Evaluation of the Live Biotherapeutic Product, Asymptomatic Bacteriuria Escherichia coli 2-12, in Healthy Dogs and Dogs with Clinical Recurrent UTI.

BACKGROUND: Antimicrobial resistance is an emerging problem. HYPOTHESIS/OBJECTIVE: To investigate the safety and efficacy of a live biotherapeutic product, ASB E. coli 2-12 for UTI treatment. ANIMALS: Six healthy research dogs; nine client-owned dogs with recurrent UTI. METHODS: Prospective noncontrolled clinical trial. For safety data, research dogs were sedated, a urinary catheter was inserted into the bladder; 1010 CFU/mL of ASB E. coli 2-12 was instilled. Urine was cultured on days 1, 3, and 8 post-instillation and dogs were observed for lower urinary tract signs (LUTS). For client-owned dogs, ASB E. coli 2-12 was instilled similarly and urine cultures analyzed on days 1, 7, and 14 days postinstillation. RESULTS: No LUTS were noted in any of the 6 research dogs after ASB E. coli 2-12 infusion. Pulse field gel electrophoresis (PFGE) studies confirmed the bacterial strains isolated matched that ASB E. coli 2-12 strain. Four of the nine client-owned dogs had complete or nearly complete clinical cures by day 14. Of these four dogs, 3 also had microbiologic cures at day 14; one of these dogs had subclinical bacteriuria (in addition to ASB E. coli 2-12). Three of these four dogs had ASB E. coli 2-12 isolated from their urine at day 14. With the exception of mild, temporary, self-limiting, hyporexia in two dogs on the day of biotherapeutic administration, there were no major adverse effects. CONCLUSIONS AND CLINICAL IMPORTANCE: These results suggest ASB E. coli 2-12 is safe and should be investigated in a larger controlled study evaluating clinical UTI in dogs.

Epidemiology and evaluation of chronic pelvic pain syndrome in men.

Chronic pelvic pain syndrome (CPPS), formerly known as chronic abacterial prostatitis, is characterised by pelvic or perineal pain without evidence of urinary tract infection. It manifests as pain in a variety of areas including the perineum, rectum, prostate, penis, testicles and abdomen [Litwin MS, McNaughton-Collins M, Fowler Jr FJ, Nickel JC, Calhoun EA, Pontari MA, et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999;2:369-75]. It is also frequently associated with symptoms including urinary urgency, frequency, hesitancy and poor or interrupted flow. CPPS may be associated with white cells in the prostatic secretions (inflammatory) (NIH-3A), or white cell absence in the prostatic secretions (non-inflammatory) (NIH-3B) [Krieger JN, Nyberg Jr L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999;3:236-7].

Plasma cell infiltration of the urinary bladder.

We report a novel entity of plasma cell bladder infiltration without other demonstrable disease. The patient had severe irritative voiding symptoms, hematuria, and a diffuse mucosal infiltrate with 90% plasma cells. Although the patient demonstrated some clinical and pathologic evidence consistent with interstitial cystitis and eosinophilic cystitis, a predominant finding of focal plasma cell infiltration of the urinary bladder suggests a new or previously unrecognized clinical entity.

Current concepts in urinary tract infections.

Urinary tract infections (UTIs) are common infectious diseases that can be associated with substantial morbidity and significant expenditures. This review highlights the current concepts and recent advances in our understanding and management of this condition. Specific topics include pathogenesis, host factors, antimicrobial resistance, recurrent UTIs in women, diagnosis, treatment of uncomplicated and complicated UTIs, prophylaxis, catheter associated bacteriuria, pregnancy, diabetes, UTIs in men, prostatitis, and the chronic pelvic pain syndrome. UTIs can be viewed as an interaction between specific bacterial virulence factors and the patient. A new model explaining the pathogenesis of recurrent UTIs has been presented. There is a need to reconsider traditional treatment recommendations in the face of local resistance patterns, as well as the need to make better use of drugs that are currently available. Prospects for prevention of recurrent UTI include natural compounds, bacterial interference and immunization. With regard to UTI risk in women, patients can be classified based on age, and functional and hormonal status. Appropriate treatment approaches must be based on this classification. In contrast to uncomplicated UTIs, management of most complicated infections depends on clinical experience and resources at individual institutions rather than on evidence based guidelines. Asymptomatic bacteriuria generally should not be treated except in high-risk catheterized patients and in pregnancy. UTIs in men generally require formal urologic evaluation. Our understanding of the etiologies, diagnostic strategies, and treatment options for prostatitis and the chronic pelvic pain syndrome in men continues to evolve.

Epidemiology and demographics of prostatitis.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a multifactorial problem affecting men of all ages and demographics. Currently, there is a relative dearth of epidemiological information on CPPS. It is clear that patients with CPPS have a dismal quality of life and many have benefited only minimally from empiric, goal-directed therapy. Long-term follow-up of the CPPS cohort will answer important questions about the natural and treated history of this syndrome. Similarly, ongoing and future studies will provide community-based and prevalence estimates for CPPS, morbidity rates for men with CPPS, and the rates of symptom improvement and symptom deterioration for these men, as well as the probability of benefits and harm from different treatments. Although men with CP routinely receive anti-inflammatory and antimicrobial therapy, recent studies suggest that leucocyte and bacterial counts do not correlate with severity of symptoms. These findings suggest that factors other than leucocytes and bacteria contribute to the symptoms associated with CPPS. The probability of benefits and harm from different treatments for CPPS, and reliable and valid measures to define these outcomes are eagerly awaited.

Relatedness of Escherichia coli colonizing women longitudinally.

PURPOSE: The longitudinal colonization patterns by Escherichia coli of the vaginal introitus and urinary tract were investigated. MATERIALS AND METHODS: Cultures of the vaginal introitus and midstream urine were collected once a week for 12 consecutive weeks from five women with (patients) and five without (controls) a history of urinary tract infection (UTI). RESULTS: A total of 63 E. coli isolates was obtained from the 10 women, 26 from controls and 37 from patients. The bacterial counts of E. coli present in control individuals were uniformly low, < or = 200 E. coli/mL. The numbers in patients were higher and more variable, reaching > 10(5)/mL in urine and vaginal specimens. In 16 instances, E. coli was present in the urine and the vaginal introitus concurrently (matched isolates). Random amplified polymorphic DNA (RAPD) fingerprinting was used to characterize all matched E. coli isolates. Concurrent vaginal and urinary tract colonization was more common in the patient population, and usually, the same E. coli strain was present at both sites; only 15% of the matched isolates represented different strains. The RAPD fingerprinting was also carried out on selected isolates recovered from four patients and three control individuals over the 12-week study period. Colonization of the vaginal introitus and urinary tract in these individuals varied over time. Generally, however, a predominant E. coli strain was present in the vaginal milieu, urinary tract, or both, either continuously (for as long as 9 consecutive weeks in one patient) or intermittently. CONCLUSION: The results support the concept that the vaginal mucosa acts as reservoir of E. coli which may enter the urinary tract.

Uropathogenic Escherichia coli potentiates type 1 pilus-induced apoptosis by suppressing NF-kappaB.

Urinary tract infections (UTIs) are among the most common inflammatory diseases. Acute UTIs are typically caused by type 1-piliated Escherichia coli and result in urothelial apoptosis, local cytokine release, and neutrophil infiltration. To examine the urothelial apoptotic response, a human urothelial cell line was incubated with various E. coli isolates and was then characterized by flow cytometry. Uropathogenic E. coli (UPEC) induced rapid urothelial apoptosis that was strictly dependent upon interactions mediated by type 1 pili. Interestingly, nonpathogenic HB101 E. coli expressing type 1 pili induced apoptosis at approximately 50% of the level induced by UPEC, suggesting that pathogenic strains contribute to apoptosis by pilus-independent mechanisms. Consistent with this possibility, UPEC blocked activity of an NF-kappaB-dependent reporter in response to inflammatory stimuli, yet this effect was independent of functional type 1 pili and was not mediated by laboratory strains of E. coli. UPEC suppressed NF-kappaB by stabilizing IkappaBalpha, and UPEC rapidly altered cellular signaling pathways. Finally, blocking NF-kappaB activity increased the level of piliated HB101-induced apoptosis to the level of apoptosis induced by UPEC. These results suggest that UPEC blocks NF-kappaB and thereby enhances type 1 pili-induced apoptosis as a component of the uropathogenic program.

Host pathogenesis in urinary tract infections.

Urinary tract infections (UTIs) are the result of an interaction between bacterial virulence and host defense factors that compete to invade or protect the host, respectively. Research over the past 30 years has demonstrated that vaginal colonization with uropathogens precedes most UTIs. Receptivity of the vaginal mucosa for uropathogens is an essential initial step in vaginal mucosa colonization. When vaginal and buccal epithelial cells were collected from patients susceptible to reinfection and compared with such cells obtained from controls resistant to UTIs, the strains that caused cystitis adhered much more avidly to the epithelial cells from susceptible women. These genotypic traits for epithelial cell receptivity may be a major susceptibility factor in UTIs. The presence or absence of blood group determinants on the surface of uroepithelial cells may influence an individual's susceptibility to UTIs. The protective effect in women with the secretor phenotype may be due to fucosylated structures at the cell surface which decrease the availability of putative receptors for Escherichia coli. Susceptibility among women who do not secrete blood group antigens may be due to specific E. coli-binding glycolipids that are absent in women who secrete blood group antigens. Recent studies have shown that the vaginal fluid, which forms an interface between uropathogens and epithelial cells, also influences vaginal colonizations.

Secretory IGA differentially promotes adherence of type 1-piliated Escherichia coli to immortalized vaginal epithelial cell lines.

OBJECTIVES: To elucidate the factors that influence bacterial adherence to vaginal epithelium. We developed an in vitro model to examine the interaction of type 1-piliated Escherichia coli, strain HB101/p1-17, with immortalized vaginal epithelial cells (VEC) from postmenopausal donors with (patient 1) and without (patient 2) clinical histories of urinary tract infections (UTI). METHODS: The VEC were incubated in microtiter plates in the presence of E. coli HB101/p1-17, and factors such as time, mannose concentration, and secretory immunoglobulin A (sIgA) concentration were assessed. After incubation, the numbers of bacteria bound per VEC were counted on a scintillation counter. RESULTS: The E. coli adhered to the VEC and the adherence was inhibited in the presence of 100-mM mannose solution. Clinical donor UTI histories were reflected in the binding characteristics of the VEC cell lines, with cells from patient 1 having a 30% higher baseline binding capacity than cells from patient 2 and an enhanced binding response in the presence of increasing sIgA concentrations. The sIgA concentration did not affect the patient 2 cell-bacterial binding. CONCLUSIONS: These results indicate that our in vitro model is suitable for studying the factors influencing bacterial adherence to vaginal mucosa, and that after immortalization, vaginal mucosa maintains clinically relevant characteristics that can be studied. Our data suggest that E. coli adherence to vaginal mucosa from postmenopausal women susceptible to UTI is affected by intrinsic baseline bacterial binding capacity of the mucosa cells as well as by increased sIgA concentration in the women's vaginal fluid. Increasing vaginal fluid sIgA concentration in this population may have a deleterious rather than beneficial effect.

IL-1beta and TNF-alpha in prostatic secretions are indicators in the evaluation of men with chronic prostatitis.

PURPOSE: Chronic Prostatitis, or Chronic Pelvic Pain Syndrome [CPPS], is a common disorder characterized by pelvic pain and varying degrees of inflammation in expressed prostatic secretions (EPS). In search of markers to more clearly define CPPS, we compared proinflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) levels in EPS from men with CPPS, to healthy men and men with Benign Prostatic Hyperplasia (BPH). METHODS: 78 men: controls (n = 16), BPH (n = 14), CPPS IIIA [>/=10 white blood cells per high power field (WBC/hpf) in EPS] (n = 18), CPPS IIIB [<10 WBC/hpf in EPS] (n = 20), and asymptomatic inflammatory prostatitis (AIP) (n = 10) were evaluated for EPS WBC, and IL-1beta and TNF-alpha by ELISA. RESULTS: IL-1beta and TNF-alpha levels in EPS were usually detectable in men with CPPS IIIA (89% and 45%, respectively) or AIP (90%; 100%), but less often in controls (31%; 17%), BPH (57%; 15%), and CPPS IIIB (35%; 15%) respectively. IL-1beta and TNF-alpha levels were higher in CPPS IIIA versus CPPS IIIB, and in AIP versus controls or BPH (p's <0.001). Cut-points for IL-1beta and TNF-alpha discriminated AIP from controls (predictive values = 94% and 83%, respectively) and CPPS IIIA from CPPS IIIB (predictive values 84% and 100%). Overall, there was a correlation between IL-1beta and TNF-alpha (p <0.003), but no correlation between WBC and IL-1beta (p <0.1) or TNF-alpha (p <0.50). CONCLUSIONS: Cytokines are frequently present and elevated in the EPS from men with CPPS IIIA and AIP and provide a novel means for identification, characterization and potential management of men with CPPS that differs from traditional methods based on WBC.

Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome.

OBJECTIVES: Pelvic floor tension myalgia may contribute to the symptoms of male patients with chronic pelvic pain syndrome (CPPS). Therefore, measures that diminish pelvic floor muscle spasm may improve these symptoms. Based on this hypothesis, we enrolled 19 patients with CPPS in a 12-week program of biofeedback-directed pelvic floor re-education and bladder training. METHODS: Pre-treatment and post-treatment symptom assessments included daily voiding logs, American Urological Association (AUA) symptom score, and 10-point visual analog pain and urgency scores. Pressure-flow studies were obtained before treatment in most patients. Instruction in pelvic floor muscle contraction and relaxation was achieved using a noninvasive form of biofeedback at biweekly sessions. Home exercises were combined with a progressive increase in timed-voiding intervals. RESULTS: Mean age of the 19 patients was 36 years (range 18 to 67). Four patients completed less than three treatment sessions, 5 patients completed three to five sessions, and 10 attended all six sessions. Mean follow-up was 5.8 months. Median AUA symptom scores improved from 15.0 to 7.5 (P = 0.001), and median bother scores decreased from 5.0 to 2.0 (P = 0.001). Median pain scores decreased from 5.0 to 1.0 (P = 0.001), and median urgency scores decreased from 5.0 to 2.0 (P = 0.002). Median voiding interval increased from 0.88 hours to 3.0 hours (P = 0.003). Presence of detrusor instability, hypersensitivity to filling, or bladder-sphincter pseudodyssynergia on pretreatment urodynamic studies was not predictive of treatment results. CONCLUSIONS: This preliminary study confirms that a formalized program of neuromuscular re-education of the pelvic floor muscles together with interval bladder training can provide significant and durable improvement in objective measures of pain, urgency, and frequency in patients with CPPS.

Evaluation of the cytokines interleukin 8 and epithelial neutrophil activating peptide 78 as indicators of inflammation in prostatic secretions.

OBJECTIVES: Chronic prostatitis/chronic pelvic pain syndrome (CPPS) is a disorder characterized by pelvic pain and varying degrees of inflammation exhibited in expressed prostatic secretions (EPS). To provide objective parameters of inflammation, we measured the cytokines interleukin 8 (IL-8) and epithelial neutrophil activating peptide 78 (ENA-78) in EPS of healthy men, men with benign prostatic hyperplasia (BPH), men with bacterial prostatitis (BP), and men with chronic prostatitis/CPPS. METHODS: Enzyme-linked immunosorbent assays of the EPS for IL-8 and ENA-78 were done in 63 men: control (n = 9), BPH (n = 6), BP (n = 3), inflammatory CPPS (National Institutes of Health [NIH] category IIIa) (n = 17), noninflammatory CPPS (NIH category IIIb) (n = 17), and asymptomatic inflammatory prostatitis (NIH category IV) (n = 11). RESULTS: IL-8 was detectable in all patients, and ENA-78 was detectable in all except 2 patients (threshold of detection 10 pg/mL for IL-8, 15 pg/mL for ENA-78). Mean levels of IL-8 [ENA-78] were similar in control (3010 pg/mL [423 pg/mL]), BPH (3341 pg/mL [98 pg/mL]), and IIIb (2751 pg/mL [335 pg/mL]) groups. Both cytokine levels were higher in BP (11,175 pg/mL [13,761 pg/mL]), IIIa (10,418 pg/mL [2240 pg/mL]), and IV (8571 pg/mL [1865 pg/mL]) groups. A statistically significant difference between the control group versus BP, IIIa, and IV (P <0.05) groups was found for IL-8 but not for ENA-78. CONCLUSIONS: IL-8 and ENA-78 are frequently elevated in the EPS of men with BP, CPPS IIIa, and asymptomatic inflammatory prostatitis category IV. These cytokines are direct mediators of leukocyte accumulation and activation at inflammatory sites and may be responsible, in part, for the presence of inflammatory reaction in the prostate.

Characterization of an immortalized human vaginal epithelial cell line.

PURPOSE: Adherence of type 1 piliated Escherichia coli to vaginal mucosa plays a major role in the pathogenesis of ascending urinary tract infections (UTIs) in women. Progress in understanding the mechanism of adherence to the vaginal surface could be enhanced by the utilization of well-characterized vaginal epithelial cells. The objective of this study was to immortalize vaginal epithelial cells and study their bacterial adherence properties. MATERIALS AND METHODS: Primary vaginal cells were obtained from a normal post-menopausal woman, immortalized by infection with E6/E7 genes from human papillomavirus 16 (HPV 16) and cultured in serum free keratinocyte growth factor medium. RESULTS: Positive immunostaining with a pool of antibodies to cytokeratins 1, 5, 10 and 14 (K1, K5, K10 and K14) and to K13 confirmed the epithelial origin of these cells. The immortalized cells showed binding of type 1 piliated E. coli in a pili specific and mannose sensitive manner. CONCLUSION: This model system should facilitate studies on the interaction of pathogens with vaginal mucosal cells, an essential step in the progression of ascending UTIs in women.

Evaluation of the bacterial flora of the prostate using a 16S rRNA gene based polymerase chain reaction.

PURPOSE: The role of bacteria in the chronic pelvic pain syndrome (nonbacterial prostatitis and prostatodynia) is controversial and difficult to assess because the bacterial flora of the prostate is not well defined. Polymerase chain reaction (PCR) is a highly sensitive molecular method of bacterial detection. It confirms the sterility of tissue with a high level of confidence and detects small numbers of microbial agents that may represent pathogens. We performed PCR to determine bacterial colonization of the prostate in presumably healthy men and in those undergoing simple or radical prostatectomy. MATERIALS AND METHODS: We analyzed 28 prostate samples from 18 organ donors from whom prostate tissue was obtained under sterile surgical conditions at organ withdrawal, 14 sterile surgical prostate specimens from 7 patients undergoing radical prostatectomy for prostate cancer who previously underwent transrectal biopsy and 6 sterile surgical specimens from 2 men who underwent simple prostatectomy for benign prostatic hyperplasia (BPH), including 1 with an indwelling catheter for several weeks. For PCR we used 2 sets of primers to detect bacterial 16S rRNA gene sequences. Normal prostate tissue seeded in vitro with known numbers of Escherichia coli was used to assess the sensitivity of PCR. RESULTS: Only 3 of the 28 organ donor samples had histological signs of minimal inflammation and all other samples appeared to be normal without evidence of inflammatory reaction. All of these samples were PCR negative. Of several PCR control reactions the mixture of prostate tissue seeded with known numbers of E. coli demonstrated the high sensitivity of the assay, allowing the detection of as few as 6 bacteria in the presence of 25 mg. of prostate tissue. A focal and heterogeneous distribution of inflammation and infection was noted in the 14 radical prostatectomy specimens. In the prostate cancer and BPH groups there was a strong association of inflammation with positive PCR findings. Of 11 samples 3 without but all 9 with inflammation were PCR positive. CONCLUSIONS: PCR is a highly sensitive method for detecting bacteria in the prostate. In our study negative PCR reactions in the prostate tissue of apparently healthy men made the presence of normal bacterial flora in the prostate extremely unlikely. The presence of bacteria and/or inflammation in radical prostatectomy specimens was found to be a localized process. Concordance between inflammation and positive PCR results in simple and radical prostatectomy specimens suggests that bacteria may frequently have a role in histologically inflammatory prostatitis.

A prospective study of interstitial cystitis: results of longitudinal followup of the interstitial cystitis data base cohort. The Interstitial Cystitis Data Base Study Group.

PURPOSE: We present baseline characteristics and longitudinal profiles of symptoms in the Interstitial Cystitis Data Base study, a prospective cohort study of patients with interstitial cystitis. MATERIALS AND METHODS: A total of 637 eligible patients were entered into the study and followed for symptoms of pain, urgency and urinary frequency. Median followup was 31 months. RESULTS: More than 90% of patients were white women with a median age of 43 years. Using the overall pain-urgency-frequency score 7% of participants presented with mild, 44% with moderate and 49% with severe symptoms. Severe urgency in 41% of cases and severe 24-hour frequency in 41% were more common than severe pain in 29%. Of the patients 51% reported nighttime frequency of 2 or more voids. Median duration of interstitial cystitis symptoms was 8 years and 68% of participants were previously diagnosed with the condition. The 36% of patients who withdrew from study or were lost to followup were more likely to have had more severe symptoms at baseline. Patterns of change with time suggest initial symptom improvement due to regression to the mean, and an intervention effect associated with the increased followup and care of cohort participants. Although all symptoms fluctuated, there was no evidence of significant long-term change in overall disease severity. CONCLUSIONS: Our observations support the clinical observation that interstitial cystitis is a chronic disease and no current treatments have a significant impact on symptoms with time. These results provide a foundation for the design and performance of future clinical trials in interstitial cystitis using these end points in a similar patient population.