Gregor Reid

Is there a role for lactobacilli in prevention of urogenital and intestinal infections

This review describes the importance of microbial adhesion in the ecology of the urogenital and intestinal tracts and the influence of host and microbial factors in bacterial interference. In a recent revival of interest in bacterial interference, lactobacillus administration has been studied as a means of treating and preventing disease. Although evidence is conflicting, Lactobacillus acidophilus appears to be involved in beneficial antagonistic and cooperative reactions that interfere with establishment of pathogens in the gastrointestinal tract. The mechanisms of action are believed to involve competitive exclusion and production of inhibitory substances, including bacteriocins. These characteristics, as well as demonstrated adherence abilities in vitro, led to selection of certain Lactobacillus strains for clinical studies of cystitis. Weekly intravaginal Lactobacillus therapy reduced the recurrence rate of uncomplicated lower urinary tract infections in women. Use of Lactobacillus strains resistant to Nonoxynol-9, a spermicide that kills members of the protective normal vaginal flora, may have potential for use in women with recurrent cystitis using this contraceptive agent. In veterinary studies, bacterial interference by administration of probiotics has also been beneficial in disease prevention in animals. Carefully selected bacterial mixtures integrate with the gastrointestinal flora of the animals and can confer disease resistance and improve physiological function. Additional human and animal trials are needed to determine the practical, long-term usefulness of bacterial interference as a protective mechanism against infectious diseases. Images

Examination of strains of lactobacilli for properties that may influence bacterial interference in the urinary tract.

Lactobacilli strains vary in their ability to interfere with colonization of uroepithelial cells by pathogenic organisms. Bacterial size, adherence capability, competitive exclusion and inhibition of pathogenic growth were examined in selected strains of lactobacilli to assess their relative importance. We tested adherence to uroepithelial cells of 34 lactobacillus isolates originating from the urogenital tract, dairy sources and chickens, and 1 lactobacillus strain isolated from a commercially available preparation. The ability to adhere differed greatly among the 34 strains, with a range of 8 to 74 bacteria per cell, and the commercial strain attached poorly with a mean of 15 bacteria per cell. Eleven strains of lactobacilli were selected and found to differ in length and width dimensions. These strains were found to exclude competitively with varying efficiency 6 strains of uropathogens from adhering to uroepithelial cells. The effective ability of Lactobacillus casei GR-1 to exclude the uropathogens confirmed previous findings and other strains (GR-2, GR-3 and A-60) gave a similar range of exclusion. The lactobacillus isolates varied greatly in their ability to inhibit the growth of 11 uropathogens under the conditions of an agar overlay inhibition assay. A combination score was allocated to each of the 11 lactobacillus strains based on size, adherence, exclusion and inhibition. Lactobacillus casei GR-1 attained the highest score while the commercial strain attained the lowest score. The results of this study identified 4 properties that should be examined to select lactobacillus strains before embarking upon bacterial interference studies to prevent urinary tract and other infections in humans.

Effect on urogenital flora of antibiotic therapy for urinary tract infection.

Specimens were examined from 70 female presenting with urinary tract infection. 50 patients were randomly treated with 7 days amoxicillin or bacampicillin and another 20 randomly received amoxicillin or enoxacin. Effective clearance of the infections was achieved with each antibiotic, and only minor side effects occurred. Bacteriological analyses of the urogenital flora demonstrated a relationship between urethral carriage and bladder infection, with Escherichia coli being the most common pathogen. Antibiotic resistant E. coli were isolated more frequently from the bladder, urethra, introitus and rectum following amoxicillin treatment compared to bacampicillin and enoxacin. An examination of the urogenital flora post therapy showed that an indigenous lactobacillus population had not been restored in the majority of patients. Rather, uropathogenic bacteria were found to dominate the urethra and introitus. The effects of antibiotics on urogenital flora is clearly a matter of importance. Future clinical trials should address this. It may be that artificial supplementation of indigenous bacteria is necessary to restore the flora back to normality.

Preliminary study on the prevention of recurrent urinary tract infection in adult women using intravaginal Lactobacilli

We now report the development of gelatin suppositories containing freeze dried Lactobacillus casei GR-1 and L. fermentum B-54 chosen for their ability to adhere to uroepithelial cells and inhibit the growth of E. coli and Enterococcus faecalis in vitro. The product has a long shelf life, and is easily and safely utilized. In a preliminary study of 10 female patients who received the therapy at weekly intervals for 12 months, there was a net reduction of 66.3% in the incidence of recurrent urinary tract infections. Lactobacilli were isolated from the vagina of the patients for the duration of treatment. Examination of random specimens showed some degree of correlation between numbers of lactobacilli adherent to vaginal epithelial cells and viable organisms recovered from swabs.

Coaggregation of urogenital bacteria in vitro and in vivo

The working hypotheses of the present study were that (1) bacterial coaggregates exist in the urogenital tract of healthy and infected women, and (2) coaggregation reactions can occur in vitro between members of the urogenital flora. Examination of urogenital specimens from 25 healthy women showed that lactobacilli were the dominant organisms colonizing the epithelia and coaggregating with other Gram-positive and Gram-negative bacteria. In vitro light and electron microscopic studies confirmed that members of the urogenital flora could coaggregate. An examination of specimens from 9 women with urinary tract infection showed the presence of autoaggregated uropathogens free-floating in the urine and attached to epithelial cells. The phenomenon of autoaggregation was also noted in vitro for various uropathogens, suggestive that this may represent a virulence factor. It is evident that bacterial cell-to-cell binding within a strain and among different genera occurs in the urogenital tract. Further studies of the mechanisms that maintain and disrupt these microbial interactions will help to improve our understanding of disease initiation.

Influence of the Spermicidal Compound Nonoxynol-9 on the Growth and Adhesion of Urogenital Bacteria in vitro

Lactobacilli and uropathogenic bacteria isolated from the female urogenital tract were tested for their susceptibility to nonoxynol-9. Nonoxynol-9 is a spermicidal compound, generally used at a concentration of 5% in cream and 12.5% in foam. The growth of 67% of fresh, vaginal lactobacillus isolates was inhibited by concentrations of nonoxynol-9 between 0.1% and 1.0%; these were termed sensitive. Of a total of 47 lactobacilli from various sources, 55% were found to be sensitive to nonoxynol-9, being bacteriostatic for 42% of these isolates and bactericidal for the remaining 58% at N-9 concentrations ⩾1.0%. The remaining lactobacilli and 96% (48/50) of uropathogenic organisms had minimal inhibitory concentrations of ⩾25% for nonoxynol-9. Inhibition of the lactobacilli did not appear to be species specific nor related to the source of the lactobacilli. The adhesion of Gram-positive bacteria, namely lactobacilli and enterococci, to HeLa cells in tissue culture was significantly increased over 60 min in the presence of physiologically used concentrations of nonoxynol-9; however, adhesion ofEscherichia coli was not affected. We believe that nonoxynol-9 has the potential to increase susceptibility to urinary tract infection in women using spermicidal preparations for contraception by inhibiting the growth of lactobacilli, which are believed to have a protective function in the vagina, and allowing overgrowth of uropathogenic bacteria.

Prostatitis Associated with Chlamydia Trachomatis in 6 Patients

A number of studies have shown that Chlamydia trachomatis bacteria are important pathogens in urogenital tract infections, such as acute urethritis, acute epididymo-orchitis in male patients and pelvic inflammatory disease in female patients. We confirm a previously reported association between Chlamydia trachomatis and prostatitis. We report on 6 patients with definitive confirmation via tissue culture and an immunofluorescent technique. The results demonstrate that chlamydial prostatitis occurs in patients with nonbacterial disease. Efforts should be made to detect and eradicate the organisms from the prostate.

Ability of uropathogens to bind to tamm horsfall protein-coated renal tubular cells

SummaryEpithelial cells were isolated from a healthy human kidney and found to be of normal, renal tubular origin. The cells were maintained in tissue culture and found to secrete Tamm Horsfall protein (THP). Three strains of uropathogenic Escherichia coli, and one each of Proteus mirabilis and Pseudomonas aeruginosa were found to adhere to the THP-coated tubular cells. Extraneous THP bound to all the organisms except P fimbriated E. coli, and caused a reduction in the adhesion of type 1 fimbriated E. coli and P. mirabilis to the renal cells. However, irrespective of reduced adhesion in three of five strains tested, there was adequate evidence to indicate that THP does not competitively exclude all uropathogenic adhesion. On the contrary, its presence on renal cells may act to mediate bacterial colonization.

Pathogenesis of urinary tract infection in the elderly: the role of bacterial adherence to uroepithelial cells

The in vitro adherence of nine strains of Gram-negative bacteria to uroepithelial cells from 24 women patients (>65 years) was significantly higher than to cells from 24 premenopausal women (18–40 years). Uroepithelial cells from patients with a history of previous urinary tract infection (UTI) were marginally more receptive to attachment of uropathogens than cells from women without a history of UTI, but this was not statistically significant. Serum from four elderly women with asymptomatic bacteriuria was used to stabilize samples for electron-microscopic examination, which showed the presence of fibrous glycocalyx material surrounding the bacteria and attached to the uroepithelial cells. Eighty uropathogenic isolates from elderly and premenopausal women were found to express adhesins, to produce urease and hemolysins, and to ferment sucrose, salicin, and dulcitol. These results suggest that the increased receptivity of uroepithelial cells to bacterial attachment may be a predisposing factor in the onset of UTI in the hospitalized and domiciliary elderly population.

Effect of culture media onLactobacillus hydrophobicity and electrophoretic mobility.

The hydrophobicity of six strains representing three species ofLactobacillus was measured using dextran-polyethylene glycol contact angle measurements. These ranged from 123.6° forLactobacillus casei douche to 26.2° forL. casei RC-17 under identical growth conditions. The results indicated that the nutritional environment affected bacterial hydrophobicity. Electrophoretic mobilities of the lactobacilli were also determined and found to be negative for all specimens, and to vary with growth media, especially when sugars were added to urine. The electrophoretic mobility histograms showed one main peak for all strains, exceptLactobacillus acidophilus T-13 which had two peaks, suggesting two morphological sizes or types within its population. In addition, strain T-13 was more positively charged than the other five strains after growth in agar, urine, and supplemented urine. The use of contact angle and electrophoretic mobility techniques allows examination of cell surface properties of lactobacilli that may have importance in the colonization of mucosal epithelia.