Urinary tract infections in men: the classical urovirulent E. coli

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Urinary tract infections in menthe classical
urovirulent E. coli?
Peter Ulleryd Regional Medical
Officer Communicable Disease Control Västra
Götaland, Sweden peter.ulleryd_at_medfak.gu.se
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Professor????
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Torsten Sandberg Infectious Diseases,
Sahlgrenska University Hospital Jonas Hugosson,
Gunnar Aus, Svante Bergdahl and Björn
Zackrisson Urology, Sahlgrenska University
Hospital, Göteborg Knut Lincoln Clinical
Bacteriology, Sahlgrenska University
Hospital Flemming Scheutz The international E.
coli and Klebsiella centre (WHO),
Copenhagen   James R. Johnson VA Medical
Center, Minneapolis
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Cross-talk

• Not only important for bacteria
• Also for people working with
• E. coli
• UTI
• Antibiotic resistance
• etc

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Menu

• Primitive creatures
• UTI - classification
• Febrile UTI in men - clinic
• Virulence factors

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Clinicians-primitive creatures!

• Internal medicine vs Surgeons
• Is this of any good for my patients?

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Giving a diagnosis

• X no. of symptoms/signsdiagnosis
• The most usual is the most abundant!
• Ex. Fever bacteriuria

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Bacterial virulence factorsare they important
to know for the treating physician?
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Just UTI - define!!

• Women Men Children
• Asymptomatic Symptomatic
• Febrile UTI Lower UTI
• Sporadic Recurrent
• Complicating factors

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Traditionally - anatomic abnormalities in the
newborn - prostatic obstruction in the elderly

• Most UTI in men are complicated
• Less E. coli than in women
• Often Pseudomonas, Serratia, enterococci

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• Lower UTI Cystitis
• Febrile UTI Upper UTI Pyelo.
• Prostatitis Acute, Kron bact., Kron abact.,
  Prostatodynia
• Urethritis

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Febrile UTI in men-the Gothenburg prospective
study
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• Temperature ?38.0C
• Clinical signs/symptoms of UTI
• Positive urine culture
• ?104 cfu/mL MSU

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Median age 63 years (18 86)   Previous history
of UTI 38 (44)   Flank pain and/or
costovertebral angle 31 (36) tenderness Med
ian temperature 39.5C (38.0 41.4)   Median
C-reactive protein 130 mg/L (9 420)
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Reduction in prostate
volume gt10 ?10 Reduction in serum
PSA gt25 40 4 ?25 2 3 BJU Int 199984470-4.
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Lower urinary tract abnormalities in 83 men with
febrile UTI Abnormality No. () of
findingsa   Infravesical obstruction from BPH
requiring TURP 10 Urethral
stricture 5   Bladder diverticulum 5   Bladder
stones 3   Bladder cancer 1   Phimosis 1   Post
-void residual urine gt50 mLb 13(22) Peak
urine flow rate lt10 mL/sb 8(15) a46
abnormal findings in 35 patients. bBased on the
best performance during the acute stage or at
follow-up.
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• Conclusion
•   
• Routine imaging of the upper urinary tract seem
  dispensable.
•  
• To reveal abnormalities of clinical importance,
  evaluation should primarily be focused on the
  lower urinary tract.
• BJU Int 20018815-20

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• At 1 (3 and 6) months
•  
• Clinical control including urinary and
  obstructive symptoms
• Dipstick for hematuria
• Urine culture
• Repetition of eventual abnormal laboratory tests
•  
• Post-void residual
• Peak flow rate
• DRE

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• Ab concentration in the prostate
• High pH, calcifications, reflux
• Quinolones, (trimethoprim), ((doxycycline)) to
  obtain ab in prostatic secretion

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CID 199418579-84
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Earlier studies of haemolysin in male UTI

• Barnes RC,Daifuku R, Roddy RE, Stamm WE. Lancet,
  1986.
• 10/11 isolates
• Spach DH, Stapleton AE, Stamm WE. JAMA 1992.
• 10/14 isolates

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Later studies of haemolysin in male UTI

• Andreu et al 22/30 73
• Terai et al 72/107 69
• Ruiz et al 30/37 81
• CNF1 was also very commonly found
• concomitantly with the haemolysin gene

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Prevalence of virulence factorsJR Johnson et al
2005

• FUTI urine
• (n70)

• Uninfected, rectal (n70)

FUTI isolates exibited a significantly higher
prevalence of virulence-associated phylogenetic
groups, serotypes, and extraintestinal virulence
genes. Including haemolysin and CNF-1
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Comparison concurrent UR isolatesJR Johnson et
al 2005, n65

• 3 last rectal isolatesmorph distinct
• Only the urine isolate in 25
• Urine clone additional clone in 22
• Only nonurine clones in 54

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Figure 1. Distribution of virulence factor scores
among concurrent urine (n 65) and rectal (n
67) Escherichia coli isolates from 65 men with
febrile urinary tract infection. Only rectal
isolates that differed clonally from the host's
urine isolate are included in the rectal group.
Fractional scores were rounded down to the next
lowest integer value.
 
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Cytotoxic necrotizing factor type 1 (CNF1)

• Contribute to prostatic inflammation by E. coli
  in a rat model.
• Rippere-Lampere KE, Inf Imm, 2001.
• However, another murine model, but female,
  demonstrated no evidence of CNF1- associated
  inflammation of the urinary tract.
• Johnson DE, FEMS Imm, 2000.

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Conclusions - general

• Studies of very well characterized patients and
  bugs with specified infections (prospective)
• Multidisciplinary in-/output of importance
  (crosstalk)

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Conclusions Male FUTI

• E. coli of course.
• Pathogenesis - Deep, Dip, Dep.
• Do not take PSA.
• If investigation - aim low.
• Treatment for the prostate also.
• Common sense allowed.

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