**7. Diagnosis of urinary tract infection in diabetics**

Upper and lower UTI can be suspected in diabetic patients with most common symptoms. Symptoms vary in upper and lower UTI. **Table 1** highlights the symptomatic difference between upper and lower UTI.

be measured. Diabetes screening is indicated in patients with other risk factors like family history and obesity. Most women do not need extensive urologic investigations. However, women who suffer infection with organisms which is not common causes of UTI, such as *Proteus, Klebsiella, Enterobacter,* and *Pseudomonas,* may have structural abnormalities or renal calculi. They would benefit from imaging studies of the upper urinary tract and cystoscopy. Women who have persistent hematuria after recovery of their infection also require a complete urologic workup. Although empirical therapy based on symptoms is generally accurate and cost-effective, women who are thought to be in the early stages of a problem with recurrent UTI should have documented cultures. Urine culture serves as the gold standard for diagnostic accuracy. The standard definition of a UTI on culture is >100,000 colony forming

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units per HPF. This value has excellent specificity but a sensitivity of only 50% [34].

Emphysematous pyelonephritis (EPN) is a severe and necrotizing form of multifocal bacterial nephritis along with gas formation within parenchyma of the kidney. So far, more than 200 cases have been reported in literature. Underlying poorly controlled diabetes mellitus is pres-

The commonest offending organisms are Klebsiella and *Escherichia coli* followed by Proteus. The clinical manifestations are nonspecific and not different from the classic triad of upper UTI (i.e., fever, flank pain and pyuria); due to this, the diagnosis of EPN is often delayed. Disseminated intravascular coagulopathy, acute respiratory distress syndrome, disturbance of consciousness, acute renal failure, and shock can reveal some severe forms. Diabetic ketoacidosis is a very uncommon presentation, and only few cases have been reported so far.

EPN needs a radiological diagnosis. Conventional radiography may indicate gas bubbles overlying the renal fossa. Ultrasonography (US) characteristically shows an enlarged kidney that contains high amplitude echoes within the renal parenchyma. Computed tomography (CT) is the imaging procedure of choice, which confirms the presence and extent of parenchymal gas.

A descriptive, cross sectional study was conducted on UTI and antibiotic sensitivity pattern among diabetic patients in National Academy of Medical Sciences (NAMS), Mahabouddha, Kathmandu, Nepal. According to this study, *E. coli* is the most common organism followed by *Klebsiella, Proteus,* and *Pseudomonas*. Most of the urinary isolates were sensitive to Ceftriaxone,

A study was conducted to find out the prevalence of UTI in diabetic patients. A total of 1470 diabetic patients (847 women and 623 men) were included in the study, admitted to the Diabetes Clinic of the Emergency Clinical County Hospital Timişoara between January and December 2012. According to this study, 10.7% in overall population had positive urine

Ciprofloxacin, and Cotrimoxazole, whereas resistance was high for ampicillin [35].

**8. Complications of urinary tract infection in diabetics**

ent in up to 90% of affected patients [28].

**9. Pathogens of UTI in diabetes**

Diagnosis of urinary tract infection can be done by following methods.

	- **Positive test:** Indicates the presence of bacteria in urine.
	- **Negative test:** is the product of low count bacteriuria or bacterial species that lack the ability to reduce nitrate to nitrite (mostly Gram-positive bacteria).

#### **7.1. Diagnosis of UTI in women patients**

All women with recurrent UTI should undergo a physical examination to evaluate urogenital anatomy and vaginal tissues estrogenization. Postvoid residual urine volume also should


**Table 1.** Symptomatic difference between upper and lower UTI.

be measured. Diabetes screening is indicated in patients with other risk factors like family history and obesity. Most women do not need extensive urologic investigations. However, women who suffer infection with organisms which is not common causes of UTI, such as *Proteus, Klebsiella, Enterobacter,* and *Pseudomonas,* may have structural abnormalities or renal calculi. They would benefit from imaging studies of the upper urinary tract and cystoscopy. Women who have persistent hematuria after recovery of their infection also require a complete urologic workup. Although empirical therapy based on symptoms is generally accurate and cost-effective, women who are thought to be in the early stages of a problem with recurrent UTI should have documented cultures. Urine culture serves as the gold standard for diagnostic accuracy. The standard definition of a UTI on culture is >100,000 colony forming units per HPF. This value has excellent specificity but a sensitivity of only 50% [34].
