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.

Microbiological Spectrum of Infection

UTIs in patients with diabetes are due to the same urinary pathogens as those found in the general population, with the majority of ascending infections being caused by E.coli. Other uropathogens found in patients with diabetes include Proteus spp., Enterobacter spp. and Enterococcus faecalis. Klebsiella pneumoniae and group B streptococci are also more common in patients with diabetes.^[35,36]Staphylococcus aureus accounts for infections caused by haematogenous spread. About 50–75% of emphysematous pyelonephritis cases are caused by E.coli^[19,37] and most of the rest are caused by other Gram-negative organisms.^[3]

Diabetes is a common predisposing factor for UTIs caused by fungi, particularly Candida species (C. albicans, C. glabrata, C. tropicalis). Around 5% of patients with candiduria will have two or more species simultaneously. The extent of involvement ranges from inconsequential lower urinary tract colonisation to clinical cystitis, emphysematous cystitis, pyelonephritis, and renal and perinephric abscess.^[38,39,40] Upper urinary tract fungal infection only rarely becomes involved as ascending infection and even in these cases the presence of urinary tract obstruction, instrumentation, urethral stents, nephrostomy tubes and reflux may contribute. The majority of cases of renal candidiasis occur as a consequence of haematogenous seeding of renal parenchyma and not as a result of ascending spread.

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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