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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 236-245

Health guidelines to prevent recurrence of urinary tract infection among diabetic patients


1 Community Health Nursing, Faculty of Nursing, Fayoum University, Fayoum, Egypt
2 Adult Health Nursing, Faculty of Nursing, Helwan University, Helwan, Egypt
3 Adult Health Nursing, Maghrabi Mansour Faculty of Nursing, British University, Cairo, Egypt

Date of Submission08-May-2018
Date of Acceptance06-Sep-2018
Date of Web Publication28-Dec-2018

Correspondence Address:
Sharbat T Hassanine
Community Health Nursing, Faculty of Nursing, Fayoum University, Fayoum
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-6021.248958

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  Abstract 


Background Urinary tract infection (UTI), the most common bacterial infections, affects humans throughout their life span. The more complicated UTI and the recurrent nature increase the risk of hospitalization by two-folds leading to economic stress on the patient. There is also an associated increase in morbidity and mortality.
Aims The aim of the study was to evaluate the effect of health guidelines on prevention and recurrence of UTI among diabetic patients.
Sample The sample was a purposive one, which composed of 186 diabetic patients of both sexes. It included control and study groups of 93 patients each, with specific criteria.
Design A quasi-experimental design was used to conduct the study.
Setting This study was carried out in the urology outpatient clinic at the National Diabetic Institute, affiliated to Cairo University Hospitals.
Tools Two tools were used for data collection: (a) an interviewing questionnaire for the diabetic patients concerning sociodemographic characteristics and medical-related data and (b) assessment tool of patient’s knowledge regarding preventive measure and care of UTI.
Results The study showed that after the application of health guidelines, and follow-up for 1 year, the recurrence of UTI was seen in less than one-tenth of the study group compared with nearly one-third of the control group.
Conclusion The results revealed a significant effect of health guidelines on prevention of recurrence of UTI among diabetic patients.
Recommendations The findings of this study lead us to recommend conducting educational programs for the diabetic patient in the outpatient clinic to raise their awareness related to the preventive measures and care of UTI and design a simple illustrated booklet in Arabic language for them.

Keywords: diabetic patients, health guidelines, urinary tract infection


How to cite this article:
Hassanine ST, Hamza MF, Abdel-Hakeim EH. Health guidelines to prevent recurrence of urinary tract infection among diabetic patients. Egypt Nurs J 2018;15:236-45

How to cite this URL:
Hassanine ST, Hamza MF, Abdel-Hakeim EH. Health guidelines to prevent recurrence of urinary tract infection among diabetic patients. Egypt Nurs J [serial online] 2018 [cited 2019 Jan 17];15:236-45. Available from: http://www.enj.eg.net/text.asp?2018/15/3/236/248958




  Introduction Top


Diabetes mellitus has a number of long-term effects on the genitourinary system. These effects predispose to bacterial urinary tract infections (UTIs) in the patient with diabetes mellitus. Bacteriuria is more common in diabetic women than in nondiabetic women because of a combination of host and local risk factors. Men can also develop UTIs, but they are less common (Drekonja et al., 2014).

Albert et al. (2015) stated that excess glucose is filtered in the kidneys, which results in significantly higher urine glucose concentrations in diabetics when compared with the urine of nondiabetics. Filtered glucose attracts water into the renal tubules, which can increase the urge and frequency of urination. High glucose concentrations in the urine provide an abundant source of nutrients for bacteria, which can proliferate and cause an infection.

Women are more prone to UTI than men. In a woman, the urethra, the vagina, and the rectum are close to each other. This allows for the bacteria from the rectum and vagina to transfer to the urethra. It has been calculated that approximately one-third of adult women have experienced an episode of symptomatic cystitis at least once.  Escherichia More Details coli and Staphylococcus saprophyticus account for ∼80% of community-acquired uncomplicated urinary infections (UTIs) (Sen, 2015).

The danger to diabetics is that if the UTI is not treated quickly, additional infections may take place. The most common infection is in the kidneys. In a healthy individual, the immune system fights off most of these infections; however, in a diabetics, the immune system may not be capable of warding off an infection without medical intervention (Schaeffer et al., 2013).

Multiple potential mechanisms unique to diabetes may contribute to the increased risk of UTI in diabetic patients. Higher glucose concentrations in urine may promote the growth of pathogenic bacteria. High renal parenchymal glucose levels create a favorable environment for the growth and multiplication of micro-organisms, which might be one of the precipitating factors of pyelonephritis and renal complications such as emphysematous pyelonephritis. Various impairments in the immune system, including humoral, cellular, and innate immunity may contribute to the pathogenesis of UTI in diabetic patients (Gupta et al., 2014).

Diabetes has been associated with an increased risk of UTI and genital infection. Furthermore, patients with diabetes often have increased complications of UTI, including emphysematous cystitis, pyelonephritis, and fungal UTIs (particularly Candida spp.), and infections are often more severe and associated with unusual manifestations. Adults with diabetes are more susceptible to develop lower UTIs and genital infections owing to various predisposing factors, such as hyperglycemia-related impairment of the immune response and glucosuria (Jepson et al., 2016).

Several factors make the urinary tract of diabetic patients more susceptible to bacteria. E. coli expressing type 1 fimbriae adhere with twice the affinity to uroepithelial cells from diabetic patients. There are also lower urinary cytokines and leukocyte concentrations in diabetic patients, which might impair the eradication of bacteria from the urinary tract. The presence of glycosuria has been shown to enhance bacterial growth in vitro (Sheffield et al., 2015).

The diagnosis of UTI should be suspected in any diabetic patient with symptoms consistent with UTI. These symptoms are increased urgency and frequency of urination, dysuria, suprapubic pain, burning feeling while voiding, the urine having an unpleasant odor, fever, and chills. Despite the urge to urinate, often only a small amount of urine is passed (Olds and Davidson, 2014). Women may feel an uncomfortable pressure above the pubic bone. Men experience a fullness in the rectum. The urine itself may look milky or cloudy, even reddish if blood is present. A fever may mean that the infection has reached the kidneys. Other symptoms may include nausea, vomiting, and pain in the back or side below the ribs. UTIs may be diagnosed from symptoms alone or in conjunction with laboratory analysis of a urine sample. A urine culture should be obtained in all cases of suspected UTI in diabetic patients, before initiation of treatment (Kontiokari et al., 2012).

If UTI is left untreated, bladder infections can migrate to the kidneys and cause permanent renal damage. Diabetes often increases the risk of recurrent UTIs. Recurrent UTIs may be difficult to treat and may require the use of prophylactic antibiotics. Although UTIs can resolve on their own, most patients require the use of antibiotics to shorten the duration of symptoms and eradicate the infection. This is especially true in diabetics as the disease promotes an environment ideal for bacterial growth in the urine. Patients should contact a physician if they have concerns regarding a UTI (Raz et al., 2013).

Behavioral changes can affect the frequency of UTI recurrence. Managing recurrent infections should include modification of known risk factors. In cases of recurrence, a test-of-cure urine culture performed ∼1–2 weeks after completion of antibiotic therapy may be considered to confirm clearance. Antimicrobial prophylaxis has proved effective in reducing the risk of recurrent UTIs in women with two episodes of infection in the previous year. Continuous prophylaxis for 6–12 months reduces the rate of UTIs during the prophylaxis period. Prophylactic antibiotic selection should be made on the basis of community resistance patterns, adverse effects, and local costs. Various dosages of prophylactic antibiotics have been suggested (Herrod, 2015; Perrotta et al., 2016).



The increased risk of UTI among diabetic patients, coupled with the increase in the incidence of diabetes mellitus worldwide in recent years, may impose a substantial burden on medical costs. The incidence rate of UTI was 46.9 per 1000 person-years among diabetic patients and 29.9 for patients without diabetes. Recurrent infections occur in ∼23–30% of adult. In addition, the high rates of antibiotic prescription, including broad-spectrum antibiotics, for UTI in these patients may further induce the development of antibiotic-resistant urinary pathogens (American College of Obstetricians & Gynecologists, 2014).

Significance of the study

Among the infections affecting the diabetic patients, there is 60% increase in the risk of UTI and a two-fold to four-fold increase in genital tract infections. UTIs in diabetes have certain unique features in that they involve the upper tract in 80%, are bilateral in most cases and are more prone to complications. In Egypt, the recurrence rate of UTIs among diabetic patients is 25–45%, which is significantly higher than in nondiabetic. This is despite the fact that diabetics tend to receive longer and more potent initial treatment (Anecdotally, 2014; Fouda, 2015).

Patients with diabetes have worse outcomes of UTI than those without diabetes. Globally mortality from UTI is five times higher in patients with diabetes. Diabetic women are significantly more likely to experience UTI than diabetic men. Nearly one in three women will have had at least one episode of UTI requiring antimicrobial therapy. Almost half of all women will experience one episode of UTI during their lifetime. Approximately 20% of all UTIs occur in men. Relapse or reinfections are also a major concern. Many diabetic patients experience relapses or reinfections of the lower urinary tract even after treatment with broad-spectrum antibiotics (Bulechek and Ray, 2016; The National Center for Health Statistics, 2014).


  Aim Top


This study aims to evaluate the effect of health guidelines on prevention and recurrence of UTI among diabetic patients.

Research hypotheses

The recurrence of UTI among diabetic patients is prevented after the application of health guidelines.


  Patients and methods Top


Sampling

A purposive sample was taken of diabetic patients, who had UTI, and referred to the urology outpatient clinic at the National Diabetic Institute, affiliated to Cairo University Hospitals. The sample was selected randomly and composed of 186 patients, included control and study groups of 93 patients each, under the following inclusion criteria: patients who can read and write, had a diabetes at least 2 years ago, and diagnosed as having UTI after referral from the diabetic outpatient clinic at the National Diabetic Institute.

Research design

A quasi-experimental design was used in this study.

Setting

This study was carried out in the urology outpatient clinic at the National Diabetic Institute, affiliated to Cairo University Hospitals.

Tools

Two tools were used for the data collection:
  1. An interviewing questionnaire tool.
    • It consisted of three parts as follows:
    1. Part 1: sociodemographic characteristics.
      1. It was used to assess the sociodemographic characteristics of the study and control groups such as age, sex, educational level, occupation, and marital status.
    2. Part 2: medical-related data.
      1. It was modified from Bulechek and Ray (2016), to assess the following:
      1. Medical history of UTI, such as the signs and symptoms, the previous rate of recurrence per year, management and care provided, risk factors, and lifestyle.
      2. Medical history of diabetes was designed by the researcher to assess, number of years having diabetes, type of medication, follow-up rate, and controlled or not.
    3. Part 3: follow-up of UTI recurrence.
      1. Follow-up of the diabetic patients was done every 2 months until 12 months after the application of health guidelines. Both the study group and the control group were assessed by the researcher in the urology outpatient clinic at the National Diabetic Institute, affiliated to Cairo University Hospitals, and by reviewing the patients’ files, with assistance of the nurses in the outpatient. Follow-up was done also by phone. It measure some factors which affect the recurrence of UTI signs and symptoms, the recurrence rate, following the treatment course, the level of blood sugar (controlled or not), following the health guidelines or not.
  2. Patients’ knowledge assessment tool.
    • A structured Arabic tool was designed by the researcher, after reviewing the related current and previous literature, to assess diabetic patients’ knowledge regarding preventive measure and care of UTI. It was done for the control group once but was done for the study group before and after the guidelines program and after 4–8–12 months of the health guidelines application, to follow their level of knowledge.


Scoring system

It contains nine questions. The answer is marked as 0 for false answer and 1 for true answer. The total knowledge is considered satisfactory if the total score is more than or equal to 60% and unsatisfactory if the total score is less than 60%.
  1. Administrative design.
    • Official letters including the title and purpose of the study were submitted to the directors of the National Diabetic Institute, affiliated to Cairo University Hospitals, to get approval for data collection to conduct the study.
  2. Operational design.
    • The study, to be completed, had passed through different phases as follows: the preparatory phase, then the pilot study phase and lastly the fieldwork phase.


Preparatory phase

During this phase, the researcher reviewed current local and international related literature, which helped her to be more acquainted with the topic, and with the process of tools designing. Then, tools were designed and tested for validity and reliability through a pilot study.

Tool validity

The study tool was submitted to a panel of five experts in the field of community health nursing and obstetric nursing to test tool validity, and suitable modifications were carried out according to the panel’s judgment on clarity of sentences and the appropriateness of the content.

Ethical consideration

Informed consent was taken from each patient to participate in the study after explaining the purpose of the study, its importance for them, that the study will not have any harmful effect on them, the information will be confidential, and that they can withdraw from the study at any time. The ethical approval was taken oral from every patient I said can you participate in my study.

Pilot study

A pilot study was done on 10% of the patients who met the criteria of selection. They were interviewed to test tools applicability and clarity and determine the needed time to answer the questions. According to its results, no modification was needed. The study sample included in the pilot study was excluded from the study sample.

Fieldwork

The process of data collection was carried out in the period from February 2015 to August 2016, every Monday per week, from 9 am to 1 pm. in three phases.

Phase 1: preparation of the program

The researcher selected all the cases who were diagnosed as having UTIs, for the first time or had a recurrence and were coming for follow-up. Interview was done after the end of the clinic for all cases who fulfill the inclusion criteria. The guideline program was performed at the urology outpatient clinic, and follow-up was done every 2 months for 12 months for each patient by interview, phone, and reviewing patients’ files.

Phase 2: implementation of the program

The researcher attended the clinic to meet the patients with the physician in the outpatient clinic. The physician describes the medication after the routine assessment and examination. The researcher interviewed the patients who were diagnosed as having UTIs, after meeting with the physician. They were selected randomly into control and study groups. Oral approval from the patients was obtained after explaining the purpose of the study. Issues of confidentiality were confirmed.

Each patient was interviewed to complete the questionnaire. The researcher faced the patients, asked them the questions in Arabic, and recorded their answer in the structured interviewing questionnaire sheet. The interview was carried out in the waiting area at the urology outpatient clinic. It took ∼20 min for each one. The researcher collected data and did assessment of the risk factors, lifestyle, and knowledge related to UTIs before and after the health guideline application, and follow-up of the level of knowledge was done every 4 months for the study group till 12 months.

The researcher started the health guidelines of UTIs preventive measures for all the study group, which were developed by the researcher after extensive review of related literature, using simple Arabic language. It was distributed to the study patients to help them to change their unhealthy behaviors toward caring and prevention of the recurrence of UTIs and decreasing their progression.

The guideline program session usually lasted between 30 and 40 min, and was conducted in a comfortable, quiet, and dedicated time and space. The program was conducted on Monday from 9 am to 1 pm, weekly, taking into consideration the following: using simple language to suit the level of the patients’ education and providing a free copy of the booklet about UTIs health guidelines regarding care and preventive measures of their recurrence to each patient in the study group to use it as a home reference.

Health guidelines for the diabetic patients to prevent recurrence of urinary tract infections

For proper management and prevention of UTIs recurrence, the diabetic patients were advised and encouraged to control the blood sugar; follow the prescribed medication; drink 2–3 l of fluids per day (decaffeinated, as caffeine irritates the bladder); void when you have the urge to pass water or at least every 2–3 h, as urination frequently helps to flush bacteria from the bladder and holding urine for a long time allows bacteria to multiply within the urinary tract, resulting in cystitis; wear cotton or cotton crotched underwear; avoid tight clothing; and change out of wet swim suits.

Preventive measures related to sexual intercourse may reduce the recurrence rate. Moreover, empty the bladder before and after sex; clean the genital areas with soap and water daily, in particular, before and after sex; and wipe from front to back, which will reduce the spread of E. coli from the perigenital area to the urethra. Try different positions during sex, which causes less friction to the urethra (opening of the urine channel). Avoiding multiple sexual partners will reduce the risk of both UTIs and sexually transmitted infections.

Women are encouraged to avoid spermicidal contraceptives, diaphragms, and vaginal douching, which may irritate the vagina and urethra and facilitate the entry and colonization of bacteria within the urinary tract. Skin allergens introduced to the genital area, such as bubble bath liquids, bath oils, vaginal creams and lotions, deodorant sprays or soaps are better avoided as they could alter vaginal flora and ultimately result in UTIs.

Phase 3: evaluation of the program

The study group was evaluated immediately after the guidelines program, by posttest, and the researcher evaluated the effect of the program. The level of knowledge was evaluated every 4 months till 12 months. An improvement was observed among the study group regarding the level of knowledge. Follow-up was conducted by interviewing each patient (during procuring the prescribed medication every month from the diabetic institute), and also by phone every 2 months for 12 months.


  Results Top


Data were analyzed using statistical package for the social sciences (SPSS Windows, Institute of Statistics, Cairo University, Egypt), version 20. Numerical data were expressed as mean±SD and range. Relations between different numerical variables were tested using Pearson’s correlation. P value less than 0.05 was considered significant and less than 0.001 was considered as highly significant.

[Table 1] shows the sociodemographic characteristics among the diabetic patients in the study and control groups. The patients’ ages in both groups ranged from 46 to 75 years, with mean of 51.4±7.1 years in the study group and of 52.8±6.3 years in the control group. It was clear from this study findings that 76.3 and 79.6% of the patients in the study and control groups, respectively, were females and 46.2 and 51.6% of the study and control groups, respectively, have basic level of education. Moreover, 83.9 and 79.6% of the study and control groups, respectively, are not working, and 87 and 82.8% of the study and control groups, respectively, are married.
Table 1 Distribution of the diabetic patients’ sociodemographic characteristics in the study and control groups (N=186)

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Regarding patients’ level of knowledge ([Figure 1] and [Figure 2]), the study revealed that 95.1% of the study group had satisfactory level of knowledge related to UTI, immediately after the program, and 98% after 4 months, 94% after 8 months, and 97% after 12 months, but 90.8% of the control group had unsatisfactory level of knowledge, with statistical significant difference between the two groups.
Figure 1 Distribution of patients’ level of knowledge related to UTIs among the study and control groups. UTI, urinary tract infection.

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Figure 2 Follow-up of patients’ level of knowledge related to UTIs among the study group. UTI, urinary tract infection.

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[Table 2] reveals that nearly 83.8–98.9% of the study and control groups had positive signs and symptoms related to UTIs, such as increased urgency with small amount, increased frequency of urination, dysuria, suprapubic pain, and burning feeling while voiding. In relation to the recurrence of UTIs in the past 2 years, the study show that 27.9% of the study group and 23.6% of the control group had one recurrence of UTIs, but 44 and 41.9% of the study and control groups, respectively, had a recurrence of UTIs of two times. Moreover, the study revealed that 58 and 52.6% of the study and control groups, respectively, were postmenopausal, and 100% of the study and control group were treated using antibiotics.
Table 2 Patients’ distribution in relation to medical history of urinary tract infection among the study and control groups (N=186)

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[Table 3] reveals that 69.9 and 81.7% of the study and control groups, respectively, had diabetes for more than 5 years, and 79.6 and 87% of the study and control groups, respectively, were using insulin for the treatment of diabetes. Moreover, 47.3 and 40.9% of the study and control groups, respectively, had a follow-up every 3–4 months. The study shows that 74.2 and 79.6% of the study and control groups, respectively, had uncontrolled blood glucose level.
Table 3 Distribution of the patients in relation to medical history of diabetes among the study and control groups (N=186)

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[Table 4] shows that the recurrence of UTI was 8.6% in the study group at 1-year follow-up after the application of the program, compared with 39.8% in the control group. Moreover, 77.4% of the study group and 46.2% of the control group had controlled their blood glucose level, with statistical significant difference between the two groups. [Table 5] shows that there is a significant relation between recurrence of UTIs and patients’ sex, postmenopausal, blood glucose level, and level of knowledge in the study and control groups.
Table 4 Follow-up of urinary tract infection recurrence and blood glucose level among the study and control groups/year (N=186)

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Table 5 The relation between recurrence of urinary tract infections, and patients’ sex, postmenopausal, blood glucose level, and level of knowledge in the study and control groups

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  Discussion Top


Diabetes mellitus has a number of long-term effects on the genitourinary system. These effects predispose patient with diabetes mellitus to bacterial UTIs. Bacteriuria is more common in diabetic women than in nondiabetic women because of a combination of host and local risk factors. Diabetes is known to increase the risk of infection, and the commonest among them are the ones involving the genitourinary tract. The infections in a diabetic patient are unique in that they are recurrent, more severe, require hospitalization, and also have higher mortality than nondiabetics (American College of Obstetricians and Gynecologists, 2015).

The results of the present study revealed that patients’ age in both groups ranged from 46–75 years, with a mean age of 51.4±7.1 years in the study group and 52.8±6.3 years in the control group. This result was highly supported by Hooton (2015) in Ethiopia. His study revealed that most diabetic patients with UTIs were in the age group of 45–60 years. Moreover, the study found that there was a statistically significant correlation between the study group and their age. On the same line, a study done by Foxman (2011), in Japan found that advanced age was a risk factor for UTI among diabetic patients.

These study findings show that more than three-quarters of the patients in both two groups were females. These results are in accordance with Ikäheimo et al. (2012). A study by University of Washington, Seattle, revealed that the risk of UTI in diabetic women was 80% higher than others. UTI in diabetic patients is not only more severe but is also more recurrent as compared with nondiabetic women. A paper from Saudi Arabia by Bogart et al. (2015) found the following factors to be associated with an increased risk of UTI among patients with diabetes: female sex [relative risk (RR), 6.1], hypertension (RR, 1.2), insulin therapy (RR, 1.4), BMI more than 30 kg/m2 (RR, 1.72), and nephropathy (RR, 1.42). The release of new antidiabetic sodium glucose cotransporter 2 inhibitors, which increase glycosuria, caused concern of a possible increase in UTIs.

The study shows that the majority of the study group patients had satisfactory level of knowledge related to UTI immediately after the program and even every 4 months until 12 months, but the majority of the control group patients had unsatisfactory level of knowledge, with a statistically significant difference between the two groups. These findings were in accordance with Gopal et al. (2014), who stated that the study group had satisfactory level of knowledge related to preventive measures of UTI after follow-up for 18 months compared with only 12% of the control group that had satisfactory level of knowledge.

It was clear from this study that, nearly most of the study and control groups had positive signs and symptoms related to UTIs, such as increased urgency with small amount, increased frequency of urination, dysuria, suprapubic pain, and burning feeling while voiding. These results were in the same line with AMMI Canada Guidelines Committee (2015). They stated that more than three-quarters of the diabetic women had positive signs and symptoms of UTI because the sugar content of urine in a diabetic patient provides a breeding ground for bacteria once they enter the bladder. The most serious but rare types of UTI like pyelonephritis, widespread infections, abscesses, inflammation of the bladder wall, occur mostly in diabetic individuals.

In relation to recurrence of UTIs, in the past 2 years, the study shows that more than one-quarter of the study group and less than one-quarter of the control group had one incidence of UTI recurrence, but more than one-third of both groups had twice, and nearly all the study and control group patients were treated using antibiotics. These findings were highly supported with Ronald (2013) and Johnson (2015) who stated in their study that diabetes often increases the risk of recurrent UTIs. Recurrent UTIs may be difficult to treat and may require the use of prophylactic antibiotics. Although UTIs can resolve on their own, most patients require the use of antibiotics to shorten the duration of symptoms and eradicate the infection. This is especially true in diabetics as the disease promotes an environment ideal for bacterial growth in the urine. His study illustrated that more than two-thirds of the study group had a recurrence of UTIs at least once per year. Another study by Scholes et al. (2010), in Jordon, showed that 27% of the study group had one recurrence of UTI after 6 months and 2.7% of the same study group had the second recurrence of UTI after another 6 months. In a primary care setting, 53% of women older than 55 years and 36% of younger women had a recurrence within 1 year.

Moreover, the study revealed that more than half of both groups were postmenopausal. This in accordance with Raz et al. (2016), who found in their study that diabetic women are at a higher risk of developing UTI after menopause as compared with nondiabetic women. They found that more than two-thirds of the diabetic women were postmenopausal. In the same line, a case–control study of postmenopausal women by Stern et al. (2012) found that mechanical and physiologic factors affecting bladder emptying (incontinence, cystocele, and postvoiding residual urine) were strongly associated with recurrent UTIs. An increased postvoid residual urinary volume (i.e. more than about 50 ml) is an independent risk factor for recurrent UTIs in postmenopausal women.

The study revealed that more than two-thirds of the study group compared with more than three-quarters of the control group had diabetes for more than 5 years, and also more than three-quarters of the study group compared with the majority of the control group were using insulin for the treatment of diabetes. These results are in accordance with Neal (2013) and Clark (2013), who found that women aged more than or equal to 40 years with type 1 or type 2 diabetes for at least 3 years have a two times higher risk of recurrent symptomatic UTI than women without diabetes. Clinical characteristics, such as duration of diabetes, treatment (especially insulin) and retinopathy, were found to be risk factors for recurrent UTI.

The study shows that less than three-quarters of the study group and more than three-quarters of the control group had uncontrolled blood glucose level. These results were in the same line with Bent et al. (2011), who found in their study that excess glucose in the blood is filtered in the kidneys and results in significantly higher urine glucose concentrations when compared with the urine of nondiabetics. Filtered glucose attracts water into the renal tubules, which can increase the urge and frequency of urination. High glucose concentrations in the urine provide an abundant source of nutrients for bacteria, which can proliferate and cause an infection. Moreover, according to an article published in ‘Diabetes Care’ by Dutch and Geerlings (2014) examined the association between diabetes and UTIs. The results showed that 20% of the women who either had type 1 or type 2 diabetes developed a UTI during the 18-month study period. Besides increased urine glucose, diabetes may increase the risk of UTIs through additional mechanisms, including impaired immune cell delivery, inefficient white blood cells, and inhibition of bladder contractions, which allow urine to remain stagnant in the bladder.

The study revealed that the recurrence of UTI was less than one-tenth of the study group compared with nearly one-third of the control group after follow-up for 1 year after the application of the program. This result is in the same line with McIsaac et al. (2014), who applied a comprehensive preventive program for the recurrence of UTIs among the diabetic female and found that more than three-quarters of the study group had no recurrence of UTIs, after 18 months of the program application. From the researcher point of view, the study group which had a recurrence of UTI did not follow the health guidelines for prevention of UTI and did not control their blood glucose level adequately.

Moreover, more than three-quarters of the study group and less than half of the study group had controlled their blood glucose level, with statistical significant difference between the two groups. This result was supported by Stamm et al. (2013) and Rebagliato et al. (2015), who showed in their study that there is a significant relation between blood glucose level and recurrence of UTI among the diabetic patients. Moreover, the study shows that there is a significant relation between recurrence of UTIs and patients’ sex, postmenopausal, blood glucose level, and level of knowledge in the study and control groups. These results were in the same line with Hooton et al. (2014), who found in their study that there were a relation between recurrence of UTI among diabetic patients and patients’ sex and postmenopausal women. Moreover, Warren et al. (2016) stated in their study that the diabetic patients who had at least once recurrence of UTI per year had a high blood glucose level, and uncontrolled diabetes is a risk factor for recurrence of UTI.


  Conclusion Top


In conclusion, UTIs are prevalent among adults with diabetes, and recurrence of these infections is common, especially among women. Evaluation of predisposing characteristics of individuals with recurrent infections may be helpful in identifying those at risk before recurrence to reduce the burden on patients, physicians, and the health care system. This study confirms that diabetes is associated with a higher risk of acute symptomatic UTI especially in women. Women undergoing pharmacologic treatment for diabetes were mainly at higher risk, suggesting an association between severity of diabetes and risk of UTI.

This study clearly showed that recurrent UTI are common in women with long-standing diabetes, especially those who are on insulin therapy. The present study and research hypothesis revealed a significant effect of health guidelines on prevention of recurrence of UTI among diabetic patients for the study group than the control group with a statistical significant difference between the two groups.

Recommendation

In the view of the previous conclusion, the following recommendations are suggested:
  1. Conduct educational programs for the diabetic patient in the outpatient clinic to raise their awareness related to the preventive measures and care of UTI.
  2. Design a simple illustrated guideline booklet in Arabic language for the diabetic patients in the outpatient clinic.
  3. Replication of this study on a larger sample, on a broad area, and different settings of the study is recommended to generalize the results.
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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C (2015). Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 3:CD001209.  Back to cited text no. 1
    
2.
American College of Obstetricians & Gynecologists (2014). Reproductive health & complementary therapy application. Women’s Health Care Phys 55:52–67.  Back to cited text no. 2
    
3.
American College of Obstetricians and Gynecologists (2015). ACOG Practice Bulletin No. 91: treatment of urinary tract infections in nonpregnant women. Obstet Gynecol 111:785–794.  Back to cited text no. 3
    
4.
Anecdotally (2014) Urinary tract infection and diabetes. J Obstet Gynecol 19:18–28.  Back to cited text no. 4
    
5.
Bent S, Brahmajee K, Nallamothu MD, David L, Simel MH (2011). Does this woman have an acute uncomplicated urinary tract infection? JAMA 287:2701–2710.  Back to cited text no. 5
    
6.
Bogart LM, Sandra H, Berry J, Quentin M, Clemens R (2015). Symptoms of interstitial cystitis, painful bladder syndrome and similar diseases in women. J Urol 177:450–456.  Back to cited text no. 6
    
7.
Bulechek S, Ray R (2016). Maternal and neonatal care. J Obstet Gynecol Neonat Nurs 33:63–87.  Back to cited text no. 7
    
8.
Clark M (2013). Community health nursing, advocacy for population health. Washington:Pearson Education, USA. 62–68.  Back to cited text no. 8
    
9.
Drekonja DM, Filice GA, Greer N, Olson A, MacDonald R, Rutks I, Wilt TJ (2014). Urinary tract infections. Prim Care 35:345–367.  Back to cited text no. 9
    
10.
Dutch GPs, Geerlings SE (2014). Diabetes care: risk factors for symptomatic urinary tract infection in women with diabetes; S.E. Geerlings, et al., in association with Diabetes Women Asymptomatic Bacteriuria Utrecht Study Group. Academic Med Cen Amsterdam The netherlands, 28:47–135  Back to cited text no. 10
    
11.
Fouda R (2015). Urinart tract infection among diabetic patients. Int J Gynecol Obstet 47:199–208.  Back to cited text no. 11
    
12.
Foxman B (2011). Recurring urinary tract infection: incidence and risk factors. Am J Public Health 80:331–333.  Back to cited text no. 12
    
13.
Gopal M, Elizabeth F, Barry C, Andre C, Bowman P (2014). Clinical symptoms predictive of recurrent urinary tract infections. Am J Obstet Gynecol 197:74.e1–74.e4.  Back to cited text no. 13
    
14.
Gupta K, Thomas M, Hooton G, Björn W, Richard G, Miller J et al. (2014). Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 135:9–16.  Back to cited text no. 14
    
15.
Herrod RA (2015). Complication of diabetes. J Obstet, Gynecol Neonat Nurs 21:65–70.  Back to cited text no. 15
    
16.
Hooton TM, Thomas M, Walter E, Stamm MD (2014). Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 11:551–581.  Back to cited text no. 16
    
17.
Hooton TM (2015). Recurrent urinary tract infection in women. Int J Antimicrob Agents 17:259–268.  Back to cited text no. 17
    
18.
Ikäheimo R, Jarmo S, Terhi T, Matti U (2012). Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. Clin Infect Dis 22:91–99.  Back to cited text no. 18
    
19.
Jepson RG, Williams G, Craig JC (2016). Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 1:CD001321.  Back to cited text no. 19
    
20.
Johnson T (2015). New technology of reproductive system. J Obstet Gynecol Neonat Nurs 45:78–90.  Back to cited text no. 20
    
21.
Kontiokari T, Jaana L, Leea J, Tytti P, Kaj S, Matti U et al. (2012). Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ 322:1571.  Back to cited text no. 21
    
22.
McIsaac WJ, Moineddin R, Ross S (2014). Validation of a decision aid to assist physicians in reducing unnecessary antibiotic drug use for acute cystitis. Arch Intern Med. 167 (20):2201–2206.  Back to cited text no. 22
    
23.
Neal DE Jr (2013). Complicated urinary tract infections. Urol Clin North Am 35:13–22.  Back to cited text no. 23
    
24.
Nicolle L; AMMI Canada Guidelines Committee (2015). Complicated urinary tract infection in adults. Can J Infect Dis Med Microbiol 16:349–360.  Back to cited text no. 24
    
25.
Olds S, Davidson M (2014). Maternal newborn nursing & women health care. 7th ed. London: Mosby. 60–78.  Back to cited text no. 25
    
26.
Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2016). Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2:CD005131.  Back to cited text no. 26
    
27.
Raz R, Yoshua G, Joseph W, Zmira S, Sophia R, Elimelech R et al. (2013). A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 329:753–756.  Back to cited text no. 27
    
28.
Raz R, Chazan B, Kennes Y (2016). Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 30:152–156.  Back to cited text no. 28
    
29.
Rebagliato M, Hemandez AI, Florey C (2015). Risk factors of urinary tract infections. J Epidemiol Community Health 48:56–70.  Back to cited text no. 29
    
30.
Ronald A (2013). The etiology of urinary tract infection: traditional and emerging pathogens. Rev Urol 113 (Suppl 1A):14s–19s.  Back to cited text no. 30
    
31.
Schaeffer AJ, John W, Warren E, Abrutyn J, Richard H, James R et al. (2013). Efficacy and safety of self-start therapy in women with recurrent urinary tract infections. J Urol 161:207–211.  Back to cited text no. 31
    
32.
Scholes D, Thomas M, Hooton L, Roberts E, Stapleton K, Gupta E (2010). Risk factors for recurrent urinary tract infection in young women. J Infect Dis. 182:1177–1182.  Back to cited text no. 32
    
33.
Sen A (2015). Recurrent cystitis in non-pregnant women. Clin Evid 15:2558–2564.  Back to cited text no. 33
    
34.
Sheffield JS, Panel VC, John S, Beck Anne E, Kwitek DW, Sandstrom EM (2015). Urinary tract infection in women. Obstet Gynecol 106 (Part 1):1085–1092.  Back to cited text no. 34
    
35.
Stamm WE, John W, Warren E, Abrutyn J, Richard H, James R et al. (2013). Diagnosis of coliform infection in acutely dysuric women. N Engl J Med 307:463–468.  Back to cited text no. 35
    
36.
Stern JA, Stewart MA, Winokur G (2012). Residual urine in an elderly female population: novel implications for oral estrogen replacement and impact on recurrent urinary tract infection. J Urol 171 (Part 1):768–770.  Back to cited text no. 36
    
37.
The National Center for Health Statistics (2014). Bladder infection in adult. New Egypt J Med 30 (Suppl 4):20–29.  Back to cited text no. 37
    
38.
Warren JW, Elias J, Richard JR, Johnson AJ, Schaeffer WE (2016). Infectious Diseases Society of America (IDSA). Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 29:745–758.  Back to cited text no. 38
    


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