Pregnant women in Uganda who have urinary tract infection symptoms drastically overconsume antibiotics because they are given the drugs without laboratory culture confirmation, according to researchers.
For clinicians, the inappropriate use of antibiotics based on urinary tract infection (UTI) symptoms alone contributes to drug resistance and represents another harbinger of the movement toward a post-antibiotic era in the region, which is closer to that point compared with the developed world.
“Clinical diagnosis and empiric antibiotic therapy of UTI among pregnant women lead to massive antibiotic misuse, inadvertently rendering the first line of drugs ineffective,” study researcher Musa Sekikubo, MD, of the department of obstetrics and gynecology at the Makerere University College of Health Sciences in Kampala, Uganda, and colleagues wrote in Clinical Infectious Diseases. “Diagnostic tests, easy to carry out and evaluate by inexperienced staff, are therefore necessary.”
The researchers assessed 2,562 women from four groups. Three groups were treated in Uganda and included 1,026 pregnant women with UTI symptoms, 595 pregnant women without UTI symptoms and 472 nonpregnant outpatients with UTI symptoms. The fourth group consisted of 469 nonpregnant outpatients with UTI symptoms in Sweden.
For all patients, the researchers conducted nitrite and leukocyte esterase tests for UTI. Patients were additionally tested using either traditional urine culture, dip slide or both as a reference.
Of the pregnant women in Uganda with UTI symptoms, 578 were tested using urine culture and urine microscopy as a reference. Only 23 of them (4%) had significant bacterial growth, the researchers said, meaning that 96% received antibiotics erroneously.
Among 39 total pregnant women with confirmed UTI in Uganda treated with commonly used antibiotics, 66% of Escherichia coli were resistant to ampicillin. In addition, 36% of E. coli strains were multidrug resistant.
Although nitrite and leukocyte esterase tests did not show high sensitivity in several groups, dip slide was effective, the researchers said.
In Sweden, dip slide results were evaluated by a clinical microbiologist and by a gynecologist with 1 week of training, independent of each other. They successfully identified E. coli in 98% and 87% of cases, respectively.
The clinical setting in Uganda was far different, the researchers stressed.
“In Uganda, most antenatal clinics are located in rural areas and run by nurses or nurse assistants with no or only occasional consultation by medical doctors,” they wrote. “To decrease antibiotic consumption, the nurses have to be able to evaluate the diagnostic tests by themselves.”
Ugandan staff also lack diagnostic equipment, which leads them to issue antibiotics based on symptoms alone.
The researchers sought to test whether staff in Uganda could effectively use dip slide. There, two nurses spent a day familiarizing themselves with the test and were given an additional week of support. They evaluated dip slide results independent of each other.
The nurses successfully identified 41 of 52 E. coli (79%) samples during the evaluation, as well as negative urine samples with no bacterial growth. However, they would have also incorrectly given antibiotics to 20 of 22 (91%) patients with mixed gram-negative flora indicating fecal contamination, the researchers said.
Despite the mixed results, the researchers concluded that dip slide testing can help identify urine samples with no bacterial growth, even when used by inexperienced staff.
“Compared to clinical diagnosis alone, the use of dip slide would imply substantially decreased antibiotic consumption and, as a consequence, decreased risk for development of resistance among bacterial pathogens,” they wrote. – by Joe Green
Disclosure: The authors report no relevant financial disclosures.