Genetic Control of the Variable Innate Immune Response to Asymptomatic Bacteriuria

The severity of urinary tract infection (UTI) reflects the quality and magnitude of the host response. While strong local and systemic innate immune activation occurs in patients with acute pyelonephritis, the response to asymptomatic bacteriuria (ABU) is low. The immune response repertoire in ABU has not been characterized, due to the inherent problem to distinguish bacterial differences from host-determined variation. In this study, we investigated the host response to ABU and genetic variants affecting innate immune signaling and UTI susceptibility. Patients were subjected to therapeutic urinary tract inoculation with E. coli 83972 to ensure that they were exposed to the same E. coli strain. The innate immune response repertoire was characterized in urine samples, collected from each patient before and after inoculation with bacteria or PBS, if during the placebo arm of the study. Long-term E. coli 83972 ABU was established in 23 participants, who were followed for up to twelve months and the innate immune response was quantified in 233 urine samples. Neutrophil numbers increased in all but two patients and in an extended urine cytokine/chemokine analysis (31 proteins), the chemoattractants IL-8 and GRO-α, RANTES, Eotaxin-1 and MCP-1, the T cell chemoattractant and antibacterial peptide IP-10, inflammatory regulators IL-1-α and sIL-1RA and the T lymphocyte/dendritic cell product sIL-2Rα were detected and variably increased, compared to sterile samples. IL-6, which is associated with symptomatic UTI, remained low and numerous specific immune mediators were not detected. The patients were also genotyped for UTI-associated IRF3 and TLR4 promoter polymorphisms. Patients with ABU associated TLR4 polymorphisms had low neutrophil numbers, IL-6, IP-10, MCP-1 and sIL-2Rα concentrations. Patients with the ABU-associated IRF3 genotype had lower neutrophils, IL-6 and MCP-1 responses than the remaining group. The results suggest that the host-specific, low immune response to ABU mainly includes innate immune mediators and that host genetics directly influence the magnitude of this response

Asymptomatic Bacteriuria. Protection against, and differential diagnosis towards symptomatic Urinary Tract Infection.

Urinary tract infections (UTIs) are among the most common infectious diseases in humans, with a subset of sus- ceptible individuals who experience recurrent episodes. e increase in antibiotic resistance in gram-negative uropathogens, due to antibiotic overuse, is a strong rationale for developing therapeutic alternatives and to improve diagnostics. In patients with incomplete bladder emptying (e.g. due to spinal lesions and in institutionalized older patients) asymptomatic bacteriuria (ABU) is frequent. In these patient groups diagnosis of UTI is obscured by subjective symptoms being difficult to interpret, and by the already positive urine culture. As ABU is known to be protective against symptomatic episodes, unnecessary treatment should be avoided, and the identification of objective biomarkers to support treatment decision of a suspected UTI episode is thus much needed. This thesis investigated if the same protective capacity as in spontaneously developed ABU could be induced in patients subjected to deliberate inoculation with the ABU strain E. coli 83972, and analyzed the variation of local host responses in patients with E. coli 83972 ABU and its possible genetic background, the role of the local inflammatory mediator Interleukin 6 (IL-6) and its correlation to symptom severity in UTI, and if IL-6 could be used as a diag- nostic tool in treatment decision of UTI. The results demonstrate that E. coli 83972 bacteriuria protects against symptomatic episodes in UTI prone individuals. This was shown in a placebo controlled inoculation study with cross-over design by demonstrating longer time to recurrences and fewer UTI episodes during E. coli 83972 bacteriuria as compared with control periods (Paper 1). In patients with long term E. coli 83972 ABU the level of mucosal host response to the standardized bacterial challenge demonstrates unique interindividual specific variation. Genetic analysis suggests this to depend on polymorphisms in specific genes coding for innate immunity (Paper II). Urinary concentrations of IL-6 correlate to symptom severity in UTI, and seem to be the superior biomarker for ABU/UTI differential diagnosis. This was demonstrated by analysis of symptom scoring in patients during long term E. coli 83972 ABU and during UTI episodes in the same patients. Furthermore, diagnostic thresholds for IL-6 in differentiating ABU/UTI were analyzed. (Paper III). The use of IL-6 as an added tool in ABU/UTI differential diagnosis was shown to be feasible in a nursing home setting, and reduced together with an educational intervention antibiotic prescription for UTI in a two phase interventional trial (Paper IV)

Escherichia coil 83972 Bacteriuria Protects Against Recurrent Lower Urinary Tract Infections in Patients With Incomplete Bladder Emptying

Purpose: We determined if the deliberate establishment of asymptomatic bacteriuria with Escherichia coli 83972 in patients with incomplete bladder emptying and recurrent urinary tract infection protects against recurrence. Materials and Methods: In phase 1 of the study the patients were randomized to blinded inoculations with E. coli 83972 or saline. Crossover occurred after monitoring for 12 months or after a urinary tract infection. The outcome was the time to the first urinary tract infection in patients with and without E. coli 83972 bacteriuria. In phase 2 patients were subjected to additional blinded inoculations to extend periods with and without E. coli 83972 bacteriuria. The outcome was the number of urinary tract infections during 12 months with and 12 months without E. coli 83972 bacteriuria. Results: A total of 20 patients completed the study. In phase 1 the time to the first urinary tract infection was longer with than without E. coli 83972 bacteriuria (median 11.3 vs 5.7 months, sign test p = 0.0129). Phase 2 was analyzed after patients had spent a total of 202 months with and 168 months without E. coli 83972 bacteriuria. There were fewer reported urinary tract infection episodes with vs without E. coli 83972 bacteriuria (13 vs 35 episodes, paired t test p = 0.009, CI 0.31-1.89). There was no febrile urinary tract infection episode in either of the study arms and no significant side effects of intravesical bacterial inoculation were reported. Conclusions: Deliberately induced E. coli 83972 bacteriuria protected patients with incomplete bladder emptying who are prone to urinary tract infection from recurrent urinary tract infection as demonstrated by the delay in time to urinary tract infection and the decrease in number of urinary tract infection episodes

Construction solutions and deformations in three Östgötska medieval parish churches

The purpose with this report is to illuminate the construction solutions and the deformations that could exist in medieval parish stone churches. But also to increase the writers understanding how activity forces effect the construction of the churches. With help from literature and a practical study, containing three churches the writers have collected the material that the conclusions and discussions are built upon in this report. The construction of the churches consists of three parts, the wall, the roof and the vault. The construction solutions are similar in the churches disregard of the roof, where the roof trusses are different. The roof trusses are yet typical for the roman style. The deformations that have been found can in most cases be could usual occurring in these old churches the writers chosen to study, the needs to repairmen are today not necessary. Yet the writers think that there are deformations that should be study more thorough, to derive the origin and take suitable measure. The writers think that the deformations that effect the constructions have most of their origin in some rebuilding and lost knowledge of old building engineering

Asymptomatic Bacteriuria is Harmless and Even Protective : Don't Treat if You Don't Have a Very Specific Reason

Symptom-free bacterial colonization of the lower urinary tract in an otherwise healthy individual was long misunderstood. Our current understanding is based on solid research proving that asymptomatic bacteriuria (ABU) is harmless and even protective against symptomatic urinary tract infection episodes. Thus, ABU should not be treated in patients with the exception of before endosurgery and, until we have accumulated more knowledge, in pregnant women

Bacterial interference-is deliberate colonization with Escherichia coli 83972 an alternative treatment for patients with recurrent urinary tract infection?

The increasing microbial antibiotic resistance motivates research for non-antibiotic treatment alternatives. In recurrent urinary tract infections (UTIs), 'bacterial interference' has attracted interest as a possible alternative treatment option. The observation that asymptomatic bacteriuria (ABU) protects against recurrent UTI has prompted clinical trials with deliberate colonization of the human urinary tract as an alternative approach in patients with recurrent UTI. The strain used for colonization, the ABU isolate Escherichia coli 83972, has been shown to cause symptom-free colonizations for long periods of time. Patients on long-term colonization report a subjective benefit, and UTI treatments are rare in colonized patients. This report presents an update on open long-term E. coli 83972 colonization trials and describes the design of an ongoing randomized trial. (c) 2006 Published by Elsevier B.V. and the International Society of Chemotherapy

Urodrill - a novel MRI-guided endoscopic biopsy technique to sample and molecularly classify muscle-invasive bladder cancer without fractionating the specimen during transurethral resection

The current diagnostic pathway for patients with muscle-invasive bladder cancer (MIBC), which involves with computed tomography urography, cystoscopy, and transurethral resection of the bladder (TURB) to histologically confirm MIBC, delays definitive treatment. The Vesical Imaging-Reporting and Data System (VI-RADS) has been suggested for MIBC identification using magnetic resonance imaging (MRI), but a recent randomized trial reported misclassification in one-third of patients. We investigated a new endoscopic biopsy device (Urodrill) for histological confirmation of MIBC and assessment of molecular subtype by gene expression in patients with VI-RADS 4 and 5 lesions on MRI. In ten patients, Urodrill biopsies were guided by MR images to the muscle-invasive portion of the tumor via a flexible cystoscope under general anesthesia. During the same session, conventional TURB was subsequently performed. A Urodrill sample was successfully obtained in nine of ten patients. MIBC was verified in six of nine patients, and seven of nine samples contained detrusor muscle. In seven of eight patients for whom a Urodrill biopsy sample was subjected to RNA sequencing, single-sample molecular classification according to the Lund taxonomy was feasible. No complications related to the biopsy device occurred. A randomized trial comparing this new diagnostic pathway for patients with VI-RADS 4 and 5 lesions and the current standard (TURB) is warranted. Patient summary: We report on a novel biopsy device for patients with muscle-invasive bladder cancer that facilitates histology analysis and molecular characterization of tumor samples

Patients and samples.

<p>Samples from patients participating in a clinical trial of induced <i>E. coli</i> 83972 ABU were analyzed. All collected urine samples were subjected to PMN, IL-6 and IL-8 quantification, and blood samples from eleven patients were collected for genotyping of promoter polymorphisms in TLR4 and IRF3. Blood and urine samples from these eleven patients were also selected for an extended urine protein analysis.</p