Professional Documents
Culture Documents
6
Printed in U.S.A.
DOI: 10.1093/aje/kwi078
Risk of Urinary Tract Infection and Asymptomatic Bacteriuria among Diabetic and
Nondiabetic Postmenopausal Women
Edward J. Boyko1,2, Stephan D. Fihn2,3, Delia Scholes4,5, Linn Abraham5, and Barbara Monsey5
1
Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA.
Department of Medicine, School of Medicine, University of Washington, Seattle, WA.
3
Northwest Health Services Research and Development Program, VA Puget Sound Health Care System, Seattle, WA.
4
Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA.
5
Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA.
2
Received for publication February 2, 2004; accepted for publication October 26, 2004.
diabetes mellitus; postmenopause; prospective studies; risk factors; urinary tract infection; women
Abbreviations: GHC, Group Health Cooperative of Puget Sound; UTI, urinary tract infection.
Correspondence to Dr. Edward J. Boyko, VA Puget Sound Health Care System (S-152E), 1660 South Columbian Way, Seattle, WA 98108
(e-mail: eboyko@u.washington.edu).
557
Am J Epidemiol 2005;161:557564
No prospective data exist on the risk of microbiologically conrmed urinary tract infection (UTI) and
asymptomatic bacteriuria (AB) in relation to diabetes mellitus and its characteristics. The authors prospectively
(19982002) followed 218 diabetic and 799 nondiabetic Washington State women aged 5575 years for UTI and
AB. The baseline examination and two annual follow-up examinations included urine culture, measurement of
hemoglobin A1c and postvoid residual bladder volume, and a survey of diabetes and other characteristics.
Surveillance for UTI included self-reports conrmed by microbiologic culture and medical record review. UTI
incidence per 100 person-years was 12.2 for diabetic women and 6.7 for nondiabetic women (relative risk (RR)
1.8, 95% condence interval (CI): 1.2, 2.7). AB incidence per 100 person-years was 6.7 for diabetic women and
3.0 for nondiabetic women (RR 2.3, 95% CI: 1.3, 3.9). In Cox models adjusted for multiple covariates, the
increased UTI risk occurred mainly in women taking insulin (RR 3.7, 95% CI: 1.8, 7.3) and women with a longer
diabetes duration (10 years; RR 2.6, 95% CI: 1.3, 5.1) compared with nondiabetic women. No clear linear
trend between hemoglobin A1c and UTI or AB risk was seen. Postmenopausal women with diabetes have higher
risks of UTI and AB in relation to diabetes duration and severity but not to recent glucose control.
The study was conducted at the Group Health Cooperative of Puget Sound (GHC), a staff-model nonprofit health
maintenance organization with approximately 450,000
enrollees. Women aged 5575 years were eligible to
participate if they resided in Pierce County, King County,
or Snohomish County in Washington State, had been
enrolled in GHC for at least 1 year, had not had a natural
menstrual cycle in the preceding 12 months, and had not had
a UTI in the preceding 90 days.
Women were randomly selected from the GHC enrollment file. We also selected additional women from the GHC
Diabetes Registry who were frequency-matched, by age, to
the main cohort. Exclusion criteria included residential
nursing care, wheelchair dependency, dementia, severe
psychiatric disorder, urinary catheterization, renal dialysis,
active nonskin cancer, and chronic antibiotic use. After
checking GHC databases for indicators of ineligibility, we
contacted potential participants by letter and telephone to
determine their eligibility and willingness to participate. We
made up to 10 attempts to reach each woman by phone. The
study protocol was approved by the human subjects
committees of the University of Washington and GHC.
Signed informed consent was obtained from all participants.
Women who participated were followed prospectively for
2 years. Exposure and outcome data were collected from
multiple sources: interviews and research clinic visits
conducted at baseline and at 12 and 24 months and GHC
laboratory, hospital, and pharmacy data (for identification
and verification of UTI and diabetes).
Primary exposures of interest included diabetes presence
and characteristics, demographic features, sexual activity,
and bladder function. The primary outcome of interest was
acute UTI, as defined by a midstream urine specimen yielding 100,000 colony-forming units per ml of a uropathogenic organism (any aerobic gram-negative rod, Lancefield
group B or D streptococci, or Staphylococcus saprophyticus), accompanied by dysuria, urgency, or frequency for 2
weeks or less.
We collected interview data at baseline and at 12 and 24
months between 1998 and 2002 to assess history of UTI,
RESULTS
559
TABLE 1. Characteristics of women with and without diabetes mellitus, Group Health Cooperative of Puget Sound, 19982002
Characteristic
5559
262
32.8
6064
166
20.8
6569
168
7075
203
Total (n 1,017)
No.
60
27.5
322
31.7
47
21.6
213
20.9
21.0
47
21.6
215
21.1
25.4
64
29.4
267
26.3
Age (years)
Annual income*
<$10,000
1.1
13
7.2
20
2.4
$10,000<$35,000
245
37.1
77
42.5
322
38.2
$35,000<$50,000
145
21.9
45
24.9
190
22.6
$50,000<$75,000
141
21.3
25
13.8
166
19.7
$75,000
123
18.6
21
11.6
144
17.1
23
2.9
15
7.0
38
3.8
340
42.7
125
58.1
465
46.0
College graduate
247
31.0
35
16.3
282
27.9
186
23.4
40
18.6
226
22.4
Ethnicity*
White
721
90.5
167
77.0
888
87.6
African-American
22
2.8
24
11.1
46
4.5
33
4.1
17
7.8
50
4.9
Other
21
2.6
4.1
30
3.0
501
63.0
134
61.5
635
62.7
99
12.5
32
14.7
131
12.9
160
20.1
46
21.1
206
20.3
35
4.4
2.8
41
4.0
364
45.7
77
35.3
441
43.4
Never
443
56.6
146
67.9
589
59.0
15
258
33.0
58
27.0
316
31.7
6
82
10.5
11
5.1
93
9.3
276
35.0
67
30.9
343
34.1
15
370
46.9
87
40.1
457
45.4
610
83
10.5
29
13.4
112
11.1
1120
34
4.3
16
7.4
50
5.0
21
26
3.3
18
8.3
44
4.4
Marital status
Married or living as married
Widowed
Divorced or separated
Never married
Sexual historyy
Sexual intercourse during past year
Frequency of intercourse per month
684
85.6
166
76.1
850
83.6
71
8.9
26
11.9
97
9.5
44
5.5
23
10.6
67
6.6
1.4
0.3
Am J Epidemiol 2005;161:557564
11 years
561
TABLE 2. Incidence of and incidence ratios for all episodes of symptomatic urinary tract infection and a rst episode of
asymptomatic bacteriuria, by diabetes status and characteristics at the time of study entry, Group Health Cooperative of Puget Sound,
19982002
All symptomatic urinary tract infections
Characteristic
Incidence
per 100 PY
No. of
events
PY
41
1,388.1
3.0
1.0y
1.2, 2.7
23
342.8
6.7
2.3
1.7
1.1, 2.7
15
221.2
6.8
2.3
1.2, 4.2
2.3
1.1, 4.4
62.4
8.0
2.7
0.8, 6.9
0.8, 4.6
49.1
4.1
1.4
0.2, 5.3
1.6
1.0, 2.7
11
177.0
6.2
2.1
1.0, 4.2
1.7
0.7, 3.3
77.9
10.3
3.5
1.4, 7.5
1.4, 4.7
77.8
3.9
1.3
0.3, 4.1
No. of
events
PY*
Nondiabetic
(n 799)
95
1,420.8
6.7
Diabetic
(n 215)
43
352.1
12.2
7.5% (n 137)
26
227.4
11.4
7.6%8.5% (n 42)
10
65.5
15.3
49.1
14.3
2.1
20
182.2
11.0
81.1
11.1
14
78.7
17.8
2.7
IR*
95% CI*
IR
95% CI
Diabetes status
1.0y
1.8
1.3, 3.9
Hemoglobin A1c
concentration
>8.5% (n 30)
Hemoglobin A1c
concentration
>7.9% (n 49)
Duration of
diabetes
<10 years (n 149)
19
239.1
7.9
1.2
0.7, 2.0
13
230.6
5.6
1.9
0.9, 3.6
24
112.1
21.4
3.2
2.0, 5.1
10
111.3
9.0
3.0
1.4, 6.2
115.9
4.3
0.7
0.2, 1.6
111.0
6.3
2.1
0.8, 4.8
Oral medications
(n 104)
17
167.7
10.1
1.5
0.9, 2.6
10
164.0
6.1
2.1
0.9, 4.2
Insulin treatment
(n 40)
21
67.6
31.1
4.7
2.8, 7.5
66.9
9.0
3.0
1.1, 7.2
Diabetes treatment
No medications
(n 69)
13.0 percent vs. 4.9 percent; other organisms, 4.3 percent vs.
2.4 percent (p 0.071)).
DISCUSSION
7.0% (n 107)
7.0%7.9% (n 53)
TABLE 3. Hazard ratios for asymptomatic bacteriuria and symptomatic urinary tract infection according to diabetes status and
characteristics, Group Health Cooperative of Puget Sound, 19982002*
First asymptomatic bacteriuria
Model
95% CIy
HR
95% CI
Diabetes status
Diabetes present
1.9
1.1, 3.2
1.5
0.9, 2.5
Diabetes present
1.9
1.2, 3.3{
1.4
0.8, 2.2
Diabetes present
2.1
1.2, 3.5{
1.4
0.9, 2.3
7.5%
1.9{
1.0, 3.5
1.2
0.7, 2.2
7.6%8.5%
1.9
0.7, 5.4
1.6
0.9, 3.0
>8.5%
2.5
1.0, 6.6
1.8
0.7, 4.7
HbA1cy concentration at
baseline and 1 year
{
2.0
1.0, 3.6
1.3
0.7, 2.3
7.6%8.5%
2.2
0.8, 6.1
1.8
0.9, 3.3
>8.5%
2.7
1.0, 7.2
1.9
0.7, 4.8
HbA1c concentration at
baseline and 1 year
7.0%
1.6
0.8, 3.3
1.3
0.7, 2.4
7.0%7.9%
2.3
1.0, 5.5
1.1
0.6, 2.1
>7.9%
2.4
1.1, 5.5
2.0
1.0, 4.1
7.0%
1.7
0.8, 3.5
1.3
0.7, 2.5
7.0%7.9%
2.5
1.0, 6.0
1.2
0.6, 2.3
>7.9%
2.6
1.1, 6.0
2.2
1.1, 4.3
No medications
1.7
0.8, 3.9
0.5
0.2, 1.2
Oral medications
1.9
0.9, 3.8
1.2
0.6, 2.2
2.4
1.0, 5.9
3.2
1.6, 6.6
Insulin treatment
Diabetes treatment
No medications
1.8
0.8, 3.9
0.5
0.2, 1.2
Oral medications
2.1
1.0, 4.3
1.3
0.7, 2.3
2.7
1.1, 6.6
3.7
1.8, 7.3
Insulin treatment
Duration of diabetes
(in years)
<10
1.7
0.9, 3.1
0.9
0.5, 1.6
10
2.5
1.2, 5.0
2.3
1.2, 4.6
<10
1.8
0.9, 3.3
0.9
0.5, 1.6
10
2.8
1.4, 5.7
2.6
1.3, 5.1
Am J Epidemiol 2005;161:557564
7.5%
Am J Epidemiol 2005;161:557564
ACKNOWLEDGMENTS
563
REFERENCES
Am J Epidemiol 2005;161:557564