Asymptomatic bacteriuria (ASB) is a condition in which urine culture reveals a significant growth of bacteria which is greater than or equal to 105 colony-forming unit per milliliter (ml) of urine taken from a clean catch midstream urine but without the patient showing symptoms such as genitourinary tract infection [
Early screening and treating promptly of ASB during pregnancy can prevent further complication of bacteriuria in pregnant women [
Asymptomatic bacteriuria is one of the major risk factors for the development of UTIs during pregnancy which accounts for about 70% of the cases [
The burden of this asymptomatic bacteriuria among pregnant women in Ethiopia also varies with the location of study [
There are number of studies conducted in different part of the world about magnitude of asymptomatic bacteriuria, antimicrobials susceptibility and its associated factors for asymptomatic bacteriuria among pregnant women [
An institutional based cross-sectional study was conducted on pregnant women attending antenatal care at Hiwot Fana Specialized University Hospital from March to April 2019. Hiwot Fana Specialized University Hospital is in Harari People’s National Regional State, Harar, Eastern Ethiopia. Currently, the hospital serves to about 5.2 million communities around Harar and neighboring regions such as, Oromia Regional State, Dire Dawa Administrative Council, and Ethiopia Somali Regional State.
The sample size was determined using a single population formula taking a prevalence of ASB (21.2%) from the study conducted in Adigrat General Hospital [
Data were collecetd using structured questionnaires developed from different literature [
First, all pregnant women who came for ANC services were screened whether they have signs and symptoms of UTI such as burning sensation, suprapubic pain, frequent urination, and fever, and then data were collected by the senior nurse from pregnant mothers who have no signs and symptoms of UTI. Other information such as history of hypertension, history of diabetes, and hemoglobin level were obtained from the medical record book of the pregnant women. Questionnairebased data were collected by face to face interview using pretested structured questionnaires.
The study participants were instructed how to collect 10–15 mL of standard midstream urine by the “clean catch” method. They were instructed to wash their hands, cleanse the genitals with clean water, dry the area with a sterile gauze pad, and collect the middle urine into a wide-mouthed screw-capped universal urine container with labia held apart. Then, study participants identification number, date, and time of collection were labelled on the outside of the container. The collected sample was kept in a cold box and sent to Haramaya University College of Health and Medical Sciences Department of Medical Laboratory Sciences within 30 minutes of collection time.
The aseptically collected and well-mixed urine sample was inoculated onto CLED media, blood agar, and MacConkey agar (Oxoid, Ltd., UK) by streaking method using a standard calibrated wire loop having capacity of containing 0.001 ml of urine. The inoculated plates were incubated aerobically at 37°C for 18–24 hours [
Then, the confirmed colony was counted from CLED media and multiplied by 1000 to determine the number of bacteria per ml (CFU) of the original urine specimen. A specimen was considered positive for ASB if a single organism was growing at a concentration of ≥105 colony-forming units/ml. A single isolated bacterium was inoculated onto nutrient agar slant and stored in a refrigerator after 24 hours of incubation for the maintenance of isolated bacteria.
Antimicrobial susceptibility testing was performed using the disc diffusion method as described by the Clinical Laboratory Standards Institute [
The inoculated plates were left at room temperature to dry for 3 to 5 minutes. The antimicrobial discs (Oxoid, Ltd., UK) representative of the penicillin group (Amoxicillin 10
Data were double entered into EpiData version 3.1, cleaned, and exported to Statistical Package for Social Science (SPSS) version 22. Descriptive statistics were performed for different variables. The results were presented in texts, tables, and graphs using summary measures such as percentages, standard deviation, and mean. The magnitude of asymptomatic bacteriuria was determined as proportion of positive urine culture to the total pregnant women participated in this study. Logistic regression was carried out to identify the associated factors with asymptomatic bacteriuria. Variables with
A structured questionnaire initially prepared in English language was translated into Afan Oromo and Amharic by a language expert and translated back to English by another language expert. The questionnaire was pretested on 5% of the total sample size at the Jugal Hospital, Eastern Ethiopia, to ensure its validity. Completeness of each questionnaire was checked daily during data collection period.
The sterility of each medium was checked by incubating (3–5% of the batch) at 35–37°C overnight and looked for bacterial growth. The media which showed growth were discarded and replaced by a new sterile batch. The reference of American Type Culture Collection strains including
The study protocol was reviewed and ethical clearance was obtained before starting the data collection process from the Institutional Health Research Ethics Review Committee (IHRERC) of the College of Health and Medical Sciences. Official letters of cooperation was submitted to Hiwot Fana Specialized University Hospital. The study participants were informed of their right to refuse or decline participation in the study at any time and that refusing to participate in the study will not affect them. Informed voluntary, written, and signed consent was obtained from all respondents before the study. The confidentiality of participants’ information was assured by excluding names and identifiers in the questionnaire.
In this study, a total of 281 asymptomatic pregnant women were included with a response rate of 99.3%. The age of the study participants ranges from 18 to 41 years with mean age ±standard deviations (SD) of 26.3 ± 5.7 years. Among the study participants, 91.8%, 44.8%, and 39.9% were married, urban dwellers, and with primary level education (1 to 8 grades), respectively. In addition to this, 64.4%, 34.2%, and 43.8% were house wife, primigravida, and at second trimester, respectively. Regarding participants’ average monthly income, about 32% of the study participants had average monthly income less than 1000 Ethiopian birr (Table
Sociodemographic characteristics of pregnant women attending at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia, 2019 (
Characteristics | Frequency number (%) |
---|---|
18–26 | 157 (55.9) |
27–34 | 107 (38.1) |
35–44 | 17 (6.0) |
Married | 258 (91.8) |
Divorced | 20 (7.1) |
Single | 1 (0.4) |
Widowed | 2 (0.7) |
Urban | 126 (44.8) |
Rural | 155 (55.2) |
<1000 | 90 (32) |
1000–1999 | 50 (17.8) |
2000–2999 | 72 (25.6) |
>2999 | 69 (24.6) |
Orthodox | 56 (19.9) |
Protestant | 32 (11.4) |
Muslim | 190 (67.6) |
Others | 3 (1.1) |
Do not read and write | 78 (27.8) |
Primary (1–8 grade) school | 112 (39.9) |
Secondary (9–12 grade) school | 45 (16.0) |
College and above | 46 (16.4) |
Student | 8 (2.8) |
House wife | 181 (64.4) |
Merchant | 41 (14.6) |
Civil servant | 49 (17.4) |
Others | 2 (0.7) |
Among the study participants; 53.7%, 81.1%, and 58.4% had second antenatal care (ANC) visit, performed sexual activities less than two times per week, and the habit of postcoital washing, respectively. In addition to this, 76.9%, 60.1%, 37.5%, and 25.6% of the study participants had no habit of postcoital urination, wiped their genitals after washing from front to back direction, and history of UTI and antibiotic use before two weeks, respectively. Among the study participants; 8.5%, 5.7%, 17.8%, and 68.7% had history of hypertension, diabetes, catheterization, and anemia, respectively (Table
Pregnancy, Clinical condition, and behavior-related factors of pregnant women attending at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia, 2019 (
Characteristics | Frequency (%) |
---|---|
Nulligravida | 69 (24.6) |
Primigravida | 96 (34.2) |
Multigravida | 58 (20.6) |
Grand multigravida | 58 (20.6) |
First trimester | 43 (15.3) |
Second trimester | 123 (43.8) |
Third trimester | 115 (41.0) |
First visit | 65 (23.1) |
Second visit | 151 (53.7) |
Third visit | 35 (12.5) |
Fourth visit | 30 (10.7) |
Yes | 105 (37.5) |
No | 176 (62.7) |
Yes | 72 (25.6) |
No | 209 (74.4) |
Yes | 24 (8.5) |
No | 257 (91.5) |
Yes | 16 (5.7) |
No | 265 (94.3) |
Anemic | 193 (68.7) |
Nonanemic | 88 (31.3) |
Yes | 50 (17.8) |
No | 231 (82.2) |
Yes | 65 (23.1) |
No | 216 (76.9) |
Yes | 165 (58.4) |
No | 116 (41.3) |
Backward | 169 (60.1) |
Forward | 112 (39.9) |
<2 times | 228 (81.1) |
>2 times | 53 (18.9) |
In this study, the overall prevalence of significant bacteriuria was 19.9% (95% CI: 16.4% to 24.6%). Six different bacterial isolates were identified. Gram-negative bacteria were the predominant isolates (60.7%), of which
In bivariate analysis, variables such as history of UTI, catheterization, the age group of 18–26 years old, the average monthly income of the participants <1000 birr, habit of postcoital urination, direction of wiping after genital wash, and educational status were significant at
In multivariable analysis, catheterization, direction of wiping after genital wash, postcoital urination remained statistically significant at
Pregnancy-related and personal factors associated with ASB among pregnant women participated in the study at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia, 2019 (
Characteristics | Significant bacteriuria no. (%) | Nonsignificant bacteriuria no. (%) | Crude odds ratio (95% CI) | Adjusted odds ratio (95% CI) | |
---|---|---|---|---|---|
Nulligravida | 14 (25.0) | 55 (24.2) | 1 | ||
Primigravida | 18 (32.1) | 78 (34.8) | 1.025 (0.432, 2.434) | 0.805 | |
Multigravida | 12 (21.4) | 46 (20.4) | 1.130 (0.500, 2.557) | 0.956 | |
Grand multigravida | 12 (21.4) | 46 (20.4) | 1.000 (0.407, 2.456) | 0.956 | |
First trimester | 10 (17.9) | 36 (15.9) | 1 | ||
Second trimester | 23 (41.1) | 102 (44.9) | 1.186 (0.510, 2.754) | 0.520 | |
Third trimester | 23 (41.1) | 89 (39.2) | 1.99 (0.661, 1.506) | 0.692 | |
Anemic | 40 (71.4) | 153 (68.0) | 1.185 (0.623, 2.255) | 0.621 | |
Nonanemic | 16 (28.6) | 72 (32.0) | 1 | ||
0–2 | 43 (76.8) | 185 (82.2) | 1 | ||
≥2 | 13 (23.2) | 40 (17.8) | 0.715 (0.352, 1.452) | 0.354 | |
Yes | 7(12.5) | 17 (7.5) | 0.929 (0.296, 2.915) | 0.899 | |
No | 49 (87.5) | 208 (92.4) | 1 | ||
Yes | 6 (10.7) | 10 (6.3) | 1.187 (0.387, 3.640) | 0.764 | |
No | 50 (89.3) | 215 (93.7) | 1 | ||
1st visit | 16 (28.6) | 49 (21.8) | 1 | ||
4th visit | 6 (10.7) | 24 (10.7) | 0.766 (0.266, 2.205) | 0.744 | |
No | 90 (51.8) | 29 (39.6) | 0.642 (0.357, 1.157) | 0.24 | 1.277 (0.666, 2.447) |
Yes | 27 (48.2) | 137 (60.4) | 1 | 1 | |
Yes | 15 (26.8) | 57 (25.1) | 0.927 (0.478, 1.800) | 0.824 | |
No | 41 (73.2) | 168 (74.9) | 1 | ||
Yes | 19 (38) | 31 (62) | 3.214 (1.643, 6.284) | 0.001 | 3.122 (1.378, 7.072) |
No | 37 (16.1) | 194 (83.9) | 1 | 1 | |
Yes | 29 (51.8) | 76 (33.8) | 1 | ||
No | 27 (37.5) | 149 (66.2) | 0.478 [0.26, 0.864] | 0.181 | 1.424 (0.719, 2.820) |
Yes | 6 (10.7) | 59 (26.0) | 1 | ||
No | 50 (89.3) | 168 (74.0) | 2.962 (1.207, 7.266) | 0.018 | 3.160 (1.173, 6.514) |
Forward | 34 (60.7) | 79 (34.8) | 2.913 (1.595, 5.320) | 0.001 | 2.853 (1.255, 4.320) |
Backward | 22(39.3) | 148 (65.2) | 1 |
CI, confidence interval;
Most of the Gram-positive isolates were highly sensitive to Ceftriaxone (90.9%).
Gram-negative bacteria isolates showed higher sensitivity to Ceftriaxone (88.2%), Gentamycin (67.5%), and Augmentin (64.7%), while showed resistance to Ampicillin (70.5%) and clindamycin (50.0%). From Gram-negative bacteria isolates, Pseudomonas spp
Antimicrobial susceptibility pattern of Gram-negative bacteria isolated from urine culture of pregnant women with asymptomatic bacteriuria at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia, 2019.
Isolates | Number | Pattern | AMP | AUG | A | CN | COT | CD | T | CRO | E |
---|---|---|---|---|---|---|---|---|---|---|---|
25 | |||||||||||
S | — | 15 (60.0) | 13 (52.0) | 17 (68.0) | 14 (56.0) | 9 (36.0) | 10 (40.0) | 23 (92.0) | 13 (52.0) | ||
I | 5 (20.0) | 4 (16.0) | 3 (12.0) | 4 (16.0) | 3 (12.0) | 4 (16.0) | 5 (20.0) | 1 (4.0) | 4 (16.0) | ||
R | 20 (80.0) | 6 (24.0) | 9 (36.0) | 4 (16.0) | 8 (32.0) | 12 (48.0) | 10 (40.0) | 1 (4.0) | 7 (28.0) | ||
5 | |||||||||||
S | 1 (20) | 4 (80) | 2 (40) | 3 (60) | 3 (60) | 2 (40) | 2 (40) | 3 (60) | — | ||
I | 3 (60) | — | — | 2 (40) | 2 (40) | — | 1 (20) | 2 (40) | 1 (20) | ||
R | 1 (20) | 1 (20) | 3 (60) | — | — | 3 (60) | 2 (40) | — | 4 (80) | ||
2 | S | 1 (50) | 1 (50) | 1 (50) | 2 (100) | — | 1 (50) | 1 (50) | 2 (100) | — | |
I | — | — | — | — | 2 (100) | 1 (50) | — | — | 1 (50) | ||
R | 1 (50) | 1 (50) | 1 (50) | — | — | — | 1 (50) | — | 1 (50) | ||
2 | |||||||||||
S | — | 2 (100) | 2 (100) | 1 (50) | — | — | — | 2 (100) | 1 (50) | ||
I | — | — | — | — | — | — | — | — | — | ||
R | 2 (100) | 1 (50) | 2 (100) | 2 (100) | 2 (100) | — | 1 (50) | ||||
Total | 34 | ||||||||||
S | 2 (5.8) | 22 (64.7) | 18 (52.9) | 23 (67.5) | 17 (50.0) | 12 (35.3) | 13 (38.2) | 30 (88.2) | 15 (44.0) | ||
I | 8 (23.5) | 4 (11.8) | 3 (8.8) | 6 (17.8) | 7 (20.5) | 5 (14.7) | 6 (17.8) | 3 (8.8) | 6 (17.8) | ||
R | 24 (70.5) | 8 (23.5) | 13 (38.2) | 5 (14.7) | 10 (29.4) | 17 (50.0) | 15 (44.0) | 1 (3.0) | 13 (38.2) |
AMP, Ampicillin; CRO, Ceftriaxone; A, Amoxicillin; CN, Gentamicin; COT, Cotrimoxazole; AUG, Augmentin; ERY, Erythromycin; CD, Clindamycin; T, Tetracycline;
In this study, the overall prevalence of ASB was 19.9%. Six different bacterial isolates were identified, of which
This finding was consistent with previous studies from Adigrat, Ethiopia (21.2%) [
Most of the isolated bacteria in this study were Gram negative (60.7%) which agrees with the study report from Adama, Ethiopia (72.6%) [
In this study, participants who wipe genitals after wash from back to front direction were more likely to develop ASB. This finding agrees with the finding reported from Cairo, Egypt [
In the current study, participants who have experienced catheterization were three-fold more likely to develop ASB. This finding is similar to a study reported in Baghdad [
In the current finding, study participants who have no habit of postcoital urination were two-fold more likely to develop ASB than their counterpart. Another study conducted in Cairo, Egypt, reported that the pregnant women who do not urinate after coitus were eight-fold more likely to develop ASB than those who have the habit of postcoital urination [
In this study, Gram-positive isolates (
Prescription of antibiotics without laboratory guidance as well as over-the-counter sales of antibiotics without prescription are a probable factor for increased bacterial resistance to antimicrobial agents [
The overall prevalence of ASB among pregnant women in the present study was higher than previous studies conducted in Ethiopia. The current study revealed that postcoital urination, catheterization, and direction of wiping after genital wash were the factors that aggravated the occurrence of ASB in pregnant women. The most frequently identified isolate was
The dataset used/or analyzed during the current study are available from the author on reasonable request.
The authors declare that they have no conflicts of interest.
ME made a substantial contribution from conception to the acquisition of data. All the authors made a great contribution to the study design, analysis, interpretation of findings, and write-up of the final work. ME and ZT were involved in the microbiological analysis. FW and DA have supervised the research work and drafted the manuscript. All authors revised the paper carefully for important intellectual contents. All authors read and approved the final manuscript.
The authors are very grateful to Department of Medical Laboratory Sciences, Haramaya University, for the support of reagents and materials, staff members of the microbiology unit for their invaluable guidance, and study participants for their voluntary participation in the study.