Rajiv Gandhi University of Health Sciences



SYNOPSIS OF DISSERTATION

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

“Clinical & laboratory profile of urinary tract infection in diabetics & the relationship of diabetic status to complications”

Name of the candidate : Dr. Ravi Shekhar

Guide : Dr. Vijayashree Thyagaraj

Course and Subject : M.D. (General Medicine)

Department of General Medicine,

M.S. Ramaiah Medical College,

Bangalore, Karnataka – 560054.

September – 2012

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

| |Name of the candidate and |DR. RAVI SHEKHAR |

|1. |Address | |

| |(in block letters) |POST GRADUATE RESIDENT |

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| | |DEPARTMENT OF GENERAL MEDICINE |

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| | |M.S. RAMAIAH MEDICAL COLLEGE |

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| | |BANGALORE, KARNATAKA-560054 |

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|2. |Name of the Institution |M.S. RAMAIAH MEDICAL COLLEGE |

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| | |BANGALORE, KARNATAKA-560054 |

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|3. |Course of study and subjects |DOCTOR OF MEDICINE (M.D) |

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| | |GENERAL MEDICINE |

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|4. |Date of admission to course |31.05.2012 |

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|5. |Title of the topic |

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| |“CLINICAL & LABORATORY PROFILE OF URINARY TRACT INFECTION IN DIABETICS AND THE RELATIONSHIP OF DIABETIC STATUS TO ITS |

| |COMPLICATIONS” |

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|6. |Brief resume of the intended work: |

| |6.1 Need for the study: |

| |. |

| |Diabetic patients are at increased risk of developing Urinary tract infection (UTI) & its complications (Renal/perirenal abscess, Papillary |

| |necrosis, Emphysematous cystitis, Emphysematous pyelonephritis/pyelitis, Xanthogranulomatous pyelonephritis). |

| |UTI in diabetics is often given less importance, more attention being paid to macro & microvascular complications. Awareness of the disease, |

| |knowledge of the spectrum of bacteria and their sensitivity to antibiotics and the common complications of UTI will help to reduce morbidity and |

| |mortality. |

| | |

| |With this study we intend to look at the clinical & laboratory profile and complications of UTI in diabetic patients presenting at MS Ramaiah |

| |Hospitals. |

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| |6.2 Review of literature: |

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| |Diabetics are more susceptible to infections & complications are more frequent and serious. This is due to impaired host response to infections |

| |eg. Mobilization & chemotaxis of neutrophils, phagocytosis, adherence, bactericidal activity, cell mediated immunity.1 |

| |In addition , the autonomic neuropathy caused by Diabetes mellitus leads to neurogenic bladder which impairs bladder emptying leading to stasis & |

| |hence infection. |

| |Diabetics are at increased risk of renal papillary necrosis. UTI may be both a cause as well as effect of renal papillary necrosis and it must be |

| |suspected in any diabetic with frequently relapsing or difficult to eradicate pyelonephritis. |

| |Most UTIs are caused by facultative anaerobes and usually originate in bowel flora. Uropathogens such as Staph. epidermidis & Candida albicans |

| |originate in flora of vaginal or perineal skin. |

| |E.coli is by far the most common cause of UTI, accounting for 85% of community acquired & 50% of hospital acquired infections. Other gram negative|

| |Enterobacteriaceae include Proteus and Klebsiella & gram positive Staph. saprophyticus and Enterococcus faecalis.2 |

| |Amongst catheterised patients also, E.coli was the most frequent isolate.3 |

| |A study at AIIMS in 2001 on prevalence of UTI and renal scars on 155 patients with Diabetes and healthy controls concluded a 10 fold increased |

| |risk of UTI and 3 fold risk of renal scarring. E.coli again was the most common isolate (64.3%) followed by Staph. aureus (21.4%) & klebsiella |

| |(14.3%).4 |

| |Abhilash et al studied the epidemiology and outcome of bacteremia caused by extended spectrum B-lactamase (ESBL) producing E.coli & Klebsiella sp.|

| |in a tertiary care hospital in South India amongst 131 bacteremic patients & concluded a very high ESBL production & resistance to multiple |

| |classes of antibiotics. The most common co-morbid condition was type 2 Diabetes mellitus, seen in 42.7% patients.5 |

| |Saleem et al. conducted a study in 2011 to compare the prevalence of UTI in diabetics versus non-diabetics in Bangalore city. They showed that |

| |prevalence of UTI was higher in diabetics as compared to non-diabetics.6 |

| |A study done on organisms causing urinary tract infections in diabetics (n=288) & non-diabetics (n=63) with symptomatic UTI concluded that |

| |isolation rate of ESBL producing gram negative bacilli was higher among diabetics (47.8%) compared to non-diabetics (9.1%).7 |

| |Study done in Canada on patients admitted with pyelonephritis identified diabetes as an overwhelming risk factor. 36% of hospitalised women and |

| |21% of hospitalised men admitted for acute pyelonephritis were found to be diabetic. |

| |The most common complications in patients with diabetes and acute pyelonephritis are acute papillary necrosis, emphysematous pyelonephritis and |

| |renal abscess.8 |

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| |6.3 Objectives: |

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| |1. To study clinical profile of urinary tract infections in diabetics. |

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| |2. Yield of urine culture in UTI, in diabetics and the common causative organisms and their antibiotic sensitivity pattern. |

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| |3. To study the relationship of duration & poor control of diabetes mellitus (defined by HbA1c>7%) to the complications of UTI. |

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| 7. | |

| |Materials and Methods: |

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| |7.1 Source of data: |

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| |Outpatients and inpatients at M.S. Ramaiah Hospitals between September 2012 and August 2014 |

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| |Type of study : Prospective observational study |

| |Duration of study : Two years |

| |Sample size : Minimum 250 patients |

| |Rationale for sample size : Based on previous study6 with |

| |Relative precision 14 |

| |Expected proportion 45 |

| |Confidence interval 95% |

| |7.2 Method of collection of data: |

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| |Patients will be identified as per inclusion and exclusion criteria. |

| |History and physical examination |

| |List of investigations : |

| |1. Urine routine and microscopy |

| |2. Urine culture and sensitivity with colony counts |

| |(mid-stream, clean catch sample) |

| |3. Haemoglobin, total WBC, differential counts |

| |4. FBG and PPBG |

| |5. Glycosylated Hemoglobin |

| |6. Renal function test |

| |7. Ultrasound abdomen |

| |8. X-ray KUB & CT Scan Abdomen, if required by the treating doctor. |

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| |Statistical analysis: |

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| |Data entry and analysis will be done using SPSS 17 |

| |Quantitative variables will be expressed as means ± SD |

| |Qualitative variables will be expressed in terms of proportion |

| |Chi-square test for significance will be used to find the association of complications with duration & control of diabetes |

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| |Inclusion criteria: |

| |Type 1 and Type 2 diabetic patients >18 year of age with & without symptoms of UTI with significant pyuria. |

| |Significant pyuria defined as: |

| |>5 WBC/HPF in males |

| |>8 WBC/HPF in females |

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| |Exclusion criteria: |

| |1. Gestational Diabetes |

| |2. Immunocompromised states- HIV |

| |Patients on steroids |

| |Malignancy |

| |Transplant recipients |

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| |7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? |

| |If so, please describe briefly. |

| |Yes, as mentioned above. |

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| |7.4 Has the ethical clearance been obtained from your institution in case of 7.3? |

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|8. |List of References: |

| |Eliopoulus GM, Sentochnik E. Infection in diabetes, Joslins textbook of Diabetes Mellitus, 13th ed, Wavely Int.1994,867-888 |

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| |Hall LM, Duke B, Urwin G Etal. |

| |Epidemiology of Enterococcus faecalis urinary tract infection in a teaching hospital in London. United Kingdom. J Clin Microbiol 1992;30,223 |

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| |Subramanium P,Sivaraman U, Kumar S, Selvaraj S, Shanmugan N |

| |Antibiotic resistance pattern of biofilm-forming uropathogens isolated from catheterized patients in Pondicherry, India. AMJ 2012,5,7,344-348 |

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| |Goswami R, Bal CS, Tejaswi S. Prevalence of urinary tract infection & renal scars in patients with Diabetes mellitus. Diabetes Res Clin Pract. |

| |2001 Sep;53(3):181-6 |

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| |KPP Abhilash, Balaji Veerarghavan, OC Abraham. Epidemiology and Outcome of Bacteremia Caused by Extended Spectrum Beta-Lactamase (ESBL)-producing |

| |Escherichia Coli and Klebsiella Spp. in a Tertiary Care Teaching Hospital in South India. Supplement to JAPI • December 2010 • VOL. 58 |

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| |Mehvish Saleem, Betty Daniel. Prevalence of Urinary Tract Infection among Pateints with Diabetes in Bangalore City. Int. J. Emerg. Sci, 1(2), |

| |133-142, June 2011 |

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| |Md Hamza Saber, Lovely Barai, J Ashraful Haq, Md Shariful Alam Jilani, Jaheda Begum. The Pattern of Organism Causing Urinary Tract Infection in |

| |Diabetic and Non Diabetic Patients in Bangladesh. Bangladesh J Med Microbiol 2010; 04 (01): 6-8 |

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| |Nicolle LE, Friesen D, Harding GK, Roos LL. Hospitalization for acute pyelonephritis in Manitoba, Canada, during the period from 1989-1992; impact|

| |of diabetes, pregnancy, and aboriginal origin. Clin Infect Dis 1996;22:1051-6. |

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| |SIGNATURE OF THE CANDIDATE : |

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| |REMARKS OF THE GUIDE : |

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| |NAME AND DESIGNATION OF GUIDE : DR. VIJAYASHREE THYAGARAJ |

| |Asso. Professor of Medicine |

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| |SIGNATURE : |

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| |HEAD OF THE DEPARTMENT : DR. U. SUDHIR |

| |Professor of Medicine |

| |SIGNATURE : |

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| |REMARKS OF CHAIRMAN |

| |AND PRINCIPAL : |

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| |SIGNATURE : |

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