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Prevalence of Urinary Tract Infections and Associated Risk Factors among Pregnant Women in Enugu Metropolis, Nigeria

The prevalence of Urinary Tract Infections (UTI) among pregnant women was carried out in the Department of Obstetrics and Gynaecology of five (5) different hospitals in Enugu metropolis. Four hundred and eighty (480) pregnant women whose ages ranged from 20 - 40 years were recruited in this study using a well-designed questionnaire by random sampling technique. The subsidiary sample size included twenty (20) obstetricians working in these hospitals. Prevalence of UTI in the present study was affected by several factors namely; age, gestational age, socio-economic status, increased number of pregnancies or parity, untreated previous UTI history, diabetes, hypertension, and lack of personal hygiene. A total of 384 urine samples were collected from these pregnant women that attended the foetus. There is also a need for continuous health education during antenatal visits to boost physical and environmental hygiene.


Introduction
Urinary tract infections (UTIs) are defined as inflammatory responses of the urothelium to bacterial invasion, which are usually associated with bacteriuria (bacteria in the urine) and pyuria (pus cells in the urine). UTIs are more common in women than in men partially due to the shorter and wider female urethra and its proximity to the anus [1]. The urinary tract includes the organs that collect and store urine and releases it from the body namely: the kidneys, ureters, bladder, and urethra. Bacteria associated with bacteriuria include Escherichia coli, Staphylococcus saprophyticus, Proteus mirabilis, Klebsiella pneumoniae, and Pseudomonas aeruginosa [1]. Urinary tract infection is one of the most frequently seen medical complications of pregnancy. Despite significant advances in managing urinary tract infections in pregnancy, its occurrence is still associated with adverse feto-maternal complications. Urinary Tract Infections in pregnancy remain a significant cause of maternal and perinatal morbidities, if untreated, the sequel is even grimmer. Routine screening for asymptomatic bacteriuria is advocated as well as prompt treatment of symptomatic and confirmed cases of suspected Urinary Tract infections [2].
Urinary tract infections (UTIs) are one of the most common medical complications of pregnancy [3]. It is estimated that one in three women of childbearing age will have a UTI [4]. Because of the normal physiologic changes induced by gestation, pregnant women are especially susceptible to these infections. UTIs are characterized by the presence of infectious agents in the genito-urinary tract that cannot be explained by contamination. These agents have the potential to invade the tissues of the urinary tract and adjacent structures. The microbiological profile is well known and pathogens such as Escherichia coli have been present in the vast majority of cases [5]. The infection may be limited to the growth of bacteria in the urine (which frequently don't produce symptoms) or it can result in several syndromes associated with an inflammatory response to the bacterial invasion. The term UTIs represents a wide variety of conditions, including asymptomatic forms of UTIs, urethritis, cystitis, acute pyelonephritis, and pyelonephritis with bacteremia or sepsis [6]. This study was done to determine the prevalence of urinary tract infections and associated risk factors among pregnant women in the Enugu metropolis.

Results
The total copies of the questionnaire distributed were 480 but the study received a total of 330 duly completed copies of the questionnaire which constituted a response rate of 86 percent as shown in Figure 1 below. De Vaus [9] informs that a response rate of 80 percent and above is considered adequate. This implies that the response rate for the study was adequate to enable the researcher to perform the analyses. As shown in Table 2, prevalence of UTI was found to be higher among subjects of age category 36 -40 years (25.18%) positive cases of the total population studied. The incidence was also found to be higher among married women with a percentage of 31.56%. Based on gestational age, UTI prevalence was higher among subjects in their third trimester with a percentage of 32.27%. A high rate of UTI was found to be among women with a high number of pregnancies or high parity having a percentage of 31.56%. The high prevalence rate was found among uneducated women and those with primary school certificates, and among unemployed, housewives, or low socio-economic subjects with percentages of 24.11%, 16.31%, and 21.63% respectively.

Prevalence of Urinary Tract Infections among Pregnant Women
The total prevalence of Urinary Tract Infection (UTI) in pregnant women in the Enugu metropolis showed that out of the total of 384 subjects screened after urine samples were collected, 282 (73%) cases of UTI were diagnosed among pregnant women in the hospitals under study while there were 102 (27%) cases of Non-UTI among pregnant women ( Figure 2).
From Figure 3, the prevalence of UTI in pregnant women to hypertension showed that the highest incidence of UTI was seen in women with high blood pressure representing 90.9% of the participants, the prevalence of UTI to untreated asymptomatic urinary tract infection showed a low incidence of UTI   As shown in Figure 4, the major prevalence risk factors are untreated asymptomatic bacteriuria, pre-existing diabetes, increased parity and low socioeconomic status with mean scores of 4.2, 4.0, 4.3 and 2.8 respectively. The least risk factor was low socioeconomic status while the highest risk factor was increased parity. As shown in Table 4, the result of the percentage occurrence of bacteria isolates shows that Escherichia coli was the most prevalent organisms, 89 isolates (40.6%), followed by Staphylococcus aureus, 62 isolates (28.3%), Klebsiella pneumoniae with 36 isolates (16.4%), Pseudomonas aeruginosa 18 isolates (8.2%), Enterococcus spp. 8 isolates (3.6%), Enterobacter spp. 4 isolates (1.8%), and Proteus spp. as the least prevalent organisms, 2 isolates (0.9%). As shown in Table 5, Staphylococcus aureus was sensitive to Streptomycin, ciprofloxacin, gentamycin, ampicillin, cloxacillin, and rifampicin which made it the highest sensitive organism to these antibiotics, followed by Klebsiella pneumoniae which was sensitive to streptomycin, ciprofloxacin, gentamycin, ampicillin and augmentin. Pseudomonas aeruginosa was sensitive to ciprofloxacin, gentamycin, and augmentin. Enterococcus spp. was sensitive to ciprofloxacin and gentamycin. Enterobacter spp. was sensitive to streptomycin, ciprofloxacin and gentamycin, while E. coli was sensitive to streptomycin, ciprofloxacin, and rifampicin.

Discussion
Urinary Tract Infections (UTI) are the most common types of infections among pregnant women. They account for complications in pregnancy [10]. The present study showed that the UTI prevalence among pregnant women living in    [15]. Urinary Tract Infections were more prevalent among women of the age category of 36 -40 years. The finding differs from the research of Kawser et al. [16] and Nwachukwu et al. [17] which shows that UTI was more prevalent among women of 26 -30 years. The high incidence of UTI among women of ages 36 -40 years may be due to a high rate of previous untreated UTI history, diabetes mellitus, high blood pressure, and lack of personal hygiene. These are known major risk factors of UTI prevalence. Among a studied population Stephen [14], Ranjan et al. [18] and Azami et al. [15] pointed out that previous UTI and diabetes can be increased risk factors for UTIs in pregnancy. Fasalu et al. [19] also stated that bacteriuria was more prevalent in multiparous women and women of advanced maternal age. A higher incidence of UTI was found to be among married women and occurred mostly in the third trimester [18] [20]. The increase in prevalence could be due to an increase in parity or a higher number of pregnancies.
The most frequently isolated bacteria were species of E. coli (40.6%) followed by S. aureus (28.3%) K. pneumoniae (16.4%) and P. aeruginosa (8.2%). Others were Enterococcus sp. Enterobacter sp. and Proteus sp. Previous researches have shown that the most prevalently isolated bacteria were E. coli. S. aureus, and K. pneumoniae [15] [17] [21] [22] Presence of members of the Enterobacteriaceae family such as E. coli, Klebsiella, and Proteus suggests that infection was due to poor personal hygiene since these organisms are of fecal origin. The antibiotic susceptibility test showed that the pathogens were highly sensitive to most of the antibiotics except streptomycin, ciprofloxacin, and gentamycin which recorded high resistance. This contradicts the report of Muhammed, [23] who recorded high sensitivity of pathogens to ciprofloxacin.

Conclusion
Early diagnosis and treatment of UTIs during pregnancy can ensure the safety of the mother and the foetus. There should be increased personal and environmental hygiene and there is a need to expand health services for the treatment of UTI in pregnant women. Infection prevention remains the best option and this can be achieved through health education during antenatal visits. Since UTIs occurred mostly in the third trimester of pregnancy, effective and proper medical care should be administered in the third trimester to checkmate the prevalence.

Limitations
• The level of education of some participants made it difficult and time-consuming in getting data from these participants. • Counseling of participants prior to getting required data was time-consuming.
• Improper cleaning of the area prior to collection of the urine specimen or failing to collect the urine midstream will likely result in contamination of the specimen.