The Open Nursing Journal




ISSN: 1874-4346 ― Volume 13, 2019
RESEARCH ARTICLE

Urinary Tract Infection Among Women Aged (18-40) Years Old in Kirkuk City, Iraq



Salwa H Almukhtar*
Department of Clinical Nursing Sciences, College of Nursing, University of Mosul, Mosul, Iraq

Abstract

Aim of the Study:

The aim of this study is to identify the prevalence of urinary tract infection among women in reproductive age who attended a Primary HealthCare Centers at Kirkuk City from February 2017 to September 2017.

Materials and Methods:

This is a cross-sectional descriptive study which was carried out in the outpatient clinics for Obstetrics and Gynecology and Urology at Kirkuk General Hospital over the period of 6 months from 1st of February-1st of September,2017. The sample of the study included 450 women who were randomly selected from the following three groups: pregnant women n=150, married women n=150, and unmarried women n=150. Each woman was interviewed using a Questionnaire containing personal information such as age, occupation, Gravidity, months of pregnancy and educational level. Data were calculated and presented as numbers and percentages

Results:

The study found that 58.4% of participants belonged to 21-30-year age group followed by 26% who belonged to 31-40-year age group. 48.4% of the study participants were illiterate, 27.3% had Secondary school graduates and 24.3% had Diploma or Bachelor degree. The majority of the women 70.2% were housewives. The total prevalence rate of UTI was 27.3%. The higher percentage of UTIs 43% was found among pregnant women. The majority of women with UTIs were housewives 65.9% from rural areas 72.4%, and illiterate 62.6%.

Conclusion:

The study concluded that the prevalence of UTIs in pregnant women was higher than that of non-pregnant and unmarried women and that Staphylococcus. Saprophyticus is the most common causative agent of disease.

Keywords: UTI, Gastrointestinal bacteria, Pregnant women, Married women, Cystitis, Asymptomatic bacteria.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 12
First Page: 248
Last Page: 254
Publisher Id: TONURSJ-12-248
DOI: 10.2174/1874434601812010248

Article History:

Received Date: 19/9/2018
Revision Received Date: 22/11/2018
Acceptance Date: 30/11/2018
Electronic publication date: 31/12/2018
Collection year: 2018

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© 2018 Salwa Almukhtar.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Correspondence: Address correspondence to this author at the Department of Clinical Nursing Sciences, College of Nursing, University of Mosul, Mosul, Iraq; Tel: +964-770-337-6490; E-mail: almukhtar_salwahazim@yahoo.com




1. INTRODUCTION

A urinary tract infection (UTI) is characterized by the presence of more than 100,000 microscopic cells in 1 mL of urine and accompanied by clinical symptoms of cystitis, pyelonephritis and asymptomatic bacteria. [1Al-Badr A, Al-Shaikh G. Recurrent urinary tract infections management in women: A review. Sultan Qaboos Univ Med J 2013; 13(3): 359-67.[http://dx.doi.org/10.12816/0003256] [PMID: 23984019] ] UTIs occur at different ages and among both sexes, but its incidence in females is higher than that of males, considering the female urethra, its proximity to the anus, and hormonal activity. [2Anuli S, Clement I, Basseye A. Review on the prevalence and predisposing factors responsible for urinary tract infection among adults. Eur J Exp Biol 2016; 6(4): 7-11.] UTIs are one of the most common problems among women especially during pregnancy. It is estimated that about 10-20% of women suffer from UTIs. [3Lee AC, Quaiyum MA, Mullany LC, et al. Screening and treatment of maternal genitourinary tract infections in early pregnancy to prevent preterm birth in rural Sylhet, Bangladesh: A cluster randomized trial. BMC Pregnancy Childbirth 2015; 15(15): 326.[http://dx.doi.org/10.1186/s12884-015-0724-8] [PMID: 26643558] ] Most cases of UTIs are caused by bacteria, especially gastrointestinal bacteria, which infects the urethra through contaminating the area that surrounds the rectum and spreading to the bladder. [2Anuli S, Clement I, Basseye A. Review on the prevalence and predisposing factors responsible for urinary tract infection among adults. Eur J Exp Biol 2016; 6(4): 7-11.] UTIs are more common during pregnancy due to changes in the urinary tract. Since the uterus sits directly on the top of the bladder, the increased weight of the uterus, as it grows, can block the drainage of urine from the bladder which results in an infection. [4Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs Am J Med 2002. Suppl (1A):5S.113.[http://dx.doi.org/10.1016/S0002-9343(02)01054-9] ] However, other factors include upper extremities and increased urinary urethral recurrence as well as reduced bladder size due to uterine contraception which increases the filtration rate thus stressing on the kidneys. [5Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ, Scott J. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol 2015; 13(5): 269-84.[http://dx.doi.org/10.1038/nrmicro3432] [PMID: 25853778] ] In addition to the factor of pregnancy, there are other factors pertaining to the host that increases the rate of infection of the urinary tract including sexual factors, urine factors, osmolality of urine, introital factors, vaginal pH, and secretor state. [4Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs Am J Med 2002. Suppl (1A):5S.113.[http://dx.doi.org/10.1016/S0002-9343(02)01054-9] ] Some of the main and common causes of UTIs are “Escherichia coli, Staphylococcus spp.,Streptococcus spp.,Proteus spp., Klebsiella spp. Corynebacterium, Neisseria and Pseudomonas spp “. The severity of a UTI depends both on the virulence of the bacteria and on the susceptibility of the host. [6Hannan TJ, Totsika M, Mansfield KJ, Moore KH, Schembri MA, Hultgren SJ. Host-pathogen checkpoints and population bottlenecks in persistent and intracellular uropathogenic Escherichia coli bladder infection. FEMS Microbiol Rev 2012; 36(3): 616-48.[http://dx.doi.org/10.1111/j.1574-6976.2012.00339.x] [PMID: 22404313] ] The significance of this study is that UTIs can be particularly dangerous in pregnant women among whom it has been shown that up to 50% of those with Asymptomatic Bacteriuria (ABU) go on to develop pyelonephritis. In addition, pregnant women experience higher rates of intrauterine growth restriction and low birth-weight infants. The presence of a UTI has also been shown to increase the risk of preterm labor, preterm birth, pregnancy-induced hypertension, preeclampsia, ammonites and anemia. [4Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs Am J Med 2002. Suppl (1A):5S.113.[http://dx.doi.org/10.1016/S0002-9343(02)01054-9] ] The objective of the present study is to assess the prevalence of UTI among pregnant women, married and unmarried women.

2. METHODS

2.1. Study Design

This is a cross-sectional descriptive study carried out in the outpatient clinic for Obstetrics and Gynecology and Urology at Kirkuk General Hospital over the period of 6 months (1st of February-1st of September),2017.

2.2. Study Population

The sample of the study included 450 women who were randomly selected from the following three groups: pregnant women 150, married women 150, and unmarried women 150. The sample size for the study was calculated based on a previous study done by Sinan et al, which showed a prevalence of 29% UTI in women. [7Sinan B, Issa A, Anwar E. Study of urinary tract infection among pregnant women in Kirkuk. Med J Tikrit 2007; 2(132): 39-43.] Using the formula 4PQ/D2, the sample size was calculated to be 425 with an absolute precision of 4%. Adding 10% refusal rate, the sample size was calculated to be 448 which was rounded off to 450.

2.3. Inclusion Criteria

The inclusion criteria for the study were females of the reproductive age group 18-44 years who live in urban and rural areas they were apparently healthy and willing to take part in the study.

2.4. Exclusion Criteria

The exclusion criteria for the study were females on any antibiotic therapy, females on menstruation phase of the menstrual cycle, and females with known urinary tract anomalies.

2.5. Study Tool

A standardized, structured questionnaire was utilized to be conducted in the study. The questionnaire consisted of the socio-demographic particulars such as age, occupation, months of pregnancy, and clinical history for the symptoms of UTI. Data are prepared, organized and entered into a computer; Statistical Package for The Social Science (SPSS, version 20) was used for data analysis. Prevalence of UTI was calculated using percentages. Quantitative data were presented by mean and SD, whereas qualitative data was presented as number and percentages. Chi-Square test was used to compare qualitative variables between groups such as age group, educational level, residency, etc.P value > 0.05 is considered insignificant, P<0.05 is significant (*) & P<0.01 is highly significant (**).

3. RESULTS

3.1. The Socio-Demographic Characteristics

The study sample is presented in Table 1. 58.4% belonged to 21-30-year age group followed by 26% who belonged to 31-40-year age group. 48.4% of the study subjects were illiterate, 27.3% had secondary school graduates and 24.3% had a diploma or bachelor degree in school education. Almost 66.7% of females were married and 33.4% were unmarried. 33.3% of them were pregnant and more than half of them were in the 3rd trimester. In relation to their occupation, the majority of the women 70.2% were housewives.

Table 1
Distribution of cases according to some risk factors


3.2. The Prevalence of UTIs

The total prevalence rate of UTI was 27.3%. The higher percentage of UTIs was found among pregnant women 43%, in their 3rd trimester 39.6%, aged between 21-30 years, 41.5%. The majority of women with UTIs were housewives 65.9%, from rural areas 72.4%, and illiterate 62.6%

3.3. Causative Agent

In this study, 20.6% of the females with UTIs suffered from Staphylococcu. Saprophyticus, followed by 17.3% from >Klebsiella Pneumoniae, 14.4% from Proteus mirabilis, and 11.7% from Escherichia coli, Staph aureus, Staph epidermidis. The results can be found in Table 2.

Table 2
Distribution of bacterial isolates among culture positive samples.


4. DISCUSSION

UTI is a health problem that affects women, especially during the pregnancy period, and it is one of the leading causes of miscarriages, premature births, and the underdevelopment of infants. The early treatment of infection reduces the probability of complications which may be very dangerous to mother and the fetus. [6Hannan TJ, Totsika M, Mansfield KJ, Moore KH, Schembri MA, Hultgren SJ. Host-pathogen checkpoints and population bottlenecks in persistent and intracellular uropathogenic Escherichia coli bladder infection. FEMS Microbiol Rev 2012; 36(3): 616-48.[http://dx.doi.org/10.1111/j.1574-6976.2012.00339.x] [PMID: 22404313] ] In this study, the prevalence of UTIs was 27.3% and was higher in pregnant women 43% as well as in married women 33.4%, and was at the lowest among unmarried women 23.6%. These results were similar to the study of Imade et al [8Imade PE, Izekor PE, Eghafona NO, Enabulele OI, Ophori E. Asymptomatic bacteriuria among pregnant women. N Am J Med Sci 2010; 2(6): 263-6.[PMID: 22574301] ] and more than other studies Neupane et al [9Neupane H, Adhikari S, Aryal B. Asymptomatic bacteriuria among pregnant women attending the outpatient clinics of Chitwan medical college teaching hospital in Chitwan, Nepal. IRJP 2012; 3(11): 78-80.], Rohini et al [10Rohini U, Reddy G, Kandati J, Ponugoti M. Prevalence and associate risk factors of asymptomatic bacteriuria in pregnancy with bacterial pathogens and their antimicrobial susceptibility in a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2017; (6): 558-62.[http://dx.doi.org/10.18203/2320-1770.ijrcog20170381] ], Sujatha et al [11Sujatha R, Nawani M. Prevalence of asymptomatic bacteriuria and its antibacterial susceptibility pattern among pregnant women attending the antenatal clinic at kanpur, India. J Clin Diagn Res 2014; 8(4): DC01-3.[PMID: 24959438] ] and Rajaratnam et al [12Rajaratnam A, Baby NM, Kuruvilla TS, Machado S. Diagnosis of asymptomatic bacteriuria and associated risk factors among pregnant women in mangalore, Karnataka, India. J Clin Diagn Res 2014; 8(9): OC23-5.[PMID: 25386490] ]. This inconsistency and difference in results may be due to variances in the environmental background and social habits of the communities, in addition to the economic situation, awareness and knowledge of the client’s hygiene standards. Parity and gestational age significantly affected the prevalence of urinary tract infection. These have been previously reported [13Haider G, Zehra N, Munir AA, Haider A. Risk factors of urinary tract infection in pregnancy. J Pak Med Assoc 2010; 60(3): 213-6.[PMID: 20225781] -15Nworie A, Eze A. Prevalence & etiologic agent of urinary tract infection in pregnancy in Abakiliki metropolis. Cont J Med Res 2010; (4): 18-3.]. Pregnant women in the 3rd trimester of current pregnancy and those having more than one child were mostly at risk of acquiring urinary tract infection. Several anatomical and hormonal changes in pregnant women lead to urethral dilation and urinary stasis which contribute to increased risk of developing UTI [16Le J, Briggs GG, McKeown A, Bustillo G. Urinary tract infections during pregnancy. Ann Pharmacother 2004; 38(10): 1692-701.[http://dx.doi.org/10.1345/aph.1D630] [PMID: 15340129] ]. Concerning the residence of the women, this study shows that a significant association was found between women’s UTIs and their residency. A greater percentage of women who lived in urban areas suffered from UTIs, 43.6% in rural areas versus 56.4% in urban areas. This may be attributed to the nature of urban sanitation as well as lower concern with personal hygiene. [17Hala M, Taghreed M, Nesreen A. Prevalence of urinary tract infection among pregnant women and possible risk factors. MMJ 2016; 29(4): 1055-9.] With regard to the level of education variable, the results found that there is a significant association between women’s UTIs and their educational level. In contrast, Sheikh et al. [18Sheikh MA, Khan MS, Khatoon A, Arain GM. Incidence of urinary tract infection during pregnancy. East Mediterr Health J 2000; 6(2-3): 265-71.[PMID: 11556011] ] found no significant effect of education on the incidence rate of UTIs in their study conducted in Pakistan. On the other hand, Gunes et al. [19Gunes G, Gunes A, Tekiner S, Karaoglu L, Kaya M, Pehlivan E. Bacteriuria and socioeconomic associations among pregnant women in Malatya, Turkey. Public Health 2005; 119(11): 1039-41.[http://dx.doi.org/10.1016/j.puhe.2004.11.007] [PMID: 15913680] ] found that UTI was significantly high among women who had less than secondary level education in their study conducted in Turkey Dimetry et al. [20Dimetry S, El-Tokhy H, Abdo N, Ebrahim M, Eissa M. Urinary tract infection and adverse outcome of pregnancy. Egypt Public Health Assoc J 2007; (82): 203-l8.] found that the highest percentage of UTIs among pregnant women was among those who were illiterate 61.5%. Regarding the occupation of women, although there is no association between women’s UTIs and their occupation, our study showed that the highest proportion of UTIs was found among housewives. One possible cause is that employed women cannot visit the health unit for antenatal care as often because of work conflicts. This finding contradicts to the finding of Okonko et al. [21Okonko I, Ijandipe L, Ilusanya A, Donbraye O, Ejembi J, Udeze A. Detection of urinary tract infection among pregnant women in Oluyoro Catholic Hospital, Ibadan, South-Western Nigeria. Malays J Microbiol 2010; (6): 16-24.] in Nigeria, who found that the highest percentage of UTI among pregnant women 77.8% were among civil workers, followed by teachers 70% and businesswomen 53.8%, and the lower percentages were among students 30.4% and housewives 36.4%. The results of the present study showed that Staphylococcus aprophyticus was the most pathogenic in the causes of infection among pregnant women, followed by Klebsiella Pneumoniae, and Proteus mirabilis, and then Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis. The emergence of this high percentage of bacteria may be due to the weakness of defence mechanisms in pregnant women during pregnancy that creates a good opportunity for UTIs. This result was consistent with Al-Rawy’s [22AL-Rawy S. Urinary tract infections in diabetic pregnant women. M.Sc Thesis, College of medicine-AL-Mustansiyia University. (1998). ] studies about the cause of infection being inconsistent with the rate of incidence. Concerning the married women, the results showed that Klebsiella Pneumoniae was the main cause of the infection, followed by Escherichia coli and Staph epidermidis., while among unmarried women, the bacteria Escherichia coli was the highest recorded cause of infection, followed by bacteria Staph epidermidis and bacteria Klebsiella Pneumoniae. It may also be due to physiological, functional and structural changes that pregnant women undergo which make them more susceptible to various germs [23Bovill B, Lewis D, Minassian M. The treatment of uncomplicated lower urinary tract infection in Women. J Antimicrob Agents 1998; (10): 39-47.]. Additionally, women’s urine during pregnancy is a favourable medium for the growth of most pathogens because it contains high amounts of albumin and amino acids. Pregnant women also have weak defence mechanisms throughout their pregnancy which make them more susceptible to pathogens, especially Staphylococcus saprophyticus. Several studies have been consistent with the current study, for example, a UK study of 1,000 pregnant women showed that the plasma-negative bacteria had an effect on the rate of UTIs, and record the third rank in the total of bacteria. The bacteria that cause UTIs are the same causes of disease in non-pregnant women. Bacteria Escherichia coli (E. coli) represents between 80-90% as a cause of infection [24Epp A, Larochelle A, Lovatsis D, Walter J, Easton W, Farrell S. Recurrent urinary tract infection. J Obstet Gynaecol Can 2010; 32(11): 1082-90.[http://dx.doi.org/10.1016/S1701-2163(16)34717-X] [PMID: 21176321] ]. Ronald [25Ronald A. The etiology of urinary tract infection: Traditional and emerging pathogens. Am J Med 2002; 113(Suppl. 1A): 14S-9S.[http://dx.doi.org/10.1016/S0002-9343(02)01055-0] [PMID: 12113867] ] stated that Group B streptococcus, Staphylococcus saprophyticus and Staphylococcus haemolyticus is less likely to cause UTIs. Enterococci including Gardnerella vaginalis and Ureaplasma ureolyticum are less common agents in UTIs. Ramalingam K et al. [26Ramalingam K, Surasani V, Bollu M. Prevalence of asymptomatic bacteriuria in antenatal women coming to NRIMC and GH. Bangladesh J Obstet Gynaecol 2015; 30(1): 30-6.[http://dx.doi.org/10.3329/bjog.v30i1.30505] ] found that (50%) of bacteria isolates are Klebsiella spp. Muharram et al. [27Muharram SH, Ghazali SN, Yaakub HR, Abiola O. A preliminary assessment of asymptomatic bacteriuria of pregnancy in brunei darussalam. Malays J Med Sci 2014; 21(2): 34-9.[PMID: 24876805] ] and Ramalingam et al. [26Ramalingam K, Surasani V, Bollu M. Prevalence of asymptomatic bacteriuria in antenatal women coming to NRIMC and GH. Bangladesh J Obstet Gynaecol 2015; 30(1): 30-6.[http://dx.doi.org/10.3329/bjog.v30i1.30505] ] also reported Klebsiella spp. as the most common micro-organism. Garnizov et al. [28Garnizov M. Asymptomatic bacteriuria in pregnancy from the perspective of public health and maternal health care: Review and case report. Biotechnol Biotechnol Equip 2016; 30(3): 443-7.[http://dx.doi.org/10.1080/13102818.2015.1114429] ] reported cases of Asymptomatic Bacteriuria (ASB) due to klebsiella pneumonia in a pregnant woman. Two studies from India and Sudan have reported Escherichia coli as the most common isolate and there is an increasing trend towards Klebsiella spp. as the most potent urinary pathogen. [29Saeed S, Tariq P. Symptomatic and asymptomatic urinary tract infections during pregnancy. Int J Microbiol Res 2011; 2(2): 101-4., 30Hamdan HZ, Ziad AH, Ali SK, Adam I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital. Ann Clin Microbiol Antimicrob 2011; 10(1): 2.[http://dx.doi.org/10.1186/1476-0711-10-2] [PMID: 21244660] ] Usually, the causative agents of the non-symptomatic bacteriuria in females are bacteria that coexist in the female reproductive system and intestines. Different determinants of the virus, such as adhesions and inactivity caused by the uterus play a role in UTIs [31Chandel LR, Kanga A, Thakur K, Mokta KK, Sood A, Chauhan S. Prevalance of pregnancy associated asymptomatic bacteriuria: A study done in a tertiary care hospital. J Obstet Gynaecol India 2012; 62(5): 511-4.[http://dx.doi.org/10.1007/s13224-011-0071-2] [PMID: 24082549] -34Kovavisarach E, Vichaipruck M, Kanjarahareutai S. Risk factors related to asymptomatic bacteriuria in pregnant women. J Med Assoc Thai 2009; 92(5): 606-10.[PMID: 19459519] ]

CONCLUSION

The study concluded that the prevalence of UTIs in pregnant women was higher than that of non-pregnant and unmarried women and that E coli is the most common causative agent of disease. A significant association was found between the prevalence of UTIs among women and their age, educational level, marital status, gravity and residency.

RECOMMENDATIONS

Since UTIs may be symptomatic and asymptomatic in most cases, it is therefore suggested that routine screening for UTIs among patients with unexplained sources of fever be conducted, and that the appropriate antimicrobials are administered after sensitivity tests have been carried out in order to prevent cases from becoming symptomatic with resultant renal damage.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

There is no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENT

I would like to express my special thanks of gratitude to Directory of Health at Kirkuk City who facilitate this research. Also, special thanks to women whose participated in this study.

REFERENCES

[1] Al-Badr A, Al-Shaikh G. Recurrent urinary tract infections management in women: A review. Sultan Qaboos Univ Med J 2013; 13(3): 359-67.[http://dx.doi.org/10.12816/0003256] [PMID: 23984019]
[2] Anuli S, Clement I, Basseye A. Review on the prevalence and predisposing factors responsible for urinary tract infection among adults. Eur J Exp Biol 2016; 6(4): 7-11.
[3] Lee AC, Quaiyum MA, Mullany LC, et al. Screening and treatment of maternal genitourinary tract infections in early pregnancy to prevent preterm birth in rural Sylhet, Bangladesh: A cluster randomized trial. BMC Pregnancy Childbirth 2015; 15(15): 326.[http://dx.doi.org/10.1186/s12884-015-0724-8] [PMID: 26643558]
[4] Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs Am J Med 2002. Suppl (1A):5S.113.[http://dx.doi.org/10.1016/S0002-9343(02)01054-9]
[5] Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ, Scott J. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol 2015; 13(5): 269-84.[http://dx.doi.org/10.1038/nrmicro3432] [PMID: 25853778]
[6] Hannan TJ, Totsika M, Mansfield KJ, Moore KH, Schembri MA, Hultgren SJ. Host-pathogen checkpoints and population bottlenecks in persistent and intracellular uropathogenic Escherichia coli bladder infection. FEMS Microbiol Rev 2012; 36(3): 616-48.[http://dx.doi.org/10.1111/j.1574-6976.2012.00339.x] [PMID: 22404313]
[7] Sinan B, Issa A, Anwar E. Study of urinary tract infection among pregnant women in Kirkuk. Med J Tikrit 2007; 2(132): 39-43.
[8] Imade PE, Izekor PE, Eghafona NO, Enabulele OI, Ophori E. Asymptomatic bacteriuria among pregnant women. N Am J Med Sci 2010; 2(6): 263-6.[PMID: 22574301]
[9] Neupane H, Adhikari S, Aryal B. Asymptomatic bacteriuria among pregnant women attending the outpatient clinics of Chitwan medical college teaching hospital in Chitwan, Nepal. IRJP 2012; 3(11): 78-80.
[10] Rohini U, Reddy G, Kandati J, Ponugoti M. Prevalence and associate risk factors of asymptomatic bacteriuria in pregnancy with bacterial pathogens and their antimicrobial susceptibility in a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2017; (6): 558-62.[http://dx.doi.org/10.18203/2320-1770.ijrcog20170381]
[11] Sujatha R, Nawani M. Prevalence of asymptomatic bacteriuria and its antibacterial susceptibility pattern among pregnant women attending the antenatal clinic at kanpur, India. J Clin Diagn Res 2014; 8(4): DC01-3.[PMID: 24959438]
[12] Rajaratnam A, Baby NM, Kuruvilla TS, Machado S. Diagnosis of asymptomatic bacteriuria and associated risk factors among pregnant women in mangalore, Karnataka, India. J Clin Diagn Res 2014; 8(9): OC23-5.[PMID: 25386490]
[13] Haider G, Zehra N, Munir AA, Haider A. Risk factors of urinary tract infection in pregnancy. J Pak Med Assoc 2010; 60(3): 213-6.[PMID: 20225781]
[14] Akinloye O, Ogbolu DO, Akinloye OM, Terry Alli OA. Asymptomatic bacteriuria of pregnancy in Ibadan, Nigeria: A re-assessment. Br J Biomed Sci 2006; 63(3): 109-12.[http://dx.doi.org/10.1080/09674845.2006.11732734] [PMID: 17058709]
[15] Nworie A, Eze A. Prevalence & etiologic agent of urinary tract infection in pregnancy in Abakiliki metropolis. Cont J Med Res 2010; (4): 18-3.
[16] Le J, Briggs GG, McKeown A, Bustillo G. Urinary tract infections during pregnancy. Ann Pharmacother 2004; 38(10): 1692-701.[http://dx.doi.org/10.1345/aph.1D630] [PMID: 15340129]
[17] Hala M, Taghreed M, Nesreen A. Prevalence of urinary tract infection among pregnant women and possible risk factors. MMJ 2016; 29(4): 1055-9.
[18] Sheikh MA, Khan MS, Khatoon A, Arain GM. Incidence of urinary tract infection during pregnancy. East Mediterr Health J 2000; 6(2-3): 265-71.[PMID: 11556011]
[19] Gunes G, Gunes A, Tekiner S, Karaoglu L, Kaya M, Pehlivan E. Bacteriuria and socioeconomic associations among pregnant women in Malatya, Turkey. Public Health 2005; 119(11): 1039-41.[http://dx.doi.org/10.1016/j.puhe.2004.11.007] [PMID: 15913680]
[20] Dimetry S, El-Tokhy H, Abdo N, Ebrahim M, Eissa M. Urinary tract infection and adverse outcome of pregnancy. Egypt Public Health Assoc J 2007; (82): 203-l8.
[21] Okonko I, Ijandipe L, Ilusanya A, Donbraye O, Ejembi J, Udeze A. Detection of urinary tract infection among pregnant women in Oluyoro Catholic Hospital, Ibadan, South-Western Nigeria. Malays J Microbiol 2010; (6): 16-24.
[22] AL-Rawy S. Urinary tract infections in diabetic pregnant women. M.Sc Thesis, College of medicine-AL-Mustansiyia University. (1998).
[23] Bovill B, Lewis D, Minassian M. The treatment of uncomplicated lower urinary tract infection in Women. J Antimicrob Agents 1998; (10): 39-47.
[24] Epp A, Larochelle A, Lovatsis D, Walter J, Easton W, Farrell S. Recurrent urinary tract infection. J Obstet Gynaecol Can 2010; 32(11): 1082-90.[http://dx.doi.org/10.1016/S1701-2163(16)34717-X] [PMID: 21176321]
[25] Ronald A. The etiology of urinary tract infection: Traditional and emerging pathogens. Am J Med 2002; 113(Suppl. 1A): 14S-9S.[http://dx.doi.org/10.1016/S0002-9343(02)01055-0] [PMID: 12113867]
[26] Ramalingam K, Surasani V, Bollu M. Prevalence of asymptomatic bacteriuria in antenatal women coming to NRIMC and GH. Bangladesh J Obstet Gynaecol 2015; 30(1): 30-6.[http://dx.doi.org/10.3329/bjog.v30i1.30505]
[27] Muharram SH, Ghazali SN, Yaakub HR, Abiola O. A preliminary assessment of asymptomatic bacteriuria of pregnancy in brunei darussalam. Malays J Med Sci 2014; 21(2): 34-9.[PMID: 24876805]
[28] Garnizov M. Asymptomatic bacteriuria in pregnancy from the perspective of public health and maternal health care: Review and case report. Biotechnol Biotechnol Equip 2016; 30(3): 443-7.[http://dx.doi.org/10.1080/13102818.2015.1114429]
[29] Saeed S, Tariq P. Symptomatic and asymptomatic urinary tract infections during pregnancy. Int J Microbiol Res 2011; 2(2): 101-4.
[30] Hamdan HZ, Ziad AH, Ali SK, Adam I. Epidemiology of urinary tract infections and antibiotics sensitivity among pregnant women at Khartoum North Hospital. Ann Clin Microbiol Antimicrob 2011; 10(1): 2.[http://dx.doi.org/10.1186/1476-0711-10-2] [PMID: 21244660]
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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