a Abdominal aorta

ava

11

10

Kidney

Ureter

7
Bladder
b
6

4
rophil

Uropathogenic
bacteria Urinary
catheter
2

a
• • • • •
• • • • •
• • •
• • •
•
• •
• •
• • • • •
• • • •
•
• •
•
• • •
• • •
•
•
•
•
•
•
• •
• •
• •
•
•

Chaperone–usher pathway pili.

Uropathogenic Escherichia coli.

Uropathogens use different mechanisms for survival in response to stresses in the bladder such as starvation and immune
responses. By forming biofilms and undergoing morphological changes, uropathogens can persist and cause recurrent
infections40,129,130.

Extracellular DNA (eDNA), exopolysaccharides called extracellular polymeric substances, pili, flagella and other adhesive
fibres create a scaffold to form a multicellular bacterial community that is protected from immune responses,
antimicrobial agents and other stresses40. The antimicrobial recalcitrance of uropathogens increases on biofilm
maturation, as the biofilm provides a physical barrier to antibiotic entry. Therefore, understanding species-specific
biofilm formation and dispersal mechanisms is crucial for the development of novel therapies that prevent colonization,
such as biofilm inhibitors, anti-adhesive molecules and molecules that induce bacterial dispersion.
Uropathogenic Escherichia coli (UPEC) forms biofilm-like intracellular bacterial communities (IBCs) that protect their
members from neutrophils, antibiotics and other stresses38 . Type 1 pili, antigen 43 and adhesive surface fibres
called curli induce biofilm formation by mediating interbacterial interactions and attachment to surfaces. Transcription
of antigen 43 is regulated by oxidative stress regulator (OxyR; also known as hydrogen peroxide-inducible genes
activator)131, whereas type 1 pilus and curli fibre genes are regulated by polymyxin-resistant protein B (PrmB; also known
as BasS) on iron sensing3, leading to phosphorylation of polymyxin-resistant protein A (PmrA; also known as BasR) and
quorum sensing regulator B (QseB)131. UPEC biofilm formation on catheters is dependent on type 1 pili35.
Proteus mirabilis produces urease, which hydrolyses urea to carbon dioxide and ammonia. This increases the urine pH
and generates calcium crystals and magnesium ammonium phosphate precipitates, which are incorporated into
polysaccharide capsules, forming crystalline biofilms on the catheter . The phosphotransferase regulator of
swarming behaviour (RsbA) upregulates polysaccharide expression, represses swarming23 and enhances biofilm
formation. Mannose-resistant Proteus-like (MR/P) pili intimately associate with the crystal layers, promoting
biofilm formation. Oxygen limitation in the biofilm activates the expression of MR/P pili by inducing the recombinase
MrpI to reorient the promoter of the pilus genes. Similarly, expression of the fimbrial operon regulator MrpJleads to
decreased motility, promoting biofilm formation53,132.
Pseudomonas aeruginosa has the ability to form biofilms on catheters and damaged bladder tissue82 through several
mechanisms, including quorum sensing autoinducers that bind to the transcriptional regulators LasR (which regulates
elastase (LasB) expression) and RhlR (which regulates the synthesis of rhamnolipids). Quorum sensing induces the
production of eDNA, rhamnolipids, lectins, elastases and toxins. The amphiphilic rhamnolipids allow microcolony
formation by changing the hydrophobicity of the P. aeruginosa surface133. Biofilm maturation is promoted by lectin
adhesins, which are important for bacterial cell–cell interactions134. The production of alginates and extracellular
polymeric substances is activated when cyclic di-GMP binds to the transcriptional regulators alginate biosynthesis44
(Alg44) and pellicle formation regulator D (PelD)135. Small RNAs from the regulator of secondary metabolites (rsm) family,
such as rsmZ and rsmY, regulate exopolysaccharide production by reducing the availability of RsmA, which is the
transcriptional repressor for exopolysaccharide-encoding genes81,136,137.

Uropathogens also adopt morphological changes, such as filamentation, to circumvent the host immune system130,138.
During IBC maturation, expression of suppressor of lon (SulA) inhibits FtsZ polymerization in a subpopulation of UPEC,
blocking septation ring formation and cell division138. When the resulting filamentous bacterial cells emerge from
epithelial cells, they are resistant to killing by neutrophils and can colonize other naive uroepithelial cells and re-enter the
IBC cycle129,138 . Alternatively, during colonization by P. mirabilis, the bacteria adopt a filamentous morphology as a
result of the sensor activities of flagella on contact with a urinary catheter. Contact creates a torsional change in
the outer membrane, and this is sensed by upregulator of the flagellar master operon (Umo) proteins, which induce the
expression of flagella to produce the highly flagellated cells that are required for swarming during a UTI6,23,53,139 .
a
Umbrella cells
Transitional cells

Escherichia coli b
a

Kidney epithelium

Lamina propria
IgA

Plasma cells

-
 Proteus mirabilis.

Enterococci.

Klebsiella pneumoniae.
 a
Transitional cells Umbrella cells

b
Transitional cells Umbrella cells
Proteases and toxins.

Urease.

Iron scavenging.
 Combination therapies.

Multidrug resistance.

Vaccines targeting bacterial adhesion.

Multidrug-resistant uropathogenic organisms are becoming an expanding public health
threat, as Enterobacteriaceae family members increasingly acquire extended-spectrum
-lactamases (ESBLs) such as cefotaximases (CTX-Ms) and oxacillinases (OXAs),
AmpC-type -lactamases and carbapenemases.

Originating in Klebsiella pneumoniae and Escherichia coli, ESBLs are now prevalent
throughout the Enterobacteriaceae family, as frequent use of cephalosporins in the
nosocomial setting and the carriage of ESBL-encoding genes on transferrable elements
together create an ideal environment for the selection of antibiotic resistance99,102.
ESBLs are plasmid-encoded or chromosomally encoded -lactamases with broad
activity against penicillins and cephalosporins. They function by splitting the amide
bond of the -lactam ring, thus inactivating -lactam antibiotics102. Troublingly, ESBLs
are encoded on plasmids that typically carry other resistance genes which provide
activity against aminoglycosides, sulfonamides and quinolones, making the bacteria
that acquire these plasmids multidrug resistant 101,102.

The plasmids encoding the ESBLs CTX-Ms form a new plasmid phylum that is
phylogenetically distinct from other plasmid-encoded -lactamases. CTX-Ms are
active against narrow-, broad- and extended-spectrum penicillins, classical and
extended-spectrum cephalosporins, and monobactams99,102,103. Notably, they also
confer high-level cefotaxime resistance99,103. CTX-Ms are the most prevalent
-lactamases in community-associated isolates and are typically encoded on plasmids
with other resistance genes102. CTX-Ms efficiently hydrolyse the -lactam ring via Vaccines targeting bacterial toxins and proteases.
nucleophilic attack of a ring carbonyl carbon by a conserved serine in the -lactamase,
resulting in a ring-opened product that is inactive140.

OXAs are ESBLs that are typically encoded by plasmids and mediate resistance to
ampicillin, cephalothin, oxacillin and cloxacillin by hydrolysing the -lactam rings99,103.
In addition, OXAs are characterized by their ability to resist the -lactamase inhibitor
clavulante103. To date, OXAs have been shown to be expressed only in Pseudomonas
aeruginosa99,103.

The chromosomally encoded AmpC enzymes hydrolyse penicillins, third-generation

and extended-spectrum cephalosporins, and cephamycins, and are resistant to
-lactamase inhibitors, including clavulanate99,102. AmpC expression is induced in
response to -lactams, cephamycin and cephalosporin exposure.

Carbapenemases are ESBLs that confer the ability to inactive carbapenems in addition
to penicillins and extended-spectrum cephalosporins99,101,102. The two most clinically
relevant carbapenemases, K. pneumoniae (serine) carbapenemase (KPC) and New Delhi
metallo- -lactamase (NDM-1), originated in K.pneumoniae and rapidly spread throughout
the Enterobacteriaceae family, creating carbapenem-resistant Enterobacteriaceae
(CRE)15,99,101,102. The broad activity of carbapenemases confers resistance against a wide
range of extended-spectrum -lactam antibiotics, particularly carbapenem. Vaccines targeting siderophores.
Small molecules targeting urease.

Small molecules targeting bacterial adhesion.

 183
35
3

13
28

28 111

Th is p a p e r p re s e n t s t h e m os t re ce n t in for m a t io n
a b ou t UTIs a n d t h e ir s o cioe con o m ic im p a ct . 79 297

7 15
11 3
366

3
52
7
Th is re vie w co m p a re s t h e s t ra t e gie s us e d b y t wo
im p or ta n t uro p a t h oge n s, E. coli a n d P. m ira b ilis ,
t h e h os t re s p o n s e to e a ch p a t h oge n , a n d t h e 6
cu r re n t t re a t m e n t s a n d t h e ra p ie s to p re ve n t UTIs. 14

Th is p a p e r h igh ligh t s t h e e m e rgin g re s is ta n ce 2

a m on g b a ct e r ia l p a t h oge n s, t h e p rob le m s we fa ce
36 in com b a t in g t h e s e re s is ta n t b a ct e r ia a n d p ot e n t ia l
e ffe ct ive a ge n t s for t h e t re a t m e n t o f UTIs ca u s e d
10 b y m ult id r u g-re s is ta n t p a t h o ge n s.
Th is p a p e r b r ie fly out lin e s t h e s t e p s of P. m ira b ilis
cr ys ta llin e -b io film for m a t io n d u r in g CAUTIs.
18

21
15 8
 α
7
Th is re vie w p re s e n t s t h e m os t cur re n t , in -d e p t h 9 11 2
u n d e rs ta n d in g o f h ow p ili a re a s s e m b le d t h rou gh
t h e ch a p e ron e – us h e r p a t h wa y.
16 282

11

98

4 67

20

1 71

81
1
1 91

293
13
Th is p a p e r p rovid e s a b r ie f ove r vie w o f t wo s im ila r 76
CUP p ilu s a s s e m b ly p a t h wa ys a n d s h ows t h a t 10
a n t ivir u le n ce co m p ou n d s (p ilicid e s ) wh ich we re
o r igin a lly d e s ign e d to s p e cifica lly t a rge t on e
p a t h wa y h a ve b roa d -s p e ct r um a ct ivit y a ga in s t b ot h 76
CUP p ilu s p a t h wa ys in E. coli. 111

κ
12 κ 18
81

496 67

76
68
1

10
194
123
10
Th is is a co m p re h e n s ive re vie w of t h e e p id e m io lo gy,
56 p a t h oge n e s is a n d m e ch a n is m of a n t im icro b ia l
re s is ta n ce of Ente rococcu s s p p . Th is re vie w a ls o 15
ou t lin e s h ow Ente rococcu s s p p . a re b e co m in g a
ch a lle n gin g n os oco m ia l p rob le m .
4

71

10 6 78

3 01

Th is is t h e firs t p a p e r to d e s cr ib e t h e in t ra ce llula r 3 55
cycle of a urop a t h oge n a n d it s im p or ta n ce for
p e rs is ta n ce.
63
30

6 22
184

3
81 152
Th is re vie w d e t a ils t h e im p or ta n ce o f b iofilm
for m a t io n fo r t h e s u r viva l a n d p e rs is ta n ce of
d iffe re n t p a t h o ge n s a n d t h e t h re a t t h a t re p re s e n t s
in clin ica l s e t t in gs. In a d d it ion , it d is cu s s e s n ove l 6
a lt e r n a t ive s t ra t e gie s fo r t h e p re ve n t ion o f b iofilm
for m a t io n . 6
Th is is t h e firs t s t ud y to d is s e ct t h e m e ch a n is m of
E. fa e ca lis in fe ct io n d u r in g a CAUTI; t h is wor k le d
to t h e d e ve lop m e n t of a va ccin e t h a t p re ve n t s 2
4 in fe ct io n in a m o us e m od e l o f a CAUTI.

59 195 70

α
79 57
11
 53

β
11

68 208
10 8

13 11 0
31 Th is s t u d y id e n t ifie s t h e ro le of ke y Fim H re s id ue s
in p rot e in co n fo r m a t ion a n d vir u le n ce.
2

1 81
21 272

276

Th is p ivota l s t ud y s h ows t h a t b lo ckin g t h e 75

55 in t e ra ct ion b e t we e n t h e b a ct e r ia l a d h e s in a n d t h e
h o s t re ce p t or t h ro ugh va ccin a t ion ca n p re ve n t
UTIs in m ice.
276 6

1 71
3 13

175
79 37

80 1 91

72

296 78 60

8
16
59

78
387

77

81 76

Th is in ve s t iga t ion us e s d a ta fro m ge n o m ic, 5

p rot e om ic a n d m e ta b olic s cre e n s to id e n t ify
va ccin e ta rge t s in E. coli., a ll of wh ich a re in vo lve d 10 3
in iron a cq u is it ion . Va ccin a t io n wit h s e ve ra l iro n
re ce p t ors d ur in g exp e r im e n ta l UTIs in m ice 248
r e ve a le d t h a t t h e s e fa ct o rs we r e a n e ffe ct ive
t a rge t for t h e d e ve lop m e n t o f va ccin e s.
194
34
41

β 50
10 3
14

298
11 3

Th is ke y wor k u s e s com p o un d s d e s ign e d to

28 p re ve n t t h e E. coli t yp e 1 p ilus a d h e s in fro m 75
β b in d in g t h e h o s t re ce p t or a n d d e m on s t ra t e s
t h a t th e s e com p oun d s a re e ffe ct ive a t p re ve n t in g
UTIs in m ice.
14 60
5
42
Th is is t h e firs t p a p e r to d e s cr ib e t h e role of
β p ilicid e in t ra n s cr ip t io n a l a n d t ra n s la t ion a l 168
73 re gula t ion in UPEC.

β
82
68 62
 Acknowle d ge m e nt s

82

31

Co m p e t ing int e re st s s t a t e m e nt

29

See online article:

78