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 |
| | | |
| | |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 |
| | | |
| | |BANGALORE, KARNATAKA-560054 |
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|3. |Course of study and subjects |DOCTOR OF MEDICINE (M.D) |
| | | |
| | |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” |
| | |
|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: |
| | |
| |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: |
| | |
| |1. To study clinical profile of urinary tract infections in diabetics. |
| | |
| |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: |
| | |
| |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. |
| | |
| |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 |
| | |
| |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 |
| | |
| |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 |
| | |
| |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 |
| | |
| |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 |
| | |
| |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 |
| | |
| |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 |
| | |
| |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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