Diversity and Complexity of Urinary Tract Infection in Diabetes Mellitus

Lukman M. Hakeem, Diptendu N. Bhattacharyya, Cyril Lafong, Khalid S. Janjua, Jonathan T. Serhan and Ian W. Campbell

British Journal of Diabetes and Vascular Disease. 2009;9(3):119-125.

Abstract and Introduction

Abstract

Urinary tract infections (UTIs) are a common burden in patients with diabetes mellitus. Cystitis, ascending infections leading to pyelonephritis, emphysematous complications and renal and perinephric abscesses are well recognised in this group of patients especially if glycaemic control is poor. Despite the clinical significance of UTI in diabetes, it is inadequately understood and management regimens are mostly not evidence based. Anticipation of potential complications and earlier interventions are vital to reduce serious adverse outcomes. Herein we discuss the aetiology, pathogenesis and management of UTI and its local and more remote complications.

Introduction

Diabetes mellitus is the most common endocrine disease and is associated with organ complications due to microvascular and macrovascular disease. People with diabetes also suffer from simple and complicated infections, although the association between diabetes mellitus and increased susceptibility to infection has been questioned.^[1,2] Nevertheless many specific infections are commoner in diabetes and some occur almost exclusively in diabetic subjects. Others may occur with increased severity and may be associated with greater risk of complications.^[3] UTIs fall into both these categories i.e. exclusive and more severe. Asymptomatic bacteriuria, acute pyelonephritis and complications of UTI are reported to be more common in patients with diabetes. Despite the clinical and economic significance, there is a paucity of research. Much has to be learned about the natural history of infection during the antimicrobial era.^[4]

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Table 1. Causative organisms and treatment of urinary tract infection in patients with diabetes
Infection	Common Organisms	Antimicrobial Therapy	Further Management and Comments
Acute bacterial cystitis	E. coli, Proteus species	Trimethoprim 200 mg ^2x Ciprofloxacin 500 mg ^2x 7–14-day course	Early surgical intervention in emphysematous infection Consider ESBL if no clinical improvement
Acute pyelonephritis	E. coli, Proteus species	Ciprofloxacin 500 mg/400 mg ^2x or third generation cephalosporins or piperacillin/tazobactam 4.5 g^3x 7–14-day course If ESBL suspected meropenem 500 mg/1 g^3x	Emphysematous infection should be considered
Emphysematous pyelonephritis	E. coli, K. pneumoniae	As above	Emergency nephrectomy often required
Perinephric and intra-renal abscess	E. coli and other Gram-negative bacilli (associated with pyelonephritis) S. aureus (associated with bacteraemia)	As above but consider adding flucloxacillin 1 g/2 g i.v. if S. aureus suspected	Surgical drainage
Fungal cystitis	Candida species (C. albicans, C. glabrata, C. tropicalis)	Fluconazole 100 mg^2x 7–14 days (Amphotericin B bladder irrigation or single dose i.v. amphotericin)	Removal of urinary catheter
Fungal pyelonephritis and abscesses	Candida species (C. albicans, C. glabrata, C. tropicalis)	Fluconazole 6 mg/kg/day prolonged therapy (2–6 weeks ) or i.v. amphotericin	Surgical drainage Removal of stents and relieve obstruction if any