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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 298-306

Determinants and bacteria associated with asymptomatic bacteriuria among women attending antenatal care service at muhoza health centre, Rwanda


1 Department of Biomedical Laboratory Sciences, INES Ruhengeri Institute of Applied Sciences, Musanze, Rwanda
2 Department of Medical Microbiology, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
3 Department of Biology, Université Hassan Ii De Casablanca, Casablanca, Morocco
4 Department of Midwifery and Gender, Moi University, Eldoret, Kenya

Date of Submission16-Mar-2022
Date of Acceptance31-May-2022
Date of Web Publication15-Sep-2022

Correspondence Address:
Dr. Callixte Yadufashije
Department of Biomedical Laboratory Sciences, INES Ruhengeri Institute of Applied Sciences, Musanze
Rwanda
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_56_22

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  Abstract 


Introduction: Asymptomatic bacteriuria (ASB) is a global health concern during pregnancy. It accounts for 2%–15% of pregnant women globally. This study was carried out to determine the prevalence of ASB, the leading cause of ASB during pregnancy, and the antibiotic susceptibility pattern of bacteria associated with ASB. Materials and Methods: This was a cross-sectional study conducted from September to December 2021 at Muhoza Health Centre. About 142 pregnant women without symptoms of urinary tract infections were recruited. The urine sample collected was put in a sterile Stuart plastic container and transported to INES Ruhengeri clinical microbiology for bacterial identification. The structured interview was conducted to assess factors associated with ASB among women. Logistic regression analysis was performed to test the relationship between demographic characteristics and ASB, while a Chi-square test (x2) was performed to test for association with ASB and other determinants considered in this study. Results: About 70.40% of participants had ASB. Pregnant women in the second trimester (28.16%) and first trimester (25.35%) were the most affected, while women aged 24–29 (28.16%) were the most affected. Escherichia coli (27.6%) and Klebsiella pneumonia (23.8%) were the predominant isolated bacteria in the urine and was observed to be the most coloniser of the urinary tract throughout all the pregnancy trimesters. Among demographic characteristics, urban residence (P = 0.005, 95% confidence interval [CI]: 0.717–4.160), primary education (P < 0.00001, 95% CI = 15.390–19.310), ordinary education (P < 0.00001, 95% CI = 16.550–20.455) and advanced level education (P < 0.00001, 95% CI = 17.194–20.650) were statistically significant to contribute to ASB. Hygiene (x2 = 6.81, P = 0.009) was significantly associated with ASB. K. pneumonia and Staphylococcus saprophyticus were the most resistant bacteria to selected antibiotics. Conclusion: ASB may be an epidemic in pregnancy. Early diagnosis of ASB is recommended in early pregnancy to prevent pregnancy-associated complications.

Keywords: Antenatal, asymptomatic bacteriuria, determinants, pregnancy


How to cite this article:
Yadufashije C, Ishimwe A, Mucumbitsi J, Muhimpundu L, Twagirumukiza G, Ndayambaje M, Migabo H, Mwanzia L. Determinants and bacteria associated with asymptomatic bacteriuria among women attending antenatal care service at muhoza health centre, Rwanda. Adv Hum Biol 2022;12:298-306

How to cite this URL:
Yadufashije C, Ishimwe A, Mucumbitsi J, Muhimpundu L, Twagirumukiza G, Ndayambaje M, Migabo H, Mwanzia L. Determinants and bacteria associated with asymptomatic bacteriuria among women attending antenatal care service at muhoza health centre, Rwanda. Adv Hum Biol [serial online] 2022 [cited 2022 Dec 1];12:298-306. Available from: https://www.aihbonline.com/text.asp?2022/12/3/298/356114




  Introduction Top


Asymptomatic bacteriuria (ASB) is defined as the presence of bacteria in the urine of an individual without signs and symptoms. During pregnancy, the significant reduction of immunity favours the growth of pathogens and opportunistic pathogens. Bacteriuria affects 2%–15% of pregnant women. About 30%–40% of these women may develop acute pyelonephritis if the condition remains untreated. ASB has contributed to adverse maternal health outcomes such as preterm birth and low birth weight.[1] The reports show that women with diabetes mellitus and gestational diabetes, women with low social-economic status, and women with a previous history of urinary tract infection (UTI) are the most predisposed to ASB.[2] Early treatments of ASB prevent pyelonephritis and lower the risk of preterm deliveries. To control ASB, hospitals and health centres have introduced the screening and treatment of ASB in antenatal care. Debates continue on how the early treatment of ASB contributes to the improvement of neonatal health outcomes and whether the treatment with antibiotics improves the reduction of pregnancy complications.[3] The causal agents of ASB among pregnant women are not different from non-pregnant women. However, immunosuppression and physiological changes during pregnancy favour bacterial colonisation compared to non-pregnant women. Escherichia coli is the main persecutor for both asymptomatic and symptomatic bacteriuria, and its uropathogenic strains lead to invasive infection and pyelonephritis during pregnancy.[4] The prevalence of ASB may change based on countries and geographical locations. In the above study carried out in Pakistan, about 200,000 pregnant women were tested, of whom 5000 (2.5%) were diagnosed with ASB, while 4600 (2.3%) were diagnosed with symptomatic UTIs. In the same population, ASB was associated with pregnancy complications such as hypertension, diabetes, long hospital stay, intrauterine growth retardation and preterm labour.[5] About 9.5% of ASB was reported in Ghana. Of these, the pregnant women in the second trimester were the most affected. In Nigeria, the high prevalence of ASB was reported by studies and stood at 47.5%, and this prevalence was attributed to factors such as personal and environmental hygiene, social-economic status and sexual intercourse. The prevalence of UTIs in East Africa was reported as follows, Tanzania (15.5%), Sudan (14%), Uganda (13.3%) and Kenya (21.5%).[6] The single catheterised urine was reported to be 2% of ASB among non-indigent pregnant women of middle social and economic status, while 6.5% were reported among indigent patients.[7]


  Materials and Methods Top


Settings

Northern Province, Musanze district, Muhoza sector of Rwanda, Musanze district has 15 sectors, 68 cells and 432 villages; it deserves a population of 406557. It covers 16 health centres, 1 prison dispensary and 13 health posts.

Study design

This was a cross-sectional study conducted from October 2021 to December 2021.

Study population and sample size

The study population included pregnant women attending antenatal care at Muhoza Health Centre (n = 142). Urine samples were collected in a sterile container and transported to the microbiology laboratory at INES Ruhengeri for further analysis. Simple random sampling was used to recruit participants. The structured interview was conducted to identify potential risk factors associated with ASB among pregnant women.

Inclusion criteria and exclusion criteria

The study included pregnant women without symptoms of UTI and any other vaginal health condition. All pregnant women with UTIs and vaginal infections were excluded.

Ethical considerations

We received a research clearance letter from INES Ruhengeri Institute of applied sciences and also Muhoza Health Center's Ethical Committee approval letter (MHCEC/10/13/2021) on October 27, 2021. We were requested to present the request for a data sample and data collection, and the request was sent with the proposal and tools for sample and data collection. They requested us to explain the study physically before we collected data. After the presentation, they delivered a letter accepting to collect data. The written informed consent was addressed to all women targeted by the study and those who voluntarily were recruited. All personal information was not mentioned.

Urine culture and identification of bacteria

Aseptically, urine samples were collected and inoculated onto sheep Blood agar, MacConkey agar and Cystine Lactose Electrolyte Deficient (CLED) media using an inoculation loop. After inoculation plates were incubated at 37°C for 12–24 h, bacterial isolation was done depending on their colony. For example, E. coli were lactose-fermenting (pink), moist and smooth colonies on MacConkey agar, while Proteus mirabilis showed swarming colonies on the sheep blood agar plate. Subsequent identification of bacteria at the species level was conducted by taking a colony from culture media and inoculating it onto various biochemical media. Briefly, Gram-positive bacteria were recognised using a series of biochemical tests such as catalase, coagulase and Citrate test, Urease test, Kligler Iron Agar, Sulphur Indole Motility and oxidase tests for Gram-negative bacteria.

Antimicrobial sensitivity testing

Antimicrobial sensitivity testing was performed using the Kirby Bauer method (disc diffusion) as described by the Clinical Laboratory Standards Institute (CLSI-2020). Pure culture from the CLED medium was transferred into Peptone water. The turbidness of the suspension was adjusted to the optical density equivalent to 0.5 McFarland. A sterile cotton swab was then soaked into the suspension, and the excess was removed by gentle rotation of the swab against the surface of the test tube. The swab was distributed over the entire surface of Mueller–Hinton agar. The inoculated Mueller–Hinton plates were kept at 37°C for 24–48 h, and the zones of inhibition were interpreted either for sensitivity, intermediate and resistance. The sensitivity test, by discs;' diffusion method, was used for different antibiotics such as cotrimoxazole 25 μg, erythromycin 15 μg, gentamicin 10 μg, amoxicillin/clavulanic acid 30 μg, streptomycin 300 μg, tetracycline 30 μg and chloramphenicol 30 μg for Gram-positive bacteria. Gentamicin 10 μg, nalidixic acid 30 μg, nitrofuration 300 μg, cotrimoxazole 25 μg, amoxicillin 20 μg and tetracycline 30 μg were used for Gram-negative bacteria.

Statistical analysis

We analysed data using a logistic regression model of demographic variables to assess their relationship with ASB. Determinants of ASB were analysed by Chi-square (x2). Descriptive statistics were used to present categorical data. SPSS version 22 was used as a tool for data analysis. Results were presented in the form of figures and tables, and the level significance was 0.05 at a 95% confidence level.


  Results Top


Demographic characteristics of participants

The demographic characteristics of the study participants are described in [Table 2]. Among142 pregnant women, 100 (70.40%) had ASB, while 42 (29.60%) of them were free from ASB. The predominant age affected was 24–29 (39.43%). The majority, 120 (84.50%), were married, while 133 (93.70%) were from social class Ubudehe C. majority of the participants, 102 (71.80%), were not employed, while 54 (38%) were in their second trimester of pregnancy.
Table 2: Logistic regression analysis of demographic characteristics

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Logistic regression of demographic characteristics

[Table 2] indicates the relationship between demographic characteristics and ASB. Among all demographic characteristics location (urban) (P = 0.005) and some educational levels such as primary (P < 0.00001), ordinary level (P < 0.00001) and advanced level were statically significant. Other demographic characteristics were not statistically significant.

Distribution of asymptomatic bacteriuria in the age group

[Figure 1] indicates the prevalence of ASB among age groups. The most affected age was 24–29 years (28.16%), the second most affected age group was 18–23 (19.71%), 30–35 (18.3%), and the least affected age groups were older women aged 36–41 (5.63%), 42–46 (1.4%).
Figure 1: Distribution of asymptomatic bacteriuria in age groups.

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Distribution of asymptomatic bacteriuria in trimesters

[Figure 2] indicates the burden of ASB among trimesters. The second trimester of pregnancy was the most affected and stood at 28.16%. The first and third trimesters stood at 25.35% and 16.9%, respectively.
Figure 2: ASB among trimesters. ASB: Asymptomatic bacteriuria.

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Distribution of isolated bacteria among pregnant women with asymptomatic bacteriuria

[Figure 3] indicates the microorganisms isolated from urine samples of women ASB. The most predominant microorganism is E. coli (27.61%), followed by Klebsiella pneumonia (23.8%), Staphylococcus saprophyticus (21.9%), Staphylococcus aureus (5.71%), Pseudomonas aeruginosa (8.57%), Proteus mirabilis (4.76%), Enterobacter aerogenes (6.6%) and Streptococcus pyogenes (0.95%).
Figure 3: Bacteria isolated from urine samples of pregnant women.

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Distribution of bacteria associated with asymptomatic bacteriuria in pregnancy trimesters

[Figure 4] indicates bacteria associated with ASB in pregnancy trimesters. The most abundant bacteria in the first trimester were E. coli (23.68%) followed by S. saprophyticus (21.0%), K. pneumonia (15.78%), E. aerogenes (13.15%), S. aureus (10.52%), P. aeruginosa (7.89%), P. mirabilis (5.26%) and S. pyogenes (2.06%). In the second trimester, the most abundant bacteria were K. pneumonia (32.5%), followed by E. coli (23.2%), S. saprophyticus (20.93%), P. aeruginosa (11.62%), P. mirabilis (6.97%), E. aerogenes (2.32%), S. aureus (2.32%) and S. pyogenes (0%). In the third trimester, the most abundant bacteria were E. coli (41.66%) followed by S. saprophyticus (25%), K. pneumonia (20.83%), E. aerogenes (4.16%), P. aeruginosa (4.16%), P. mirabilis (0%) and S. pyogenes (0%).
Figure 4: Distribution of bacteria associated with ASB in trimesters. ASB: Asymptomatic bacteriuria.

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Association with determinants and asymptomatic bacteriuria

[Table 3] indicates the association with determinants and ASB. Hygiene (x2 = 6.81, P = 0.009) was statistically significant. Other determinants were not statistically significant such as UTI history (x2 = 0.1, P = 0.752), multiple sexual intercourse (x2 = 4.39, P = 0.11), number of children (x2 = 10.23, P = 0.115), HIV (x2 = 3.561, P = 0.56) and history of miscarriage (x2 = 2.631, P = 0.105).
Table 3: Determinants associated with asymptomatic bacteriuria

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Antibiotic susceptibility of isolated bacteria among pregnant women asymptomatic bacteriuria

[Figure 5] illustrates the antibiotic susceptibility of E. coli which was highly sensitive to Ciprofloxacin (28 mm), followed by cefotaxime (27 mm), clindamycin (22 mm), gentamycin (20 mm), cotrimoxazole (18 mm) and it was resistant to ampicillin (13 mm), novobiocin (14 mm), bacitracin (2 mm), amoxicillin (11 mm) and penicillin (8 mm).
Figure 5: Antibiotic susceptibility of Escherichia coli.

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Antibiotic susceptibility of Klebsiella pneumonia

[Figure 6] indicates the antibiotic susceptibility of K. pneumonia. This bacterium was sensitive to ciprofloxacin (24 mm) and intermediate to gentamycin (14 mm). It resisted the remaining antibiotics as follows: ampicillin (13 mm), cotrimoxazole (9 mm), cefotaxime (13 mm), clindamycin (11 mm), novobiocin (5 mm), bacitracin (2 mm), amoxicillin (10 mm) and penicillin (8 mm).
Figure 6: Antibiotic susceptibility of Klebsiella pneumonia.

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Antibiotic susceptibility of Enterobacter aerogenes

[Figure 7] illustrates the antibiotic susceptibility of E. aerogenes. The microorganism was sensitive to ciprofloxacin (27 mm), followed by gentamicin (16 mm), cotrimoxazole (16 mm). It was intermediate to cefotaxime (20 mm). It was resistant to ampicillin (2 mm), clindamycin (12 mm), novobiocin (8 mm), bacitracin (1 mm), amoxicillin (2 mm) and penicillin (5 mm).
Figure 7: Antibiotic susceptibility of Enterobacter aerogenes.

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Antibiotic susceptibility of Pseudomonas aeruginosa

[Figure 8] demonstrates the antibiotic susceptibility of P. aeruginosa. The microorganism was sensitive to ciprofloxacin (25 mm), followed by cefotaxime (21 mm), gentamicin (18 mm). It was resistant to ampicillin (3 mm), cotrimoxazole (10 mm), clindamycin (10 mm), novobiocin (10 mm), bacitracin (2 mm), amoxicillin (3 mm) and penicillin (2 mm).
Figure 8: Antibiotic susceptibility of Pseudomonas aeruginosa.

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Antibiotic susceptibility of Proteus mirabilis

[Figure 9] illustrates the antibiotic susceptibility of P. mirabilis. The microorganism was sensitive to Ciprofloxacin (27 mm) followed by gentamicin (17 mm), cotrimoxazole (16 mm). It was intermediate to penicillin (16 mm) and resistant to ampicillin (2 mm), cefotaxime (11 mm), clindamycin (11 mm), novobiocin (9 mm), bacitracin (4 mm) and amoxicillin (2 mm).
Figure 9: Antibiotic susceptibility of Proteus mirabilis.

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Antibiotic susceptibility of Staphylococcus saprophyticus

[Figure 10] indicates the antibiotic susceptibility of S. saprophyticus. The bacterium was intermediate to cotrimoxazole (14 mm) and gentamicin (13 mm). It was resistant to ampicillin (4 mm), cefotaxime (13 mm), clindamycin (12 mm), ciprofloxacin (15 mm), novobiocin (12 mm), bacitracin (3 mm) and amoxicillin (4 mm).
Figure 10: Antibiotic susceptibility of Staphylococcus saprophyticus.

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Antibiotic susceptibility of Staphylococcus aureus

[Figure 11] illustrates antibiotic susceptibility of S. aureus. The microorganism was sensitive to novobiocin (26 mm), followed by cefotaxime (23 mm), ciprofloxacin (21 mm), clindamycin (21 mm), gentamicin (15 mm), cotrimoxazole (17 mm) and intermediate to gentamicin (13 mm). It was resistant to ampicillin (4 mm), bacitracin (5 mm) and amoxicillin (12 mm).
Figure 11: Antibiotic susceptibility of Staphylococcus saprophyticus.

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Antibiotic susceptibility of Streptococcus pyogenes

[Figure 12] indicates the antibiotic susceptibility of S. pyogenes. The microorganism was sensitive to cotrimoxazole (16 mm) and bacitracin (17 mm). It was intermediate to gentamicin (13 mm), clindamycin (14 mm) and penicillin (15 mm). The microorganism was resistant to amoxicillin (2 mm), cefotaxime (12 mm), novobiocin (13 mm) and amoxicillin (4 mm).
Figure 12: Antibiotic susceptibility of Streptococcus pyogenes.

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  Discussion Top


UTIs are prevalent during pregnancy and are significant predisposing factors for adverse maternal and foetal complications. Pregnant women may develop UTIs throughout pregnancy and remain asymptomatic, which is a leading cause of untreated cases and further complications related to pregnancy and childbirth. This study investigated the burden of ASB and its determinants among pregnant women attending antenatal care. About 70.40% of the randomly selected pregnant women who were without clinical symptoms of UTI tested positive for ASB. The most predominant age range was younger women aged 24–29 years, while the least range was older women aged 42–47 years. A majority of the women, 94.36%, were educated and living with a marriage partner, while fewer of the women were single [Table 1]. Young women were predominant in the current study, and this is not critical since this age is inactive in sexual and reproductive activity. The old women were the least presented. This might be because some of them are in the menopause period others permanently limited birth and slowly become reproductive inactive. It was observed that women with low economic status could face health problems during pregnancy. Poverty may be a persecutor of infectious diseases and is a serious exposure to pregnant women because their immunity is not stable during this critical period. High unemployment was observed among women with ASB, which is an indicator of economic instability among women. The economic instability of women is a leading cause of dependence on men, a serious cause of having many sexual partners, which is one cause of UTIs. The second trimester comes with a lot of physiological changes among pregnant women, which pushes these women to frequently visit antenatal care. The least women were in the third trimester, and this could be due to the period of preparation for childbirth. Furthermore, it could be due to problems with prenatal labour and miscarriage that could not allow some women to reach in third trimester leading to a reduction of women attending antenatal care during the third trimester. The prevalence of 10.8% was reported by similar findings, but also the global prevalence of this health outcome was reported and varied from 2% to 11%. The variation in the prevalence rates among the studies could be due to the differences in variables in consideration, such as the study participants, socioeconomic status, geographical location and more so with the methods of the screening test.[8] This study observed 38 cases of significant bacteriuria among the 100.0 pregnant women screened, giving a prevalence of 38.0%. A similar study observed that 40% of the women were self-employed, 18% were traders, 30% were civil servants and 12% were students. About 77.0% of the women were in their third trimesters, 22% were in the second trimesters, and 1% were in the first trimester. The literacy rate was high, with 70% tertiary education and 30% having secondary education.[9]
Table 1: Demographic characteristics

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In the conducted study, the analysis of logistic regression on demographic characteristics was performed to test for a relationship with ASB [Table 2]. It was a challenge to observe that pregnant woman living in urban areas suffering compared to rural ones. Although girls in rural areas are likely to migrate to towns and cities to find domestic jobs, most of them serve as a maid. Lack of support in their life exposes them to untended pregnancies and leads to other adverse pregnancy devastating outcomes. Lack and sharing of sanitation infrastructures such as toilets are a health unsafety to pregnant women of lower economic classes since it exposes them to adverse health conditions such as UTIs. These women experience multiple sexual intercourses, which is a serious contributor to ASB or UTIs. The findings of this study also found that women with primary level education to an advanced level were the most affected. Considering that they are sexually active, also considering their health status, they must be affected by this silent killer of maternal and child health. A contradictory study reported that pregnant women from a rural area (Mkuranga district) were more prone to UTI, which was reflected in the observed higher prevalence of the infection. The prevalence of UTI among pregnant women in urban and rural areas was 2.1% and 12.5%, respectively. The findings from rural areas are comparable with the previous studies conducted in Ethiopia (10.2%).[4] The most affected age group was 24–29 years (28.16%). This age group is well placed in the reproductive range but also highly sexually active. This is enough to put them in danger, including the risk of UTIs. Experience of taking care and attention to their pregnancy status is not enough, and they may sometimes be sexually abused, which is exposure to ASB. Women in the range of 30–35 were not much affected, and may it is a due number of reasons such as their experience, capacity and economic status [Figure 1]. The previous findings reported the same situation where the highest prevalence of ASB was observed among women in the age group 26–30 years, followed by 21–25 years. This observation could be explained as early exposure to sexual intercourse, which could lead to the damage of the urethra and thereby cause the transfer of bacteria from the anal region into the urinary bladder.[8] In the second trimester, the foetus starts pushing the womb towards the urethra. This organ may be pushed closer to the vaginal openings exposing the woman to the invasion of pathogens in this trimester compared to other trimesters [Figure 2]. The study that analysed the study subjects by their trimester and party reported the high prevalence of ASB among pregnant women in the second trimester (37%).[8] This study also showed that about 77% of the women were in their third trimesters, 22% were in their second trimester, and only one was in the first trimester 1%.[9] The comparison of the prevalence of ASB between the first and second trimesters reported a high prevalence of ASB (3.55%) in the second trimester compared to the first trimester (3.50%). However, there was no statistically significant association between the two trimesters.[10] Asymptomatic UTI was reported throughout pregnancy, where it reported contradictory findings. The third trimester was the most affected compared to the remaining trimesters and stood at 55.31%.[11] Changes in the prevalence of ASB may change trimester by trimester, and it may be due to different factors such as immunity of women and social-economic status. The prevalence of ASB among women in Ghana reported a high prevalence of ASB in the second trimester with 52.6%.[12] The main contributors to UTI such as E. coli which was the most common bacteria isolated, followed by K. pneumonia and S. saprophyticus. E coli is a normal flora in the rectal region, closed to the urethra, and could migrate through faecal contamination while cleaning the anal region after defecation. K. pneumonia was the following common bacteria, and it is a normal flora in the rectal region and saprophyte in soil and water. K. pneumonia spreads through sexual intercourse and cleaning genital parts using contaminated water, and this may be due to the contaminated hands of health care providers while checking for the readiness of the baby to be delivered. S. saprophyticus is a normal flora in the urethra and gastrointestinal tract, and it is an opportunistic pathogen in the urethra during pregnancy due to immunosuppression [Figure 3]. Previous findings on the contribution of vaginal microbiota imbalance to the occupancy of UTI at Gisenyi District Hospital reported E. coli as the main contributor to UTIs.[13] The isolation of E. coli in the urine sample of women without symptoms of UTIs is a high risk of developing symptomatic UTIs during pregnancy. E. coli, the main contributor to the UTI, was associated with intra-amniotic infection; this was observed. Among women with preterm birth, Klebsiella species and Staphylococcus species were isolated but not in full-term birth. E. coli was observed to contribute to 90% of UTIs and to be ascendancy toward the uterus that leads to devastating birth outcomes, including preterm birth.[14] In this study, E. coli was the most common in the first and third trimesters, while K. pneumonia was the most common in the second trimester [Figure 4]. E. coli could be the most common in the first trimester due to the anatomical changes of the urethra and reduction in immunity, providing a favourable environment for it to multiply, the same as S. saprophyticus normally, it was a normal flora in the urethra as the immunity decreases it becomes opportunistic and colonise the area. K. pneumonia was the most common in the second trimester due to difficulty with hygiene as the pregnant belly becomes distended and the weight of the foetus putting pressure on the kidney might cause trouble emptying the bladder; the microorganism tends to be acquired easily during sexual intercourse. In the third trimester, E. coli was the most predominant bacteria due to the similar problem of difficulty in handling hygiene with a distended pregnant belly. The shortness of the urethra also contributes to the severity of these bacteria. The same applies to the severity of S. saprophyticus in the third trimester.

A similar study showed that the most common isolated organism was E. coli 14 (36.8%) cases. This was followed by proteus spp. 8 (22.1%), Psudomonous aeruginosa 7 (18.4%), S. aureus 6 (15.8%) and Klebsiella spp. 3 (7.9%). E. coli is the predominant isolate. The proximity of the anal opening to the genital region and the multiple virulent factors expressed by E. coli such as P fimbriae, S fimbriae, haemolysin, aerobactin and serum resistance may contribute to this organism being well-suited to colonise the urinary tract.[15] The findings of this study analysed the association with ASB, and different determinants selected for them, hygiene (x2 = 6.81, P = 0.0009) was statistically significant in contributing to ASB [Table 3]. Hygiene being the contributor to ASB is understandable. Pregnant women are weakened by pregnancy until they cannot support hygienic activities and handle domestic activities with lower economic status. Failure to the cleaning the anal region, especially after using the toilet, may favour the migration of anal bacteria towards the vagina and cause different health outcomes, including ASB. Environmental hygiene could not be forgotten. It may contribute to ASB by sharing uncleaned toilets with many people. It might be due to insufficient materials that would assist them in handling hygiene. A similar study observed that the results of this study elicited surprise from midwifery colleagues at the high number of women wiping themselves from back to front since there was a general assumption that daughters were taught to wipe from front to back from an early age. Certainly, from a hygiene point of view, it makes sense to wipe from front to back, but judging from the results of this study, one cannot believe the anecdotal hearsay of the vertical transmission of good hygiene practice. Uropathogenic bacteria reside in the rectal vault, colonise the vagina and then ascend per the urethra into her bladder.[16] Antibiotic susceptibility pattern of various selected antibiotics was performed. Most of the organisms except K. pneumonia and S. saprophyticus were very sensitive to ciprofloxacin, gentamicin, co-trimoxazole and cefotaxime and resistant to the rest of the antibiotics [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]. The sensitivity was due to the permeability of antibiotics into bacteria cell membrane, while the resistance might be due to the lack of the target that the antibiotic attacks. Genetic variations also lead to resistance others produce enzymes that protect them from the antibiotics. The previous findings reported that microorganisms associated with UTIs were highly sensitive to to ciprofloxacin, ofloxacin, gentamicin, ceftazidime and nitrofurantoin. Resistance to augment and cefixime was relatively high. Nitrofurantoin is relatively safe in pregnancy and is effective against most UTIs.[17]


  Conclusion Top


Pregnancy is persecutor to adverse health conditions among women. ASB was prevalent among pregnant attending antenatal service at Ruhengeri Referral Hospital. Women in the second trimester were the most affected, while women aged 24–29 were the most affected by ASB. E. coli was the most urine isolate. Bacteria associated with UTI were observed to colonise the urinary tract throughout pregnancy. Hygiene was associated with ASB among women. Urban residence and some education levels were associated with ASB among demographic characteristics. Early detection of ASB is recommended to prevent maternal and foetal complications.

Data sharing

Data are available through corresponding author

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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