Scand J Infect Dis 17: 277-283, 1985

An Epidemiological Survey of Urinary Tract

Infections among Outpatients in
Northern Norway
LARS H. VORLAND,I, 2 KARIN CARLSON!
and ODD AALEN 3
From the Institutes oflMedical Biology and 3Mathematical and Physical Sciences,
University of 'Iromse, and the 2University Hospital, Tromsp, Norway
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Urinary tract infections (UTI) in all outpatients from several municipalities in Northern
Norway were examined during 1 year. Comparatively high frequencies of UTI were found
among women of all ages, among people >60 years of both sexes, in coastline municipalities,
and during the fall and winter. About 70 % of all UTI were caused by Escherichia coli, more
in women than in men. Other gram-negative enterobacteria (Klebsiella, Proteus) and gram-
positive cocci (Staphylococcus epidermidis, Staph. saprophyticus, Staph. aureus, Streptococ-
cus faecalis) caused the majority of remaining infections. Relatively more gram-positive cocci
(except Staph. saprophyticus) than gram-negative enterobacteria were from males. Patients
with gram-positive cocci, except Strep. faecalis, were generally younger than those with
gram-negative enterobacteria.
K. Carlson, PhD, Institute of Medical Biology, University of 'Iromse, N-900I Tromse, Norway
For personal use only.

INTRODUCTION
Urinary tract infections (UTI) have been recognized as a major problem in clinical
medicine for many years, but answers to important questions still remain obscure.
Investigations of hospital outpatients, or samples from general practice, have shown
that the frequency of UTI increases with age (1, 2, 3,4). Some bacterial species attack
certain age groups, while others seem to have no such predilection (3, 4).
The reasons why some people are more prone than others to UTI are poorly under-
stood. Both internal (anatomical?, immunological?, bacterial?, other?) and external (eli-
mate?, dressing habits?, physical activities?, other?) factors may be important.
Northern Norway provides regions with rather harsh coastal and inland climate, a
largely stationary population, and good physician coverage, where an epidemiological
survey may provide information concerning factors influencing UTI occurrence. The
present investigation concerns the occurrence of UTI in a large sample of the general
population in Northern Norway. The variation in UTI frequency according to age, sex,
season of the year and geographical areas was analyzed.

MATERIALS AND METHODS

Collection of UTI samples. The location of the 6 participating municipalities is shown in Fig. 1. The
areas were chosen to allow a comparison between coastal (Lyngen, Ibestad, and Gratangen) and
inland (Malselv and Bardu) municipalities with about the same total population, and between these 5
rural municipalities and the city of Harstad. On our request, all practising physicians (except 1 in
Harstad) in these 6 municipalities collected and sent urine samples from all patients with symptoms of
UTI (frequent, painful urination with or without fever) from June 1, 1979 through May 30, 1980. No
specific instructions concerning use of antibiotics were given to the participating physicians. Since
most physicians were personally known to one of the authors, and expressed strong interest in the
investigation, we believe our UTI samples to be representative. The urinary samples were inoculated
by the participating physicians on transport agar (Uricultl!!>/Urotubel!!» (5), and incubated overnight
 278 L. H. Vorland et al. Scand J Infect Dis 17 (1985)
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Fig. 1. Map of Troms coun-

ty. Municipalities participat-
ing in the study are Lyngen,
Ibestad, Gratangen (coastal),
o 1020.10 4050 Malselv and Bardu (inland),
I I I I I I kill and Harstad (city, coastal).
For personal use only.

before being sent to the Microbiological Laboratory, University Hospital, Trornse, which is the only
microbiological laboratory in this area. Urines with >100000 bacteria/ml, indicating significant
bacteriuria (6) were defined as UTI and included in the study. The bacteria were streaked on blood
agar and bromthymol blue lactose agar for further studies. The patients' domicile, the month in which
the sample was collected, and the bacterial strain was recorded in all cases. If the same person

Table 1. Weather records from the M/llselv (inland) and Evenskjer (coastal: covers
Harstad, lbestad and Gratangen) weather stations"

Time

1979 1980

Weather parameters Area" May-Aug." Sept.-Dec. Jan.-Apr.

Mean temp. (Oe) I 9.7 -0.6 -6.6

e lOA 2.5 -1.5
Mean relative humidity (%) I 72 74 74
e 82 83 78
Mean monthly precipitation (mm) I 55 56 34
e 62 64 47
Mean wind force (Beaufort) I 1.6 I.I 0.9
e 2.6 2.6 2.7
No. of days with wind velocity I 0 0 0
above 12.5 m/sec e 4 4 8

G From the Norwegian Weather Bureau.

b I = Malselv, e = Evenskjer.
C No data were available from the inland for July.
 Scand J Infect Dis 17 (1985) Urinary tract infections in Norway 279

Fig. 2. Estimated annual rate of UTI/IOoo by age

and geographical location. Since age and sex were
registered only for 1208/1433 patients an adjust-
~ 100
ment had to be made. For each group the number
of cases with age known was multiplied by
1433/1208 to get an estimate of the total number of
a so cases in that group. This estimated number was
'" then divided by the total population in the group
'"
ex
and multiplied by 1000. H = city, C = rural coast,
I = rural inland.
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Age He]
groups 70 and above

experienced> I episode of UTI during the study period, these would have been recorded as separate
infections of separate patients. The "ex of the patient was registered in 1221 cases (881 patients with
E. coli), and the patients' age and sex in 1208 cases (872 with E. coli).
Identification and analysis of bacteria. Gram-negative bacteria were identified by the 3 tube test
system (7), if necessary supplemented with API-20E (8). Gram-positive cocci were recognized by
their colony morphology. Staphylococcus aureus is coagulase-producing. Staph. epidermidis does not
produce coagulase and is sensitive to novobiocin, in contrast to Staph. saprophyticus, which is
resistant to novobiocin. Strep. faecalis is catalase negative.
For personal use only.

Blood agar plates and bromthymol blue lactose plates were prepared according to the Oxoid
Manual (1979 ed.) as modified by Statens Institutt for Folkehelse, Oslo, Norway.
Weather records. Weather records were obtained from the Norwegian Weather Bureau. The
weather records from one inland and one coastal station are summarized in Table I.
Statistical methods. Pearson's chi-square test was used to test for significance.

RESULTS
Description of the material
The geographical (Fig. 1) distribution of the population, participating physicians and
patients with UTI is shown in Table II.

Table II. Geographical distribution of patients with UTI

No. of No. of
Population participating No. of patients
Geographical area Dec. 31, 1979a physicians patients with E. coli

City
Harstad 21 605 IO 701 511
Costal municipalities
Lyngen 3881 3 250 163
Ibestad 2705 2 107 87
Gratangen I 712 2 100 70
Inland municipalities
Malselv 7668 4 153 116
Bardu 4043 3 122 97
Total 41 614 24 I 433 1044

a From Annual Statistics of Norway, 1979 (9).

 280 L. H. Vorland et al. Scand J Infect Dis 17 (1985)

DE colr
o Other species of bacteria

1 0
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Fig. 3. Monthly rate of UTI/lOoo in-

habitants.
Jan. Feb Minh April May June July Aug. Sept. Oct Nov. Dec

Distribution by age, sex and geographical district

Fig. 2 shows the incidence of infection in each age group in the city (H), coastal (C) and
inland (I) municipalities. The markedly lower incidence of UTI in the inland region was
highly signficant (p<O.OOOl). All rural coastal districts showed higher incidence of UTI
than both inland rural districts. There may have been a lower incidence of UTI in Harstad
than in the rural municipalities on the coast, but the results from Harstad are somewhat
For personal use only.

uncertain since one physician did not participate in the investigation. (This may also have
caused a slight underestimate of the rates given below.)
The increase of UTI >60 years of age was highly significant (p<O.OOOI), and seemed to
be largest in the rural municipalities on the coast. The overall I year incidence of UTI was
6.4% for women (4.8% caused by E. coli) and 0.6% for men (0.3% caused by E. coli).
The variation with age for men was more pronounced: very few UTI occurred in men
between to and 60 years (data not shown).

Distribution of the samples throughout the year

Fig. 3 shows that the highest frequency of UTI was found in the autumn (September-No-
vember) and the lowest in May through July. A statistical test for homogeneity (10)
showed that the variation through the year was significant (p<O.OOOl) for both E. coli and
other bacteria. The high incidence in February was not, however, statistically significant.

Table III. Estimated rate of UTI according to sex, age and season

Rate of UTI a
Age Sex Jan.-Apr. May-Aug. Sep.-Dec.

0-20 years Men 1.2 0.3 1.1

Women 13.6 12.7 19.0
21-50 years Men 0.6 0.8 0.7
Women 17.4 16.1 24.4
Above 50 years Men 6.9 3.9 5.5
Women 36.1 18.3 40.7

a Rates per 1000 individuals in respective groups, adjusted for incomplete registration of age as
described in legend to Fig. 2.
 Scand J Infect Dis 17 (1985) Urinary tract infections in Norway 281

Table IV. Distribution of bacterial species

Percent of total number of strains"

Bacterial species From men" From women" Both sexes"

E. coli 48.1 (4.9) 74.1 (1.3) 72.7

Klebsiella 9.6 (2.9) 6.7 (0.7) 6.7
Proteus 10.6 (3.0) 6.1 (0.7) 6.1
Staph. albus" 1.9 (1.3) 3.5 (0.5) }
Staph. epidermidis" 9.6 (2.9) 1.8 (0.4) 6.7
Staph. saprophyticus" 6.0 - 1.3 (0.3)
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Staph. aureus 3.8 (1.9) 1.4 (0.4) 1.7

Strep. faecalis 9.6 (2.9) 2.2 (0.4) 2.5
Pseudomonas 1.9 (1.3) 0.5 (0.2) 0.9
Acinetobacter 1.9 (1.3) 0.5 (0.2) 0.7
Other 2.9 (1.6) 1.8 (0.4) 1.9

Q The numbers in parentheses are the standard error.

b In all 104 strains.
C In all I 121 strains.

d In all 1437 strains (patient sex was not always noted).

e During June-December Staph. epidermidis and Staph. saprophyticus were grouped together as
Staph. albus.
For personal use only.

Further breakdown of the data showed a similar seasonal variation for each geographical
region (data not shown). The effect of autumn and winter was greatest among older people
(Table III).

Occurrence of different bacterial species

Table IV shows that the majority of the UTI were caused by E. coli. There was no
difference in bacterial distribution between different geographical areas (data not shown).

Q See footnote' to Table IV.

b The 1212 strains were isolated from the 1208 patients for whom age and sex were registered.
 282 L. H. Vorland et al. Scand J Infect Dis 17 (1985)

The distribution among the sexes, on the other hand, varied. Of the UTI caused by E. coli
only 5.7 % occurred in men. Other gram-negative strains showed somewhat less sexual
bias. A higher proportion of gram-positive cocci (with the exception of Staph. saprophyti-
cus) were isolated from men. The variation in distribution of bacterial species according to
sex is highly significant (p<O.OOOl).
The distribution of the bacterial species according to the patients' age is shown in Table
V. This analysis would have given essentially the same results if only strains from women
had been included. The enterobacteriaceae (E. coli, Klebsiella and Proteus) and Strep.
faecalis were isolated from older patients. All patients with Staph. saprophyticus were
women <50. The variation in age distribution between the bacterial species is statistically
significant (p<O.OOI).
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DISCUSSION
Epidemiology of UTI
Several factors may contribute to the observed variations in UTI incidence according to
season, geographical district, and age of patient.
1. Climate. The coast is considerably more windy, and the humidity here higher than
inland. These observations may indicate that windy, humid climate (coast, winter) predis-
poses for UTI more than a cold climate (inland, winter) or a windy, warm climate
(summer, coast). A statistical analysis was attempted in order to study more closely the
For personal use only.

connection between climate and rate of UTI. This analysis, although somewhat vague in
its conclusions, indicated the importance of rain together with cold as a risk factor for
UTI.
An effect of the climate on UTI susceptibility may be indirect. Other infections may
precede UTI (11, 12, 13). Since coughs and colds are more common in the winter they
could predispose for UTI. Stansfeld (14), however, could not confirm an association
between infections of the respiratory and urinary tracts.
2. Occupation. UTI patients are mostly women. Different occupations on the coast,
inland, or in the city, need therefore not be a major factor, since women are rarely found in
the most exposed occupations.
3. Mobility of the population. Except for the occasional need to travel to find work, the
population in these areas is quite stable. Women rarely work away from their home
municipality. Some increased travel during the summer months might affect our observa-
tions.
4. Other factors. Dressing habits may vary between the different geographical regions,
and also between seasons. One could also imagine that physician practices might vary
between the geographical areas, which might explain some of the differences. This,
however, is unlikely to mean much, since a large number of independent physicians were
involved in the project.
Relatively few investigations of seasonal variation in UTI have been published. Stans-
feld (14) and Elo et al. (15) examined UTI in children, and found the highest incidence in
the winter. Elo et al. (15) correlated a high frequency of observed UTI to low temperature
and high relative humidity. The age and sex distribution of UTI agreed with that found in
other studies (I, 2, 3, 4).

Bacterial species causing UTI

The Enterobacteriaceae were especially common in UTI in females and older people,
while gram-positive cocci attacked relatively more males (except Staph. saprophyticus
which was only found in young women). There are no obvious relationships between the
 Scand J Infect Dis 17 (1985) Urinary tract infections in Norway 283

normal habitats of the bacteria and their ability to cause UTI in different sex and age
groups. Thus, these differences probably result from specific host-parasite interactions.
The frequencies of the different bacterial species were very similar for coast and inland.
This is noteworthy in view of the much higher incidence of UTI on the coast.

ACKNOWLEDGEMENTS
We thank the general practitioners for their participation in this study and the staff at the Microbio-
logical Laboratory, University Hospital for technical assistance.

REFERENCES
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