1. Urinary Tract Infections in Diabetics
and non-Diabetics in Tripoli-Libya:
associated uropathogens and their
susceptibility to antimicrobials.
Einass El-Kateb, Khalifa Sifaw Ghenghesh,
Nuri Berbash, Amal Rahouma,
Nadia Saifnasser, Taher Belreesh,
Mohamed Abdulwahab Elgabroun
Faculty of Science and Faculty of Medicine,
Tripoli University; Tripoli Diabetic Center;
and Alkhadra Hospital;
Tripoli, Libya

2. Introduction
• Urinary tract infections (UTIs) are a serious health
problem and are second only to respiratory infections
as the most common type of infections in Human
beings.
• Escherichia coli is the most common cause of
uncomplicated UTIs.
• Several investigators have observed that infections
including UTIs are more frequently reported among
patients with diabetes mellitus (DM) than the general
population, although this is not universally accepted.
• It has been suggested by various epidemiologic studies
that bacteriuria and UTIs are more common in women
with diabetes than among non-diabetic women.

3. Introduction
• Studies on UTIs in diabetic patients in developing
countries are few and mainly in asymptomatic patients.
• Worldwide, there is great concern due to high rates of
resistance to antimicrobials used in the treatment of
infections caused by E. coli.
• In developing countries, there is dearth of information
on the antimicrobial susceptibility testing of E. coli
from diabetics with UTIs to the newly available drugs
including the fluoroquinolones and third generation
cephalosporins.

4. Objectives of the Study
• To determine the causative organisms of UTIs
in diabetic patients in Tripoli, Libya, compared
with non-diabetic patients.
• To determine the susceptibility of the isolated
organism to the commonly used antimicrobial
agents.
• To determine the influence of age, gender,
marital status and education level on the
species and frequency of isolation of
organisms from diabetics compared with nondiabetics.

5. Materials and Methods
• Urine specimens from 135 diabetic and 164
non-diabetic patients both with clinically
diagnosed UTIs (D-UTIs and ND-UTIs,
respectively), attending attending Elkhadra
Hospital and the Diabetic Center in Tripoli,
were examined for different uropathogens
using standard microbiological procedures.
• The study was carried out between July 2005
and June 2006.
• The commonly isolated uropathogens were
tested for their susceptibility to different
antimicrobials using the disc diffusion
method.

6. Results
• Uropathogens were isolated from 57% (77/135) of D-UTIs and
from 67.1% of (110/164) ND-UTIs (P>0.05).
• Of isolated uropathogens, Escherichia coli was isolated from
13.3% and 17.7%, Klebsiella sp. from 13.3% and 14%, and
Staphylococcus aureus from 8.9% and 7.3% of D-UTIs and
ND-UTIs respectively.
• These differences are not statistically significant (P>0.05).
• Age, gender, education level and marital status had no
significant influence on the isolation rates of different
organisms from D-UTI when compared with ND-UTI.
• Multiple drug resistance (>3 antibiotics) was common among
the commonly isolated uropathogens, however, no
significant differences in the resistance rates of
uropathogens isolated from D-UTIs and ND-UTIs to different
antimicrobials were observed (P>0.05).

7. Table 1. Uropathogens isolated from diabetic and
non-diabetic patients with urinary tract infections
No (%) positive for:
Diabetics
with UTIs
(n=135)
Non-diabetics
with UTIs
(n=164)
Total
(n=299)
Escherichia coli
18 (13)
29 (18)
47 (16)
Klebsiella spp.
18 (13)
23 (14)
41 (14)
Proteus spp.
2 (1.5)
9 (5.5)
11 (4)
7 (5)
7 (4)
14 (5)
Citrobacter spp.
2 (1.5)
4 (2)
6 (2)
Serratia spp.
0 (0.0)
3 (2)
3 (1)
Pseudomonas spp.
6 (4)
7 (4)
13 (4)
Staphylococcus aureus
12 (9)
12 (7)
24 (8)
S. saprophyticus
1 (1)
2 (1)
3 (1)
Candida albicans
10 (7)
9 (5.5)
19 (6)
Total
77 (57)
110 (67)
187 (62.5)
No organism identified
58 (43)
54 (33)
112 (37.5)
Organism
Enterobacter spp.

8. Table 2. Antimicrobial resistance of Escherichia coli isolated
from diabetic and non-diabetic patients with urinary tract
infections.
No (%) resistant to:
Antimicrobial agent
Total
(n=48)
Diabetic
(n=19)1
Non-Diabetic
(n=29)
Ampicillin
12 (63)
17 (59)
29 (60)
Amoxicillin +
clavulanic acid
8 (42)
9 (31)
17 (35)
Cephalothin
9 (47)
19 (66)
28 (58)
Cefotaxime
1 (5)
1 (3.5)
2 (4)
Chloramphenicol
2 (11)
6 (21)
8 (17)
Gentamicin
2 (11)
3 (10)
5 (10)
Nalidixic acid
6 (32)
8 (28)
14 (29)
Ciprofloxacin
6 (32)
4 (14)
10 (21)
Streptomycin
6 (32)
14 (48)
20 (42)
Trimethoprimsulphamethoxazole
6 (32)
7 (24)
13 (27)
1
Two different isolates from one patient

9. Table 3. Antimicrobial resistance of Klebsiella spp. isolated
from diabetic and non-diabetic patients with urinary tract
infections.
No (%) resistant to:
Antimicrobial agent
Diabetic
(n=18)
Non-Diabetic
(n=23)
Total
(n=41)
18 (100)
23 (100)
41 (100)
Amoxicillin +
clavulanic acid
8 (44)
21 (91)
29 (71)
Cephalothin
10 (56)
17 (74)
27 (66)
Cefotaxime
4 (22)
7 (30)
11 (27)
Chloramphenicol
6 (33)
4 (17)
10 (24)
Gentamicin
6 (33)
9 (39)
15 (37)
Nalidixic acid
8 (44)
10 (44)
18 (44)
Ciprofloxacin
4 (22)
8 (35)
12 (29)
Trimethoprimsulphamethoxazole
3 (17)
2 (9)
5 (12)
Ampicillin

10. Table 4. Antimicrobial resistance of Staphylococcus aureus
isolated from diabetic and non-diabetic patients with urinary
tract infections.
No (%) resistant to:
Antimicrobial agent
Diabetic
(n=12)
Non-Diabetic
(n=12)
Total
(n=24)
Ampicillin
8 (67)
7 (58)
15 (63)
Amoxicillin +
clavulanic acid
1 (8)
4 (33)
5 (21)
Cefotaxime
1 (8)
4 (33)
5 (21)
Chloramphenicol
2 (17)
1 (8)
3 (13)
Gentamicin
0 (0.0)
4 (33)
4 (17)
Ciprofloxacin
0 (0.0)
1 (8)
1 (4)
Trimethoprimsulphamethoxazole
0 (0.0)
0 (0.0)
0 (0.0)
Tetracycline
5 (42)
7 (58)
12 (50)
Methicillin
1 (8)
4 (33)
5 (21)
Fusidic acid
3 (25)
4 (33)
7 (29)
Vancomycin
0 (0.0)
0 (0.0)
0 (0.0)

11. Conclusions
• In the population studied diabetes is not a significant
factor that may influence the type, rates of isolation
or antibiotic resistance of uropathogens that cause
UTIs in diabetics when compared with those from
non-diabetics.
• Our findings and those of other investigators
suggest that diabetes mellitus per se is not
associated with an increase in antimicrobial
resistance.
• However, all classes of isolated uropathogens in the
present work, regardless of their source, showed
high rates of multiple-antimicrobial resistance,
particularly to some of the commonly used drugs for
treatment of UTI with more than 20% of E. coli and
Klebsiella spp. isolates were resistant to
ciprofloxacin.

12. Conclusions
• The high rates of multiple-drug resistance among
uropathogens observed in our study no doubt will
limit the choices of drugs available for clinicians
involved in the treatment and management of UTI
in diabetics in our region.
• Ciprofloxacin and cefotaxime were observed to be
the most appropriate agents in the population
studied. However, treatment should be tailored to
local resistance patterns, and the most likely
causative agent in the individual patient.
• Studies are needed on the molecular level to
determine whether the uropathogens isolated from
both groups are similarly virulent or not.