Recurrent bacterial infections are a significant burden worldwide, and prior history of infection is often a significant risk factor for developing new infections. For urinary tract infection (UTI), a history of two or more episodes is an independent risk factor for acute infection. However, mechanistic knowledge of UTI pathogenesis has come almost exclusively from studies in naive mice. Here we show that, in mice, an initial Escherichia coli UTI, whether chronic or self-limiting, leaves a long-lasting molecular imprint on the bladder tissue that alters the pathophysiology of subsequent infections, affecting host susceptibility and disease outcome. In bladders of previously infected versus non-infected, antibiotic-treated mice, we found (1) an altered transcriptome and defects in cell maturation, (2) a remodelled epithelium that confers resistance to intracellular bacterial colonization, and (3) changes to cyclooxygenase-2-dependent inflammation. Furthermore, in mice with a history of chronic UTI, cyclooxygenase-2-dependent inflammation allowed a variety of clinical E. coli isolates to circumvent intracellular colonization resistance and cause severe recurrent UTI, which could be prevented by cyclooxygenase-2 inhibition or vaccination. This work provides mechanistic insight into how a history of infection can impact the risk for developing recurrent infection and has implications for the development of therapeutics for recurrent UTI.
This is a preview of subscription content, access via your institution
Open Access articles citing this article.
A blinded observational cohort study of the microbiological ecology associated with pyuria and overactive bladder symptoms
International Urogynecology Journal Open Access 17 February 2018
Subscribe to Journal
Get full journal access for 1 year
only $9.92 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Get time limited or full article access on ReadCube.
All prices are NET prices.
Medzhitov, R. Recognition of microorganisms and activation of the immune response. Nature 449, 819–826 (2007).
Foxman, B., Barlow, R., D'Arcy, H., Gillespie, B. & Sobel, J. D. Urinary tract infection: self-reported incidence and associated costs. Ann. Epidemiol. 10, 509–515 (2000).
Foxman, B. The epidemiology of urinary tract infection. Nat. Rev. Urol. 7, 653–660 (2010).
Hooton, T. M. et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N. Engl. J. Med. 335, 468–474 (1996).
Scholes, D. et al. Risk factors associated with acute pyelonephritis in healthy women. Ann. Intern. Med. 142, 20–27 (2005).
Mulvey, M. A. et al. Induction and evasion of host defenses by type 1-piliated uropathogenic Escherichia coli. Science 282, 1494–1497 (1998).
Anderson, G. G. et al. Intracellular bacterial biofilm-like pods in urinary tract infections. Science 301, 105–107 (2003).
Carey, A. J. et al. Urinary tract infection of mice to model human disease: practicalities, implications and limitations. Crit. Rev. Microbiol. 42, 780–799 (2016).
Hannan, T. J., Mysorekar, I. U., Hung, C. S., Isaacson-Schmid, M. L. & Hultgren, S. J. Early severe inflammatory responses to uropathogenic E. coli predispose to chronic and recurrent urinary tract infection. PLoS Pathogens 6, e1001042 (2010).
Hannan, T. J. et al. Inhibition of cyclooxygenase-2 prevents chronic and recurrent cystitis. EBioMedicine 1, 46–57 (2014).
Mulvey, M. A., Schilling, J. D. & Hultgren, S. J. Establishment of a persistent Escherichia coli reservoir during the acute phase of a bladder infection. Infect. Immun. 69, 4572–4579 (2001).
Schwartz, D. J., Conover, M. S., Hannan, T. J. & Hultgren, S. J. Uropathogenic Escherichia coli superinfection enhances the severity of mouse bladder infection. PLoS Pathogens 11, e1004599 (2015).
Marrs, C. F., Zhang, L. & Foxman, B. Escherichia coli mediated urinary tract infections: are there distinct uropathogenic E. coli (UPEC) pathotypes? FEMS Microbiol. Lett. 252, 183–190 (2005).
Totsika, M. et al. Insights into a multidrug resistant Escherichia coli pathogen of the globally disseminated ST131 lineage: genome analysis and virulence mechanisms. PLoS ONE 6, e26578 (2011).
Mobley, H. L. et al. Pyelonephritogenic Escherichia coli and killing of cultured human renal proximal tubular epithelial cells: role of hemolysin in some strains. Infect. Immun. 58, 1281–1289 (1990).
Andersson, P. et al. Persistence of Escherichia coli bacteriuria is not determined by bacterial adherence. Infect. Immun. 59, 2915–2921 (1991).
Rosen, D. A. et al. Utilization of an intracellular bacterial community pathway in Klebsiella pneumoniae urinary tract infection and the effects of FimK on type 1 pilus expression. Infect. Immun. 76, 3337–3345 (2008).
Kline, K. A., Schwartz, D. J., Gilbert, N. M. & Lewis, A. L. Impact of host age and parity on susceptibility to severe urinary tract infection in a murine model. PLoS ONE 9, e97798 (2014).
Gerdes, S. Y. et al. Experimental determination and system level analysis of essential genes in Escherichia coli MG1655. J. Bacteriol. 185, 5673–5684 (2003).
Nissle, A. Über die Grundlagen einer neuen ursächlichen Bekämpfung der pathologischen Darmflora. Dtsch. Med. Wochenschr. 42, 1181–1184 (1916).
Hansson, S. et al. Follicular cystitis in girls with untreated asymptomatic or covert bacteriuria. J. Urol. 143, 330–332 (1990).
Schlager, T. A., LeGallo, R., Innes, D., Hendley, J. O. & Peters, C. A. B cell infiltration and lymphonodular hyperplasia in bladder submucosa of patients with persistent bacteriuria and recurrent urinary tract infections. J. Urol. 186, 2359–2364 (2011).
Ray, D. et al. Transcriptional profiling of the bladder in urogenital schistosomiasis reveals pathways of inflammatory fibrosis and urothelial compromise. PLoS Negl. Trop. Dis. 6, e1912 (2012).
Leigh, R. et al. Dysfunction and remodeling of the mouse airway persist after resolution of acute allergen-induced airway inflammation. Am. J. Respir. Cell Mol. Biol. 27, 526–535 (2002).
Hannan, T. J. et al. Host–pathogen checkpoints and population bottlenecks in persistent and intracellular uropathogenic Escherichia coli bladder infection. FEMS Microbiol. Rev. 36, 616–648 (2012).
Rosen, D. A., Hooton, T. M., Stamm, W. E., Humphrey, P. A. & Hultgren, S. J. Detection of intracellular bacterial communities in human urinary tract infection. PLoS Med. 4, e329 (2007).
Robino, L. et al. Intracellular bacteria in the pathogenesis of Escherichia coli urinary tract infection in children. Clin. Infect. Dis. 59, e158–e164 (2014).
Wright, K. J., Seed, P. C. & Hultgren, S. J. Development of intracellular bacterial communities of uropathogenic Escherichia coli depends on type 1 pili. Cell. Microbiol. 9, 2230–2241 (2007).
Langermann, S. et al. Prevention of mucosal Escherichia coli infection by FimH-adhesin-based systemic vaccination. Science 276, 607–611 (1997).
Langermann, S. et al. Vaccination with FimH adhesin protects cynomolgus monkeys from colonization and infection by uropathogenic Escherichia coli. J. Infect. Dis. 181, 774–778 (2000).
O'Brien, V. P., Hannan, T. J., Nielsen, H. V. & Hultgren, S. J. Drug and vaccine development for the treatment and prevention of urinary tract infections. Microbiol. Spectrum 4, http://dx.doi.org/10.1128/microbiolspec.UTI-0013-2012 (2016).
Eto, D. S., Sundsbak, J. L. & Mulvey, M. A. Actin-gated intracellular growth and resurgence of uropathogenic Escherichia coli. Cell. Microbiol. 8, 704–717 (2006).
Berry, R. E., Klumpp, D. J. & Schaeffer, A. J. Urothelial cultures support intracellular bacterial community formation by uropathogenic Escherichia coli. Infect. Immun. 77, 2762–2772 (2009).
Bleidorn, J., Gagyor, I., Kochen, M. M., Wegscheider, K. & Hummers-Pradier, E. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection? Results of a randomized controlled pilot trial. BMC Med. 8, 30 (2010).
Gágyor, I. et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. Br. Med. J. 351, h6544 (2015).
Froom, J. et al. A cross-national study of acute otitis media: risk factors, severity, and treatment at initial visit. Report from the international primary care network (IPCN) and the ambulatory sentinel practice network (ASPN). J. Am. Board. Fam. Pract. 14, 406–417 (2001).
Bjornsdottir, S. et al. Risk factors for acute cellulitis of the lower limb: a prospective case–control study. Clin. Infect. Dis. 41, 1416–1422 (2005).
Fekety, R. et al. Recurrent Clostridium difficile diarrhea: characteristics of and risk factors for patients enrolled in a prospective, randomized, double-blinded trial. Clin. Infect. Dis. 24, 324–333 (1997).
Rasko, D. A. & Sperandio, V. Anti-virulence strategies to combat bacteria-mediated disease. Nat. Rev. Drug Discov. 9, 117–128 (2010).
Wright, K. J., Seed, P. C. & Hultgren, S. J. Uropathogenic Escherichia coli flagella aid in efficient urinary tract colonization. Infect. Immun. 73, 7657–7668 (2005).
Hultgren, S. J., Porter, T. N., Schaeffer, A. J. & Duncan, J. L. Role of type 1 pili and effects of phase variation on lower urinary tract infections produced by Escherichia coli. Infect. Immun. 50, 370–377 (1985).
Hung, C. S., Dodson, K. W. & Hultgren, S. J. A murine model of urinary tract infection. Nat. Protoc. 4, 1230–1243 (2009).
Pfaffl, M. W. A new mathematical model for relative quantification in real-time RT-PCR. Nucleic Acids Res. 29, e45 (2001).
Shishkin, A. A. et al. Simultaneous generation of many RNA-seq libraries in a single reaction. Nat. Methods 12, 323–325 (2015).
Trapnell, C., Pachter, L. & Salzberg, S. L. Tophat: discovering splice junctions with RNA-Seq. Bioinformatics 25, 1105–1111 (2009).
Anders, S., Pyl, P. T. & Huber, W. HTSeq—a Python framework to work with high-throughput sequencing data. Bioinformatics 31, 166–169 (2015).
Love, M. I., Huber, W. & Anders, S. Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2. Genome Biol. 15, 550 (2014).
Metcalfe, P. D. et al. Bladder outlet obstruction: progression from inflammation to fibrosis. BJU Int. 106, 1686–1694 (2010).
Blango, M. G., Ott, E. M., Erman, A., Veranic, P. & Mulvey, M. A. Forced resurgence and targeting of intracellular uropathogenic Escherichia coli reservoirs. PLoS ONE 9, e93327 (2014).
Justice, S. S., Lauer, S. R., Hultgren, S. J. & Hunstad, D. A. Maturation of intracellular Escherichia coli communities requires SurA. Infect. Immun. 74, 4793–4800 (2006).
This work was supported by the National Institutes of Health (NIH) and the Office of Research on Women's Health Specialized Center of Research (P50 DK64540 and R01 DK51406 to S.J.H; AI95542 to S.J.H. and M.C.; Mucosal Immunology Studies Team consortium U01 AI095776 Young Investigator Award and Mentored Clinical Scientist Research Career Development Award K08 AI083746 to T.J.H. and F30 DK096751 to D.J.S.) and by the National Science Foundation (Graduate Research Fellowship DGE-1143954 to V.P.O.). RNA-seq analysis design and support was provided by the Rheumatic Disease Core Center at Washington University (P30-AR048335, to E.D.O.R). This publication was made possible by grant no. U19 AI110818 from NIAID. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. SEM studies and sample preparation were performed by the Research Center for Auditory and Vestibular Studies, which is supported by the NIH NIDCD grant P30DC04665, and by the Washington University Center for Cellular Imaging (WUCCI), which is supported by the Washington University School of Medicine, The Children's Discovery Institute of Washington University and St Louis Children's Hospital, the Foundation for Barnes-Jewish Hospital and the National Institute for Neurological Disorders and Stroke (NS086741). The authors thank K. Dodson and D.J. Frank for editorial assistance and D. Liu, J. Lett, M. Joens and J. Fitzpatrick for technical assistance.
S.J.H. may receive royalty income based on the FimH vaccine technology that he developed, which was licensed by Washington University to Sequoia Sciences. The other authors declare no competing financial interests.
Supplementary Figures 1–14, legends for Supplementary Tables 1–4 and Supplementary References (PDF 2163 kb)
Gene list from whole-bladder RNA-seq experiment, in which gene expression was compared between Sensitized and Resolved mice during convalescence (four weeks after the initiation of antibiotics). (XLSX 957 kb)
The fold changes in gene expression from whole-bladder RNA-seq, compared with the fold enrichment/depletion of the most significantly enriched/depleted proteins from a previously published analysis of the urothelial proteome enriched for membraneassociated glycoproteins. (XLSX 26 kb)
Pathway analysis showing the canonical pathways enriched in the differentially expressed genes in the RNA-seq experiment. (XLSX 30 kb)
Broad meta-pathways assembled by Ingenuity IPA from the specific enriched pathways given in Supplementary Table 3. (XLSX 34 kb)
About this article
Cite this article
O'Brien, V., Hannan, T., Yu, L. et al. A mucosal imprint left by prior Escherichia coli bladder infection sensitizes to recurrent disease. Nat Microbiol 2, 16196 (2017). https://doi.org/10.1038/nmicrobiol.2016.196
This article is cited by
Reduced urothelial expression of uroplakin-IIIa in cystitis areas in bladders of postmenopausal women with recurrent urinary tract infections: pilot study
World Journal of Urology (2022)
Mucosal Immunology (2021)
Nature Reviews Urology (2021)
A highly polarized TH2 bladder response to infection promotes epithelial repair at the expense of preventing new infections
Nature Immunology (2020)
Nature Reviews Urology (2020)