We read with interest the article of Geerlings et al.(1) that analyzed asymptomatic bacteriuria as a complication in diabetic women. It is known that urinary tract infections (UTIs) are an important problem in diabetic individuals, and bacteriuria is more common in diabetic women than in nondiabetic women(2) because of several factors that predispose diabetic individuals to infection(3). Furthermore, many UTIs are asymptomatic, and, as observed by Vejlsgaard(4), it is not clear if symptomatic infections are preceded by asymptomatic bacteriuria (ASB). Several studies confirm that there is a higher prevalence of ASB in diabetic women than in nondiabetic women (1). Unfortunately, ASB is not easily detected, even if there are some elements and clinical signs that indicate the presence of ASB. Furthermore, as reported by Mizock (5) and Perschel et al.(6), many stress factors, such as infections, burns, or trauma, are associated with alterations in carbohydrate metabolism, inducing a need for higher insulin doses or insulin injection in patients normally on oral medication. Therefore, it is important to investigate the presence of possible stress factors such as infections in diabetic patients with suspicious elevation of glycemia.

During the last year, in the diabetes outpatient clinic of Santo Spirito Hospital in Rome, we observed 148 diabetic women with an increased average glucose value of 2.2 mmol/l (range 0.5-5.51); this variation of glycemia was present throughout each day for a period of several days. There were no significant variations in HbAlc levels. After this observation, we interviewed the patients about possible stress factors, including UTIs and ASB that was defined as the presence of at least 105 colony-forming units (cfu)/ml of one or two bacterial species in a clean-voided midstream urine sample from individuals without symptoms of a UTI(7).

ASB was found in 79 of the 148 patients with alterations of glucose values;all 79 patients were postmenopausal. Furthermore, 69 patients had type 2 diabetes (age 58 ± 14.9 years), and the other 10 had type 1 diabetes(age 47.3 ± 7.4 years); all of the patients suffered from habitual UTIs or ASB.

As observed in other studies, Escherichia coli was the most frequently isolated microorganism (42 patients [53%])(1,8). In addition, Klebsiella oxytoca was found in 18 patients (22.7%), Enterobacter cloacae was found in 12 patients (15.1%), and Proteus mirabilis was found in 7 patients (8.8%). ASB disappeared after successful treatment with specific antibiotics.

Moreover, we investigated the hygiene habits of the 79 patients with ASB. We found that 68 patients used one hand and one towel to wash and dry both the genital and anal regions. The remaining 11 patients used both hands to wash,one for the genital and one for the anal region, but only one towel to dry the two different regions. The anatomical characteristics of women may facilitate the migration of intestinal microorganisms in the urinary tract. Therefore, we recommended that the 68 patients change their habits and use both hands and two different towels to wash and dry the two different regions.

After 6 months of these hygiene modifications, we repeated the midstream urine analysis and found that only 16 (20.2%) of the 79 patients had ASB. E. coli remained the most frequently isolated microorganism, with 11 cases (68.7%); Klebsiella oxitoca was found in 3 of the 16 patients(18.7%), and Enterobacter cloacae was present in 2 cases (12.5%). None of the patients had ASB caused by Proteus mirabilis.

In conclusion, careful hygiene habits in diabetic women could present an easy and cost-free way to help prevent ASB and UTIs. Unfortunately, published studies of this kind are uncommon. We often forget that a patient's quality of life can sometimes be improved by adopting simple solutions.

Geerlings SE, Stolk RP, Camps MJL, Netten PM, Hoekstra JBL, Bouter KP, Bravenboer B, Collet JT, Jansz AR, Hoepelman AIM, for the Diabetes Mellitus Women Asymptomatic Bacteriuria Utrecht Study Group: Asymptomatic bacteriuria may be considered a complication in women with diabetes.
Diabetes Care
Patterson JE, Andriole VT: Bacterial urinary tract infections in diabetes.
Infect Dis Clin North Am
Pozzilli P, Leslie RD: Infections and diabetes: mechanism and prospects for prevention.
Diabet Med
Vejlsgaard R: Studies on urinary infection in diabetics:bacteriuria in patients with diabetes mellitus in control subjects.
Acta Med Scan
Mizock BA: Alterations in carbohydrate metabolism during stress: a review of the literature.
Am J Med
Perschel WT, Langefeld TW, Federlin K: Susceptibility to infections in diabetes: effects on metabolism.
Immun Infekt
Recommended terminology of urinary tract infection: a report by the members of Medical Research Council Bacteriuria Committee.
Br Med J
Lye WC, Chan RK, Lee EJC, Cumarasinghe G: Urinary tract infections in patients with diabetes mellitus.
J Infect