Reinhard Fünfstück

S-Fimbria-Encoding Determinant sfaI Is Located on Pathogenicity Island III536 of Uropathogenic Escherichia coli Strain 536

ABSTRACT The sfaI determinant encoding the S-fimbrial adhesin of uropathogenic Escherichia colistrains was found to be located on a pathogenicity island of uropathogenic E. coli strain 536. This pathogenicity island, designated PAI III536, is located at 5.6 min of theE. coli chromosome and covers a region of at least 37 kb between the tRNA locus thrW and yagU. As far as it has been determined, PAI III536 also contains genes which code for components of a putative enterochelin siderophore system of E. coli and Salmonella spp. as well as for colicin V immunity. Several intact or nonfunctional mobility genes of bacteriophages and insertion sequence elements such as transposases and integrases are present on PAI III536. The presence of known PAI III536 sequences has been investigated in several wild-type E. coli isolates. The results demonstrate that the determinants of the members of the S-family of fimbrial adhesins may be located on a common pathogenicity island which, in E. coli strain 536, replaces a 40-kb DNA region which represents anE. coli K-12-specific genomic island.

Uncomplicated Urinary Tract Infections

BACKGROUND Urinary tract infections (UTIs) are among the most common types of bacterial infection in outpatient medicine. Rising rates of antibiotic resistance and a better understanding of the ecological adverse effects (collateral damage) of antibiotics warrant a reevaluation of the treatment recommendations for uncomplicated UTI. The new S3 guideline contains updated recommendations. METHODS The new S3 guideline is based on a review of publications on uncomplicated UTI retrieved by a systematic search of the Medline and Cochrane Library databases. Guidelines from abroad were also considered in the review. RESULTS Uncomplicated UTI is classified as either uncomplicated cystitis (UC) or uncomplicated pyelonephritis (UP). The choice of a suitable antibiotic is determined by the following main criteria: the patients individual risk profile and prior antibiotic treatment, if any; the spectrum of pathogens and antibiotic susceptibility; the proven efficacy of the antibiotic; the ecological adverse effects (collateral damage) of antimicrobial therapy; the side effects for the patient under treatment. On the basis of these criteria, co-trimoxazole/trimethoprim and fluoroquinolones can no longer be recommended as first-line empirical treatment for UC. Rather, the new recommended treatment of first choice consists of fosfomycin-trometamol, nitrofurantoin, or pivmecillinam. High-dose fluoroquinolones are still recommended, however, as first-line oral treatment for UP. Asymptomatic bacteriuria should only be treated in exceptional situations such as pregnancy or before urological procedures that will probably injure the mucosa of the urinary tract. CONCLUSION The new S3 guideline on uncomplicated UTI incorporates a forward-looking approach to the use of antibiotics in treating this common type of infection. It is intended to bring about a sustained improvement in the quality of care.

Differential expression of β-chemokines MCP-1 and RANTES and their receptors CCR1, CCR2, CCR5 in acute rejection and chronic allograft nephropathy of human renal allografts

Background: The (3-chemokines MCP-1 (CCL2) and RANTES (CCL5) have been shown to play important roles in acute renal transplant rejection (AR) and chronic allograft nephropathy (CAN). The potential relationship of expression of these chemokines, their chemokine receptors CCR1, CCR2, CCR5, and the cell populations of inflammatory infiltrate, histological and clinical diagnoses were investigated in biopsies at the time of AR and compared with biopsies of CAN. Methods: In 24 renal transplant biopsies with AR (n = 15) and CAN (n = 9), the expression of MCP-1 and RANTES, their receptors CCR 1, CCR2, and CCR5 and the infiltration with monocytes/ macrophages and T cells were studied. Results: As previously described, chemokine and chemokine receptor expression was found mainly in mononuclear cells infiltrating the interstitium and glomeruli. In the tubulointerstitial area and glomeruli the expression of MCP-I, RANTES, and their receptors correlated with an infiltration by monocytes/macrophages. Biopsies with CAN revealed a lower expression of MCP-1, RANTES, CCR 1, CCR2 and CCR5 in tubulo-interstitial cells, and a significantly lower infiltration with MRP14-positive monocytes/ macrophages than biopsies with AR. In AR, MCP-1 and CCR1 showed a lower expression compared to RANTES, CCR2, and CCR5. Conclusions: The positive correlation between chemokines and chemokine receptors and infiltrating leukocytes during acute rejection, the lower but detectable expression of MCP-1, RANTES, CCR1, CCR2 and CCR5 in CAN, and the differences in the quantity of expression between the different chemokines and chemokine receptors point to a complex regulation of chemokine expression in renal allografts. Since chemokines are not only involved in inflammation but also in tissue regeneration, this could have impact on the development of CAN.

THE EFFECTS OF PROLONGED PHYSICAL EXERCISE ON RENAL FUNCTION, ELECTROLYTE BALANCE AND MUSCLE CELL BREAKDOWN

BACKGROUND Postexercise proteinuria, hematuria and changes in serum electrolyte balance as well as increased levels of plasma indicators for muscle leakage are believed to be transient and of benign character. METHODS A group of 51 healthy athletes took part in a 100 km race over 14.25 hours. All of them had to reach the finish together. Urine and blood samples were collected before (a) and immediately after running (b) as well as 6 hours after the race (c). RESULTS The serum concentrations of potassium (4.8 +/- 0.5 (a) vs. 4.0 +/- 0.3 (c) mmol/l), protein (73.1 +/- 5.2 (a) vs. 71.1 +/- 3.9 (c) g/l) and albumin (44.0 +/- 2.85 (a) vs. 42.9 +/- 2.8 (c) g/l) decreased significantly (p < 0.0001, p < 0.05, p < 0.05, respectively) but remained within physiological ranges. The serum sodium concentration decreased immediately after the race (136.9 +/- 4.5 (a) vs. 131.1 +/- 2.4 (b) micromol/l, p < 0.0001). The fractional sodium excretion decreased 6 hours, but not immediately after the race (0.78 +/- 0.59 (a) vs. 0.48 +/- 0.82 (c), p < 0.05). Myoglobin (31.8 +/- 6.9 (a), 291.5 +/- 197.2 (b) and 182.2 +/- 135.3 (c) microg/l, p < 0.0001) and creatine kinase (1.13 +/- 0.45 (a), 10.76 +/- 6.9 (b) and 9.46 +/- 15.5 (c) pmol/l, p < 0.0001) increased dramatically. Troponin I was also significantly increased at finish (0.0186 +/- 0.0121 (a) vs. 0.0213 +/- 0.0165 (b) ng/ml, p < 0.05) and positively correlated with myoglobin and creatine kinase, but remained far below the pathologic range. Serum creatinine and urea remained almost unchanged. Glucosuria and hematuria occurred 6 hours after the run in 9.1% and 6.8%, respectively. The erythrocytes examined by phase-contrast microscopy were not damaged in terms of dysmorphic cells. Glomerular-type proteinuria was found in 11.4% of the participants 6 hours after the race. CONCLUSIONS We conclude that long lasting, mild exertion is harmless for renal function, electrolyte balance and skeletal muscle as well as myocardial metabolism in healthy persons.

Reinfektionsprophylaxe durch L-Methionin bei Patienten mit einer rezidivierenden Harnwegsinfektion

Zusammenfassung□ FragestellungEine Vielzahl verschiedener antimikrobieller Chemotherapeutika steht zur Behandlung bakterieller Infektionen der Nieren und des Urogenitaltraktes zur Verfügung. Problematisch ist die Beeinflussung chronischer Erkrankungsverläufe, da rezidivierende/rekurrierende Infektionen zu Störungen der Blasen- und Nierenfunktion sowie zu einer irreversiblen Nierenparenchymschädigung führen können. Die vorliegenden Untersuchungen sollten klären, ob durch die regelmäßige Einnahme von L-Methionin (Acimethin®) bei Patienten mit einer rezidivierenden Harnwegsinfektion eine wirksame Reinfektionsprophylaxe möglich ist.□ Patienten und MethodikIn die Untersuchungen wurden 33 Frauen einbezogen. Nach einer akuten Erkrankung wurden zur Verhütung einer erneuten Infektexazerbation 23 Frauen (Alter: 47,4±13,3 Jahre) für einen Zeitraum von 26 Monaten mit 3mal 1 Filmtablette Acimethin® (L-Methionin) täglich behandelt. Als Kontrollgruppe dienten zehn Patientinnen (Alter: 47,4±12,2 Jahre), die für die Dauer von 21,6 Monaten 3mal täglich 1 Tablette Nevigramon® (Nalidixinsäure) einnahmen. Zur Beurteilung des Therapieerfolgs wurden vor Beginn, im mittleren Behandlungszeitraum sowie nach der letzten Medikamenteneinnahme Kontrolluntersuchungen vorgenommen.□ ErgebnisseUnter der Behandlung mit L-Methionin kam es zu keiner akuten Infektion. Die Entzündungsparameter (Leukozytenzahlen, C-reaktives Protein, Blutkörperchensenkungsreaktion, α2-Globulin-Konzentration) befanden sich im Normbereich; Beeinträchtigungen der Nierenfunktion wurden nicht registriert. Obwohl die Therapie mit L-Methionin bzw. Nalidixinsäure zu keiner signifikanten Veränderung des Keimspektrums führte, wurde die Adhärenz uropathogener Mikroorganismen an den Zellen des Harntraktes durch beide Medikamente verringert. Vor Beginn der Behandlung mit L-Methionin betrug die durchschnittliche Beladung der Uroepithelzellen 95,9±73,6 Bakterien pro Zelle, und zum Abschluß der Beobachtungsperiode wurden 51,2±56,4 Bakterien pro Zelle (p<0,03) registriert. Unter der Verordnung mit Nalidixinsäure wurde die Zytoadhärenz von 74,0±88,4 auf 34,4±37,8 Bakterien pro Zelle (p<0,25) reduziert. Unter der Behandlung mit L-Methionin fanden sich keine Escherichia-coli-Stämme mehr mit den Fähigkeiten zur Hämolysinproduktion und Aerobactinbildung. Dagegen fiel bei den auf den Uroepithelzellen adhärierten Erregern eine Zunahme der Fähigkeit zur mannose-resistenten Hämagglutination auf.□ SchlußfolgerungL-Methionin eignet sich zur Reinfektionsprophylaxe bei chronischen Harnwegsinfektionen. Der wesentliche Behandlungserfolg ergibt sich durch die Beeinflussung der bakteriellen Zytoadhärenz. Im Gegensatz zu den bereits etablierten Empfehlungen zur Reinfektionsprophylaxe mit Antibiotika oder Sulfonamiden, die bei einer längeren Anwendung resistente Stämme selektieren, ist über Resistenzentwicklungen gegenüber L-Methionin nichts bekannt.Summary□ ProblemA great variety of different antimicrobial chemotherapeutics is available for the treatment of urinary tract infections. Influencing the course of chronic diseases is a problem because recurrent diseases may result in disturbances of renal and bladder functions as well as in irreversible damages of the renal parenchyma. The present investigations are expected to clarify whether an effective prevention of reinfection in patients with chronically recurrent urinary tract infection is possible by a regular administration of L-methionine (Acimethin®).□ Patients and Methods33 female patients were included in the examinations. Following acute disease, 23 females (aged: 47.4±13.3 years) were treated with 3×1 tablet of Acimethin® (L-methionine) daily over a period of 26 months. Ten female patients (aged: 47.4±12.2 years) taking 1 tablet of Nevigramon® (nalidixic acid) three times daily over 21.6 months served as a control group. Before starting treatment and in the middle of the therapy period control examinations were performed and following the last drug administration so as to assess the therapeutic result.□ ResultsNo acute infection occurred during L-methionine treatment. All parameters of inflammation (leucocyte count, C-reactive protein, blood sedimentation rate, α2-globulin concentration) were in the normal range; no impairment of renal function was observed. Although L-methionine, i. e. nalidixic acid, did not yield any significant changes in the range of bacteria, the adherence of uropathogenic microorganisms to the cells of the urinary tract was reduced. Before L-methionine treatment, the average load of the uroepithelial cells was 95.9±73.6 bacteria per cell. When the observation period was completed, 51.2±56.4 bacteria per cell were registered (p<0.03). During nalidixic acid treatment, the rate of adherence was reduced from 74.0±88.4 to 34.4±37.8 bacteria per cell (p<0.25). During L-methionine treatment, no Escherichia coli strains that are able to produce hemolysin or to form aerobactine were found. Among agents adhering to uroepithelial cells, however, an increase in their ability to produce mannose-resistant hemagglutination was conspicuous.□ ConclusionL-methionine is suitable to prevent reinfection with chronic urinary tract infection. The therapeutic result is essentially due to its influence on bacterial cytoadherence. In contrast to the established recommendations concerning the prevention of reinfection by the use of antibiotics and sulphonamides selecting resistant strains during long-term treatment, nothing is known about the development of resistance to L-methionine.PROBLEM A great variety of different antimicrobial chemotherapeutics is available for the treatment of urinary tract infections. Influencing the course of chronic diseases is a problem because recurrent diseases may result in disturbances of renal and bladder functions as well as in irreversible damages of the renal parenchyma. The present investigations are expected to clarify whether an effective prevention of reinfection in patients with chronically recurrent urinary tract infection is possible by a regular administration of L-methionine (Acimethin). PATIENTS AND METHODS 33 female patients were included in the examinations. Following acute disease, 23 females (aged: 47.4 +/- 13.3 years) were treated with 3 x 1 tablet of Acimethin (L-methionine) daily over a period of 26 months. Ten female patients (aged: 47.4 +/- 12.2 years) taking 1 tablet of Nevigramon (nalidixic acid) three times daily over 21.6 months served as a control group. Before starting treatment and in the middle of the therapy period control examinations were performed and following the last drug administration so as to assess the therapeutic result. RESULTS No acute infection occurred during L-methionine treatment. All parameters of inflammation (leucocyte count, C-reactive protein, blood sedimentation rate, alpha 2-globulin concentration) were in the normal range; no impairment of renal function was observed. Although L-methionine, i.e. nalidixic acid, did not yield any significant changes in the range of bacteria, the adherence of uropathogenic microorganisms to the cells of the urinary tract was reduced. Before L-methionine treatment, the average load of the uroepithelial cells was 95.9 +/- 73.6 bacteria per cell. When the observation period was completed, 51.2 +/- 56.4 bacteria per cell were registered (p < 0.03). During nalidixic acid treatment, the rate of adherence was reduced from 74.0 +/- 88.4 to 34.4 +/- 37.8 bacteria per cell (p < 0.25). During L-methionine treatment, no Escherichia coli strains that are able to produce hemolysin or to form aerobactine were found. Among agents adhering to uroepithelial cells, however, an increase in their ability to produce mannose-resistant hemagglutination was conspicuous. CONCLUSION L-methionine is suitable to prevent reinfection with chronic urinary tract infection. The therapeutic result is essentially due to its influence on bacterial cytoadherence. In contrast to the established recommendations concerning the prevention of reinfection by the use of antibiotics and sulphonamides selecting resistant strains during long-term treatment, nothing is known about the development of resistance to L-methionine.

Secretion of cytokines by uroepithelial cells stimulated by Escherichia coli and Citrobacter spp.

Urinary tract epithelial cells (T 24/83) are able to express interleukin (IL)-6, IL-8, platelet-derived growth factor (PDGF) and tumour necrosis factor-alpha, but not IL-1 beta, IL-2, IL-4 and IL-10 in response to an infection with uropathogenic bacteria. The process of cytokine secretion is time dependent, with a significant increase in the cytokine activity after 60 min. The expression of virulence factors of the bacteria does not seem to play a role. The interaction between bacterial products (e.g. lipopolysaccharide) and/or bacterial adhesion mediated by adhesins and specific receptor molecules of cell surfaces may be responsible for the activity of mediator protein expression in the epithelial cells. The release of PDGF and IL-8 was found to be higher when due to Escherichia coli HB 101 (rough form) than that caused by other bacterial strains. Citrobacter CB 3009 provoked the highest level of IL-6. The PDGF level correlated significantly with IL-6 and IL-8 values (P<0.001). There was a significant correlation between the time-dependent release of IL-6 and IL-8 (P<0.05). In epithelial cytokine response to bacterial infection, the reaction of the epithelial cells may modify themselves (e.g. internalization of bacteria) and the immuno-regulatory processes that are caused by infection and responsible for parenchymal injury.

Urinary tract infection in patients with diabetes mellitus.

Urinary tract infection occurs with increased frequency and severity in patients with diabetes mellitus. General host factors enhancing risk for urinary tract infection in diabetics include age, metabolic control, and long term complications, primarily diabetic nephropathy and cystopathy. Alterations in the innate immune system have been described and may also contribute. Treatment of asymptomatic bacteriuria in diabetic patients is not indicated. Early diagnosis and prompt intervention is recommended to limit morbidity of symptomatic infection. Clinical studies comparing management of urinary tract infection in persons with diabetes compared to those without as well as diabetic patients with good or poor glucose control will be necessary to improve care of urinary infection in persons with diabetes mellitus.

Time Course of Cytokine mRNA Expression in Kidneys of Rats with Unilateral Ureteral Obstruction

The development of renal interstitial fibrosis (RIF) is related to the expression and excretion of cytokines and growth factors. Thus, we investigated the time course of mRNA expression of cytokines known as causative factors in a model of RIF in rats before and on day 10 after unilateral ureteral obstruction (UUO), when first signs of fibrosis were visible, as well as during progressive RIF. UUO causes a fivefold increase in mRNA expression of monocyte chemoattractant protein 1 15 days after surgery as compared with contralateral kidneys. The level remains elevated about three-fold up to day 25. The mRNA of the fibrogenic cytokine transforming growth factor beta 1 (TGF-β1) is increased two- to threefold during the time course, whereas the mRNAs of platelet-derived growth factor B chain (PDGF-B) and its receptor beta (PDGF-Rβ) increase after UUO, reaching their maxima on days 10–15. PDGF-B mRNA increase up to day 15, marking the onset of fibrosis, and decreases thereafter, whereas the expression of the PDGF-Rβ mRNA remains elevated more than threefold over the entire study period. Incubation of cultured renal fibroblasts with TGF-β1 and/or PDGF-B suggests that their specific action on cell growth and proliferation is maintained even when they are used in combination. The sustained elevation of TGF-β1 and PDGF-B/PDGF-Rβ mRNA levels confirms the assumption of a particular involvement of these cytokines in the pathogenesis of RIF. The mRNA expression of the gap junctional protein connexin 43 in ureteral ligated kidneys is increased sixfold already 5 days after UUO. In this way, the increased connexin 43 mRNA levels indicate a possible function in the remodeling of the kidney tissue after tubular damage and fibrosis.

Abnormal Growth and Clonal Proliferation of Fibroblasts in an Animal Model of Unilateral Ureteral Obstruction

The time course for the development of renal interstitial fibrosis (RIF) in rats between days 5 and 25 after unilateral ureteral obstruction (UUO) was studied. In kidneys with UUO under histological examination, an interstitial fibrosis was observed after more than 10 days with progression up to day 25. On day 5, collagen peptidase activity in homogenates of UUO kidneys was about 50% higher than in controls but gradually declined afterwards until reaching the level obtained from contralateral kidneys (CL) on day 25. 10 days after UUO, renal hydroxyproline content was elevated about twofold as compared to CL and sham-operated rats, and increased considerably by day 25 of UUO. In primary cultures of cells obtained from UUO kidneys, fibroblast proliferation increased regardless of the extent of fibrosis. This could be a result of an early inflammatory process. Renal fibroblasts from rats are heterogenous when studied in vitro. When fibroblasts of passage 1 obtained from kidneys 25 days after UUO were plated at low density, the number of mitotic type I clones was elevated 5.5-fold as compared with cultures from CL kidneys. The majority of type I clones in UUO cultures from fibrotic kidneys developed in an unusual fashion with formation of three-dimensional structures. The changes detectable under the unfavorable conditions of clonal culture suggest phenotypical differentiation of a small fraction of fibroblasts from kidneys with RIF. These cells are able to overgrow cell monolayers forming circular growing colonies. Obviously, one needs to distinguish between intensitive proliferation as a consequence of acute inflammation, and the changes in phenotype of a small fraction of renal fibroblasts which are resistant to normal physiologic regulative mechanisms in cell culture. The latter may contribute to matrix disorders and RIF.

Colocalization of BAX and BCL-2 in small intestine and kidney biopsies with different degrees of DNA fragmentation

Abstract Morphological changes associated with apoptosis are closely correlated with the expression of specific proteins. However, the cause-effect relationships between the expression of these proteins and DNA degradation are barely known. For studying expression of apoptosis-related proteins in relation to different degrees of DNA fragmentation, the small intestine with its spatially organized continuum of proliferation, differentiation and death is a very useful preparation. Enterocytes towards the apex of the villi become increasingly susceptible to apoptosis. Here, this ”apoptotic gradient” is used to demonstrate the presence of BAX and BCL-2 proteins in the cytoplasm of cells at the onset of apoptosis. In semithin serial sections of the small intestine, BAX, BCL-2 and DNA fragmentation were demonstrated. BAX and BCL-2 are always colocalized and only in cells with fragmented DNA. The gradient of BAX or BCL-2 staining is similar to the gradient of DNA fragmentation. Immunoreactivity for BCL-2 or BAX is most intense in cells that are prone to become apoptotic next in the course of cellular turnover but not in cells in an advanced apoptotic state, showing strongly condensed chromatin. When using the same technique on semithin sections of kidney biopsies, containing epithelia with low cellular turnover, we found DNA fragmentation mainly in the epithelial cells of the distal tubules. Similar to the situation in the enterocytes, BAX staining was confined to the cytoplasm of epithelial cells with a moderate degree of DNA fragmentation and reduced in epithelial cells with a high degree of DNA fragmentation. In contrast to the situation in the small intestine, very low levels of BCL-2 were found. The results suggest that expression of BCL-2 and BAX is related to cell damage as indicated by DNA fragmentation but not to advanced stages of cellular death, as indicated by chromatin condensation and cellular shrinkage.