Asymptomatic Bacteriuria and Leukocyturia in Type 1 Diabetic Children and Young Adults

doi:10.2337/diacare.26.7.2209-a

HOME

HELP

FEEDBACK

SUBSCRIPTIONS

Letters: Observations
Letter

Asymptomatic Bacteriuria and Leukocyturia in Type 1 Diabetic Children and Young Adults

Barnabás Rózsai, MD, Éva Lányi, MD and Gyula Soltész, MD, PHD, DSC

From the Department of Paediatrics, Faculty of Medicine, University of Pécs, Pécs, Hungary

Address correspondence to Barnabás Rózsai, MD, József Attila u. 7, Pécs, Hungary, H-7623. E-mail: barnabas.rozsai{at}aok.pte.hu.

In the study of Geerlings et al. (1), one of five type 1 diabeticwomen had asymptomatic bacteriuria (ASB). In the few studiesof diabetic children a low prevalence of $~$ 1% was found (2–4).Our clinical experience suggested a much higher prevalence;therefore, we decided to estimate the prevalence and possiblerisk factors of ASB in type 1 diabetic children.

There were 178 (86 male) type 1 diabetic children and youngadults (age 15.1 ± 5.9 years) with diabetes durationof 6.2 (3.0–10.1) [median (interquartile range)] yearswho participated in this study.

The control group consisted of 194 (103 male) school children/medicalstudents (14.4 ± 5.1 years). After careful cleaning,midstream voiding morning urine samples were collected and immediatelycultured on 2 consecutive days.

ASB was defined as the presence of ≥10⁵ colony-forming units/mlof one and the same bacterial species in both samples withoutsymptoms of urinary tract infection (UTI). In 140 diabetic patientsand 191 control subjects, we had the possibility to evaluatethe presence of leukocyturia by dip-slide method and/or microscopically(>5 cells/high-power field).

Student’s t test, Mann-Whitney test, ${chi}$ ² test, and Fisher’sexact test were used to assess statistically significant differences.

The prevalence of ASB was 10.1% (95% CI 5.7–14.5%), whichwas significantly higher than in the control group (2.6%, 0.35–4.8%)(P = 0.003) and tended to increase with age (P = 0.064). Wedid not find any difference in prevalence of ASB between diabeticmale (9.3%) and female (10.9%) subjects (P = 0.73). The age,duration of diabetes, BMI, morning and mean daily blood glucoselevels, urinary glucose excretion, HbA_1c, and albumin excretionrate (in the normal range) were similar in diabetic patientswith and without ASB.

Leukocyturia tended to be more frequent in diabetic patientswithout ASB than in control subjects (14.4 vs. 7.6%; P = 0.052).Almost half (46.7%) of the diabetic children with ASB, but only14.4% of those without ASB, had leukocyturia (P = 0.002).

In the 18 diabetic patients with ASB S. agalactiae (n = 6),Enterococcus sp. (n = 5), E. coli (n = 4), and K. pneumoniae(n = 3) were cultured. The proportion of leukocyturia in patientswith Gram-positive and Gram-negative bacteria was 2/11 to 6/7(P = 0.041), respectively. In control subjects, E. coli (n =2), S. agalactiae, K. pneumoniae, and P. vulgaris (n = 1:1)were cultured.

In contrast to pediatric studies performed several decades ago(2–4), but in agreement with more recent adult observations(1) and textbook data (5), ASB in diabetic children occuredwith a higher frequency. Samples were collected by diabetesnurse specialists, and care was taken to avoid contamination.The increased prevalence of ASB is not readily explainable,particularly because our study could not demonstrate a relationshipwith ASB and hyperglycemia. Other possible reasons for the higherprevalence may include increased residual urine volume or impairmentof several aspects of host defense mechanisms (e.g., cytokinesecretion in the urinary tract), factors that are currentlybeing investigated in our patients.

In UTI, the most common bacterium is E. coli, which was isolatedin $~$ 80–90% of positive cultures (6). In our diabetic patientswith ASB, E. coli was found in only about a quarter of cases.Similarly low rates were found in adult type 1 diabetic womenwith ASB (1). It therefore seems that the spectrum of pathogenicbacteria causing ASB and UTI is different. The reason for thismay be that the virulence factors are different in ASB and UTI.

In conclusion, we have found that the prevalence of ASB andleukocyturia was higher in diabetic children and young adultsthan in control subjects and that the spectrum of bacteria inASB was different from the usual spectrum of UTI. As the treatmentof ASB in adult type 1 diabetic women did not appear to preventUTI (7) and may promote the invasion of more virulent pathogens(8), a careful follow-up of these pediatric patients is warrantedbefore antibiotic therapy can be considered. This conclusionis underlined by a recent observation (9) that showed that womenwith type 1 diabetes and ASB had a tendency toward a declinein renal function.

References

Geerlings SE, Stolk RP, Camps MJL, Netten PM, Hoekstra JBL, Bouter KP, Bravenboer B, Collet JT, Jansz AR, Hoepelman AIM, for the Diabetes Mellitus Women Asymptomatic Bacteriuria Utrecht Study Group: Asymptomatic bacteriuria may be considered a complication in women with diabetes. Diabetes Care 23:744–749, 2000[Abstract/Free Full Text]
Pometta D, Rees SB, Younger D, Kass EH: Asymptomatic bacteriuria in diabetes mellitus. N Engl J Med 276:1118–1121, 1967
Etzwiler DD: Incidence of urinary tract infections among juvenile diabetics. JAMA 191:93–95, 1965
Lindberg U, Bergström AL, Carlsson E, Dahlquist G, Hermansson G, Larsson Y, Nilsson KO, Samuelsson G, Sjöbland S, Thalme B: Urinary tract infection in children with type 1 diabetes. Acta Paediatr Scan 74:85–88, 1985
Joshi N, Mahajan M: Infection and diabetes. In Textbook of Diabetes. 3rd ed. Pickup JC, Williams G, Eds. Oxford, U.K. Blackwell Science, 2003, p. 40.1–40.16
Nicole LE: Epidemiology of urinary tract infection. Infect Med 18:153–162, 2001
Harding GKM, Zhanel GG, Nicolle LE: Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med 347:1576–1583, 2002[Abstract/Free Full Text]
Stein G, Fünfstück R: Asymptomatic bacteriuria: what to do. Nephrol Dial Transplant 14:1618–1621, 1999[Free Full Text]
Geerling SE, Stolk RP, Camps MJL, Netten PM, Collet JT, Schneeberger PM, Hoepelman AIM: Consequenses of asymptomatic bacteriuria in women with diabetes mellitus. Arch Intern Med 161:1421–1427, 2001[Abstract/Free Full Text]