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Gram-positive bacteria are a common cause of urinary tract infection UTIparticularly among individuals who are elderly, pregnant, or who have other risk factors for UTI. Here we review the epidemiology, virulence mechanisms, and host response to the most frequently isolated Gram-positive uropathogens: Staphylococcus saprophyticus, Enterococcus faecalisand Streptococcus agalactiae.

We also review several emerging, rare, misclassified, and otherwise underreported Gram-positive pathogens of the urinary tract including Aerococcus, Corynebacterium, Actinobaculum, and Gardnerella. The literature strongly suggests that urologic diseases involving Gram-positive bacteria may be easily overlooked due to limited culture-based assays typically utilized for urine in hospital microbiology laboratories.

Some UTIs are Lee c kling sperm st louis in nature, often involving one or more Gram-positive bacteria. We herein review the risk factors and recent evidence for mechanisms of bacterial synergy in experimental models of polymicrobial UTI. Recent experimental data has demonstrated that, despite being cleared quickly from the bladder, some Gram-positive bacteria can impact pathogenic outcomes of co-infecting organisms.

When taken together, the available evidence argues that Gram-positive bacteria are important uropathogens in their own right, but that some can be easily overlooked because they are missed by routine diagnostic methods.

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Finally, a growing body of evidence demonstrates that a surprising variety of fastidious Gram-positive bacteria may either reside in or be regularly exposed to the urinary tract and further suggests that their presence is widespread among women, as well Lee c kling sperm st louis men. Experimental studies in this area are needed; however, there is a growing appreciation that the composition of bacteria found in the bladder could be a potentially important determinant Lee c kling sperm st louis urologic disease, including susceptibility to UTI.

Uncomplicated urinary tract infection UTI is most common in young, sexually active, nonpregnant, premenopausal women. The remaining proportions of uncomplicated UTI are associated with a variety of organisms, including the Gram-positive bacteria Staphylococcus saprophyticus, Enterococcus faecalis, Streptococcus agalactiae group B StreptococcusGBSand other less frequently isolated organisms. In demographic groups such as in pregnant women and the elderly, Gram-positive bacteria are found more often as etiologic agents of UTI.

While the gold standard for UTI diagnosis is bacterial culture of the urine, dipstick urinalysis is commonly used in point-of-care diagnosis. One likely explanation is that nitrite tests are likely to be negative if the infecting organism does not reduce nitrate, as is the case for most Gram-positive uropathogens including S.

Given the higher prevalence of Gram-positive bacteria as causes of UTI in certain populations such as the elderly, it is perhaps not surprising that some studies conclude that LE and nitrite are inadequate for UTI screening in this setting [ 8 ].

In short, while dipstick urinalyses can help to quickly identify UTI caused by Gram-negative bacteria, they are less useful for infections involving Gram-positive uropathogens and perform poorly in ruling out these infections with certainty.

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Complicated UTI is defined as cystitis or pyelonephritis that occurs in individuals with predisposing anatomic, metabolic, or functional risk factors that make UTI more difficult to Lee c kling sperm st louis. A recent meta-analysis of five comparative studies showed that women who had experienced FGM were at 3-times higher risk of UTI compared to those who were uncut [ 12 ]. Catheter-associated bacteriuria is often asymptomatic [ 15 ] and there is no good way to distinguish between pathogenic CAUTI and asymptomatic bacteriuria ASB ; even the presence of neutrophils in the urine pyuriawhich are a Lee c kling sperm st louis identifier of uncomplicated UTI, is not a good diagnostic indicator of CAUTI [ 13 ].

Catheter-associated bacteria are largely in a biofilm state and are thus recalcitrant to antibiotic treatment [ 131819 ].

However, if left untreated, these infections can lead to severe complications such as acute pyelonephritis, bacteremia, urosepsis, and death [ 1316 ]. While the well-adapted uropathogenic E. For example, enterococci are rarely associated with community-acquired UTI but play a prominent role in the pathogenesis of CAUTI Lee c kling sperm st louis are among the predominant pathogens isolated from polymicrobial communities Lee c kling sperm st louis the surface of indwelling urinary catheters and biliary stents [ 20 — 22 ].

Model systems to recapitulate and study infection by Gram-positive uropathogens have been adapted from those used to study UTI caused by Gram-negative bacteria. Transurethral inoculation with 1.

Under the same infection conditions, GBS showed similar kidney tropism at 1, 7, and 14 days post infection [ 25 ].

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In the murine model, catheter material is inserted transurethrally into the murine bladder prior to bacterial inoculation, where it remains throughout the course of infection. The CAUTI murine model has recently been used to test the efficacy of novel UTI therapeutics and will continue to be useful in the search for antimicrobial agents aimed at preventing or dispersing Gram-positive biofilms that arise in catheterized individuals [ 32 ].

Polymicrobial infections occur most often among the elderly, immune compromised, and those with indwelling catheters, Lee c kling sperm st louis, malignancy, and diabetes. Polymicrobial UTI is less common among young sexually active women. Since the highly polymicrobial microbiota of the GI and reproductive tracts are thought to be a major inoculation source leading to UTI, and since truly dual species or polymicrobial UTI do arise, several investigators have sought to examine the consequence of mixed microbial inoculation into the urinary tracts of model organisms.

In a rat model, transurethral inoculation of Staphylococcus saprophyticus or Proteus mirabilisresulted in ascending pyelonephritis significantly more often when the two organisms were inoculated together compared to single Lee c kling sperm st louis infection, suggesting a synergistic virulence between the two species [ 33 ].

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The use of complementary, rather than competing, central metabolism pathways in the urinary tract by UPEC and P. Co-infection with the urease-positive Gram-negative organisms P. Similar studies in mice showed that Pseudomonas aeruuginosa and E. Microscopic and microbial culture examinations, as well as culture-independent DNA sequence analysis of bacterial biofilms found on urinary Lee c kling sperm st louis, show that CAUTI biofilms are often polymicrobial in nature [ 41 — 45 ].

By analogy to mixed species effects in ascending UTI, the nature of the mixed microbial community in CAUTI may also influence the spectrum or severity of sequelae. In the next section of this chapter, we will examine the epidemiology, virulence mechanisms, and host response to the most frequently isolated Gram-positive uropathogens: Staphylococcus saprophyticus is a Lee c kling sperm st louis, coagulase negative, nonhemolytic coccus.

Colonies of Staphylococcus saprophyticus are often yellow-pigmented [ 46 ].

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It is thought that a major source of urethral inoculation is the gastrointestinal GI microbiota. However, one study found no correlation between GI colonization and subsequent S.

The cause for this seasonality is not well understood. In Lee c kling sperm st louis absence of complicating conditions, S. When it is observed, male UTI caused by S.


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