The UTI Project

So we’ve mentioned a few times that because of the sample debacle with his original project, M decided to pursue another research project while we’re here, especially since it’s urology related. M has settled on urology when he applies for residency next year so this was a good opportunity to perform some urology research.

The vaccine project M is working on collects tons of data on maternal and baby health and one of the routine things they do at the first prenatal visit is a screening for urinary tract infection. Urinary tract infections can have significant impact on fetal outcomes including preterm birth and low birth weight so it was interesting to the researchers that Msambweni mothers had positive results for urinary tract infections (UTI) about 50% of the time. The researchers didn’t have time to pursue this angle since they were focusing on other diseases but they told M about it and he decided to look into it.

First, he wanted to determine if there was a difference between the tests they were using (a simple dipstick) and the gold standard test, a urine culture. Second, what kinds of ‘bugs’ were causing these infections? The goal of course is to figure out if these women do indeed have lots of UTIs and if so, how to treat them. The current dipstick test gives no information about what kind of organism caused the infection so the doctors are blindly prescribing medication that may not help the women.

He designed a simple study for 150 women. The women would give a urine sample and then the sample would be tested with a dipstick and a culture. This demonstrates the accuracy of the dipstick. If the culture was positive, the infection would be identified (i.e. is it a Staph infection, an E. coli infection, etc.), and then it’s sensitivity to various antibiotics would be identified so that women could receive the correct antibiotic. Sounds fairly simple, right? Wrong. Have you learned nothing about Kenya?

First, he approached the nurses about the project. Even though the study is already paying them, they all wanted more money to be a part of M’s extension study. Their part includes a 30 second description of the study, writing the patient’s name and age and sending them to the lab. They were having none of it. After several meetings, they absolutely refused unless they could have more money. M explained how this could help their patients and how it was a part of the original study, even going so far as to show them the protocol but it was not happening. Msambweni has the worst infant mortality rate in the country but here it’s all about the money, only slightly maddening.

Then M approached the people in the lab where he works. Would they be willing to do the dipsticks since they had originally done the dipstick work? Turns out, the nurses had riled up the lab staff and they were having none of it. They wanted more money and they were concerned that their work was being “quality-controlled” against the cultures. Apparently in Kenya, the idea that your work might be checked for accuracy is horrifying. That wasn’t the aim of the study and M (and his advisor) explained it several times but they would not help. Mzungu, who I was working for, outright refused to help and led the others to refuse as well. Needless to say, I stopped working for him a few days later.

The only people who were happy to help were the people in the hospital clinical lab. You see, these guys were not involved in the other study so by helping, they were getting paid. Apparently the people who were already getting paid (the nurses and the people in M’s lab) had heard about this and that’s why they were demanding more money.

Eventually, one person from M’s lab came forward and said he needed to write a paper for his Master’s thesis and he would help if he could use this research too. He would like M to explain to him the project and for M to turn over all the papers he had found to back up the need for this study and then he would help. Perfect. With time dwindling, M agreed to help the guy out in exchange for his assistance since the master’s thesis would not be publishable in medical literature and it seemed the only way to get this done.

Meanwhile, while all this wrangling over who would help was occurring, M and I were helping the lab get their procedures for the cultures up and running. This sounds more formal and glamorous than it really was. Basically it just involved us giving repeated urine samples every day and they would culture it. Sometimes we contaminated them to make sure that these were showing up properly on culture. I’m sure everyone at the hospital thought we were insane since we spent a solid week carrying our urine around every time we left the bathroom. After a while, we started joking that we should just write a paper on our urine since no one would agree to help. We envisioned the methods section of the paper reading, “So, my wife and I peed in cups and cultured it…”. Lovely.

Actually though, our testing paid off because we realized very quickly that the samples were being contaminated by airborne contaminants floating around the hospital clinical lab. The lab is not air conditioned; in fact it’s about 100 degrees at all times. Without proper ventilation and air filtration, mold spores were drifting onto and contaminating the plates. We did a test where we opened a plate, waited one minute and closed the plate. The next day the plate was covered in mold. Also, we did a plate where we never even opened it, and mold even grew on that one! Turns out they poured the agar (the stuff on which the bacteria grows) to make the plate in open air and thereby contaminated it. M finally agreed with them that all samples from this project would be done under the lab hood and though there’s still contamination, it had been significantly reduced.

Here’s the lab below:


Did you notice the open windows and the mold on everything? Also, notice how much the refrigerator is sweating:


Also, their only equipment is microscopes and centrifuges. They have none of the standard equipment seen in an American hospital lab. Heck, they don’t even have ventilation!

Here is their equipment:


Eventually though, we finally got everyone together and on the same page and were ready to start the study. At this point, 40 mothers have been recruited and the findings are very interesting. The rate of UTI is higher than would be expected and the bacterial causes appear to be different than in US. It’s still very early the study, but contributing factors may be dehydration, hygiene, or sexual practices.

M bought some cool agar that actually determines what the bacteria is by turning a specific color so here are the results:


The blue is Enterococcus, the pink is E. coli.

These are the antibiotic sensitivities:

Basically they plate the bacteria and then drop those white pieces of paper onto the plates. Each "arm" has a different antibiotic. If the bacteria grows right next to a given arm, the bacteria is resistant to that antibiotic. If there is no growth, it means that antibiotic will work for the patient.

The clinical lab people are delighted to have this since otherwise they have to put it under the microscope and try to determine the bacteria just by looking at it. M’s study will only have 150 mothers and he bought enough for 500 plates so the lab will also get to keep these supplies.

It’s been a unique experience for M. Most med students join research projects that are already ongoing and that are conducted in US labs. They are simply handed data to ran an experiment or data to analyze. For this study, M had to buy all his own supplies, recruit the lab people, and design the culturing process. Plus, we had to design all the forms and the data capture techniques and explain them in detail to all the people involved so that the data is useful. M works with the people every day to record the data accurately and troubleshoot. It’s been a very interesting experience and I think he’s pretty happy that he doesn’t have to write a paper on our urine after all!