Prostatitis.

The laboratory diagnosis of acute bacterial prostatitis is straightforward and easily accomplished in clinical laboratories. Chronic bacterial prostatitis, and especially chronic idiopathic prostatitis (most often referred to as abacterial prostatitis), presents a real challenge to the clinician and clinical microbiologist. Clinically, the diagnosis of chronic idiopathic prostatitis is differentiated from that of acute prostatitis by a lack of prostatic inflammation and no "significant" (controversial) leukocytes or bacteria in the expressed prostatic secretions. Despite these diagnostic criteria, the etiology of chronic idiopathic prostatitis is unknown. While this review covers the entire spectrum of microbially caused acute prostatitis (including common and uncommon bacteria, viruses, fungi, and parasites) and microbially associated chronic prostatitis, a special focus has been given to chronic idiopathic prostatitis. The idiopathic syndrome is commonly diagnosed in men but is poorly treated. Recent data convincingly suggests a possible bacterial etiology for the condition. Provocative molecular studies have been published reporting the presence of 16S rRNA bacterial sequences in prostate biopsy tissue that is negative for ordinary bacteria by routine culture in men with chronic idiopathic prostatitis. Additionally, special culture methods have indicated that difficult-to-culture coryneforms and coagulase-negative staphylococci are present in expressed prostatic secretions found to be negative by routine culture techniques. Treatment failures are not uncommon in chronic prostatitis. Literature reports suggest that antimicrobial treatment failures in chronic idiopathic prostatitis caused by organisms producing extracellular slime might result from the virulent properties of coagulase-negative staphylococci or other bacteria. While it is difficult to definitively extrapolate from animal models, antibiotic pharmokinetic studies with a murine model have suggested that treatment failures in chronic prostatitis are probably a result of the local microenvironment surrounding the persistent focal and well-protected small bacterial biofilms buried within the prostate gland. These conclusions support the molecular and culture data implicating bacteria as a cause of chronic idiopathic prostatitis.

Cryptic bacterial infection in chronic prostatitis: diagnostic and therapeutic implications.

Chronic idiopathic prostatitis, sometimes called prostatodynia or abacterial prostatitis, is a commonly diagnosed and poorly treated urological syndrome. Clinically, this condition frustrates the patient and physician due to its chronicity and resistance to therapy. Recent studies suggest that the etiology of chronic idiopathic prostatitis may be of bacterial origin. Three types of provocative data have demonstrated bacterial presence from prostatic specimens (tissue and secretions) that were negative by traditional clinical microbiologic tests: (i) presence of bacterial gene sequences in prostatic tissue encoding 16S rRNA and tetracycline resistance (tetM-tetO-tetS); (ii) controlled cultural findings showing coagulase-negative staphylococci as the most common isolates (68%) in prostatodynia (chronic idiopathic prostatitis); and (iii) culture of difficult-to-grow coryneforms in expressed prostatic secretions (EPS) on enriched culture media and direct microscopic observation of these pleomorphic bacteria in EPS. Additionally, earlier experimental studies in a rat model support the concept that antibiotic therapy in chronic bacterial prostatitis may not be due to altered antibiotic pharmacokinetics in the chronically inflamed prostate gland. Rather, ineffective antimicrobial eradication might result from protected bacterial micro-colonies within an infection-induced altered micro-environment deep within the prostate gland. We postulate that extracellular slime substances produced by bacteria that are buried in prostatic tissues could impair host defenses by their anti-phagocytic and anti-chemotactic properties that affect neutrophils as well as anti-proliferative characteristics that affect lymphocytes. These extracellular slime substances could also have cytoprotective properties which can conceal bacteria from otherwise bactericidal levels of antibiotics and lead to recrudescent infections resistant to therapy. Persistence of bacterial antigens might initiate a cascade of cellular immunologic events resulting in chronic inflammation of the prostate gland.

Bacterial persistence and expression of disease.

A considerable body of experimental and clinical evidence supports the concept that difficult-to-culture and dormant bacteria are involved in latency of infection and that these persistent bacteria may be pathogenic. This review includes details on the diverse forms and functions of individual bacteria and attempts to make this information relevant to the care of patients. A series of experimental studies involving host-bacterium interactions illustrates the probability that most bacteria exposed to a deleterious host environment can assume a form quite different from that of a free-living bacterium. A hypothesis is offered for a kind of reproductive cycle of morphologically aberrant bacteria as a means to relate their diverse tissue forms to each other. Data on the basic biology of persistent bacteria are correlated with expression of disease and particularly the mechanisms of both latency and chronicity that typify certain infections. For example, in certain streptococcal and nocardial infections, it has been clearly established that wall-defective forms can be induced in a suitable host. These organisms can survive and persist in a latent state within the host, and they can cause pathologic responses compatible with disease. A series of cases illustrating idiopathic conditions in which cryptic bacteria have been implicated in the expression of disease is presented. These conditions include nephritis, rheumatic fever, aphthous stomatitis, idiopathic hematuria, Crohn's disease, and mycobacterial infections. By utilizing PCR, previously nonculturable bacilli have been identified in patients with Whipple's disease and bacillary angiomatosis. Koch's postulates may have to be redefined in terms of molecular data when dormant and nonculturable bacteria are implicated as causative agents of mysterious diseases.

Bacterial infection in prostatodynia.

PURPOSE: We investigated a possible bacterial etiology for prostatodynia. MATERIALS AND METHODS: We evaluated segmented urine specimens from 22 patients and 16 controls by bacteriological localization studies. Immunological studies were performed on patient and control sera. RESULTS: Nine patients had positive cultures from prostatic secretions. When compared to controls, this novel finding was statistically significant (p < 0.025). Coagulase-negative staphylococci were the most common isolates (68%). No humoral (IgG) immune differences were found between patients and controls. CONCLUSIONS: In a subset of prostatodynia patients bacteria may have an etiological role. Antibiotic treatment demonstrated clinical efficacy.

Dormant microbes in interstitial cystitis.

Interstitial cystitis (IC) is an inflammatory disease of the urinary bladder that has no known etiology. A microbial association with this disease has not been supported since routine cultures of urine from IC patients are usually negative. However, we have demonstrated the presence of bacterial 16S rRNA genes in bladder biopsies from 29% of patients with IC, but not from control patients with other urological diseases. The ability to identify the presence of bacterial DNA in these patients was accomplished using a sensitive and specific nested PCR method capable of amplifying 16S rRNA genes from a wide variety of bacterial genera. Cloning and sequencing of 16S rRNA gene fragments amplified from bladder tissue of IC patients showed that these genes were derived from genera representing Gram-negative bacteria. In addition to the molecular data, a novel finding of 0.22 micron. filterable forms has been isolated in culture from the biopsy tissue of 14 of 14 IC patients and from 1 of 15 controls. The forms contain nucleic acids and resemble cell wall-deficient bacteria in gross morphology; however, their swirled myelin-like ultrastructure is unusual and suggests a heretofore unclassified microbe. These results demonstrate for the first time an association of Gram-negative bacterial DNA and filterable forms with affected bladder tissue from patients with IC.

Antibodies to Escherichia coli 06 porins cross-react with urinary pathogens.

Antibodies to partially purified E. coli 06 35-40 KDa porin trimers recognized the reactive epitopes in the intact porin surface molecule present in various wild-type, heterologous, urinary pathogens. The presence of lipopolysaccharide in the membrane did not shield the antibody binding sites. The reactivity was shown to be specific for porins since LPS-absorbed porin antisera reacted with porins on immunoblots and showed no reactivity with LPS. Additionally, the cross-reactions were abolished by absorption of the porin antisera with E. coli 06 containing porin trimers. These data strengthen the rationale for exploring the enhancement of immunoprotection by monoclonal antibodies to specific immunoreactive antigens in the porin molecule.

Electroeluted outer membrane proteins as immunogens.

Electroeluted outer membrane proteins [(EOmp), (35-37 KDa, porins)] were highly immunogenic in New Zealand White rabbits. An ELISA peak titer of 51,200 to EOmp as compared to 6,400 for non-eluted outer membrane protein (Omp) was demonstrated. EOmp enhanced the antigenicity of Omp possibly due to epitopes which were masked in the non-eluted antigen. Non-eluted, partially purified, Omp elicited high anti-lipopolysaccharide (LPS) titers (25,600); however, electroelution diminished LPS contamination (non detection of LPS chemically and on immunoblots) and greatly reduced the anti-LPS titer (400). It is biologically significant that anti-EOmp antibodies cross-reacted with wild-type urinary pathogens. Specificity for Omp reactivity was demonstrated by ELISA and on immunoblots with absorbed EOmp (LPS-free) antisera. These findings strengthen the rationale for exploring the protective potential of anti-Omp antibodies.

Cell wall deficient bacteria as a cause of idiopathic hematuria.

Idiopathic hematuria in the absence of bacteriuria is a medical challenge. Routine cultures of catheterized bladder and endoscopically obtained ureteral urine specimens from a 22-year-old woman with a 6-week history of hematuria showed no growth after 24 to 48 hours of incubation. However, bacterial variants were grown on enriched media. Colonies were typical cell wall deficient/defective bacteria. Phase and electron microscopy of cystoscopic urine specimens obtained by retrograde ureteral catheterization as well as phase microscopy of the cultures revealed the classic morphology of these organisms. When the variant cultures were subcultured the organisms reverted to their related walled forms, that is Streptococcus agalactiae and Staphylococcus haemolyticus. Because the colonies of these organisms showed various patterns of biochemical reactivity, each phenotype was tested against 15 antimicrobials. Collectively, all biotypes had a common susceptibility to only nitrofurantoin. The patient was treated with nitrofurantoin for 6 weeks. Four days after initiation of therapy she had complete remission of hematuria. During the next 3 years she remained well and free of hematuria.

Outer membrane proteins of E. coli in the host-pathogen interaction in urinary tract infection.

Outer membrane protein patterns (Omp) of Escherichia coli obtained directly from the urine of bacteriuric patients without passage on artificial culture media (ACM) were studied by polyacrylamide gel electrophoresis (SDS-PAGE) in an effort to determine whether in vivo conditions of growth affected the expression of these bacterial surface structures. Seventeen strains studied showed two distinct Omp patterns: one protein band appeared at the level of porin proteins (40 kDa) in both patterns, but Omp A protein was at the level of 36 kDa in the first pattern and a new protein was observed at 21.5 kDa in the second pattern suggesting that it is a fragment of Omp A. High molecular weight proteins were also observed in most of the strains and this finding was related to lack of free iron when the same strains were grown under iron restricted conditions in vitro. The same strains grown in pooled urine from normal females showed the first pattern mentioned above. Comparative growth on ACM of urinary strains and E. coli strains isolated from blood, feces and wounds showed an increase in the number of porins expressed (from 1 to 2 or 3, with some variability observed between strains). Differences in osmolality between pooled urine and ACM used, plus in vitro studies varying the osmolality of culture media, showed that osmolality accounted for differences in the number of porins expressed: porin expression decreased in urine the ACM of high osmolality, suggesting that the same phenomena occurred in vivo. It is concluded that host factors including low availability of iron and high osmolality present in the urinary tract influence the expression of several E. coli surface proteins. These proteins may relate to the ability of E. coli to colonize and invade the urinary tract by regulating the physiologic and/or metabolic state of the bacterial cell favoring survival of the organism in a hostile environment. Specific immune responses directed against porins could influence the outcome of this host-parasite interaction.

Initial antibiotic therapy for alligator bites: characterization of the oral flora of Alligator mississippiensis.

An open thumb fracture resulting from an alligator bite became infected with Aeromonas hydrophila, Enterobacter agglomerans, and Citrobacter diversus. The patient was treated by surgical debridement and antibiotic therapy. We obtained cultures from the mouth of ten alligators to characterize their oral flora. Initial empiric therapy after alligator bites should be directed at gram-negative species, in particular, Aeromonas hydrophila and anaerobic species including Clostridium. Of the numerous fungi that were isolated, none has been reported to result in wound infection after alligator bites.

Virulence of wild-type E. coli uroisolates in experimental pyelonephritis.

This study was designed to analyze the colonizing and invasive properties of wild-type bacteriuric E. coli possessing a variety of phenotypic characteristics in experimental nonobstructive pyelonephritis (P and Type 1 [T] fimbriae, hemolysin [Hly], presence of K capsules, flagella [H], serotype, biotype, human and mouse serumcidal resistance). Special emphasis was on the role of Gal-Gal adhesin (P fimbriae) of non-genetically engineered uroisolates. It was shown that organisms that are P+ or T+ or Hly+ are more likely to colonize bladders than strains negative for those parameters (P less than 0.001). Additionally, P+ strains were more often associated with kidney histopathology than P- E. coli (P less than 0.05). However, the data also indicated that fimbriae (P and Type 1) were not sole determinants of virulence since two strains devoid of fimbriae, hemolysin, K capsules and sensitive to human serumcidal activity caused incipient and acute pyelonephritis. Even among identical serotypes and biotypes, the presence/absence of fimbriae did not appear to be the critical factor in urovirulence, nor did the presence of several positive characteristics (hemolysin, K capsule, flagella, serum resistance) in a given strain enhance uropathogenicity. Therefore, these properties do not need to work together to render an E. coli urovirulent. These phenotypic characters may simply represent associated or serologic markers with the host serving as the dominant determinant of susceptibility to urinary infection. The findings emphasize the inherent limitations in relating and extrapolating colonizing and invasive properties of genetically engineered strains to those of naturally occurring, wild-type E. coli human uroisolates causing pyelonephritis.

Human choriogonadotropin-like material in bacteria of different species: electron microscopy and immunocytochemical studies with monoclonal and polyclonal antibodies.

Immunocytochemical studies using antisera to whole human choriogonadotropin (hCG), to its alpha- and beta-subunits and to the COOH-terminal peptide of hCG beta, and two monoclonal antibodies to hCG beta, demonstrated expression of hCG-like material, its individual subunits and/or fragments in nine bacterial strains. Seven of these were isolated from patients with cancer and were definitely identified as Streptococcus faecalis (three strains), Staphylococcus haemolyticus (two strains) and Staphylococcus epidermidis and Escherichia coli (single strains). The other two strains were cell-wall-deficient (CWD) variants, one identified as Streptococcus bovis, isolated from the blood of a patient with a fever of unknown origin and a possible brain abscess. The other was a Gram-negative diphtheroid isolated from the urine of a pregnant woman, which during the period of study reverted to a Gram-positive Corynebacterium identified as a 'C. ulcerans' strain and expressed the hCG-like factor only during its phase as Gram-negative diphtheroid. Electron microscopy of these nine strains (including negative controls of strains of the same species subjected to the same immunocytochemical analyses and under identical cultural conditions) revealed morphological alterations in the bacterial cell walls and cytoplasmic material and/or bizarre forms of reproduction in six of the nine strains expressing hCG-like material including the two CWD variants. Collectively, these results provided evidence that (1) hCG-producing bacteria isolated from patients with overt cancer are not a new and unique species as claimed by others, and (2) there is a close resemblance between the bacterial protein and the human trophoblastic hormone, based on immunochemical recognition of different parts of the hCG molecule.(ABSTRACT TRUNCATED AT 250 WORDS)

Host-parasite relationships in acute pyelonephritis.

During a 1-year prospective study, a total of 15 patients (seven children and eight adults) were observed with acute nonobstructive pyelonephritis. P-fimbriated Escherichia coli was the causative pathogen in all 15 patients. The same serotype of E coli that was P-fimbriated was isolated from the vaginal introitus of 60% and from the fecal flora of 86% of these patients. The only host abnormality was moderate vesicoureteral reflux in 20% of the patients. Uroepithelial cells were isolated from the first morning-voided urine from patients, who had recovered from pyelonephritis, and from age-matched controls. Using fluorescein-labelled type 1 and P-fimbriated reference strains of E coli and fluorescence-activated cell sorting (FACS) analysis, we evaluated their ability to adhere to these uroepithelial cells. P-fimbriated E coli was more adherent than type 1 fimbriated E coli, and more P-fimbriated E coli adhered to the patients' cells. Our data show that both colonization with P-fimbriated strains of E coli and receptor availability are important in the pathogenesis of pyelonephritis.

Antibodies to bacterial vaccines demonstrating specificity for human choriogonadotropin (hCG) and immunochemical detection of hCG-like factor in subcellular bacterial fractions.

Investigations were done to determine whether vaccines prepared with chemically killed Staphylococcus haemolyticus RU1 and Streptococcus bovis AV46 (bacteria that have been demonstrated to express human choriogonadotropin [hCG]-like material on their surface) elicited antibodies in rabbits with specificity for hCG determinants. In addition, the anatomical locus of the hCG-like factor was determined by separation of bacterial subcellular fractions. The results demonstrated that these bacterial vaccines elicited antibodies immunologically similar to those antibodies produced in response to the whole human trophoblastic hormone, a similarity extending even to cross-reactivity with human luteinizing hormone. The bacterial hCG-like material appeared to be localized in the membranes of the cell wall, and most was present in the soluble membranous and cytoplasmic constituents. Its expression in bacteria was a strain characteristic and not a species characteristic.

Cross-reactive immunoprotective antibodies to Escherichia coli O111 rough mutant J5.

The potential immunoprotective role of antiserum to an Escherichia coli J5 mutant derived from E. coli O111:B4 was demonstrated in an experimental mouse model. Overwhelming bacterial inocula masked the effects of cross-reactive immunoprotection due to antiserum to strain J5. Enhanced bacterial clearance was observed in mice receiving antiserum to strain J5 in sublethal infections but not from lethal doses. Incorporation of hemoglobin with the bacterial inocula decreased the 50% lethal dose of challenge organisms, allowing the demonstration of protective activity of antiserum to strain J5 in lethal infection. Pretreatment of mice with antiserum to strain J5 did not protect against lethal doses of endotoxin. The protective factor was demonstrated by exhaustive adsorption experiments to be an antibody specific for strain J5 lipopolysaccharide. The protective activity of antiserum to strain J5 was abolished only after adsorption with strain J5 lipopolysaccharide but not with Salmonella typhimurium mutants with or without enterobacterial common antigen.

Pathogenic significance of P-fimbriated Escherichia coli in urinary tract infections.

The over-all aim of this study was to determine the pathogenic significance, and bacteriological and serological characteristics of P-fimbriated organisms isolated from a general population of patients with bacteriuria. A P-receptor specific particle agglutination test was used to identify P-fimbriated bacteria among 2,010 isolates from male and female patients with bacteriuria (age range infancy to 91 years). Of the 2,010 isolates 206 (10.2 per cent) were positive for P-fimbriae by the P-receptor specific particle agglutination test. Only Escherichia coli was found to be P-fimbriated, with an incidence of 21.5 per cent among 956 Escherichia coli isolates. The critical characteristic of pyelonephritic strains of Escherichia coli was P-fimbriation. In cases of nonobstructive acute pyelonephritis 100 per cent of the infecting bacteria were P-fimbriated. The data indicated clearly that the serotype, biotype, presence of type 1 fimbriae (mannose sensitive), undefined mannose-resistant adhesions, hemolysin production and motility of P-fimbriated Escherichia coli were clinically unimportant differential strain characteristics and not indicative of the virulence of P-fimbriated Escherichia coli within clinical syndromes. Isogenic P-fimbriated Escherichia coli strains were isolated from noncompromised patients in all clinical categories, that is pyelonephritis, asymptomatic bacteriuria and cystitis. A variety of bacterial strains appears to be capable of causing acute pyelonephritis in the presence of obstructive uropathic conditions, regardless of P-fimbriation. Therefore, P-fimbriation becomes a noncritical factor in compromised patients. The P-receptor specific particle agglutination test is a simple and rapid method to determine whether bacteria are P-fimbriated and may be an important screening method to identify those bacteria isolated from individuals at risk for nonobstructive acute pyelonephritis.

Antigenic and immunogenic characteristics of subcellular fractions and whole cells of a rough E. coli 0111 (J5) mutant.

Little information is available on the antigenic and immunogenic properties of an E. coli rough mutant: J5 derived from E. coli 0111:B4, and the relationship of J5 to other cross-reacting antigens of Enterobacteriaceae. Subcellular fractions of J5 and various antigen preparations were tested against antisera to Enterobacterial Common Antigen (ECA-Kunin) and to the Re mutant of S. minnesota (R595). ECA-Kunin was demonstrated in all subcellular fractions of the J5 mutant by means of indirect hemagglutination and by hemagglutination inhibition tests. This common antigen was separable from J5 LPS by ethanol fractionation and by phenol-chloroform-petroleum ether extraction. Treatment with alkali destroyed the hemagglutinating reactivity of ECA-Kunin and revealed the complex nature of J5 surface antigens; an alkalinized 20p30 fraction (containing cell wall components) contained both specific J5 antigen and an antigen which cross-reacted with S. minnesota and S. typhimurium. This antigen was shown by absorption studies to be a new common antigen other than Re LPS or ECA-Kunin. Studies of J5 LPS by ELISA demonstrated that there was a shared cross-reactive immunodeterminant between the glycolipids of J5 and Re. Accordingly, heat-killed J5 preparations were complex vaccines which were able to elicit an antibody response with at least two specificities: ECA-Kunin and the specific J5 antigen.

Immunology of pyelonephritis in the primate model. II. Effect on immunosuppression.

Nonobstructive pyelonephritis was produced in the rhesus monkey (Macaca mulatta) by means of retrograde inoculation of Escherichia coli to the point of pyelotubular backflow. The effects of treatment with cyclophosphamide or azathioprine were determined. Commensal renal viruses were not activated by the immunosuppression, and thus did not complicate our results. Both cyclophosphamide and azathioprine prolonged the bacteriuria and produced more severe pathology. Cyclophosphamide decreased the leukocytic response and partically suppressed the antibody response. The increased amount of acute pyelonecytic response and partially suppressed the antibody response. The increased amount of acute pyelonephritic lesions after treatment with this drug suggest that the antibody and inflammatory responses may be important protective mechanisms, particularly regarding prevention of abscesses. In contrast, azathioprine did not decrease the leukocytosis nor the antibody responses, but resulted in decreased in vitro responsiveness of lymphocytes to mitogens. The increased severity of chronic pyelonephritic lesions after azathioprine treatment suggests that the cellular immune response also may be an important protective mechanism during late stages of the disease. The results thus indicate that the immune response is protective and is not directly responsible for the chronic scarring of pyelonephritis.

Immunology of pyelonephritis in the primate model: live versus heat-killed bacteria.

We produced nonobstructive pyelonephritis in the rhesus monkey (Macaca mulatta) by means of a retrograde inoculation of Escherichia coli to the point of pyelotubular backflow. To evaluate the immune response separate from the effects of infection, we introduced heat-killed bacteria in the same fashion. The disease from live bacteria is self-limited and associated with both a local and generalized immune response. The most marked cellular response is in the regional lymph nodes and is more specific to the bacterial antigen than is generalized stimulation of the immune system. Dead bacteria, while eliciting the formation of serum antibody to the O antigen, appear to ablate the cellular response seen with live bacteria. Loss of renal tubules with attended scarring and loss of renal function does occur from live bacteria. This does not appear to be due to the antigen alone (unless a heat labile antigen is responsible), because heat-killed bacteria do not cause renal scarring. Thus, renal damage seems dependent on an active infection and not on the immune response.