Susceptibility profile and associated factors of urinary tract infections among women with established preterm labor delivering at a tertiary teaching hospital in Eastern Uganda: a cross-sectional study

Abstract

Background

Urinary tract infections have been recognized as a significant health issue since ancient times, but they are particularly concerning during pregnancy due to their potential to cause severe complications like preterm labor and low birth weight leading to significant neonatal morbidity and mortality. This study aimed to determine the prevalence, antibiotic susceptibility and factors associated with urinary tract infections among women with established preterm labor at Jinja Regional Referral Hospital.

Methods

This was a hospital-based cross-sectional study carried out from 1st January 2024 to 30th April 2024. Using a consecutive sampling method, 385 pregnant women were enrolled until the desired sample size was reached. Data was collected via pretested questionnaires, and antibiotic susceptibility patterns were determined via urine culture and sensitivity. Data was analysed using STATA Version 14.2. Bivariate and multivariate analyses were used to determine association between the dependent and independent variables, with P < 0.05 as the level of significance at 95% confidence interval. The results were presented in pie charts, bar graphs and tables.

Results

The prevalence of urinary tract infection was 114 (29.6%). The effectiveness of antibiotics against common Urinary tract Infection (UTI) pathogens varied significantly. E. coli was the most frequently isolated organism in UTIs, accounting for 42.98% of the cases followed by Enterococcus at 24.56%. Ceftriaxone was the most effective agent overall, with 81% of the pathogens showing susceptibility, followed by cefixime (78%) and co-amoxiclav (73%). Nitrofurantoin (64%) and cefuroxime (66%) had moderate effectiveness, whereas ampicillin (50%) was less effective. Azithromycin (34%) and erythromycin (28%) were the least effective. No formal education, being unemployed, monthly income less than 500,000 Ugandan Shillings, a history of urinary tract infection, Parity of one or more, a gestational age ≥ 26 weeks and diabetes (aOR = 8.00; 95% CI = [1.75–36.48]; P = 0.007), (aOR = 2.72; 95% CI = [1.38–5.23]; P = 0.003), (aOR = 2.55; 95% CI = [1.29–5.16]; P = 0.007), (aOR = 4.60; 95% CI = [2.64–8.25]; P < 0.001), (aOR = 1.90; 95% CI = [1.07–3.45]; P = 0.028), (aOR = 2.41; 95% CI = [1.17–4.92]; P = 0.017), (aOR = 3.11; 95% CI = [1.33–7.12]; P = 0.009), respectively, were significantly associated with urinary tract infection.

Conclusions

In this study, the prevalence of urinary tract infection was high compared with the worldwide prevalence. The majority of the isolates were susceptible to ceftriaxone, followed by co-amoxiclav, cefixime, nitrofurantoin, ampicillin, azithromycin and erythromycin. Primary or no formal education, monthly income ≤ 500,000Ugandan shillings, history of urinary tract infections, gestational age ≥ 26 weeks and diabetes were significantly associated with urinary tract infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-07215-w.

Introduction

Preterm labor is a frequent complication of pregnancy, and its prevalence varies from 5 to 18% globally [1]. Studies have shown that premature labor is a problem in many African nations. The prevalence of UTI is approximately 14.2% in Tanzania [2], 11.4% in Ethiopia [3], 18.3% in Kenya [4], and 17.5% in Rwanda [5]. Preterm birth has been linked to urinary tract infections [6]. While the exact mechanism is not clear, UTIs are thought to trigger an inflammatory response, leading to the increased production of cytokines, prostaglandins, and enzymes which can break down the extracellular matrix, cause cervical dilation, and result in preterm premature rupture of membranes (PPROM) and/or uterine contractions [7]. In a prospective study carried out in India, preterm labor rates were greater among pregnant women with asymptomatic bacteriuria, significantly different from those who did not have asymptomatic bacteriuria [8]. Another recent prospective study revealed a significant link between premature labor and urinary tract infection [9]. According to a meta-analysis, pregnant women with urinary tract infections are 2.19 times more likely to have preterm labor than pregnant women without Urinary tract infections (UTIs) [6]. The most accurate way to diagnose a urinary tract infection is through urine culture [10].

UTIs are a common complication in pregnancy, particularly among women experiencing preterm labor [6]. A cross-sectional study in India involving 250 patients revealed that the prevalence of UTIs in preterm labor was high (29.2%, of which 78% were asymptomatic), emphasizing the importance of early detection and management to prevent complications [11]. In Syria, a descriptive case‒control study with 125 pregnant women reported a UTI prevalence of 22.8% among the preterm labor group compared with 7.3% in the full-term labor group [12]. Recent research has shown that pregnant women in sub-Saharan Africa had a 32.12% prevalence of urinary tract infections [13]. According to Getaneh and colleagues, the total pooled prevalence of UTIs among pregnant women in Ethiopia was 15.37% [14], whereas that in Sudan was 14.0% [15]. Uganda had the highest rate of urinary tract infections during pregnancy among the nations of East Africa, with 64% in Kitgum [16] and 35% in Mbarara [17]; however, the rates were 15.7% in Kenya [18] and 8.9% in Tanzania [19].

Different studies have demonstrated that several factors are associated with urinary tract infections, including age, marital status, education level, residence, parity and history of abortion [20–24]. iA study iconducted iin iNigeria ifound ithat ipregnant iwomen iaged i30 iand iabove were imore ilikely ito idevelop iUTIs icompared ito iyounger iwomen, possibly due ito ihormonal ichanges iand ireduced iimmunity associated iwith iaging [20]. iA study iin India demonstrated ithat ipregnant iwomen ifrom irural iareas ihad i.a. ihigher iincidence iof iUTIs icompared ito ithose ifrom iurban iareas, imainly idue ito iinadequate ihealthcare iinfrastructure iand ihygiene ipractices [15]. iIn iPakistan, iless ieducated iwomen ishowed i.a. ihigher iincidence iof iUTIs icompared ito itheir ieducated icounterparts i [23].

Escherichia coli has been the most frequently isolated bacterium [25]. According to Kalita and Deka, other typical isolated pathogens include Proteus mirabilis, Klebsiella pneumoniae, Enterococcus, Group B beta-haemolytic streptococci, and Staphylococcus saprophyticus [26]. Similarly, various studies have explored the antibiotic susceptibility of pregnant women to uropathogens, revealing key trends and challenges. Recent research in Bangladesh revealed that the most common uropathogens were E. coli (38%), Staphylococcus species (23%), and Group B Streptococcus (5.3%) [27]. In Nigeria, a study identified Staphylococcus aureus in 16.8% of UTI cases, with 11 cases of significant resistance to erythromycin (62.5%) and ceftriaxone (79.6%) but high sensitivity to nitrofurantoin and imipenem [28]. Similarly, in Johannesburg, South Africa, Enterococcus faecalis was found in 12.9% of UTI cases, that displayed resistance to ampicillin and vancomycin [29]. In Ghana, Klebsiella pneumoniae was present in 8.3% of cases [30]. In South Africa, a study on pregnant women revealed that Escherichia coli was the most common uropathogen (54.2%), followed by Klebsiella pneumoniae (12.9%) and E. coli showed high resistance to trimethoprim-sulfamethoxazole (65.1%) and cephalothin (38.3%) but low resistance to ceftriaxone (9.1%) and nitrofurantoin (7.7%) [31]. Findings from Kisii County, Kenya, revealed E. coli in 23.5% of UTI cases among pregnant women, with high resistance to sulfamethoxazole (100%) and amoxyclav (85.75%) but lower resistance to gentamycin (14.28%) and ofloxacin (21.42%) [32]. In southwestern Uganda, E. coli was found in 28.78% of cases, showing high resistance to ampicillin and amoxicillin but sensitivity to ciprofloxacin and ceftriaxone [17]. Despite the benefits of addressing UTIs during pregnancy, there is limited data on the prevalence, antibiotic susceptibility, and associated factors of UTIs in women with preterm labor in Eastern Uganda especially at Jinja Regional Referral Hospital, making this study essential for improving healthcare practices and outcomes. This study aimed to assess the prevalence, antibiotic susceptibility and factors associated with urinary tract infection among women with established preterm labor.

Materials and methods

Study design and setting

We conducted a cross-sectional study from the labor suite of Jinja Regional Referral Hospital (JRRH) from 1st January 2024 to 30th April 2024. JRRH is one of the busiest public healthcare facilities serves that serves multiple districts in the eastern and central regions of the country, including the Bugiri, Iganga, Jinja, Kaliro, Kamuli, Luuka, Mayuge, Namayingo, Kayunga, and Buikwe districts. The obstetrics department typically receives 15 to 20 laboring women each day, including those experiencing premature births leading to approximately 100 deliveries each month before 37 weeks of gestation (JRRH,2023, unpublished). JRRH has a well-equipped modern laboratory that performs microbiological, biochemical, parasitological, serological and hematological tests. The department has a bed capacity of 600 beds and is run by four consultants, 6 senior house officers, two medical officers, and twelve midwives, and it has four delivery beds as well as a NICU close to the maternity ward.

Study population

All pregnant women with established preterm labor attending Jinja regional referral hospital during the study period who consented to take part of the study were included. Those pregnant women with established preterm labor who were receiving antibiotic therapy were excluded from the study.

Sample size calculation

The following sample size formula, Daniels WW, 1999 was used.

where N is the required sample size estimate and Z is the critical value for a normal distribution at the 95% confidence level, corresponding to 1.96. P = estimated prevalence rate of culture-positive urinary tract infection, which is 35% from a study performed in Mbarara [17]. q = 1-p Therefore,

Therefore, the minimum required sample size was 350. By adding 10% (350*0.1) of the expected nonrespondents, the sample size used in this study became 385.

Study procedure

The data collection for the study was carried out by the principal investigator (PI) and trained research assistants, who approached pregnant women with established preterm labor attending Jinja Regional Referral Hospital during the study period to determine eligibility. Before the interviews began, the nature of the study was explained to each eligible participant, and written informed consent was obtained. The participants were assured of the confidentiality, privacy, and anonymity of their information via an approved informed consent form from Bishop Stuart University Research and Ethics Committee (REC). The community engagement plans involved educating, counselling, and sensitizing community members, hospital administrations, research assistants, and laboratory technologists about the study’s needs, benefits, and outcomes. Study outcomes were communicated directly to individual participants while maintaining their privacy and confidentiality.

Data collection procedure

A structured, pretested interviewer-administered questionnaire (Appendix I) was used to gather information on sociodemographic, obstetrical, medical, and environmental factors associated with urinary tract infection among the participants. Using a consecutive sampling method, 385 pregnant women were enrolled until the desired sample size was reached. The questionnaire was pretested at Kampala International University Teaching Hospital by randomly selecting 10% of the sample size to ensure its reliability and validity, resulting in necessary adjustments before the final data collection. The reliability of the questionnaire was confirmed with a Cronbach’s coefficient alpha test score of 88%, and the validity was ensured through precise and consistent instrumentation.

For sample collection, pregnant women with established preterm labor who consented to participate had a urine sample collected for microbiological examination. Before starting routine treatment, the samples were obtained via the “midstream clean catch” method and placed in sterile containers. The participants were instructed to thoroughly wash and dry their hands, remove the container’s lid, hold the skin folds apart while voiding, and clean their genital area with a towelette before urinating. They were then instructed to pass a small amount of urine into the toilet, collect 40 ml of urine starting from mid-urination into the container, finish voiding into the toilet, securely replace the container lid, and wash their hands after collection. Each sample was transported to the laboratory within 24 h for culture and sensitivity testing, and each container was labelled with the patient code, source of the sample, date, and time of collection.

Diagnosis of UTI

In this study, the diagnosis of UTI was solely based on culture. A positive urine culture (UTI) was confirmed by the growth of a single pathogen in a urine sample at a concentration of ≥ 100,000 colony-forming units (CFU)/mL. Subsequently, antibiotic susceptibility testing was performed [33].

Study variables

The primary focus of this study was the dependent variable, urinary tract infection, which was assessed among mothers with established preterm labor through culture and sensitivity testing for antibiotic susceptibility. Several independent variables were considered in this study to explore urinary tract infection. These variables include age, educational level, occupation, marital status, obstetrical factors, gravidity, parity, gestational age, number of abortions, HIV status, diabetes, hypertension, history of urinary tract infection, gravidity, parity, and history of abortion.

Data quality control

We meticulously followed the specified inclusion and exclusion criteria to guarantee the credibility and accuracy of the study. The questionnaires underwent thorough scrutiny before data collection to ensure the capture of precise information. The principal investigator delivered comprehensive training to the research assistants and consistently supervised their work to guarantee accurate utilization of data gathering instruments and compliance with ethical principles. Urine samples were collected and transported to the laboratory for examination in accordance with established protocols. Every sample was labelled with the participant’s number code to facilitate identification. Every day, the data backup copies underwent inspection, verification for consistency, and safe storage to ensure the integrity of the data.

Data management and analysis

The information from the data collection sheet was compiled into Microsoft excel version 16, cleaned, coded and then imported into STATA version 14.2 for analysis. Proportions were used to characterize sociodemographic, medical, and obstetrical characteristics descriptively. The prevalence of urinary tract infections was calculated by dividing the total number of women with positive urine cultures by the total number of women with established preterm labor. This prevalence is presented as a percentage on a pie chart. The proportion of each bacteria cultured was calculated by dividing the frequency of specific bacteria cultured in the laboratory by the total number of all positive cultures. The most common bacterial isolate was identified and presented as percentages in a table. The proportion of each bacterial isolate that was sensitive to the antibiotics used was calculated by dividing the frequency of sensitive bacteria cultured in the laboratory by the total number of positive cultures. The most common bacterial isolate was identified and presented as percentages in a table. For each type of bacterial isolate, the frequencies and percentages of the susceptible (S), intermediate (I), and resistant (R) categories were computed and are presented in the tables. Binary bivariate and multivariate logistic regression were used to identify the sociodemographic, obstetrical, and medical factors related to urinary tract infections among women with confirmed preterm labor. After a binary variable was created, a bivariate analysis based on logistic regression was performed. Repeated analyses comparing sociodemographic, obstetrical, and medical factors linked to urinary tract infections among women with confirmed preterm labor were conducted. Unadjusted odds ratios and their associated 95% confidence intervals were provided. In the multivariate analysis, factors with a p value of less than 0.2 and those that were biologically plausible were considered to control for confounding factors. Factors which turned with p value less than 0.05 were considered statistically significant in this study.

Ethical considerations

Ethical approval for the study was obtained from the Research and Ethics Committee of Bishop Stuart University (BSU-REC) and was registered with the Uganda National Council for Science and Technology. Privacy and confidentiality were ensured by individually assessing participants, anonymizing questionnaires with number codes, and securely storing data. Written informed consent was obtained after the study details were thoroughly explained to the participants, with signatures or fingerprints collected.

Results

Socio-demographic, obstetric and medical characteristics of the study participants

The study was conducted from labor suite of FRRH and enrolled 385 participants with a response rate of 100% (Study flow Chart in appendix II). Among 385 participants, most were aged 20–29 years (59.22%), resided in rural areas (72.99%), had secondary education (51.17%), and were married (89.87%). Over half were unemployed (51.17%) and had a monthly income less than 500,000Ugandan Shillings (74.81%). In terms of obstetric characteristics, 25.71% had a history of abortion, 32.99% had a history of UTIs, and 64.16% had one or more children. Gestation ages varied, with 44.68% in the extreme stage. In terms of medical status, 9.09% had diabetes, 8.05% had hypertension, and 5.19% were HIV positive (Table 1).

Table 1.

Socio-demographic, obstetric and medical characteristics of the study participants (N = 385)

Variable	Category	Frequency(n)	Percentage (%)
Sociodemographic characteristics
Age	< 20	37	9.61
	20–29	228	59.22
	30–39	108	28.05
	≥ 40	12	3.12
Residence	Rural	281	72.99
	Urban	104	27.01
Level of education	No formal	20	5.19
	Primary	133	34.55
	Secondary	197	51.17
	Tertiary	35	9.09
Marital status	Not married	39	10.13
	Married	346	89.87
Occupation	Unemployed	197	51.17
	Formal	104	27.01
	Informal	84	21.82
Monthly income	< 500,000Ugx	288	74.81
	≥ 500,000Ugx	97	25.19
Obstetrics characteristics
History of an abortion	No	286	74.29
	Yes	99	25.71
History of UTI	No	258	67.01
	Yes	127	32.99
Parity	< 1	138	35.84
	≥ 1	247	64.16
Gestation age (weeks)	Extreme	172	44.68
	Very	88	22.86
	Moderate	55	14.29
	Late	70	18.18
Medical characteristics
Diabetes	Yes	35	9.09
	No	350	90.91
Hypertension	Yes	31	8.05
	No	354	91.95
HIV	Positive	20	5.19
	Negative	365	94.81

Ugx: Ugandan Shillings

Prevalence of urinary tract infection among women with established preterm labor admitted at JRRH

Among the 385 pregnant women tested, 114 were positive for urinary tract infection (UTI), resulting in a prevalence of 29.6% (95% CI: 25.2–34.4%) (Fig. 1).

Fig. 1.

Prevalence of urinary tract infection among women with established preterm labor admitted to JRRH

Common pathogens isolated from women with urinary tract infection in established preterm labor at JRRH

In this study, E. coli was the most frequently isolated organism, accounting for 42.98% of the cases. This was followed by Enterococcus at 24.56%, Staphylococcus at 11.4%, Streptococcus at 10.53%, Klebsiella pneumoniae at 7.89%, and Proteus mirabilis at 2.63%. These results highlight E. coli as the dominant pathogen in UTIs, with significant contributions from Enterococcus and Staphylococcus species (Fig. 2).

Fig. 2.

Common pathogens isolated from women with UTIs in established preterm labor at JRRH

Antimicrobial susceptibility patterns of isolates among women with established preterm labor at Jinja regional referral hospital

Overall, Ceftriaxone and Cefixime were the most effective antibiotics for urinary tract infections among women with established preterm labor, with overall effectiveness rates of 81% and 78%.

respectively, showing high susceptibility particularly against Enterococcus, E. coli, and K.

pneumoniae. Co-amoxiclav also demonstrated good effectiveness (73%), especially against Staph ssp. and Enterococcus. Nitrofurantoin was moderately effective (64%) but ineffective against P. mirabilis, while Ampicillin showed lower effectiveness (50%). Additionally, Azithromycin and Erythromycin had the lowest effectiveness rates, at 34% and 28% respectively, with moderate susceptibility only against Strep ssp. (Fig. 3).

Fig. 3.

Antimicrobial Susceptibility patterns (percentages of effectiveness) for each bacterial Isolates among Women with Established Preterm Labor

Factors associated with urinary tract infection among women with established preterm labor

At bivariate analysis, Factors with p values less than 0.2 that were considered for multivariate analysis included education level, occupation, income, history of UTI, parity, gestational age, diabetes status, and HIV status (Table 2). The multivariate level of analysis at a 95% CI with a p ≤ 0.05 as a statistically significant level revealed that individuals were significantly more likely to have a UTI if they had no formal education (8 times more likely), were unemployed (almost 3 times more likely), had a less than 500,000UGX monthly income (more than 2.5 times more likely), had a history of UTI (more than 4.5 times more likely), or had one or more pregnancies (nearly 2 times more likely). Specifically, those with very preterm gestation were more than 2 times more likely, those with moderate preterm gestation were nearly 6 times more likely, and those with late preterm gestation were more than 11 times more likely to have a UTI. Additionally, individuals with diabetes were more than 3 times more likely to experience a UTI (Table 3).

Table 2.

Bivariate analysis of factors associated with urinary tract infection among women with established preterm labor at Jinja Regional Referral Hospital (N = 385)

Variable	Category	Urine Culture results		cOR (95%CI)	P
		Negative UTI (n = 271) (%)	Positive UTI (n = 114) (%)
Age	< 20	28(75.68)	9(24.32)	Ref
	20–29	162(71.05)	66(28.95)	1.30(0.57–2.83)	0.563
	30–39	74(68.52)	34(31.48)	1.41(0.61–3.36)	0.412
	≥ 40	7(58.33)	5(41.67)	2.23(0.56–8.76)	0.254
Residence	Urban	77(74.04)	27(25.96)	Ref
	Rural	194(69.04)	87(30.96)	1.30(0.77–2.12)	0.341
Level of education	No formal	9(45.00)	11(55.00)	7.31(2.01–26.73)	0.003
	Primary	86(64.66)	47(35.34)	3.32(1.19–9.01)	0.021
	Secondary	146(74.11)	51(25.89)	2.13(0.77–5.69)	0.147
	Tertiary	30(85.71)	5(14.29)	Ref
Marital status	Not married	28(71.79)	11(28.21)	Ref
	Married	243(70.23)	103(29.77)	1.12(0.52–2.25)	0.839
Occupation	Formal employee	80(76.92)	24(23.08)	Ref
	Unemployed	124(62.94)	73(37.06)	2.01(1.14–3.37)	0.014
	Informal	67(79.76)	17(20.24)	0.82(0.42–1.70)	0.640
Monthly income	≥ 500,000Ugx	77(79.38)	20(20.62)	Ref
	< 500,000Ugx	194(67.36)	94(32.64)	1.90(1.08–3.23)	0.026
Obstetric characteristics
History of an abortion	No	205(71.68)	81(28.32)	Ref
	Yes	66(66.67)	33(33.33)	1.30(0.77–2.07)	0.347
History of UTI	No	203(78.68)	55(21.32)	Ref
	Yes	68(53.54)	59(46.46)	3.20(2.02–5.07)	< 0.001
Parity	< 1	106(76.81)	32(23.19)	Ref
	≥ 1	165(66.80)	82(33.20)	1.62(1.02–2.65)	0.040
Gestation age (weeks)	Extreme	147(85.47)	25(14.53)	Ref
	Very	64(72.73)	24(27.27)	2.20(1.17–4.15)	0.014
	Moderate	28(50.91)	27(49.09)	5.72(2.88–11.17)	< 0.001
	Late	32(45.71)	38(54.29)	7.01(3.701–13.15)	< 0.001
Medical characteristics
Diabetes	No	255(72.86)	95(27.14)	Ref
	Yes	16(45.71)	19(54.29)	3.20(1.57–6.45)	0.001
Hypertension	No	251(70.90)	103(29.48)	Ref
	Yes	20(64.52)	11(35.48)	1.32(0.62–2.90)	0.456
HIV status	Negative	262(71.78)	103(28.22)	Ref
	Positive	9(45.00)	11(55.00)	3.11(1.25–7.72)	0.015

cOR: crude odds ratio, CI: confidence interval, bolded P value is P < 0.2, Ugx: Ugandan shillings

Table 3.

Multivariate analysis of factors associated with urinary tract infection among women with established preterm labor at Jinja Regional Referral Hospital (N = 385)

Variable	Category	cOR (95%CI)	P	aOR (95%CI)	p
Sociodemographic characteristics
Level of education	No formal	7.31(2.01–26.73)	0.003	8.00(1.75–36.48)	0.007*
	Primary	3.32(1.19–9.01)	0.021	2.20(0.71–6.89)	0.171
	Secondary	2.13(0.77–5.69)	0.147	1.81(0.59–5.55)	0.304
	Tertiary	Ref		Ref
Occupation	Formal employee	Ref		Ref
	Unemployed	2.01(1.14–3.37)	0.014	2.72(1.38–5.23)	0.003*
	Informal	0.82(0.42–1.70)	0.640	0.9(0.42–2.16)	0.901
Monthly income	≥ 500,000Ugx	Ref		Ref
	< 500,000Ugx	1.90(1.08–3.23)	0.026	2.55(1.29–5.16)	0.007*
Obstetric characteristics
History of UTI	No	Ref		Ref
	Yes	3.20(2.02–5.07)	< 0.001	4.60(2.64–8.25)	< 0.001*
Parity	< 1	Ref		Ref
	≥ 1	1.62(1.02–2.65)	0.040	1.90(1.07–3.45)	0.028*
Gestation age (weeks)	Extreme	Ref		Ref
	Very	2.20(1.17–4.15)	0.014	2.41(1.17–4.92)	0.017*
	Moderate	5.72(2.88–11.17)	< 0.001	5.64(2.59–24.42)	< 0.001*
	Late	7.01(3.71–13.15)	< 0.001	11.40(5.28–24.42)	< 0.001*
Medical characteristics
Diabetes	No	Ref		Ref
	Yes	3.20(1.57–6.45)	0.001	3.11(1.33–7.12)	0.009*
HIV status	Negative	Ref		Ref
	Positive	3.11(1.25–7.72)	0.015	1.62(0.57–4.49)	0.373

cOR: Crude odds ratio, CI: confidence interval; bold P value is P < 0.05, aOR: adjusted odds ratio. Ugx: Ugandan Shillings

Discussion

The prevalence of UTIs among women with established preterm labor in our study was 29.6%. This prevalence was lower than 46.3% reported in the study conducted from Saudi Arabia, with significant associations with diabetes and recurrent infections [34]. The higher prevalence observed in Saudi Arabia could be related to underlying comorbid conditions and less specific diagnostic capabilities. This study utilized a comparative design and was conducted online, diagnosing UTIs symptomatically via a questionnaire. This methodology might overestimate the prevalence by including self-reported cases without laboratory confirmation. In Damt District, Yemen, a study reported a significantly higher UTI incidence of 60% among pregnant women [22] and that could be attributed to lower socioeconomic status, poor hygiene practices, and inadequate antenatal care facilities. These factors likely increase exposure and susceptibility to infections [35], leading to a higher rate of UTIs compared with our findings. In Nigeria, a study at Ahmadu Bello University Teaching Hospital reported a proportion of 64% among pregnant women [36]. This high prevalence was attributed to poor hygiene practices among the study participants, such as cleaning from the anus to the vagina after defecation, a lack of access to clean water, and inadequate healthcare facilities as they increase the likelihood of UTI [35]. The prevalence of UTIs was reported to be 35% among pregnant women at Mbarara Regional Referral Hospital in Uganda [17]. Notably, this study considered only symptomatic pregnant women over a one-year period, unlike our study, which considered all pregnant women over a shorter duration.

The lower prevalence was reported in other studies like 16% in Hyderabad, Pakistan [23]. This study included only 150 women and considered all pregnant women irrespective of gestational age. The majority of participants (64%) were from urban areas, which usually have better access to healthcare. In Harar, Eastern Ethiopia, the prevalence of UTIs was found to be 14.1% among all pregnant women [37]. The lower prevalence in this study may be attributed to effective prenatal care and routine screening practices. The large sample size of 651 and the comparative cross-sectional design used in their study also contribute to the robustness of these findings. Our study’s higher prevalence could indicate differences in healthcare access and prenatal care practices between the two regions. A systematic review and meta-analysis in Ethiopia reported that the prevalence of UTIs was 15.37% among pregnant women [14]. The lower prevalence observed in this meta-analysis is likely due to robust antenatal care and effective infection control practices. This systematic review involved 14 studies in Ethiopia, and the inclusion of various studies with different methodologies and populations from different regions could have created heterogeneity and contributed to the lower prevalence compared with our cross-sectional study design. A study in Dambam, Bauchi State, Nigeria, reported a UTI prevalence of 17.24% among pregnant women attending antenatal care clinics [38]. The lower prevalence observed in their study may be due to effective public health interventions and the widespread use of preventive measures. The study also involved only 290 pregnant women and considered both preterm and term pregnancies. The lower sample size and inclusion of term pregnancies, a group with a lower risk of UTIs as compared to preterm [6], could have contributed to the lower prevalence compared with our findings. The prevalence of UTIs in our study is within the reported global range [36, 37]. Our findings emphasize the need for routine screening and effective management of UTIs in pregnant women to prevent adverse maternal and fetal outcomes.

E. coli was the most frequently isolated organism in UTIs, accounting for 42.98% of the cases. This high prevalence can be attributed to several factors. E. coli possesses various virulence factors, such as adhesins and toxins, which facilitate its attachment to and invasion of the urinary tract epithelium, leading to infection [39]. Additionally, E. coli is a common commensal organism in the human gut, making it readily available to cause infections when it enters the urinary tract [40]. In terms of antibiotic susceptibility, ceftriaxone (78%) and nitrofurantoin (71%) are highly effective against E. coli. The effectiveness of ceftriaxone is due to its broad-spectrum activity and ability to inhibit cell wall synthesis, leading to bacterial cell death [41]. Nitrofurantoin is effective because of its unique mechanism of action, which damages bacterial DNA [42]. However, E. coli showed lower susceptibility to ampicillin (41%) and erythromycin (10%), likely due to widespread resistance mechanisms such as beta-lactamase production and efflux pumps, which reduce antibiotic efficacy [43, 44]. The second most prevalent organism was Enterococcus, which was isolated in 24.56% of the cases. Enterococcus species are known to cause UTIs, especially in hospitalized patients or those with catheterization and are resilient to survive harsh conditions, including high salt concentrations and bile, which may contribute to their ability to cause infections in the urinary tract [45]. Enterococcus strains were highly susceptible to Ceftriaxone (93%) and Cefixime (82%). The effectiveness of these antibiotics against Enterococcus is likely due to their strong activity against gram-positive bacteria [46]. However, susceptibility to ampicillin (64%) is moderate due to intrinsic resistance mechanisms such as beta-lactamase production and alterations in penicillin-binding proteins. The lower effectiveness of erythromycin (50%) can be attributed to efflux mechanisms and ribosomal mutations that confer resistance [47, 48].

Staphylococcus species were isolated in 11.4% of the patients. Staphylococcus species, including Staphylococcus aureus, can cause UTIs, particularly in patients with urinary catheters or underlying health conditions because the ability of these bacteria to form biofilms on catheters and other surfaces within the urinary tract makes them significant pathogens in healthcare-associated infections [25]. Staph species presented the greatest susceptibility to Co-amoxiclav (77%) and Ceftriaxone (69%). Co-amoxiclav is effective because of its combination of amoxicillin with clavulanic acid, which inhibits beta-lactamase enzymes, thus increasing amoxicillin activity [49]. The effectiveness of ceftriaxone is related to its broad-spectrum activity [41]. However, the lower susceptibility to ampicillin (46%) and erythromycin (46%) is likely due to the presence of beta-lactamase and macrolide resistance genes, such as erm and msrA, which modify antibiotic targets or pump the drug out of the bacterial cell [50].

Streptococcus species accounted for 10.53% of the infections. These bacteria are less common but can still be significant pathogens in UTIs, especially in pregnant women and individuals with diabetes. Their presence in the urinary tract can be attributed to their ability to adhere to and invade the epithelial cells of the urinary system [51]. Strep species showed high susceptibility to Ceftriaxone (83%) and Co-amoxiclav (75%). These antibiotics are effective because of their broad-spectrum activity and ability to disrupt bacterial cell wall synthesis [41, 49]. The moderate effectiveness of ampicillin (58%) and erythromycin (58%) can be attributed to resistance mechanisms such as altered penicillin-binding proteins and efflux pumps that reduce drug accumulation in bacterial cells [52, 53].

Klebsiella pneumoniae was isolated from 7.89% of the patients. This organism is known for its resistance to multiple antibiotics and its role in causing UTIs, particularly in healthcare settings and its ability to produce extended-spectrum beta-lactamases (ESBLs) and other resistance mechanisms make it a challenging pathogen to treat [54]. Klebsiella pneumoniae showed high susceptibility to Ceftriaxone (78%) and Co-amoxiclav (67%). The effectiveness of Ceftriaxone is due to its ability to inhibit cell wall synthesis, whereas the effectiveness of Co-amoxiclav is increased by the inhibition of beta-lactamases by clavulanic acid [49]. The lower effectiveness of cefixime (56%) and nitrofurantoin (22%) can be attributed to resistance mechanisms such as the production of ESBLs and plasmid-mediated resistance factors [55, 56].

The least common organism isolated was Proteus mirabilis, which was found in 2.63% of the cases. Proteus mirabilis is associated with complicated UTIs and can lead to the formation of kidney stones due to its ability to produce urease, which alkalizes the urine and facilitates stone formation [57]. Proteus mirabilis showed high susceptibility to Ceftriaxone (67%) and Co-amoxiclav (67%). However, Proteus mirabilis was highly resistant to nitrofurantoin (0%) and erythromycin (0%), which is consistent with its intrinsic resistance mechanisms against these antibiotics [58].

Individuals with no formal education were 8 times more likely to have a UTI. This significant association may be attributed to a lack of awareness and knowledge about personal hygiene and healthcare practices, which are essential in preventing infections such as UTIs [59, 60]. Without formal education, individuals might not understand the importance of hygiene practices and timely medical consultations, leading to higher infection rates [59]. Furthermore, lower educational levels often correlate with lower socioeconomic status, which can limit access to healthcare and clean-living conditions, further exacerbating the risk of UTIs [59, 60].

Unemployed individuals are almost 3 times more likely to have a UTI. Unemployment can lead to economic instability, which limits access to healthcare services, clean water, and sanitation facilities [61, 62]. This economic constraint can prevent individuals from seeking timely medical care and maintaining proper hygiene, increasing the risk of infection [61]. Additionally, unemployment-related stress and nutritional deficiencies can weaken the immune system, increasing the susceptibility of individuals to infections [61–63].

Individuals with a lower monthly income are more than 2.5 times more likely to have a UTI. Financial constraints can impede access to quality healthcare, medications, and necessary hygiene products. A lower income is often associated with living in environments with poor sanitation, which can increase the risk of UTIs [64]. Additionally, financial stress can negatively impact overall health, increasing the vulnerability of individuals to infections. A lower socioeconomic status can also limit access to health education, reducing knowledge about UTI prevention and treatment [64–66].

A history of UTI increases the likelihood of experiencing another UTI by more than 4.5 times. The presence of residual bacteria, persistent inflammation, or structural abnormalities in the urinary tract from previous infections can predispose individuals to recurrent UTIs [50]. Additionally, once the urinary tract is colonized by bacteria, subsequent infections can more easily occur [47, 50, 53].

Individuals who have had one or more pregnancies were nearly 2 times more likely to have a UTI. Pregnancy itself is a risk factor for UTIs because of hormonal changes and mechanical pressure on the urinary tract, which can facilitate bacterial entry and colonization and Multiple pregnancies may exacerbate these risks because of repeated physiological changes and potential weakening of the pelvic floor muscles [58]. Each pregnancy can increase the likelihood of urinary stasis and reflux, which are risk factors for UTIs [43, 52, 58].

The risk of urinary tract infections (UTIs) increased significantly with increasing gestational age in this study; those with very preterm gestation are more than 2 times more likely, those with moderate preterm gestation are nearly 6 times more likely, and those with late preterm gestation are more than 11 times more likely to have a UTI. Physiological changes during pregnancy, such as uterine enlargement, decreased urine flow through the ureters (urinary peristalsis), and decreased bladder tone, cause an increase in plasma volume that triggers bacterial growth [67]. These physiological changes create an environment conducive to bacterial proliferation, thereby increasing susceptibility to UTIs as pregnancy progresses [12, 68, 69].

Individuals with diabetes are more than 3 times more likely to experience a UTI. Diabetes is a well-known risk factor for UTIs for several reasons. High blood sugar levels can promote bacterial growth in the urinary tract [69–71]. Additionally, diabetes can impair immune function and lead to autonomic neuropathy, which affects bladder function and increases the risk of urinary retention and subsequent infections [70]. Research consistently shows that diabetic pregnant women have a greater risk of developing UTIs [69–71]. These findings highlight the multifaceted nature of risk factors associated with UTIs in preterm deliveries.

Conclusions and recommendations

The prevalence of UTIs in our study is within the reported global range, highlighting the need for routine screening and management. E. coli, the most frequently isolated organism, is highly susceptible to ceftriaxone and nitrofurantoin but resistant to ampicillin and erythromycin, suggesting the need for careful antibiotic selection. UTIs were linked to a lack of education, unemployment, low income, a history of UTIs, high parity, increasing gestational age, and diabetes. We recommend that the Uganda Ministry of Health and stakeholders provide health facilities with necessary diagnostic materials, implement routine UTI screening protocols for pregnant women, develop and disseminate updated antibiotic guidelines prioritizing Ceftriaxone and Nitrofurantoin, and launch public health campaigns to increase awareness of UTI risk factors and prevention, particularly in low-income and less educated populations.

Study strengths and limitations

The study employed laboratory-confirmed diagnoses of UTIs via urine culture, ensuring accuracy in identifying infection status, and included a substantial number of participants, enhancing the statistical power and reliability of the findings. As a cross-sectional study, it provides only a snapshot of UTI incidence and associated factors, limiting causal inferences.

Electronic supplementary material

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Abbreviations

PTL

Preterm labor

JRRH

Jinja Regional Referral Hospital

WHO

World Health Organization

REC

Research Ethics Committee

US

United States

KIU

Kampala International University

UTI

Urinary tract infection

Author contributions

AAI developed the proposal, and participated in data collection, data analysis. EE, TH and MPSI contributed significantly to the data collection, data entry, analysis and drafting of the manuscript. CABC participated in making corrections to the proposal, analysis process and the revision of manuscript. All authors have read and approved the final manuscript.

Funding

This study did not receive any grants or funding.

Data availability

The datasets utilized in this study can be obtained from the corresponding author upon request. Please contact Dr Theoneste Hakizimana via email at theonestehakizmana5@gmail.com.

Declarations

Human ethics and consent to participate

This research was approved by the research ethics committee of Bishop Stuart University and the administration of JRRH under registration number BSU-REC-2023- 273. The study was registered with the Uganda National Council for Science and Technology (UNCST). All study participants provided their written consent. All ethical standards were followed according to the Declaration of Helsinki.

Conflict of interest

There are no conflicts of interest related to this study.

Consent for publication

Not applicable to this study.

Competing interests

The authors declare no competing interests.