Diagnosing UTI Complications in Mothers and Newborns

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Diagnosing UTI Complications in Mothers and Newborns

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Diagnosing UTI Complications in Mothers and Newborns

Urinary tract infections (UTIs) are one of the most common bacterial infections that occur in humans. Over 50% of women become infected with a UTI at least once in their lives, with up to 10% of women suffering from yearly infections5. Recurrence rates are high in UTIs, almost 50% of women who contract a UTI experience reinfection or relapse within one year of the initial infection5. Men are four times less likely to contract a UTI due to a longer urethra seen in men when compared with women.

Infections occur in the urinary organs and structures which can be categorized by the site of infection: cystitis (bladder), pyelonephritis (kidney) and bacteriuria (urine)5. So-called, uncomplicated UTIs are sited only in the bladder, however, UTIs are highly likely to cause secondary infections, commonly in the kidneys. Pyelonephritis has been shown to result in renal scarring and in some cases, subsequent renal failure2. There are various species of bacteria responsible for UTIs, which have different mechanisms of infection and virulence. However, most species have surface adhesins which function like hooks, attaching the bacteria to the urothelial mucosal surface, and colonizing the bladder. From here, the bacteria can ascend the ureters, reaching the kidney and causing secondary infections2.

Under normal conditions, the innate immune system actions an inflammatory response to the infection site. However, some species of bacteria that cause UTI can inhibit or delay the immune response resulting in secondary infections in the ureters and kidneys where the risk of severe renal defects is considerable, and the bacteria have direct access to the bloodstream2.

Common symptoms of UTI include:

  • Frequent urination
  • Painful urination
  • Incomplete voiding of the bladder
  • Pelvic, back, and/or abdominal pain
  • Haematuria
  • Lethargy
  • Nausea and/or vomiting
  • Fever

Antibiotic therapies are effective and aim to facilitate the immune response and inhibit the spread of the infection to the kidneys and upper urinary tract. Although these treatments are usually effective, antimicrobial resistance (AMR) has become a global crisis encompassing all medical disciplines3. This resistance to antibiotics can occur through several mechanisms such as dysregulation of protein expression, structural modifications, and mutations to name a few11.

Bacteria are capable of some level of intrinsic resistance, or insensitivity, to antibiotics through the production of various enzymes designed to degrade the drug or inhibit its mechanism11. Mutations found in the genome of bacterial species are often responsible for the resistance they display. These mutations commonly alter the bacterial binding sites used by antibiotics, therefore inhibiting their action. Some bacteria produce enzymes, which alter the chemical structure of the antibiotic, again, inhibiting them from binding to the antibiotic. Other examples include horizontal gene transfer and biofilm formation10.

One study reported in 2019, that AMR was the twelfth leading cause of death when compared with a susceptible infection counterfactual9. The same study went on to show that AMR had the highest mortality rate in low to middle-income countries providing evidence that AMR is an even bigger problem in the most impoverished parts of the world. New techniques such as CRISPR-Cas9 and antibiotic re-sensitization methods are at the forefront of the fight against AMR, however, the scale of the problem warrants taking all possible action to elevate the risk posed by AMR8.

UTI During Pregnancy

UTIs are a common occurrence in pregnancy with one hospital reporting over 15% of pregnant women being diagnosed with some form of UTI4. Diagnosis can usually be confirmed by a bacterial growth of over 105 counts/ml in urine4, 12, 13. Many hormonal and anatomical changes occur in a woman’s body during pregnancy that create favorable conditions for UTI. Firstly, the glomerular filtration rate is altered, causing an increase in glucose concentration and pH of the urine3. The urethral dilation, smooth muscle relaxation, enlarged mechanical compression of the uterus, and increased plasma volume result in lower urinary concentration and increased bladder size leading to urinary tract reflux and urine stagnation. These conditions are favorable for the proliferation of bacterial infections1.

Diagnosis of UTIs in pregnant women can be complicated. For example, the increased frequency of urination experienced could also be caused by additional pressure placed on the woman’s bladder by the baby, or the abdominal pain indicative of a UTI could be interpreted as Braxton Hicks contractions and vice versa3. There are several established risk factors associated with UTI in pregnancy including advanced maternal age, diabetes, sickle cell anemia, history of UTI, urinary tract abnormalities, and various immunodeficiencies3. Other reports claim that UTI in pregnancy is more common in women with hypothyroidism and women who are carrying their first child4.

Bacterial Species Responsible for UTI

There are a multitude of bacterial species responsible for UTIs, the most common is Escherichia coli (E. coli), followed by group B streptococcus (GBS), enterococcus, and Klebsiella pneumonia. Escherichia coli infections are categorized as either enteric or extraintestinal (ExPEC). Of the latter, there are two main culprits: neonatal meningitis E. coli (NMEC) and uropathogenic E. coli (UPEC)2. These infections can exist in the gut and spread, colonizing other parts of the host such as the blood or central nervous system, causing other potentially severe infections. Of these strains, UPEC is responsible for around 80% of both symptomatic and asymptomatic UTIs. UPEC strains have been associated with acute renal damage and are thought to encourage bacterial growth and persistence by inhibiting or delaying the innate immune response2.

Maternal and Perinatal UTI Complications

UTI complications in mothers and children have long been debated. However, there is sufficient evidence to support several prognostic claims. Preterm delivery is a major complication associated with UTI and has been well studied. Preterm neonates face a high risk of fatality with up to 1 million babies dying every year due to premature labor6. Those that survive are at risk of developing one or more of the following health defects1:

  • Lung problems
  • Diabetes
  • Heart Disease
  • Hearing loss
  • Visual impairment
  • Learning disabilities
  • Behavioral problems
  • Cerebral palsy

The risk of preterm birth in women who suffered from a single UTI was increased when compared to women who had no infection during their pregnancy but recurrent UTIs did not increase the risk3. Risk of low birth weight has been shown to increase by 50% in women who suffered symptomatic UTIs compared to those who remained uninfected throughout their pregnancy; this risk can be mitigated through antibiotic therapy. The same treatments did not show any significant ameliorative effects on preterm birth4. Women who contract a UTI during pregnancy are also at a higher risk of various conditions such as preeclampsia, postpartum endometritis, sepsis1, hypertensive disorders, anemia and amnionitis4.

Asymptomatic UTIs, also known as asymptomatic bacteriuria (ASB), are not known to cause as drastic primary effects on pregnancy as seen with symptomatic infections. Despite this, ASB can spread and colonize in the kidneys. At this point, pyelonephritis is likely to occur, increasing the risk of severe renal scarring4 and advanced risk of preterm birth3. In these cases, it is common to treat the patient with antibiotics to reduce the risk of a secondary, symptomatic infection. While these treatments are effective at limiting the progression of the infection, overuse of antibiotics is a primary factor contributing to antimicrobial resistance4.

Screening and Treating UTI Complications

Women who are not pregnant and show no risk factors can be tested for UTI through a simple urine dipstick. The presence of leukocyte and absence of nitrite can be considered a positive UTI diagnosis. However, where complications are likely, a urine culture is required. Cultures can be carried out on blood or MacConkey agar and require preservation of the sample in boric acid, or in a refrigerator, for 24 hours prior to testing. This culture can then be isolated and used to identify the strain of bacteria causing the infection7.

Species identification is imperative in maternal UTIs. Different species have different levels of sensitivity to the various antibiotics available. E. coli, for example, shows 93% sensitivity to Nitrofurantoin but is only 86% sensitive to Fosfomycin. Selection of the correct treatment can ameliorate symptoms rapidly and reduce the possible complications for both mother and baby4. Many species of bacteria known to be responsible for UTIs have displayed resistance to antibiotics. Group B streptococcus has been shown to be 42% resistant to clindamycin4. The selection of antibiotics available to clinicians treating maternal UTI are already limited as many antibiotics have been associated with increased risk of miscarriage and birth defects independent of UTI1.

With the patient in mind, Randox provides clinicians with both laboratory and near patient testing solutions. Bringing to the market, to help eliminate distress and improve testing turnaround times, the Randox Urinary Tract Infection Array. It has the ability to detect 30 bacterial, fungal, and associated antibiotic resistance markers from a single urine sample in under four hours. This multiplex diagnostic tool can help detect specific bacterial and fungal strains known to cause UTI allowing laboratories to confidently diagnose patients in a timely manner, aiding with targeted treatments and helping to reduce risk of complications.

The Ongoing UTI Battle

Maternal UTI is a very common problem resulting in many fatalities and morbidities worldwide. It is crucial to identify and characterize these infections to limit the negative effects seen to both mothers and their children. Quick and efficient screening is paramount in the battle against bacteria to allow the prescription of targeted treatment. While antibiotics are often an effective weapon against UTIs, care should be taken when prescribing these treatments to pregnant women due to the potential adverse effects that have been reported. Furthermore, unnecessary treatments using antibiotics should be avoided at all costs due to the increasingly serious issue of antimicrobial resistance.

References

1.Eslami V, Belin S, Sany T, Ghavami V, Peyman N. The relationship of health literacy with preventative behaviours of urinary tract infection in pregnant women. Journal of Health Literacy. 2022;6(4):22-31. doi:https://doi.org/10.22038/jhl.2021.59768.1183

2.Bien J, Sokolova O, Bozko P. Role of Uropathogenic Escherichia coli Virulence Factors in Development of Urinary Tract Infection and Kidney Damage. International Journal of Nephrology. Published online 2012:1-15. doi:https://doi.org/10.1155/2012/681473

3.Werter DE, Kazemier BM, van Leeuwen E, et al. Diagnostic work-up of urinary tract infections in pregnancy: study protocol of a prospective cohort study. BMJ Open. 2022;12(9):e063813. doi:https://doi.org/10.1136/bmjopen-2022-063813

4.Balachandran L, Jacob L, Al Awadhi R, et al. Urinary Tract Infection in Pregnancy and Its Effects on Maternal and Perinatal Outcome: A Retrospective Study. Cureus. 2022;14(1). doi:https://doi.org/10.7759/cureus.21500

5.Bono MJ, Reygaert WC. Urinary Tract Infection. Nih.gov. Published 2018. https://www.ncbi.nlm.nih.gov/books/NBK470195/

6.World Health Organization. Preterm birth. Who.int. Published February 19, 2018. Accessed February 8, 2023. https://www.who.int/news-room/fact-sheets/detail/preterm-birth

7.Sinawe H, Casadesus D. Urine Culture. PubMed. Published 2021. https://www.ncbi.nlm.nih.gov/books/NBK557569/

8.Schrader SM, Botella H, Vaubourgeix J. Reframing antimicrobial resistance as a continuous spectrum of manifestations. Current Opinion in Microbiology. 2023;72:102259. doi:https://doi.org/10.1016/j.mib.2022.102259

9.Murray CJ, Ikuta KS, Sharara F, et al. Global Burden of Bacterial Antimicrobial Resistance in 2019: A Systematic Analysis. The Lancet. 2022;399(10325):629-655. doi:https://doi.org/10.1016/S0140-6736(21)02724-0

10.Ali J, Rafiq QA, Ratcliffe E. Antimicrobial resistance mechanisms and potential synthetic treatments. Future Science OA. 2018;4(4):FSO290. doi:https://doi.org/10.4155/fsoa-2017-0109

11.Nelson DW, Moore JE, Rao JR. Antimicrobial resistance (AMR): significance to food quality and safety. Food Quality and Safety. 2019;3(1):15-22. doi:https://doi.org/10.1093/fqsafe/fyz003

12.Myers AL. Curbside Consultation in Pediatric Infectious Disease : 49 Clinical Questions. Slack; 2012:4.

13.Oie S, Kamiya A, Hironaga K, Koshiro A. Microbial contamination of enteral feeding solution and its prevention. American Journal of Infection Control. 1993;21(1):34-38. doi:https://doi.org/10.1016/0196-6553(93)90205-i

7. Sinawe H, Casadesus D. Urine Culture. PubMed. Published 2021. https://www.ncbi.nlm.nih.gov/books/NBK557569/

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Urinary Tract Infection (UTI)

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Urinary Tract Infection (UTI)

Rapid Diagnostic Point of Care Test for UTI Detection

Timely Identification of UTIs, Facilitating Improved, Targeted Treatment

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    Species level identification and complete patient profiling from a single urine sample
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    The Randox UTI array includes a MecA antibiotic resistance marker to assist antibiotic stewardship
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    Detecting 23 bacterial, 1 fungal and 8 resistance markers

     

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    Same-day results to facilitate health professionals in their selection of most appropriate treatment approach for patients

     

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    Assay run time from DNA extraction to data interpretation in under 4 hours

     

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    Identification of significant UTI bacteria which cannot be recognised through traditional nitrite and leukocyte dipstick tests

     

     

A UTI is defined as the detection of a micro-organism in the urine, measured from a midstream urine sample, with presence of clinical symptoms. UTIs occur when a micro-organism migrates from the urethra to the bladder or kidney.

The Urinary Tract Infections (UTI) array is a market leading test detecting 30 bacterial, fungal and associated antibiotic resistance markers from a single urine sample. Identification of a multiplex UTI can prevent further damage to the renal system including the kidneys and bladder.

Biochip

Biomarkers Tested

Bacteria

  • Acinetobacter baumannii
  • Escherichia coli
  • Citrobacter freundii
  • Citrobacter koseri
  • Klebsiella oxytoca
  • Klebsiella pneumoniae
  • Klebsiella aerogenes
  • Serratia marcescens
  • Staphylococcus aureus
  • Staphylococcus epidermidis
  • Staphylococcus saprophyticus
  • Streptococcus agalactiae (GBS)
  • Morganella morganii
  • Enterobacter cloacae
  • Enterococcus faecalis
  • Enterococcus faecium
  • Proteus spp.
  • Providencia stuartii
  • Providencia rettgeri
  • Pseudomonas aeruginosa

Acinetobacter is a genus of Gram-negative bacteria belonging to the wider class of Gammaproteobacteria. It is present in the environment and can live on human skin. Some types can cause blood, lung or urinary tract infections.

Also known as E. coli, is a Gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus Escherichia that is commonly found in the lower intestine of warm-blooded organisms.

A species of facultative anaerobic gram-negative bacteria of the family Enterobacteriaceae.

A gram-negative, non-lactose fermenting rod that is often part of normal human flora, the urinary tract is one of the most common sites of infection by Citrobacter.

KO is one of several Klebsiella bacteria. It is an emerging bacterial isolate causing hospital-acquired infections in adults and having multiple drug resistance to commonly used antibiotics.

Bacteria that normally live in your intestines and faeces. These bacteria are harmless when they’re in your intestines. But if they spread to another part of your body, they can cause severe infections.

Previously known as Enterobacter aerogenes, is a Gram-negative, oxidase negative, catalase positive, citrate positive, indole negative, rod-shaped bacterium.

A species of rod-shaped, Gram-negative bacteria in the family Yersiniaceae. It is a facultative anaerobe and an opportunistic pathogen.

The most dangerous of all of the many common staphylococcal bacteria. These gram-positive, sphere-shaped (coccal) bacteria often cause skin infections but can cause pneumonia, heart valve infections, and bone infections.

A common bacterial colonisers of the skin and mucous membranes of humans and other mammals.

A gram-positive, coagulase negative, non-hemolytic coccus that is a common cause of uncomplicated urinary tract infections.

A gram-positive, β-hemolytic organism in the Streptococcus genus that carries the Lancefield group B antigen.

Belongs to the tribe Proteeae of the Enterobacteriaceae family. This species is considered as an unusual opportunistic pathogen that mainly causes post-operative wound and urinary tract infections.

A member of the normal gut flora of many humans and is not usually a primary pathogen. Some strains have been associated with urinary tract and respiratory tract infections in immunocompromised individuals.

Formerly classified as part of the group D Streptococcus system – is a Gram-positive, commensal bacterium inhabiting the gastrointestinal tracts of humans and other mammals.

Contains decarboxylase enzymes that use both l-phenylalanine and l-tyrosine as substrates, producing 2-phenylethylamine and p-tyramine.

Are Gram-negative bacteria belonging the Enterobacteriaceae family and are common commensals of the gastrointestinal microbiota.

An opportunistic pathogen being the most common cause of catheter-associated urinary tract infections.

Can be identified by its motility and its ability to produce acid from mannitol.

A common encapsulated, Gram-negative, rod-shaped bacterium that can cause disease in plants and animals, including humans.

Fungi

  • Candida albicans

The most prevalent fungal species of the human microbiota; this species asymptomatically colonizes many areas of the body, particularly the gastrointestinal and genitourinary tracts of healthy individuals.

 

Antibiotic Resistance Markers

  • mecA (incl MRSA)
  • Trimethoprim Resistance 1-5
  • Vancomycin Resistance A/B

A gene found in bacterial cells which allows them to be resistant to antibiotics such as methicillin, penicillin and other penicillin-like antibiotics.

 

Can be caused by changes in cell permeability, loss of bacterial drug-binding capacity, and overproduction of or alterations in dihydrofolate reductase.

Vancomycin acts by binding to d-Ala-d-Ala pentapeptides blocking cell wall biosynthesis. Resistance to vancomycin is conferred by the van operon, which consists of a two-component regulatory system (vanS-vanR) that responds to either vancomycin, disruption at the cell membrane, or both.

Available Platforms

Evidence Investigator

The Evidence Investigator is a compact, semi-automated benchtop analyser that offers efficient and comprehensive testing. Renowned for its versatility, robustness and effective reporting methods, the Evidence Investigator has been used in a wide range of laboratory settings for over 15 years.

 

The Vivalytic platform is a universal, fully automated all in one solution for molecular diagnostics. It is a cartridge-based platform enabling Hi-Plex and Lo-Plex testing, consolidating the full molecular workflow into a small benchtop platform, capable of extraction, PCR amplification and detection.

 

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