Shobha Hajarnis, MBBS

Department of Occupational Medicine and Epidemiology Unit, Ministry of Health, Seychelles

Abstract

Urinary tract infection (UTI) is a commonly diagnosed and may require antibiotic treatment. To identify micro-organisms found in suspected UTI and micro-organism sensitivity to antibiotics, a study was conducted on 792 consecutive urine samples collected in hospitals and clinics in Seychelles. Among the 792 samples, 70.8% showed no growth and only 6.3% showed growth for specific organisms, while the remaining 22.9% showed mixed growth (likely to indicate contamination). E. coli was the micro-organism most often identified while Klebsiella, Proteus and Pseudomonas were found with in a few cases. As much as 78.6% of coliform organisms were resistant to ampicillin and 54.8% were resistant to septrin while 75% were sensitive to gentamicin, nitrofurantoin and nalidixic acid. Results of this study suggest that routine urine culture in suspicion of uncomplicated UTI is unnecessary (however clinical practice requires that urine culture is done in complicated or recurrent UTI). A test to detect leukocytes in a midstream sample of urine (e.g., Combur 9) is an alternative simple and inexpensive way to identify the presence of bacteriuria in patients with uncomplicated UTI. In patients testing positive for leukocytes (and in all patients with complicated UTI), culture and antibiotic sensitivity should be carried out and a nalidixic acid course can be a first choice treatment.

Introduction

Urinary Tract Infection (UTI) is commonly suspected in clinical practice and up to 50% of all women may suffer from symptomatic UTI at some time during their lives. UTI is considered to be complicated when it affects pregnant women, children, men or the elderly and if it affects kidney tissue (Upper UTI). While simple UTI is uncommon in men aged 20-50, prostatic enlargement in older men may cause urinary tract obstruction and thereby UTI (1). The majority of organisms causing UTI are E. coli. Other organisms are Klebsiella, Proteus and Pseudomonas. A challenge in UTI treatment faced by community and hospital doctors in Seychelles is that antibiotic sensitivity patterns to organisms causing UTI is changing world wide, and the Seychelles is no exception. This study therefore examined the micro-organisms associated with suspected UTI and their sensitivity to antibiotics.

Methods

The study was designed to identify micro-organisms in urine and examine the sensitivity of the micro-organisms to different antibiotics in Seychelles. Data on age, sex, urine culture and sensitivity was collected for all urine samples analysed in July 1995 at the Clinical Laboratory of the Victoria Hospital. Thirteen reports, for which the patients age was not recorded were excluded from the study.

Results

Altogether, 792 urine samples were tested for culture sensitivity, from 254 men and 538 females of all ages. Among these 792 samples, 561 (70.8%) samples showed no growth, 181 (22.9%) showed mixed growth and only 50 (6.3%) showed growth for specific organisms (Tables 1 and 2).

Only 5 (0.9%) samples (all from women between 20-39 years) grew Klebsiella organisms: all samples (100%) were resistant to ampicillin and 75% to cotrimoxazole while all (100%) samples were sensitive to gentamicin, nitrofurantoin and nalidixic acid. Two (0.2%) samples grew the Pseudomonas organism and its sensitivity was tested for gentamicin and azlocilline and it was sensitive to both of them. Only one sample (0.1%) grew the Proteus organism, which was, surprisingly, sensitive to ampicillin, septrin, gentamicin, nalidixic acid and resistant to nitrofurantoin. Table 3 shows the sensitivity of coliform organisms to various antibiotics.

Discussion

Urinary tract infection (UTI) is commonly seen in health centres and in hospitalised patients. Large numbers of urine samples are sent from clinics and hospitals to the laboratory each month for culture and sensitivity tests. This study indicates that only 6.3% of all samples sent to the laboratory show specific micro-organism growth in case of suspected UTI. Identified micro-organisms were accounted by E. coli (84%), Klebsiella (10%) and other organisms (3%). Similar results were shown by a study conducted in Bangalore in 1994 where 6163 samples of urine were analysed. Among these, only 24.15% showed some evidence of infection and E. coli was found most frequently (61.4%) followed by Klebsiella (17.1%) (2). In our study, as many as 23% of all samples showed mixed growth, which may indicate contamination (i.e. artefactual presence of micro-organisms due to inappropriate manipulation of the samples). This important problem may be addressed by using proper containers for urine samples, a correct technique for collecting urine and a short time interval between the collection and the delivery of the urine sample.

This study showed that most coliform organisms are resistant to ampicillin (78.6%) and more than half of them to cotrimaxazole (54.8%). A similar finding was reported in Benin in 1992. Of 1194 E. coli isolated from UTI at the National University Hospital at Cotonou, 87% were resistant to ampicillin which was claimed to be due to an uncontrolled use of antibiotics in Cotonou (3). The same could be true in Seychelles, where ampicillin and, to a lesser extent cotrimoxazole, are often given in case of febrile infections in both children and adults, when many of them would not require antibiotic treatment.

Results of this study suggest that although UTI is a common problem encountered in health centres and hospitalised patients, a routine urine culture is probably not indicated except in complicated or recurrent UTI. Indeed, microbial testing of MSU is expensive and unnecessary in many cases. The use of a dipstick test (e.g. Combur 9) to detect leucocytes associated with infection in a midstream sample of urine is likely to be a more cost effective method of identifying patients with bacteriuria. Only in cases where there is evidence of leucocytes in the urine should culture be requested to detect and treat genuine infection properly (1). This two-step strategy could lessen the burden on the Clinical Laboratory without decreasing the quality of case management. It is also important to conduct regular surveys to note the changing patterns of antibiotic sensitivity so that UTI is appropriately managed in the future.

In patients with no predisposing factors (e.g., defects of the urinary tract, manipulations, pregnancy, old age) a UTI management strategy could be as follows. Urine should be screened for leucocytes in all suspected UTI cases using quick and inexpensive dipstick tests. Culture should not be requested nor an antibiotic treatment given to patients without leucocytes in urine. In patients with a test positive for leucocytes, a mid stream urine should be collected for culture and antibiotic sensitivity and a nalidixic acid course given while awaiting results. In 36-48 hours the test results should be available and treatment continued or changed according to the results. A five day course should be sufficient in this uncomplicated group, and excessive drinking of water is no longer recommended nowadays. In patients with predisposing factors, culture and sensitivity testing is essential for rational treatment. If such patients are systemically unwell at the time of presentation it is prudent to start antibiotic therapy with gentamicin, and then change to a less expensive and/or better tolerated oral antibiotic based on the culture results. In children under 5 years and in pregnant and lactating women, accurate diagnosis and treatment of UTI is essential to prevent later complications, and specialist advice should be obtained early.

Acknowledgments

The author wishes to thank Dr. C. Shamlaye, Dr. N. Wickremesinghe, Dr P. Bovet and Dr. Ballala for their valuable advises in conducting this study, and Ms. M. Iman and Ms. B. Farabeau for typing the manuscript.

Merec Bulletin 1995; 6(No. 8).

Ramaprasad AV, Jayaram N, Nageshappa GJ. Ind Path Microbiol 1993; 36 (2): 119-23.

Anogonou SY, Eslabpazive J, Makoutod M, Josse R, Massougbodi A, Sadler BC. Bull Soc Path Exot 1994; 87: 223-5

 

Pseudomonas; ** Klebsiella or Pseudomonas; *** Klebsiella; **** Proteus

Daniella Larue, RD, Head Nutritionist

Nutritional Unit, Ministry of Health, Seychelles

Abstract

In the absence of dietary survey data, information from two Household Expenditure Surveys of 1983/84 and 1992/93 was used to estimate the amount of nutrients available to an average person and to identify shifts in food consumption patterns in the Seychelles. The data shows heavy dependence on refined foods and low purchase of fruits and vegetables. There is an increase in consumption of most foods and the greatest increase is seen in the consumption of milk (395%) and meat products. The amount of nutrients provided by purchased foods has improved between 1983 and 1993. In 1992/93 purchased foods provided marginal amounts of energy but protein intake remains above recommended requirements. Purchased foods provide a high carbohydrate, moderate protein and low fat intake which is not commensurate with a high prevalence of cardiovascular disease risk factors in the local population. With the exception of niacin, all other nutrients are provided in amounts below recommended intakes. Iron intake is adequate for male but not for female household members. The data suggest the need to improve the availability of wholesome foods, promote the consumption of local foods and obtain better data in order to elucidate the link between diet and disease in Seychelles.

Introduction

Although it is recognized that food consumption patterns have altered and are still changing in Seychelles, it has not been possible as yet to quantify the magnitude of this change. Information from Information from Food Balance Sheets compiled by the Food and Agriculture Organization from 1961 to 1988 indicates a progressive improvement in the availability of calories, protein and fats over the last two decades, in Seychelles (1). However, Food Balance Sheets only provide information on national availability (inclusive food for hotels, boats or fed to animals) without taking into account access to food by individual households and distribution within households.

The emergence of diet-related non-communicable diseases makes it imperative that consumption patterns are identified and monitored to allow the elaboration of appropriate nutrition education programs. In the absence of national nutrition and dietary surveys, information from the Household Expenditure Survey of 1983-84 (2) and 1992-93 (3) was used to estimate nutrient intake of the population. Data from Household Expenditure Survey indicate how much food is available to an individual at household level but does not tell us household distribution

Methods

The food expenditure sections of the Household Expenditure Surveys of 1983-84 and 1992-93 were used to estimate the average amount of nutrients available to a person in Seychelles. For each food, fFood expenditure was divided by the average price of the food in 1992 to obtain weights of food in kilograms available to the household per month. Nutrients available on average to the household per month were calculated using food tables. Commodities were grouped according to nutritional value to ease analysis and discussion.

The total amount of nutrients available to the household was divided by average household size to obtain nutrients available per head. Household size of 4.1 was used, being the provisional figure from the 1994 National Census. As household composition is not known exactly, the average nutrient requirements of a hypothetical family of 4, comprising of one adult male, one adult female one 10-year old boy and one child under 7, were worked out. This was compared to the amount of nutrients available per head in an attempt to assess nutritional adequacy of purchased foods.

This report focuses mainly on information from the 1992-93 survey. Information from the 1983-84 survey is used to show changes in consumption patterns. Throughout this report, 1 month = 30 days and 1 year = 365 days.

Limitations

Nutritional evaluation of the food expenditure information should take account of the following:

1. Only purchased foods were recorded in the 1992-93 survey. The survey did not record foods produced by individual households or foods received as gifts or as a result of barter. Home produce was included in the 1983-84 survey. It is estimated that approximately 90% of foods consumed by households is purchased (MISD, personal communication). The figures therefore provide a good estimate of what is actually available for consumption at the household level.

2. Foods were not weighed at household level. For commodities such as fish, local fruits and vegetables, prices and weights vary.

3. There is always the possibility of under-reporting especially of alcohol and foods purchased and consumed outside the home.

4. Numerous factors affect the nutritive value of food, including the degree of processing, geographical location, the type of species. The nutrient values used in the calculations were not obtained from foods available in Seychelles. For some food items, nutrient values were not available and were estimated using similar items.

5. It is assumed that all foods purchased by the households were actually consumed by household members only. Wastage of items such as fruit and vegetable parings, fish bones, is taken into account in the calculations.

Food expenditure. Food expenditure has decreased from 34% of household expenditure in 1983-84 to 29% in 1992-93. The amount spent on alcohol is high accounting for 22% of total expenditure. Due to the nature of the data, it was impossible to compare food expenditure of high income households to that of low income households. The breakdown of household food expenditure is displayed in Figure 2. Fish and meat is the biggest single expense category, followed by cereals, starchy vegetables and dairy products.

Types of foods purchased. Table 1 shows the percentage change in amounts of food available per head between 1983-84 and 1992-93. The figures indicate an increase in the consumption of most foods except for fresh fish, condensed milk, rice, sugar, fruits and vegetables. The greatest increase is in milk consumption, which has increased by 395% and in the consumption of meat products, such as bacon, sausages and cold meats, which are expected to contribute to an increase in fat intake.

Adequacy of nutrient intake. The amount of nutrients provided by purchased foods has improved as illustrated in Figure 3. Nutrient adequacy has improved for most nutrients. Purchased foods provide adequate amounts of protein and niacin and iron for men. All other nutrients are provided in inadequate amounts.

Energy intake. Figure 3 suggests that purchased foods provide 90% of energy requirements in 1992/93 compared to 82% in 1983/84. Purchased foods ensure a high carbohydrate, low fat intake since carbohydrates contribute 62% of the calories, protein 12% and fat 26% (Figure 4). Slightly less energy is coming from carbohydrates and an increase in fat and protein calories is observed. Figure 5 suggests that the cereals, starchy fruits and roots group contribute the largest share of energy (46%), followed by fats and oils (18%), fish and meat (11%) and other foods such as sugar, confectionery, sauces, etc. (11%). Although alcohol accounts for 22% of expenditure, it only accounts for 5% of the calorie intake.

Despite this high carbohydrate availability, fiber remains very low at 9.3 g per day. This is because the bulk of the available carbohydrates comes from refined products such as polished white rice, white bread, pasta and products made from white flour, which are all low in fiber.

Specific types of fats available could not examined due to limited information in available food tables. However, the increased consumption of powdered whole milk, meat and meat products, and the 30% increase in vegetable (palm) oil consumption should all add to an increase in saturated fat intake between 1983/84 and 1992/93.

Although the data suggests a decrease between 1983 and 1993, the amount of protein available to households remains above recommended requirements. The fish and meat group makes up 53.6% of protein intake and fish alone contributes 12.6% to protein intake. However, 1992-93 expenditure figures suggest that only 64.3g of fresh fish was available per head per day compared to 101.0g per head per day in 1982-83. This suggests a 36% decrease in the amount of fresh fish consumed. Figures from the Seychelles Fishing Authority, SFA, suggest that 156.7g fish was available per head per day in 1992, taking into account tourist consumption and excluding fish for exportation. The discrepancy between the SFA figures and the expenditure figures can be due to the fact that fish was not weighed at house-hold level and prices of fish vary across the islands and seasons.

Protein. Interesting trends in the consumption of protein foods include the increase in consumption of all meats, eggs and milk products (Table 1). The meat consumed the most in 1983-84 was pork, whereas chicken was consumed the most in 1992-93.

Vitamins and minerals. With the exception of niacin, purchased foods provide iron, calcium, thiamin, riboflavin and vitamin C in inadequate amounts (Table 1). Surprisingly, only 26% of vitamin A requirements are satisfied by purchased foods.

Table 2 suggests that fruits and vegetables are the main sources of vitamins A and C but it seems that there is a need for them to be consumed in larger amounts. Thiamin intake also seems to be low and it is mainly provided by cereals and starchy vegetables and the fish and meat group.

The calcium adequacy of the diet has improved largely due to a four-fold increase in powdered milk consumption. The other nutrient of concern is iron, although the amount of iron available has improved considerably between 1983 and 1992. Purchased foods provide adequate amounts of iron for males but not for female members of the household.

Discussion

The need for proper nutrition and dietary surveys to identify trends and indicate areas for nutrition education cannot be over-emphasized. Resources for conducting national dietary surveys are limited and information on household expenditure has provided estimates of types of food and consequently amounts of nutrients available at household level. However, the figures do not indicate intra-household food distribution. Weighing of samples of local foods such as fish and vegetables and inclusion of own production would have greatly improved the quality of the data.

Despite limitations of the data, clear trends are emerging in the consumption patterns of the population. The dietary habits of the population as a whole have tended to move towards consumption of more animal products and less vegetable products. Information from Food Balance Sheets lends support to the trend of decreasing consumption of vegetable products and increasing consumption of animal products in Seychelles. In 1961-63, 91.6% calories were from vegetable sources and this decreased to 82.4% in the period 1986-88 (1).

The figures also indicate marginally low calorie availability. It is doubtful whether food production at household level will significantly improve calorie availability. Energy foods produced and consumed at household level are the starchy fruits and roots, such as cassava, sweet potato and plantains. Availability of starchy fruits and roots have been on the decline in Seychelles since the 1960’s going from 35 kg/head/year in 1961-63 to 26 kg/head/year in 1986-88 (1). Consumption of starchy fruits and roots was found to be low in 1989 and limited to once a week or less(4). However, this low calorie availability is suspect given the high prevalence of obesity in the adult population especially amongst women (5). Under-reporting is strongly suspected, especially of foods bought and consumed outside the home. It is noted that purchase of fried Indian pastries and other shop foods is lower than would be expected, given that most workers in Victoria and school children usually buy a fair number of snacks. These snacks are usually deep-fried and are very high in calories and would be expected to make a significant contribution to the calorie intake and especially to the fat intake.

The distribution of carbohydrate, protein and fat calories is in line with healthy eating guidelines but it is also unexpected especially where fat consumption is concerned. The prevalence of cardiovascular diseases risk factors is currently high in the local population (6) and this low fat consumption is not commensurate with this finding. Under-reporting of shop foods could also explain this discrepancy.

Alcohol is very expensive to purchase. However, under-reporting of alcohol purchase is strongly suspected since this is one item which is purchased and consumed outside the home especially by adult males. Furthermore, the purchase of local alcohols represents less than 1% of alcohol expenditure. It is true that local alcohols are cheaper than imported alcohols or locally produced beers, but there is evidence that local alcohols are consumed in significantly large amounts (7), and would therefore be expected to contribute to a larger share of alcohol expenditure.

Although an improvement in the adequacy of almost all nutrients is observed, heavy dependence on unfortified refined products means that trace nutrient intake, especially of the B vitamins, is still not adequate and fiber intake is low. Thiamin deficiency seems common in Seychelles especially among alcoholics (7) and improved availability of B vitamins is essential. Despite thiamin being widely distributed in foods, animal foods and cereals are the biggest contributors to thiamin intake in the Seychelles. It should be noted that the best source of thiamin is pork in the meat and fish group. Most wholesome and unrefined products have appreciable quantities of thiamin. Increased availability of more wholesome products, such as wholemeal flour, wholemeal cereals and especially vitamin enriched products, could contribute to improving the level of B vitamins, including thiamin, available from purchased foods and at the same time improve fiber intake.

The low level of vitamin A available is also suspect. Local households usually produce their own green leafy vegetables such as drumstick leaves and amaranth, which are very good sources of vitamin A and which are not reported in the 1992-93 survey. Furthermore, with the increased consumption of powdered milk and margarine, which are supplemented with vitamins A and D, an improvement in the amount of available vitamin A would be expected. This therefore points to the very important nutrient contribution, in this case vitamin A, that household food production can make to the diet in Seychelles.

Fruits and vegetables remain the best source of vitamins A and C. Food Balance Sheets indicate an increase in the availability of both fruits and vegetables. In fact, vegetable and fruit availability (production and importation) has almost doubled from 24.0 kg/head/year and 12.3 kg/head/year respectively in 1961-62 to 41.9 kg/head/year and 28.9 kg/head/year respectively in 1986-88 (1). In contrast, the expenditure figures indicate a decrease in the amount of fruits and vegetables purchased. This could be due to the relatively high cost of these items. It is also observed by Seychelles Ministry of Agriculture and Marine Resources, that lately, more households have been growing their own fruit trees. So it could be that more and more households are consuming their own produce. However, there are no figures on own production and consumption. But it is generally observed that apart from bananas, other fruits are rarely harvested for consumption by households.

Despite the apparent decrease in fruits and vegetable consumption, an improvement in vitamin C requirement is noticed possibly due to consumption of fruits and vegetables with very high vitamin C content.

Conclusion

There is a notable shift in food purchasing patterns away from basic foodstuffs to more refined products. Given the high rates of diet-related non-communicable diseases, more emphasis needs to be put on improving availability of wholesome foods or fortified foods to improve both the intake of trace nutrients and fibre. Education efforts should also concentrate on promotion of local foods, especially fruits and vegetables and starchy fruits and roots, realizing that they can make important contributions to the quality of the diet. At the same time, efforts should concentrate on obtaining individual dietary data to better understand the link between diet and disease in Seychelles.

Acknowledgments

I am indebted to the staff of the Management Information Systems Division (MISD) who conducted the survey; Mr. Hendricks Gappy, the Director General of MISD for allowing us the use of the information; Mr. Ralph Charlette of MISD, who provided information on commodity prices; Mr. Joel Nageon from the Seychelles Fishing Authority, who supplied information on fish caught in Seychelles.

Food and Agriculture Organisation. Food balance sheets 1984-86 average. Rome, 1991.

Statistics Section. Household expenditure survey, 1983-84. Seychelles, 1985.

Management Information Systems Division. Household expenditure survey, 1992-93, Seychelles (in press).

Rosalie D. Diet pattern in the Seychelles. Soz Preventivmed 1991; 36 (Suppl 1): S15.

Bovet P. The cardiovascular risk factor profile in the Seychelles. Soz Preventivmed 1991; 36(Suppl 1): S13.

Investigators of the Seychelles Heart Study. The epidemiologic transition to chronic diseases in developing countries: Cardiovascular mortality, morbidity and risk factors in Seychelles (Indian Ocean). Soz Preventivmed 1995; 40: 35-43.

Pinn G, Bovet P. Alcohol related cardiomyopathy in the Seychelles. Aust J Med 1991; 155: 529-533.

 

Figure 1. Food expenditure as a percentage of total expenditure, 1992/93.

Figure 2. Food expenditure by food group, 1992/93.

Figure 3. Percentage daily nutrient requirements of an average household member satisfied by purchased foods.

(b) 1983/84 (a) 1992/93

Figure 4. Contribution of macronutrients to energy intake in 1983/84 and 1992/93.