BACTERIAL INFECTIONS

OF URINARY RTACT

By
Dr. Marwa Salah

Learning objectives
1.
2.

3.

List names, major structural features, pathogenic

mechanisms, clinical significance & laboratory diagnosis
of the main bacteria that cause urinary tract infection.
Outline structure, pathogenesis, clinical significance and
laboratory diagnosis of the following bacteria as
uropathogens:
Escherichia coli
Klebsiella pneumonia
Staphylococcus saprophyticus
Proteus mirabilis
Serratia marcescens
Enterococcus faecalis
Describe structure, pathogenesis, clinical significance &
laboratory diagnosis of Pseudomonas aeruginosa as
uropathogen

References

Monica Cheesbrough, District laboratory practice in tropical

countries, part 2, 2nd edition, 2006
Jawetz, Melnick & Adelburg, Medical microbiology, 25 th ed., 2010
Kayser,Medical Microbiology, 2005

BACTERIAL INFECTIONS OF URINARY

RTACT
Bacteria

Major
structur
al
features

pathogenes
is

Clinical
significa
nce

Lab
diagnosis

Escherichi G ve
a coli
motile
bacilli

Adhesins
Haemolysin
s
K antigen

UTI

M/E
Quantitative
urine culture

Klebsiella G ve
pneumoni nona
motile
bacilli

Capsule

UTI

M/E
Quantitative
urine culture

Proteus
mirabilis

G ve
motile
bacilli

Adherence
Urease
Motility

UTI

M/E
Quantitative
urine culture

Serratia

G-ve

Adherence

UTI

M/E

Other bacteria that may cause UTI

S aureus
Other coagulase negative staphylococci
B fragilis
M tuberculosis

Predisposing factors of UTI

Short female urethra

Sexual intercourse
Senile prostatic hypertrophy
Structural & neurological abnormalities of
UT which are associated with residual
urine (incomplete emptying of bladder)
Catheterization
Host factors as DM & immunosuppression

Escherichia coli

Enterobacteriacaea (General
Features)
1. Facultative anaerobes
2. Oxidase negative
3. Ferment D-glucose (lactose fermentation is
an important differential character)
4. Reduce nitrate to nitrite

Morphology:
Gram -ve bacilli, motile, some
are capsulated
Cultural Characters:
Facultative anaerobic, 24h, 37oC
Selective indicator medium:
MacConkey agar rose pink
colonies due to lactose
fermentation

Biochemical Reactions:
1. Oxidase negative
2. Ferments glucose, lactose,
maltose, mannite, sucrose &
salicin with production of acid &
gas
3. Urease negative
4. Indole +ve, methyl red (MR)
+ve, Voges-Proskauer (VP) ve,
citrate -ve (IMVC ++--)

Antigenic structure:
Serological classification of E. coli is based on:
1. O (somatic) antigen of the cell wall lipopolysaccharide
(LPS)

2. H (flagellar) antigen
3. Capsular (K) antigen in capsulated strains

Pathogenesis
Most predominant facultative anaerobe in large intestine of man
Provides protection against harmful microorganisms
One of the important indicators of faecal pollution of water;
since it is constantly found in human & animal faeces (besides E.
faecalis & Cl. Perfringens)

Virulence Factors of uropathogenic strains

1.Uropathogenic strains have fimbrial adhesins, exotoxins
(haemolysins) and K antigen
2.LPS causes endotoxic shock

Diseases Caused by E. coli

1.Urinary tract infection (UTI)
2.Neonatal meningitis. pneumonia, sepsis, septicaemia &
endotoxic shock
3.Diarrhoea: by diarrhaeogenic strains

Urinary Tract Infection (UTI)

Community-acquired UTI:
>80% of infections
Uropathogenic strains of E. coli are
present in faeces & subsequently colonize
the vagina & periurethral region
May ascend to urethra (urethritis),
bladder (cystitis), ureters, renal pelvis
(pyelitis) and renal parenchyma
(pyelonephritis)

Hospital-acquired UTI:
Associated with urinary catheters &
caused by multi-drug resistant strains

Laboratory Diagnosis
A. Specimen: urine
Urine Sample collection
B. Direct detection:
Microscopy:
Wet mount: pus cells, motility test
Gram-stained smear

C. Culture:
Urine should be quantitatively
cultured to determine significant
bacteruria (105 CFU/ml)
D. Identification:
1.
2.
3.
4.

Colony morphology
Gram stain
Oxidase test
Biochemical reactions

In vitro susceptibility to antibiotics

(because of emergence of resistant
strains)

KLEBSIELLA

Enterobacteriacaea
Important members are K. pneumoniae,
K. ozaenae, K. rhinoscleromatis & K. oxytoca
(K. pneumoniae is the medically most
important species)

Morphology:
Gram-negative bacilli, non-motile,
capsulated (capsule is the most important
virulence factor)

Culture:
Facultative anaerobic, 24h, 37oC
Selective indicator medium:
MacConkey agar rose pink
colonies due to lactose
fermentation
Colonies are usually mucoid

Biochemical Reactions:
Klebsiella ferments sugars with production
of acid & gas
IMVC is --++

Pathogenesis
habitats:
(1) the environment: in surface water, sewage, soil
& on plants
(2) mucosal surfaces of intestinal & respiratory
tracts
Multi-drug resistant Klebsiella strains may

prevail in hospitals & cause serious

nosocomial infections

Diseases: (Community- or Hospital-acquired)

1. Urinary tract infection: The most common infection
2. Pneumonia
3. Wound & bloodstream infections
4. Neonatal sepsis & meningitis

Laboratory Diagnosis
A.Specimens: urine
B. Direct detection:
Microscopy:
Wet mount: pus cells, motility test
Gram-stained smear

C. Culture & Identification: (similar to E. coli)

Urine count

In vitro susceptibility to antibiotics

Proteus mirabilis

 Important species include Pr. mirabilis,

Pr. Vulgaris
Providencia rettgeri & M. morganii are
classified as new genera

Morphology
Gram-negative bacilli, motile,
usually pleomorphic

Cultural characters
FA, 37oC, 24h
Simple media: nutrient agar
swarming (due to high motility)
Selective indicator media:
MacConkey NLF

Biochemical reactions
Lactose non-fermenter (LNF)
H2S +ve
Phenylalanine deaminase +ve
Urease +ve

Pathogenesis

habitat: environment & human and animal

intestines
Urinary tract infection is due to ascending
infection
Virulence factors:
1.Motility invasion
2.Urease alkaline urine stone formation

Diseases (usually nosocomial)

Urinary tract infection especially caused by Pr.

Mirabilis
Wound infections

Serratia marcescence

Enterobacteriacaea
Morphology
G-ve bacilli

Culture
Some strains produce red pigment & are used for
testing efficiency of bacterial filters

Pathogenesis & clinical significance

Found in soil, water & occasionally in human

respiratory tract & faeces
Produce DNase, lipase, gelatinase
Cause opportunistic infections (bacteremia,
endocarditis, pneumonia) in hospitals

PSEUDOMONAS
AERUGINOSA

Morphology
G ve motile bacilli

Cultural characters
Aerobic, 24h, 37oC (can grow
in 42oC)
Simple media: nutrient
agar greenish exopigment
(yellow pyoverdin+blue
pyocyanin), grape-like odour
Some are -haemolytic
MacConkey agar: NLF

Biocemical reactions
Non-fermentative (acid is
produced from glucose only
oxidatively)
Oxidase +ve
Pseudomonas is not an
Entrobacteriacaea as it is
aerobic, non-fermentative &
oxidase +ve

Pathogenicity
Worldwide, part of normal flora
Grows in moist environments
Highly resistant to antibiotics & disinfectants
In hospitals (nosocomial infection)
Significant human pathogen particularly in
immunocompromised
Virulence factors: invasive, toxigenic & pyogenic
1.Pili: attachment
2.LPS: endotoxin
3.Enzymes: elastase, protease, two haemolysins
4.Exotoxin A: tissue necrosis

P. aeruginosa Infections
Community-acquired
infections

Folliculitis
External ear infections
Eye infections
Osteomyelitis
Endocarditis

Nosocomial
infections
Respiratory
infections
Urinary tract
infections
Wound infections
Meningitis
following lumbar
puncture
Chronic lung
infection in cystic

Laboratory Diagnosis
A. Specimen: urine
B. Direct detection
C. Culture:
D. Identification:
1.Colony morphology
2.Gram stain
3.Oxidase test & other
biochemical reactions
4.Phage & pyocin typing for
epidemiological purposes

In vitro susceptibility to
antibiotics

Staphylococcus
saprophyticus

 Coagulase ve staphylococci
Mannitol fermentation is
variable, usually fermenter on
mannitol-salt agar
Non-haemolytic on blood agar
Differentiated from S
epidermidis in being
novobiocin resistant
Second to E coli as a cause of
UTI in sexually active young
female

Enterococcus faecalis

 E faecalis causes 85-90% of

enterococcal infections, E faecium
causes 5-10%
Morphology
Gram +ve cocci, single, pairs or
short chains
Cultural characters
FA, can grow in 10-45oC
Grow in broth containing 6.5 %
NaCl
Non-haemolytic, occasionally
alpha-haemolytic
LF on MacConkey

E faecalis in NaCl 6.5%

S pyogenes in NaCl 6.5%

Biochemical reactions
Hydrolyse esculin in presence of
bile salts
Catalase ve
PYR +ve

Antigenic structure
Most strains react with Lancefield
group D antibodies

Pathogenesis
Part of normal intestinal flora
Antibiotic resistant: resistant to
penicillin & vancomycin, lactamase production

Clinical diseases
Hospital acquired rather than community
acquired (particularly in ICU)
Urinary tract infection: the most
common
Intra-abdominal or pelvic wound
infection
Bacteremia, endocarditis, meningitis,
peritonitis, osteomyelitis, abscesses,
wound infection