The Proportion of Asymptomatic Bacteriuria among Pregnant

Women in a Primary Health Centre Medan, Indonesia

Putri Wulandari

, Rina Yunita

Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Department of Microbiology, Universitas Sumatera Utara, Medan, Indonesia

*Corresponding author

Keywords: Pregnant women, asymptomatic bacteriuria, UTI

Abstract: Pregnancy is a risk factor for urinary tract infection (UTI). UTI in pregnant women is generally

asymptomatic bacteriuria. Although asymptomatic, 40% of asymptomatic bacteriuria can develop into

symptomatic UTI if left untreated, this condition can increase lower weight in infants and premature labor.

Screening and treatment for asymptomatic bacteriuria reduce the risk of symptomatic UTI and

complications. The objective of this study was to determine the proportion of asymptomatic bacteriuria in

pregnant women at the Padang Bulan Health Center Medan. This study is a descriptive study with a cross-

sectional design involving 50 pregnant women who came to the Padang Bulan Health Center. Data was

obtained by taking the central portion of urine and examine them for UTI. The results of the study found

significant bacteriuria as many as in 14 pregnant women (28.0%) with Escherichia coli (28.6%) as the most

common bacteria. The highest proportion was found in women aged 16-25 (57.1%), with income

<Rp.1,000,000, had sexual activity in the last 2 weeks (64.3%), nullipara (71.4%), and with gestational age

13-26 weeks (50.0%). Meropenem, ceftazidime, and nitrofurantoin were the antimicrobials still effective

against these isolates.

1 INTRODUCTION

Urinary tract infection (UTI) is a significant public

health problem worldwide. More than 10 million

outpatient visits and nearly 1 million emergency

department visits in the United States are related to

UTI every year. Women bear the most risk of

infections, nearly half of all women will experience

at least one episode of UTI during their lifetime.

This difference is attributed to factors such as the

urethra is shorter in women, and one-third of the

lower part of the urethra continues to be

contaminated with pathogens of the vagina and

rectum, women tend not to empty their bladder

completely like a man, and the female urogenital

system is exposed to bacteria during sexual

intercourse (Pais and reinstalled, 2018).

Pregnancy itself is an independent risk factor

for UTI (Pais and reinstalled 2018). UTI in

pregnancy generally do not cause symptoms or

asymptomatic bacteriuria (Bukitwetan et al., 2004).

It is defined as positive bacteriuria if the colony

counts yielding bacterial growth of ≥ 10

CFU/ml of

urine midstream taken by the method of clean-catch

(Azkia, 2018). Although the incidence of bacteriuria

in pregnant women is similar to that in the

nonpregnant, the incidence of pyelonephritis in

pregnant women is significantly increased compared

with non-pregnant women (Macejko and Schaeffer,

2006). The anatomic and physiologic changes

induced by the gravid state significantly alter the

natural history of bacteriuria, these changes may

cause pregnant women to be more susceptible to

pyelonephritis and may require alteration of therapy.

About 20% to 40% of pregnant women with

untreated bacteriuria will develop pyelonephritis

(Schaeffer et al.,2016) and may lead to adverse

obstetric outcomes such as prematurity, low birth

weight, and higher fetal mortality rate (Turpin et al.,

2007). Therefore, the treatment of bacteriuria early

in pregnancy has been shown to decrease the

incidence of pyelonephritis by 90% (Macejko and

Schaeffer, 2006).

Detection asymptomatic bacteriuria in

pregnancy is important so asymptomatic UTI could

be prevented with treatment. Screening for

Wulandari, P. and Yunita, R.

The Proportion of Asymptomatic Bacteriuria among Pregnant Women in a Primary Health Centre Medan, Indonesia.

DOI: 10.5220/0009864102470252

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 247-252

ISBN: 978-989-758-469-5

247

asymptomatic bacteriuria became standard obstetric

care, and most antenatal guidelines include routine

screening for asymptomatic bacteriuria (Schaeffer et

al., 2016). USPTF, IDSA, ACOG, American

Academy of Pediatrics (AAP), and the American

Academy of Family Physicians (AAFP) recommend

screening pregnant women for asymptomatic

bacteriuria. IDSA, AAP, and ACOG recommend

screening with urine culture early in pregnancy,

whereas USPTF and AAFP recommend screening at

12-16 weeks gestation, or at first prenatal visit

(Turpin et al., 2007).

The prevalence of asymptomatic bacteriuria in

America ranges from 4% to 7%, but in certain

groups can range from about 2% to 11%. In Nigeria,

the prevalence of asymptomatic bacteriuria was as

high as 86.6%. Prevalence of asymptomatic

bacteriuria in pregnancy in Indonesia itself is 7.3%,

but research in Tambora Health Center, West

Jakarta, showed a higher prevalence at 35.3%

(Bukitwetan et al., 2004).

Based on this background, researchers wanted to

evaluate the proportion of asymptomatic UTI among

pregnant women in the Padang Bulan Clinic, Medan,

Indonesia.

2 MATERIALS AND METHODS

2.1 Study Area

This study is a descriptive study with a cross-

sectional approach, was carried out in the Padang

Bulan Primary health center, Medan.

2.2 Study Population

The population in this study were all pregnant

women, while the accessible population of this study

was pregnant women attending Padang Bulan

Primary Health Center, Medan from September to

November 2018. Samples who fulfilled the inclusion

criteria selected were asked to participate in the

study by signing the consent form. Demographic

data were obtained from the questionnaire (Laily,

2017). The sampling technique in this study was

non-probability sampling with purposive sampling.

Inclusion criteria included pregnant women

attending Pada Bulang Primary Health Centre

Medan, and those who agreed to participate.

Exclusion criteria included pregnant women with the

signs and symptoms of UTI or symptomatic

(dysuria, urgency, frequency, suprapubic discomfort,

fever, and low back pain), patients who had

difficulty in collecting the urine, and patients who

took antibiotics in the previous 2 weeks.

2.3 Specimen Collection and

Processing

The proportion of asymptomatic bacteriuria is

determined based on the freshly voided midstream

urine sample, Subjects were properly educated to

collect clean-catch midstream urine with sterile

technique into wide-mouthed, sterile capped

containers. After urine was collected, urine samples

were properly labeled and placed in a cold box. The

urine specimen was processed in the Microbiology

laboratory at Universitas Sumatera Utara within 2

hours of collection. Samples were cultured on Blood

agar and McConkey agar and were incubated at

C aerobically for 24 hours. Bacterial isolate

growth was monitored on the culture media and was

identified using colony characteristics, gram-

staining, and series of biochemical test.

Antimicrobial susceptibility testing was performed

using the disk diffusion method on Mueller-Hinton

agar.

The collected data were processed using the

computer program. The results of the examination

were recorded, compiled, and analyzed by the Chi-

Square test.

3 RESULTS

Fourteen of 50 pregnant women (28%) who were

analyzed with urine culture and had significant

colony counts (≥10

CFU/mL) had asymptomatic

bacteriuria (table 1). The most dominant bacteria

was Escherichia coli (28,6%), followed by

Staphylococcus coagulase negative (21,4%),

Klebsiella pneumonia (14,3%), Pseudomonas

aeruginosa (14,3%), Staphylococcus aureus (7,1%),

Klebsiella oxytoca (7,1%), and Staphylococcus

epidermidis (7,1%) (table 2).

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Table 1: Distribution of frequency of pregnant women

based on colony count.

Colony counts Frequency

(n=50)

Significant growth

(>100,000 CFU/ml)

28.0

No significant growth

(<100,000 CFU/ml)

34.0

No growth 19 28.0

Table 2: Bacterial isolates among pregnant women with

significant bacteriuria

Bacterial isolate Frequency

(n=14)

Escherichia coli 4 28.6

Staphylococcus coagulase

negative

21.4

Staphylococcus aureus 1 7.1

Staphylococcus epidermidis 1 7.1

Klebsiella pneumonia 2 14.3

Klebsiella oxtica 1 7.1

Pseudomonas aeruginosa 2 14.3

The collected data showed that pregnant

women with asymptomatic bacteriuria cases were

found mostly in pregnant women with age group 16-

25 years old (57,1%), were in high school (42,9%),

had monthly income <1.000.000 Rupiah (50,0%),

had sexual intercourse in the last 2 weeks (64,3%),

nullipara (71,4%), and were in second trimester

(50,0%).

Table 3: Distribution of frequency of pregnant women

with asymptomatic bacteriuria based on the characteristic.

Characteristics Total

number

(n=14)

Age group (years)

16-25

26-35

36-45

57.1

35.7

7.1

Educational status

Junior high school

High school

Higher education/university

21.4

42.9

35.7

Monthly income

<Rp.1.000.000

Rp.1.000.000-Rp.3.000.000

>Rp.3.000.000

50.0

28.6

21.4

Sexual intercourse in the last 2

weeks

Yes

64.3

35.7

Parity

Nullipara

Primipara

Multipara

71.4

14.3

Trimester

Trimester 1

Trimester 2

Trimester 3

14.3

40.0

35.7

Based on table 4, gram-negative isolates were found

sensitive to meropenem (100%), ceftazidime

(88,8%), piperacillin-tazobactam (77,7%),

ampicillin-sulbactam, cefotaxime, chloramphenicol,

nitrofurantoin (55,5%). And gentamycin (44,4%).

On the other hand, all gram-positive isolates were

found sensitive nitrofurantoin and meropenem

(100%), followed by gentamycin (40%) and

chloramphenicol (20%).

Table 4: Antimicrobial susceptibility pattern of bacterial isolates

Gram (-)

isolates

Profile Antimicrobial sensitivity, n (%)

SAM CTX CAZ C CN MEM F TZP

E. coli (4)

S 2 (50) 3 (75) 3 (75) 3 (75) 3 (75) 4 (100) 3 (75) 3 (75)

I 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

R 2 (50) 1 (25) 1 (25) 1 (25) 1 (25) 0 (0) 1 (25) 1 (25)

Klebsiella

pneumoniae

(2)

S 1 (50) 1 (50)

(100)

1 (50) 1 (50) 2 (100) 1 (50) 2 (100)

I 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

R 1 (50) 1 (50) 0 (0) 1 (50) 1 (50) 0 (0) 1 (50) 0 (0)

The Proportion of Asymptomatic Bacteriuria among Pregnant Women in a Primary Health Centre Medan, Indonesia

249

Pseudoman

aeruginosa

(2)

(100)

1 (50) 2 (100) 0 (0) 0 (0) 2 (100) 1 (50) 1 (50)

I 0 (0) 1 (50) 0 (0) 1 (50) 1 (50) 0 (0) 0 (0) 0 (0)

R 0 (0) 0 (0) 0 (0) 1 (50) 1 (50) 0 (0) 1 (50) 1 (50)

Klebsiella

oxytica (1)

S 0 (0) 0 (0) 1 (100) 1 (100) 0 (0) 1 (100) 0 (0) 1 (100)

I 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

(100)

1 (100) 0 (0) 0 (0) 1 (100) 0 (0) 1 (100) 0 (0)

Total

(9)

5 (55,5) 5 (55,5) 8 (88,8) 5 (55,5) 4 (44,4) 9 (100) 5 (55,5) 7 (77,7)

Gram (+)

isolates

Profile Antimicrobial sensitivity, n (%)

AK MEM F C E CN DA

Staphylococcus

coagulase (-) (3)

S 0 (0) 3 (100) 3 (100) 1 (33.3) 0 (0) 2 (66.6) 0 (0)

I 0 (0) 0 (0) 0 (0) 1 (33.3) 0 (0) 0 (0) 0 (0)

R 3 (100) 0 (0) 0 (0) 1 (33.3) 3 (100) 1 (33.3) 3 (100)

Staphylococcus

aureus (1)

S 0 (0) 1 (100) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0)

I 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

R 1 (100) 0 (0) 0 (0) 1 (100) 1 (100) 1 (100) 1 (100)

Staphylococcus

epidermidis (1)

S 0 (0) 1 (100) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0)

I 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

R 1 (100) 0 (0) 0 (0) 1 (100) 1 (100) 1 (100) 1 (100)

Total (5) 0 (0) 5 (100) 5 (100) 1 (20) 0 (0) 2 (40) 0 (0)

4 DISCUSSION

This study is a cross-sectional study to see the

proportion of asymptomatic bacteriuria among

pregnant women in Padang Bulan Primary Health

Center, Medan.

The result In this study found the proportion

was 28%. This proportion is higher than the study in

Sundari Hospital Medan with the proportion of

21.8% (Novita, 2016), but lower than the 30.2%

reported in Janti Primary Health Center, Malang

(Zahroh, 2014).

The most common bacterial isolated were E.

coli. This result is consistent with Tosin et al.

(2014), Enayat et al. (2008), and Tadesse et al

(2018)., that E. coli is the dominant organism

causing asymptomatic bacteriuria. Escherichia coli

is a normal flora in the vaginal and rectal area (Tosin

et al., 2014), and because the female urethra is

shorter compared to men therefore the chance of

bacteria ascends into the bladder is higher and may

cause an infection (Curtiss et al., 2017). This

bacteria also has a unique structure (pilus adhesions)

which help the bacteria for attachment to the

uroepithelium lining and prevent them from urinary

lavage, which allows them for multiplication and

tissue invasion resulting in invasive infections in

pregnancy (Tadesse et al., 2018).

In this study, according to age the highest

frequency of asymptomatic bacteriuria in pregnant

women was in the age group 16-25 years old. This

result is in accordance with the research of Tadesse

et al. (2018) with the most bacteriuria was in the age

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group 18-25 years old. This might due to that early

and intensive sexual intercourse which may cause

minor urethral trauma and transfer bacteria from the

perineum into the bladder. In contrast to findings by

Tosin et al. (2014) with the highest prevalence of

asymptomatic bacteriuria in the age group 25-34

years old.

According to educational status, we found a

higher frequency of asymptomatic patients in the

high school group. A similar result was reported by

Laily in Kenangan Primary Health Center

Puskesmas Kenangan, Kabupaten Deli Serdang

(Laily, 2017). Most asymptomatic pregnant women

also had monthly income <1.000.000 rupiah, as

found by Tadesse et al. (2018). Reported pregnant

women with low family income were found 7 times

more likely to be positive for asymptomatic

bacteriuria (Tadesse et al., 2018). This could be due

to the relation of low socioeconomic status with

nutrition and immunity (Emiru et al., 2013).

In this study, we also found that asymptomatic

bacteriuria was more common in pregnant women

who had sexual intercourse in the last 2 weeks. A

similar finding was reported by Zahroh et al where

61.5% of pregnant women with high sexual activity

had bacteriuria. Pregnant women who had sexual

intercourse >3 per week were more likely have UTI

than women who had sexual intercourse <3 per

week, with the theory that sexual intercourse can

potentially cause skin irritation which increases the

occurrence of urethra infection (Zahroh et al., 2014).

Another theory that is sexual intercourse can

encourage bacterial ascending (Curtiss et al., 2017).

According to parity, the highest frequency of

asymptomatic bacteriuria was in pregnant women

with nullipara, this finding is in line with studies by

Zahroh et al. (76,9%) (Zahroh et al., 2014).

Different finding reported by Turpin et al. with

multiparity had the highest percentage of

asymptomatic bacteriuria (Turpin et al., 2007).

In this study, pregnant women in the second

trimester of pregnancy had the highest percentage of

asymptomatic bacteriuria followed by pregnant

women in the third trimester of pregnancy, similar

finding by Tosin et al. was also reported in Lagos,

Nigeria (45,3%) (Tosin et al., 2014). Different

findings reported by Turpin et al. with most of the

infected subjects were in their first and early second

trimesters. This could be because most pregnant

women report at the antenatal clinic for booking

during these periods (Turpin et al., 2007) it also

indicated that the gold standard for screening

asymptomatic bacteriuria is in early pregnancy of

12-16 weeks (Tadesse et al., 2018).

The dominant organism in this study was E.

coli which was sensitive to meropenem (100%),

nitrofurantoin, piperacillin-tazobactam, gentamycin,

chloramphenicol, ceftazidime, and cefotaxime

(75%). A similar finding was reported by Tosin et

al. where E. coli was observed to be sensitive to

nitrofurantoin and gentamycin (Tosin et al., 2014).

5 CONCLUSIONS

The proportion of asymptomatic bacteriuria in

pregnant women in Padang Bulan Primary Health

Center was 28.0%, and the most frequent isolates

were Escherichia coli followed by Staphylococcus

coagulase negative. Most pregnant women with

asymptomatic bacteriuria were in the age group of

16-25 years, with educational status in high school,

low socioeconomic status, had sexual intercourse in

the last 2 weeks, at trimester II, and a nullipara.

The antibiotic sensitivity from this study

showed all gram-negative and gram-positive were

sensitive to meropenem (100%), and nitrofurantoin

was sensitive to gram-negative (100%).

ACKNOWLEDGMENTS

We thank the staff of Padang Bulan Primary Health

center for their assistance and the staff of USU

Microbiology Laboratory for their help in the

specimen processing.

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