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Urinary tract infections in men: the classical urovirulent E. coli?. Peter Ulleryd Regional Medical Officer Communicable Disease Control Västra Götaland, Sweden [email protected] Professor????. No!. Co-workers.

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slide1

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

Peter Ulleryd

Regional Medical Officer

Communicable Disease Control

Västra Götaland, Sweden

[email protected]

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

professor
Professor????

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide3

No!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide4

Co-workers

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

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

cross talk
Cross-talk
  • Not only important for bacteria
  • Also for people working with:
  • E. coli
  • UTI
  • Antibiotic resistance
  • etc

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide6
Menu
  • Primitive creatures
  • UTI - classification
  • Febrile UTI in men - clinic
  • Virulence factors

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

clinicians primitive creatures
Clinicians-primitive creatures!
  • Internal medicine vs Surgeons
  • Is this of any good for my patients?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

giving a diagnosis
Giving a diagnosis
  • X no. of symptoms/signs=diagnosis
  • The most usual is the most abundant!
  • Ex. Fever + bacteriuria

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide9

Bacterial virulence factors:are they important to know for the treating physician?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide10

No!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

just uti define
Just UTI - define!!
  • Women Men Children
  • Asymptomatic Symptomatic
  • Febrile UTI Lower UTI
  • Sporadic Recurrent
  • Complicating factors

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide12

Virulence

Host factors

Infection

No infection

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide13

UTI in men

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………

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide14

Male UTI

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

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide15

Febrile UTI in men-the Gothenburg prospective study

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide16

Inclusion criteria

  • Temperature 38.0°C
  • Clinical signs/symptoms of UTI
  • Positive urine culture
  • 104 cfu/mL MSU

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide17

Investigations

  • Transrectal ultrasound (TRUS)
  • Residual urine
  • Uroflowmetry
  • Urography
  • Cystoscopy
  • Prostate-specific antigen (PSA)

At entry and after3 months

During follow-up

At entry and follow-up

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide18

Characteristics of men with febrile UTI (n=86)

Median age 63 years (18 – 86)

Previous history of UTI 38 (44%)

Flank pain and/or

costovertebral angle 31 (36%)

tenderness

Median temperature 39.5°C (38.0 – 41.4)

Median C-reactive protein 130 mg/L (9 – 420)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide19

Bacteriological findings in 86 patients with febrile UTI

Urinary isolates Blood isolates

Escherichia coli1 67 (78 %) 10

Klebsiella pneumoniae 7

Enterobacter aerogenes 1 1

Enterobacter agglomerans 1 1

Proteus mirabilis 1 1

Enterococci 4

Staphylococcus epidermidis 3 1

Group B streptococci 2

1 In one case together with Serratia marcescens

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide20

?

Is the prostate frequently involved in men with

febrile urinary tract

infection?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide21

Fig 2. Median serum PSA after an episode of febrile UTI

15

14.0

10

PSA (µg/L)

5

3.6

2.9

2.0

1.5

0

0

1

3

6

12

n=70

n=69

n=55

n=50

n=41

months

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide22

Serum PSA after an episode of febrile UTI

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide23

Prostate volume in 55 men with febrile UTI (range)

• At entry • After 3 months

49 mL 35 mL

(14 - 104 mL) (15 - 91 mL)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide24

Changes in serum PSA and prostate volumebetween the acute stage of infection and 3 months later in 49 men with febrile UTI

Reduction in prostate volume

>10% 10%

Reduction in serum PSA

>25% 40 4

25% 2 3

BJU Int 1999;84:470-4.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide25

?

Is the prostate frequently involved in men with

febrile urinary tract

infection?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide26

Yes!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide27

Febrile UTI in men

One infection – different manifestations

Acute

pyelonephritis

Febrile

UTI

Acute

prostatitis

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide28

?

Is it always necessary to examine the upper and

lower urinary tract

after a febrile UTI?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide30

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 >50 mLb 13(22)

Peak urine flow rate <10 mL/sb 8(15)

a46 abnormal findings in 35 patients.

bBased on the best performance during the acute stage or at follow-up.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide32

?

Is it always necessary to examine the upper and

lower urinary tract

after a febrile UTI?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide33

No!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide34

Urological evaluation of male febrile UTI

  • 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 2001;88:15-20

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide35

Proposed urological evaluation of male febrile UTI

  • 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

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide36

Treatment

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

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide38

Virulence characteristics of E. coli in febrile UTI

MenWomen

n=74Uncomplicated Complicated FU

Hemolysin 74% 51% 41%

P-fimbriae 51% 80% 65%

Aerobactin 46% 73%

Suggesting differences in host-parasite relationships in the male and female urinary tract.

TS

JJ

CID 1994;18:579-84

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

earlier studies of haemolysin in male uti
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. JAMA1992.
  • 10/14 isolates

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

later studies of haemolysin in male uti
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

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

prevalence of virulence factors jr johnson et al 2005
FUTI urine

(n=70)

Uninfected, rectal (n=70)

Prevalence of virulence factorsJR Johnson et al 2005

FUTI isolates exibited a significantly higher prevalence of virulence-associated phylogenetic groups, serotypes, and extraintestinal virulence genes.

Including haemolysin and CNF-1

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

comparison concurrent u r isolates jr johnson et al 2005 n 65
Comparison concurrent U+R isolatesJR Johnson et al 2005, n=65
  • 3 last rectal isolates+morph distinct
  • Only the urine isolate in 25 %
  • Urine clone + additional clone in 22%
  • Only nonurine clones in 54%

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide43

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.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

cytotoxic necrotizing factor type 1 cnf1
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.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide45

Febrile UTI in men

One infection – different manifestations

Acute

pyelonephritis

Febrile

UTI

Acute

prostatitis

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

conclusions general
Conclusions - general
  • Studies of very well characterized patients and bugs with specified infections (prospective)
  • Multidisciplinary in-/output of importance (cross–talk)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

conclusions male futi
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.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

slide48

Thank you!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

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