day of oral antimicrobial treatment, patients were allocated to insert either vaginal suppositories containing freeze-dried Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum B-54 or to insert

(48)

47 active-control suppositories twice weekly for 2 weeks and once at the end of the next 2 months (total duration of treatment, 2.5

months). Specimens for urine culture were obtained during follow - up visits at 48 hours, 2 weeks, 5 weeks, 3 months, and 6 months.

There was no difference in the rate of recurrence of symptomatic lower UTI over 6 months in the antimicrobial-plus- Lactobacillus group compared with the antimicrobial-plus-placebo group (21%

and 41%, respectively). E coli was the most commonly isolated organism associated with recurrent UTI. No adverse events were reported during the study.

In another randomized, double-blind study, Reid et al (49)

compared the effect of lactobacilli and Lactobacillus growth factor (LGF)—which has been reported to stimulate the growth of

indigenous lactobacilli—on the recurrence of UTI in 55

premenopausal women. Patients were randomized to receive once - weekly vaginal suppositories containing either Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum B-54 (≥1.0 u 10 9 CFU per suppository) or LGF for 12 months. There was no

significant difference in the number of recurrent UTIs over 12

(49)

48 months between the group receiving lactobacilli and the group

receiving LGF; the mean incidence of UTIs in the 2 groups was 1.6 and 1.3 per patient per year, respectively. However, both rates were 73% lower than those in the year before prophylaxis (6.0 per

patient per year in both groups; P = 0.001). E coli was the most commonly isolated causative organism (57%) in both groups. No adverse events were reported.

In a randomized, open-label study, Kontiokari et al (50) compared a probiotic drink and cranberry–lingonberry juice in the prevention of recurrent UTI in 149 middle aged women with a history of recurrent UTI, as evidenced by bacterial counts of ≥1,00,00

CFU/mL on urine culture. Participants were randomly assigned to ingest 100 mL of a drink containing Lactobacillus rha mnosus GG 5 days per week for 1 year (n = 49), to drink 50 mL of cranberry – lingonberry juice daily for 6 months (n = 50), or to receive no intervention (n = 50). At 6 months, more patients in the

Lactobacillus and control groups had ≥1 recurrence of UTI

compared with the group that received cranberry–lingonberry juice (39%, 36%, and 8%, respectively). E coli was the most commonly

(50)

49 isolated organism (80%); other causative organisms were found but not specified. Treatment was well tolerated, with no adverse events reported in any group.

In a randomized, double blinded, non-inferiority trial by Beerepoot et al (51) comparing TMP/SMX vs Oral lactobacilli in preventing recurrent UTI in 252 post menopausal women. Randomized to TMP/SMX, 480 mg, 1 tablet at night and 1 placebo capsule twice daily for 12 months (n= 127) Or 1 capsule of Lactobacillus

rhamnosus GR-1 and Lactobacillus reuteri RC-14 twice daily and 1 placebo tablet at night for 12 months (n=125). The mean number of CRs was 2.9 (95% CI, 2.3 to 3.6) in the TMP/SMX arm 3.3 (95%

CI, 2.7 to 4.0) in the lactobacilli arm. The most common organism demonstrated being Escherichia coli (42%), enterococcus spp.

(18%) and non fermenters (17%). The study also looked at drug resistance and demonstrated significant development of drug resistant strains in the TMP/SMX arm and none in the lactobacilli arm. No lactobacilli was noted in the vaginal swabs and there was no change in Nugents score from baseline. No major adverse events were reported.

(51)

50 In a phase 2 randomized, double blinded, placebo -controlled trial by Stapleton et al (52) in 100 previously healthy pre-menopausal women who had presented with index uncomplicated urinary tract infection. They were randomized to receive Lactobacillus crispatus intravaginal suppositories once daily for 5 days followed by once weekly for 10 weeks (n=50) or placebo (n=50). 15% in the

lactobacillus arm developed a new urinary tract infection in the follow up period as compared to 27% of the placebo arm (RR, 0.5;

95% CI, 0.2–1.2). The study also showed high level vaginal colonization in the lactobacillus arm.

An in-depth review of literature from multiple sources did not yield any data on use of lactobacilli for the prevention of catheter associated urinary tract infection.

(52)

51

RATIONALE AND JUSTIFICATION OF THIS STUDY

While the studies have shown some benefit in the prevention of recurrent urinary tract infections in women in both premenopausal and post-menopausal age group there have been no studies

extending this principal to the use of lactobacillus spp. for preventing catheter associated urinary tract infection. Nugent

scoring (described below in methodology section) of Gram -stained smears was found to co-relate to lactobacilli and other vaginal bacteria detected microscopically in each subject. (38) This study attempts to find an association between catheter associated urinary infections and lactobacillus present in the patient ’s own vaginal flora by means of Nugent scoring.

If found to be so, it would warrant further interventional trials involving the administration of probiotic species of lactobacillus for the preventions of catheter associated urinary tract infection in the scenario of growing anti-microbial resistance.

(53)

52

METHODOLOGY

SAMPLE AND SETTING:

Observational study planned between January 2015 to July 2015 in female inpatients requiring insertion of indwelling urinary catheter admitted through the emergency or directly to general medical or medical ICU/HDU under general medicine units 1, 2, 3, 4, 5 in Christian Medical College Vellore, Tamil Nadu, India.

(54)

53

PARTICIPANTS:

INCLUSION CRITERIA:

 Female inpatients

 Age > 18 years

 Admitted under general medical units in Christian Medical College Vellore, Tamil Nadu, India.

 Time of enrolment within 24 hours of catheterization.

EXCLUSION CRITERIA:

 Indwelling urinary catheter > 24 hours prior to admission

 Total duration of catheterization less than 48 hours.

 Clinical diagnosis of urinary tract infection at the time of admission.

 History of catheterization/ instrumentation in the past 3 month.

 Pregnancy status known positive at enrolment.

 Does not consent to take part in the study

(55)

54

OUTCOMES

PRIMARY OUTCOME

Incidence of a symptomatic urinary tract infection (SUTI) within 30 days of urinary catheterization.

SECONDARY OUTCOME/S:

 Incidence of Catheter associated urinary tract infection (CAUTI as defined by CDC)

 Incidence of SUTI following catheterization between Day 31 – Day 90.

 Asymptomatic bactiuria at time of insertion

 Association between Nugent’s score with symptomatic urinary tract infection

 Association between Vaginal lactobacilli score with symptomatic urinary tract infection

 Catheter associated urinary tract infection’s per catheter day

 Risk factors for symptomatic urinary tract infection following catheterization

(56)

55

SAMPLE SIZE CALCULATION:

For presumption that observed higher lactobacilli indices (≥2+

on gram staining of vaginal swab) will reduce the incidence of symptomatic Urinary tract infection following catheterization from observed 30% to 15% with a Zα =1.96, Zβ =0.84;

the following formula was used:

N= 2 P¯Q¯ (Zα + Zβ) ² / (P1 - P2)²

and sample size of 122 was calculated(53,54).

Assuming 10% loss to follow up, the sample size planned for the study is 135.

(57)

56

STUDY DESIGN

The study was a prospective observational study done among female inpatients requiring insertion of indwelling urinary catheter admitted through the emergency or directly in general medical wards or medical ICU/HDU under general medicine units in CMC Vellore who give consent to participate in the study and fulfil in the above mentioned inclusion criteria.

Subjects were serially enrolled during the study period January 2015 to July 2015.

Patients were assessed for eligibility if they had been planned for urethral catheterization or if they had already had an indwelling catheter in situ, inserted during the past 24 hours.

The study and the research procedures were fully explained to the participants, participating in the prospective study (Annexure 1) and those who gave written consent were allowed to participate in the study. The consent was obtained in the regional language that the patient/relative was conversant (Annexure 2).

(58)

57 Following consent, demographic data and data pertinent to the study including co-morbid illness and other risk factors for a urinary tract infection was collected from the patient or patient’s relative if the patient was unable to furnish the necessary information by direct interview at the time of enrolment using the CRF designed for this study (Annexure 3) by the principal investigator. The medical personnel who performed the catherization was also interviewed regarding details of the procedure.

A day 0 urine culture and a vaginal swab was collected and processed in the manner as described below. Following which patients were followed up during the period of their inpatient stay. Daily bedside follow-up of the patient by the principal investigator was done to assess for symptomatology of a CAUTI on clinical assessment. Patient’s inpatient chart was also reviewed during the period of inpatient stay to assess for fever as defined earlier.

(59)

58 If the patient had developed symptoms of CAUTI with or without fever, urine culture specimen was collected and analysed following re-catheterization, if indicated; else by clean catch of

midstream voided urine specimen from a patient whose urethral, had been removed within the previous 48 hours (17).

If the patient had developed a symptomatic urinary tract infection in the remainder period of the inpatient stay, clean catch of midstream voided urine specimen was obtained for analysis.

If the patient had developed a new onset fever while on an indwelling urinary catheter or within 48 hours of its removal;

with no symptoms of a catheter associated urinary tract infection as defined earlier, patient was assessed along with the primary clinician for any alternate obvious foci. If no alternate foci was found, it was planned to send urine cultures following re-catheterization if indicated.

(60)

59 If the primary treating physician had sent urine or blood cultures for any indication as felt necessary on clinical assessment, the data was obtained from the clinical workstation used at the institution (Clinical Workstation, Version 5.7.16; Christian Medical College; Department of Computerized Hospital Information Processing Services)

Microbial confirmation by urine culture using standard CSLI methods as described in detail below.

If during the period of inpatient stay, the patient did not develop a urinary tract infection and was discharged, they were followed up telephonically at days 30, day 60 and day 90 or till they developed a symptomatic urinary tract infection.

After education of symptoms of a urinary infection, they had been requested to appear for clinical assessment by the principal investigator and to submit a urine sample for routine analysis and culture if they were symptomatic during the follow up period.

(61)

60

Figure 1: Study algorithm

+ -

Assessed for eligibility

Urine culture taken during catheterization (Day 0 sample)

Consent to participate in study

Nugent score on swab

Monitored until 48 hours after catheter removal

Clinical features of

UTI

CAUTI

Urine culture on mid stream voided

specimen CATHETERIZATION

Urine culture from catheter sampling port

if catheter insitu

Urine culture on midstream voided specimen if catheter

removed

Vaginal swab taken during / within 24

hours of catheterization

Phone call D30

If symptomatic for UTI

SUTI 30

SUTI D60/90 SUTI

Urine culture on mid stream voided

specimen

If > 48 hours after catheter removal

(62)

61

BIAS:

This was a prospective study with consecutive recruitment.

This was done to minimize bias in the Cohort. Other bias as part of observational studies will be present.

(63)

62

DATA SOURCES/MEASUREMENT:

Data was collected from the patient or patient ’s relative if the patient was unable to furnish the necessary information by direct interview at the time of enrolment using the CRF designed for this study (Annexure 2) by the principal investigator. The patients were followed up daily during the period of their IP stay. Some of the required data required was acquired from the clinical workstation used at the institution (Clinical Workstation, Version 5.7.16; Christian Medical College; Department of Computerized Hospital Information Processing Services)

COLLECTION AND PROCESSING OF URINE SAMPLES:

A urine culture was obtained within 24 hours of catheterization, and sent to the Microbiology laboratory for culture and susceptibility. In addition, the urine for culture was also cultured for the presence of lactobacilli to determine the species present.

(64)

63 The catheter specimen was obtained as the first urine sample collected at the time of catheterization or from a sampling side-port (55) if available, else by direct puncture of the proximal portion of the catheter with a needle after disinfecting the tube (56) or if a catheter associated urinary tract infection was suspected and the patient continued to require placement of an indwelling catheter; the catheter was replaced as per standard procedure and the first urine sample from the new urinary catheter was sent for analysis (57,58).

The specimen was sent directly to the lab and maintained at 4°C prior to processing for culture.

The routine urine culture was performed by the semi- quantitative culture method(59). An initial assessment of the un-centrifuged specimen gram stain was performed to grade the specimen for the amount of inflammatory reactive cells, epithelial cells and bacteria(60). The semi-quantitative culture was performed with 10µl of the specimen on sterile and quality

(65)

64 passed 7% Sheep blood agar and MacConkey media, prepared in the Department of Clinical Microbiology (59,61). The cultures were incubated aerobically at 37°C for up to 48hours.

The interpretations of the routine urine cultures, for a freshly inserted catheter were as follows(59):

a) Normal flora was interpreted as contaminants, Insignificant bacteriuria

b) Single organisms below 1000 cfu/ml as Insignificant bacteriuria

c) Up to 2 organisms between 1000 - <100,000 cfu/ml as Probably significant bacteriuria

d) Up to 2 organisms >100,000 cfu/ml as Significant bacteriuria e) More than 3 organisms as a Mixture of organisms,

Insignificant bacteriuria

f) In asymptomatic patients with no inflammatory cells, growth was reported as colonization.

(66)

65 The gram negative bacilli were identified using the oxidase test and the preliminary screening media consisting of the mannitol motility media, triple sugar iron agar, peptone water, Simmon’s citrate and Christensen’s urea media. Enterococcus species was identified using bile esculin agar.

Susceptibility testing was performed by the Kirby-bauer disk diffusion method on Mueller-Hinton agar, Difco, India.

Standard American Type culture collection (ATCC) control strains were used as quality control strains for the drugs tested.

The reports were not reported to the clinicians as the reports were not required for patient management and were used only for study analysis.

The urine specimen was also cultured on the Lactobacillus deMan, Rogosa Sharpe media (MRS agar), HiMedia Laboratories Pvt. Ltd, India and incubated anaerobically at 37°C for up to one week. ATCC 33197 Lactobacillus crispatus was used as the quality control for the media.

(67)

66 Colonies growing on the MRS agar were identified by gram stain. A catalase test was performed on all the gram positive bacilli. ATCC 25923 Staphylococcus aureus was used as the test positive control and ATCC 33197 Lactobacillus crispatus as the test negative control.

On a subset of the patients, in addition to the urine culture a vaginal swab was sent within 24 hours of catheter insertion.

The swabs were cultured on 7% sheep blood agar, chocolate agar, Mac Conkey agar and Thioglycollate media and incubated aerobically for 48 hours and on to Lactobacillus MRS agar which was incubated anaerobically at 37°C for one week. Colonies growing on the MRS agar were identified by gram stain. A catalase test was performed on all the gram positive bacilli. ATCC 25923 Staphylococcus aureus was used as the test positive control and ATCC 33197 Lactobacillus crispatus as the test negative control.

(68)

67 Isolates identified as Lactobacillus species were identified for species identification using the VITEK 2 identification system, Bio Merieux, India. The isolates were then lyophilized for future molecular testing.

COLLECTION AND PROCESSING OF VAGINAL SWAB:

The vaginal swab was collected by the female medical personnel involved in the study as a co-investigator or trained female medical staff after consent, taken at the time of urethral catheterization or within 24 hours of catheterization.

The procedure was explained to the patient wherever possible.

The procedure was done in a setting so as to ensure her privacy. The swab was collected either by trained female medical personnel or with a chaperone. The patient was requested to lie in a dorsal position with the knees flexed and hips abducted and draped appropriately. Standard hand disinfection procedure were followed and sterile gloves donned. Additional lighting was used where necessary.

(69)

68 The swab was collected by parting the lips of the labia minora with the non-dominant hand. Using the dominant hand, a sterile flocked swab was inserted 1 to 2 cm into the lower vaginal entrance(38) without lubrication or speculum(62) examination. The swab was collected by contacting the swab to the lower 1/3^rd of the lateral and posterior wall by a few linear and rotatory passes till adequate sample was obtained.

The swab was then gently roll the swab 2-3 timed in non- overlapping passes on to the middle of a glass slide and allowed the smear to dry in air. The slide was then labelled and placed in a designated slide carrier. The was transported to the trained microbiologist for performing the staining and reporting by standardized gram stain techniques.

Upon receipt of the slide for processing, the smear was air - dried and then heat fixed over an incandescent lamp. Gram stained was done by using methylene blue followed by Gram’s iodine and using safranin as the counterstain following

(70)

69 acetone wash. The slide was then blot dried and microscopic examination with scoring was done as follows:

Each Gram-stained smear was evaluated for the following morphotypes under oil immersion (x1,000 magnification): - - Large gram-positive bacilli (Lactobacillus spp.

morphotypes)

- Small gram-variable bacilli (Gardnerella spp.

morphotypes)

- Curved gram-negative or gram-variable bacilli (Mobiluncus spp. morphotypes)

Quantitate each morphotype from 1 to 4+ with regard to the number of morphotypes per oil immersion field according to the following scale:

0 = 0 cell in smear

1+ = <1 cell per 1000x oil immersion field 2+ = 1-4 cells per 1000x oil immersion field 3+ = 5-30 cells per 1000x oil immersion field 4+ = >30 cells per 1000x oil immersion field

(71)

70 Scoring system used for lactobacillus quantitative assessment by Nugent et al.(63) The Nugent criteria are widely used to diagnose bacterial vaginosis according to the proportions of different cellular morphologies seen in gram stained smears of vaginal samples. The weighted score computed using these criteria is thought to reflect the relative abundance of the following morphotypes: lactobacilli, Gardnerella vaginalis or Bacteroides (small gram-variable rods or Gram-negative rods), and curved gram-variable rods. The resulting scores range from 0 to 10, with those of 7 and higher considered to be indicative of bacterial vaginosis, whereas scores of 4 – 6 are considered intermediate and and 3 or less normal. A strong correlation between high pH and high Nugent scores has been demonstrated.(64)

(72)

71 Table 2: Nugent scoring system; adapted from Nugent et al (63)

Per 1000x oil immersion field

Lactobacilli Gardenella GV

4+ 0 4 2

3+ 1 3 2

2+ 2 2 1

1+ 3 1 1

0 4 0 0

* Tabulated above are scored points and not per HPF

(73)

72

GUIDE AND CO-INVESTIGATORS

GUIDE

Dr. Thambu David S.

Professor and Head of Unit, Medicine 2

Christian Medical College, Vellore

CO- GUIDE

(S) Dr. John Victor Peter

Associate Professor of Medicine and Critical Care Dept. Of Critical Care

Dr. Rani Diana Sahni

Associate Professor of Microbiology Dept. of Microbiology

Dr. Renu George

Professor & Head of Department, Dept. of Dermatology 1

(74)

73

Dr. Jayaprakash Muliyil Professor & Academic Officer Dept. of Community Health

Dr. Prasanna Samuel Biostatistician

Dept. Of Biostatistics

Mr. Ravikumar T.S.

Professor of Nursing Accident and Emergency

Dr. Anand Zachariah Professor

HOU, Medicine 1 & HOD, Dept. of General Medicine Christian Medical College, Vellore

Dr. Sudha Jasmine Associate Professor Dept. of Medicine 3

(75)

74

Dr. Abhilash K.P.P

Acting Head & Associate Professor

Dept. of Accident and Emergency Medicine.

Dr. Manjeera Jagannati Assoc. Professor

Dept. of Medicine 5

Dr. Cijoy Kuriakose Assoc. Professor Dept. of Medicine 2

Dr. Deepthi Bal Asst. Professor Dept. of Medicine 2

(76)

75

CO- INVESTIGATOR

^(S)

Mrs. Sheeba Tennyson Microbiologist

Dept. of Dermatology

Dr. Anjali Sarah George Junior Clinical Assistant Dept. of Neurological Sciences Christian Medical College, Vellore

(77)

76

DATA ANALYSIS AND STATISTICAL METHODS

Data entry was done by the principal investigator in Epidata 3.1 form (Annexure 4) which was prepared based on data abstraction sheet and exported to SPSS for analysis (Annexure 5).

Statistical analysis was done by Dr. Prasanna Samuel, department of Biostatistics, Christian Medical College, Vellore using IBM SPSS Statistics version 23.0.0 64-bit edition.

(78)

77

FUNDING AND APPROVAL

FUNDING SOURCE

A sum of Rs.1,00,000 (Rupees one lakh only) was obtained from an institutional research grant and Rs. 50,000 (Fifty thousand only) from Medicine 2 special fund. (Annexure 6)

IRB Fund 22y432 was the active account for the study.

INSTITUTIONAL RESEARCH BOARD APPROVAL AND ETHICAL

CONSIDERATIONS

The research proposal was discussed by the Institutional Review Board in August 2014 and approval was obtained after receiving the suggested modifications[IRB Min No: 8990 dated 04.08.2014];

and approved to be conducted as presented following the modifications on 02-October 2014. (Annexure 5)

There were no ethical issues related to this study.

(79)

78

RESULTS

PRIMARY OUTCOME: INCIDENCE OF

SYMPTOMATIC URINARY TRACT INFECTION

A total of 6 (11.32%) of symptomatic urinary tract infections was observed during the study period at follow up to 30 days. There were 2 (3.77%) catheter associated urinary tract infection as defined by CDC. One occurred while the indwelling catheter was still in-situ; and the other within 48 hours o f its removal. In the telephonic follow up period at 30 days 4 more patients had developed symptoms of a urinary tract infection.

Table 3: Incidence of symptomatic urinary tract infection

SUTI Sample (%)

Nil 47 (88.68)

Total SUTI 6 (11.32 %)

 CAUTI – Catheter in-situ 1 (1.89 %)

 CAUTI - <48 hours of removal 1 (1.89 %)

 Symptomatic UTI > 48 hours < 30 day 4 (7.56%)

(80)

79 Figure 2: Symptomatic urinary tract infection

Figure 3: Time plot to event of symptomatic urinary tract infection

Catheter in-situ 16%

< 48 hours of removal

>48 hours; < 30 17%

days 67%

SYMPTOMATIC URINARY TRACT INFECTION

Catheter in-situ < 48 hours of removal >48 hours; < 30 days

0 5 10 15 20 25 30

>48 hours of removal < 30 days from catherization

<48 hours of removal Catheter in-situ

Days from catheterization

TIME PLOT

(81)

80

CORELATION OF LACTOBACILLI WITH SUTI

It was observed that in 5 (83.33%) of the 6 observed UTI, there was low vaginal lactobacillary indices of 3-4 (ie. 1+ or 0 per high powered field).

P=0.094, RR= 5.92 CI-0.74 to 47.68

Table 4: Incidence of symptomatic urinary tract infection in relation to vaginal lactobacilli

PARAMETER Lactobacilli score

Lactobacilli / 1000x field

SUTI

NO (47) YES (6) Lactobacilli 0 4+ 10 (100%) 0

1 3+ 10 (90.91%) 1 (9.09%)

2 2+ 14 (100%) 0

3 1+ 9 (75%) 3 (25%)

4 0 4 (66.67%) 2 (33.33%)

Figure 4: Incidence of SUTI in relation to lactobacilli score

10 10

14

9

4

0 1

0

3

2

0 2 4 6 8 10 12 14 16

0 (4+ HPF) 1 (3+ HPF) 2 (2+ HPF) 3 (1+ HPF) 4 (0 per HPF)

Lactobacilli score vs SUTI

No UTI UTI

(82)

81

STROBE FIGURE (65)

Figure 5: STROBE

ENROLMENT

Assessed for eligibility (n=98) 9898)

Excluded (n= 43)

 UTI at presentation (n= 15)

 Declined to participate (n=11)

 Death before admission (n=3)

 Discharged without admission (n=14)

Analysed (n=53)

 *Excluded from analysis (protocol error) (n=2)

Follow up day 30 (n= 31)

 Lost to follow-up (n= 11)

 Death after discharge (n= 0) Observed during IP stay (n= 55)

 *Protocol error (n= 2)

 Death before discharge (n= 11) IP STAY

ANALYSIS

PRIMARY

Patients recruited into study (n= 55)

Follow up day 90 (n= 29)

 Lost to follow-up [n= 13]

 Death after day30 (n= 1)

FOLLOW-UP

CAUTI = 2

SUTI = 2

catheter associated urinary tract infections among

A dissertation submitted in partial fulfilment of the rules and regulations for MD General Medicine examination of the Tamil Nadu Dr. M.G.R. Medical University, Chennai, to be held in April 2016.

Vaginal lactobacilli and