The Prevalence of Asymptomatic Urinary Tract Infection and Its

Relationship with Combur Strip Test Results among Pregnant

Women

Sri Amelia

, Dian Dwi Wahyuni

, Rina Yunita

and Tetty Aman Nasution

Microbiology Department, Faculty of Medicine, Universitas Sumatera Utara, Jl. dr. Mansur, Medan, Indonesia

Keywords: Infection, Urinary, Combur.

Abstract: Urinary tract infection is one of the health problems among the world population including pregnant

women. Several physiologic changes increase the susceptibility of pregnant women suffered from UTI. In

addition, Combur strip test is one of the screening methods that can directly detect urinary tract infection

especially in primary clinical care setting. Combur strip results can determine the management and prevent

the serious implications among high-risk patients. This study was descriptively performed using 33 clean-

catch midstream urines of pregnant women. We inoculated the specimen into blood agar and McConkey

agar. Combur strip test was also performed to detect any significant pH, leukocyte esterase, nitrite

production, protein, and glucose. Positive significant bacteriuria was found among 16 participants (48.4%),

and Klebsiella oxytoca became the most common bacteria causing UTI (18.2%) followed by

Staphylococcus aureus (15.2%), and Escherichia coli (12.1%). Significant association was also evident

between parity (p-value = 0.037), leukocyte esterase (p-value = 0.022), and nitrite production (p-value =

0.009) with significant bacteriuria. Susceptibility of pregnant women suffered from UTI is evident and

several indicators obtained from Combur strip still become a useful method that can be used to screen UTI

among pregnant women.

1 INTRODUCTION

Urinary tract infection (UTI) is the second most

common health problems after anemia among

pregnant women. UTI defines as an infection of the

urinary tract including kidney, ureters, bladder, and

urethra. It is divided into two categories, for

instance, upper UTI (kidney and ureters) and lower

UTI (bladder and urethra) (Tan and Chlebicki,

2016). In primary clinical care setting, UTI becomes

major clinical case admitted to the clinic. UTI is

suffered by approximately 150 million people each

year worldwide (Flores-Mireles, 2015), while in

Indonesia alone, 180,000 of people admitted to

hospital diagnosed as UTI each year, data was

obtained from Department of Health in 2014. The

incidence is higher among infant boys, older men,

and female of all ages particularly pregnant woman

(Mohsin and Siddiqui, 2010). Recurrent infection,

sepsis-related UTI, chronic kidney damage in

pediatric patients, pre-term birth, and high resistance

to certain antibiotic caused by repeated use of

antibiotic are most common serious implications

related to UTI.

Escherichia coli, uropathogenic strain or UPEC,

and Staphylococcus aureus are still become the most

common etiologic bacteria causing UTI (80% of

uncomplicated UTI). UPEC is different from

intestinal pathogenic E.coli by the presence of

specific virulence factors. UPEC often has

attachment-pills called P-fimbriae which function as

anchoring its cell to glycolipid, the outer membrane

of a urinary tract epithelial cell and it is only found

in the kidney (Minardi, 2011). Klebsiella

pneumonia, Proteus, Acinetobacter, Staphylococcus

saprophyticus, Streptococcus beta-hemolytic group

B, and Pseudomonas aeruginosa also cause the UTI

(Amiri, 2015).

The presence of susceptibility factor in woman

population increases its incidence among them.

Susceptibility factors are related with basic

anatomic, behavioral, genetic, age-specific,

catheterization, and pregnancy (Dielubanza and

Schaeffer, 2011). In men, longer urethra causes

Amelia, S., Wahyuni, D., Yunita, R. and Nasution, T.

The Prevalence of Asymptomatic Urinary Tract Infection and Its Relationship with Combur Strip Test Results among Pregnant Women.

DOI: 10.5220/0010075104810485

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

481-485

ISBN: 978-989-758-449-7

481

delay of ascending infection progress rapidly, and it

would be washed out before the infection produce

symptom. While in women, short urethra could

cause invasion will occur in a short period of time.

Besides, it is well-documented that female urethral

meatus is closer to bacterial reservoir structure such

as the vagina and rectum (Michelim, 2016). As the

matter of fact, pregnancy is evident as an

independent risk factor of upper UTI, commonly

identical with asymptomatic bacteriuria. UTI among

pregnant woman will eventually occur in the sixth

week of pregnancy and its peak commonly in weeks

22-24. Several changes that lead to the increased

susceptibility of having upper UTI are inevitable in a

pregnant woman. For instance, physiologic changes

are the ones with the most influence, increased of

progesterone levels would induce ureteric smooth

muscle relaxation while blood volume and

glomerular filtration rate are also increasing at this

time. Besides, 90% of pregnant will have a renal

pelvis and urethral dilatation, and it also induces

vesicoureteral reflux and urinary stasis. This

combination effect would become supportive for

bacterial colonization (MacLean, 2001). Several

studies conducted in a different location found that

the prevalence of UTI among pregnant women

increased, 25.3-55% in Nigeria (Ebidor, 2015;

Oladeinde, 2015), 29% in Egypt (Mohamed, 2017),

18.8% in Ethiopia (Tadesse, 2014), and 56.8% in

Iran (Amiri, 2015).

Morbidity and mortality related to UTI among

pregnant woman are emphasized from literature

consisting of serious complications in mother and

fetus, maternal complication include anemia,

preeclampsia, renal failure, and septicaemia while in

fetus it can cause low birth weight infants (LBW),

intrauterine growth retardation, premature birth, and

intrauterine fetal death (Foxman, 2014), (Foxman,

2002). Therefore early detection and effective

therapeutic strategies are indispensable

(Matuszkiewicz-Rowińska, 2015). Bacteriuria can

be diagnosed by using a semi-quantitative urine

culture yet culture is costly and impractical, it takes

24 hours before experts can evaluate it. The dipstick

test can replace urine culture in primary care settings

and it is still reliable because it shows excellent

accuracy among high-risk patients. In addition, it

also can rule out uninfected patients primarily based

on nitrite production and leukocyte esterase (Deville,

2004).

We conducted a study to determine the

prevalence of significant bacteriuria among pregnant

women of all gestational age and tried to reveal the

prevalence of UTI among them. Combur strip test

was also performed to identify its relationship with

significant bacteriuria.

2 SIGNIFICANT BACTERIURIA

Our cross-sectional descriptive study enrolled 33

pregnant women in Medan Selayang subdistrict,

Medan, Indonesia from April 2018 to May 2018.

The study also did not use any inclusion criteria

since we performed total sampling which means all

pregnant women in the Medan Selayang subdistrict

must be included in the study.

2.1 Sample Collection and Bacterial

Identification

Firstly, we invited all pregnant woman with all

gestational age in one place. Then we provided the

full explanation about significance of UTI among

pregnant women and the implications for the fetus.

Without any coercion, all participant gave their

approval and we collected clean-catch midstream

urine samples in a sealed sterile small plastic

container to proceed further examination. The whole

process of the sampling was carried out in

subdistrict office. We transported the specimen

shortly to Microbiology Department, Faculty of

Medicine, Universitas Sumatera Utara, Medan,

Indonesia. Secondly, the bacterial assessment was

begun with inoculating the specimen on the total

plate agar, blood agar plate, and McConkey agar

(Oxoid Basingstoke, UK) at 370 C for 24 hours. The

interpretation was made in the colony forming units,

equal or greater than 105 CFU/ml was mentioned as

positive or significant bacteriuria, and less than 105

CFU/ml were called as negative or non-significant

bacteriuria.

The results were assessed by microbiologist

using total plate count method. In addition, we also

performed gram staining, specific test including

coagulase and catalase test, and their pattern based

on biochemical reactions results if we found gram-

negative bacilli in gram staining such as indole

production, methyl red, Voges-Proskauer, Simmons

citrate, urease, motility test, using Triple Sugar iron

(TSI), gas and sulphur production, glucose, lactose,

maltose, mannitol, and sucrose fermentation.

We also performed the urine test strip (Combur

Test®M, Roche company) to detect pH, leukocyte

esterase, nitrite, protein, and glucose shortly after the

urine collection. Then, the strip was plunged into a

urine sample container for 2-4 seconds at room

temperature. Demographic data including age,

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

482

gestational age, and parity were also obtained by a

short questionnaire method.

2.2 Ethical Consideration and Data

Analysis

We conducted our study after getting permission and

approval from the local ethical committee of the

Faculty of Medicine, Universitas Sumatera Utara,

Medan, Indonesia. We provided the data by using

the Statistical Package for Social Sciences 21 (SPSS

Inc. version 21) in univariate fashioned. We did not

assess the participant symptom nevertheless whether

our findings gave us a positive result or significant

bacteriuria, the participant would be referred to an

OB&GYN specialist to obtain further assessment

and management.

3 RESULTS AND DISCUSSIONS

This study is a part of our social activities held

annually. After we gathered all pregnant woman in

one auditorium and obtained a urine sample, we

found that 16 of 33 pregnant women (48.4%) were

positive for significant bacteriuria. The most

common etiologic bacteria that caused asymptomatic

UTI in our study were Klebsiella oxytoca (18.2 %),

followed by Staphylococcus aureus and Escherichia

coli, 15.2% and 12.1% respectively. However, we

also performed a bivariate analysis to correlate

specific variables with the prevalence of significant

bacteriuria, by using chi-square we acquired a

significant association between parity and significant

bacteriuria (p-value= 0.037).

Based on Combur strip test results, we obtained a

significant association between leukocyte esterase

(p-value=0.022) and nitrite production (p-

value=0.009) with significant bacteriuria. All related

variables were also listed in Table.1. Nevertheless,

there are three participants who positive for certain

bacteria without significant bacteriuria, and we

defined the specimen as a contaminant, the

specimens were contaminated with E.coli (1 sample)

and S.aureus (2 samples). After obtaining the

sample, we did not perform symptom assessment. In

the next few days, we were referring positive

significant bacteriuria participant for an OB&GYN

specialist.

Table 1: Demographic data and Combur strip test results among pregnant women.

Characteristics Si

nificant bacteriuria N (%) PR 95% CI p-value

Yes N

(

)

No N

(

)

Age (years)

< 30

≥ 30

9 (47.4)

(

42.9

)

10 (52.6)

(

57.1

)

19 (57.6)

(

42.4

)

0.833

0.208-

3.345

0.797

Gestational age

(weeks)

< 20

≥ 20

3 (33.3)

12 (50.0)

6 (66.7)

12 (50.0)

9 (27.3)

24 (72.7)

2.000

0.404-

9.909

0.392

Parity

Primipara

Multi

ara

3 (23.1)

(

60.0

)

10 (76.9)

(

40.0

)

13 (39.4)

(

60.6

)

5.000

1.040-

24.034

0.037*

< 7

≥ 7

10 (58.8)

(

31.3

)

7 (41.2)

(

68.8

)

17 (51.5)

(

48.5

)

3.143

0.751-

13.159

0.112

Leukocyte

esterase

Positive

ative

11 (64.7)

(

25.0

)

6 (35.3)

12 (75.0)

17 (51.5)

16 (48.5)

5.500

1.219-

24.813

0.022*

Nitrite

Positive

ative

11 (68.8)

(

23.5

)

5 (31.3)

(

76.5

)

16 (48.4)

(

51.5

)

0.140

0.030-

0.653

0.009*

Protein

Positive

ative

1 (100.0)

(

43.8

)

0 (0.0)

(

56.3

)

1 (3.5)

(

96.5

)

Glucose

Normal

Elevate

14 (43.8)

1 (100.0)

18 (56.3)

0 (0.0)

32 (96.5)

1 (3.5)

The Prevalence of Asymptomatic Urinary Tract Infection and Its Relationship with Combur Strip Test Results among Pregnant Women

483

Urinary tract infection is defined as the presence

of symptoms and significant bacteriuria while

asymptomatic bacteriuria or asymptomatic pyuria is

characterized by significant isolation amount of

bacteria obtained from asymptomatic patients

(Yamamoto, 2016). Symptomatic UTI patients are

required to be treated while asymptomatic patients

need further assessment or positive result from

double tests using dipstick is indicated to be

managed (Goonewardene and Persad, 2015).

Nevertheless, we did not perform any symptoms

assessment; therefore, use of the term UTI and

significant bacteriuria are interchangeably used in

our study.

Urinary tract infection or the presence of

significant bacteriuria in a pregnant woman is higher

than in other populations. We previously described

physiologic changes that increased the susceptibility

of pregnant women suffered from UTI is evident.

There are 48.4 % of pregnant women are categorized

with significant bacteriuria, in our former study the

incidence of UTI is 38.9% (Laily, 2018), and

individual risk factors also had significant

association including age, gestational age, and

sexual intercourse. A study conducted by (Shaheen,

2016) detect UTI among 32% of pregnant women

and highly associated with the socioeconomic issue,

unsatisfied personal hygiene, history of diabetes

mellitus, anemia, and history of previous UTI. UTI

perception, screening methods, confounding factors

such as age, parity, and pregnancy have led to

variability in UTI prevalence at different sites. The

study also stated that UTI is commonly associated

with urban living than rural (56.4% in urban versus

43.6 % in rural).

Based on demographic data, we only acquired a

significant relationship between parity and

significant bacteriuria (p=0.037). In contrast,

(Obirikorang, 2012) found there is no significant

relationship between parity and significant

bacteriuria but pregnant woman with multiparity had

higher prevalence of asymptomatic UTI (p=0.251),

it might be explained by the low incidence of

asymptomatic UTI, only about 9.5%, and there was

no clinical data on UTI signs and symptoms

provided in the study. We also included data on

gestational age, and we found that gestational age ≥

20 weeks had a higher prevalence of significant

bacteriuria than under 20 weeks, but it is not

statistically significant. (Alghalibi, 2007) also

proved a similar result while (Sullivan, 2016) and

(Kline, 2014) using a murine model to correlate age

and parity with UTI, it was evident that age and

parity affected the severity of UTI. Hormonal

changes cause susceptibility, mainly estradiol,

occurred during gestation and childbirth.

We also performed a urine dipstick to detect pH,

leukocyte esterase, nitrite production, protein, and

glucose. We only found nitrite and leukocyte

esterase were significantly related with significant

bacteriuria, p= 0.009 and p=0.022 respectively. In

one study, the dipstick method or Combur strip test

still becomes one of the highly sensitive tests that

can be easily used to screen, the accuracy was about

72% (Laosu-angkoon, 2011). A study performed in

Kenya 77.5 % of pregnant women expressed as

positive UTI using dipstick while 67.5% were

positive on urine microscopy (Fred, 2015).

Therefore, the use of a dipstick method can still be

considered. Nitrite and leukocyte esterase are

commonly used as a reference marker for UTI.

Nitrite formation will occur if the infection progress,

it is the product of bacterial reduction product of

urine nitrate and highly associated with gram-

negative bacteria (Majid and Buba, 2010). Our study

result found a significant relationship between nitrite

and significant bacteriuria since in our study we

detected almost 60% of identified bacteria is gram-

negative including K.oxytoca and E.coli.

4 CONCLUSIONS

The high prevalence of UTI among pregnant woman

is obvious from our study. In addition, Combur strip

test still becomes a reliable method for screening

UTI, and it will reduce the time between admission-

prompt treatment. This study has become part of our

social activities held in several locations. Therefore,

we only provided some demographic data and

related them with significant bacteriuria. Further

assessment related with UTI symptomatology was

held in related specialist since early detection and

prompt management are compulsory. Lastly, we also

conducted health education session about UTI

among pregnant woman, and it has been the first

step in raising awareness of its several serious

complications.

ACKNOWLEDGEMENTS

Our study was granted by Lembaga Pengabdian

Kepada Masyarakat Universitas Sumatera Utara,

through Non-PNBP and BPPTN USU with Letter of

Assignment no. 365/UN5.2.3.2.1/PPM/2018.

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

484

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