A mucosal imprint left by prior Escherichia coli bladder infection sensitizes to recurrent disease


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.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Figure 1: Mice from different genetic backgrounds with a history of chronic infection have long-lasting, enhanced susceptibility to recurrent UTI caused by clinical uropathogens.
Figure 2: Prior UPEC infection results in bladder epithelial remodelling that varies according to disease outcome.
Figure 3: Bladder remodelling fundamentally alters acute cystitis pathogenesis upon UPEC challenge, conferring resistance to early bladder colonization.
Figure 4: COX-2-dependent inflammation during acute cystitis in sensitized mice allows UPEC to circumvent the early urothelial resistance to colonization.


  1. 1

    Medzhitov, R. Recognition of microorganisms and activation of the immune response. Nature 449, 819–826 (2007).

    CAS  Article  Google Scholar 

  2. 2

    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).

    CAS  Article  Google Scholar 

  3. 3

    Foxman, B. The epidemiology of urinary tract infection. Nat. Rev. Urol. 7, 653–660 (2010).

    Article  Google Scholar 

  4. 4

    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).

    CAS  Article  Google Scholar 

  5. 5

    Scholes, D. et al. Risk factors associated with acute pyelonephritis in healthy women. Ann. Intern. Med. 142, 20–27 (2005).

    Article  Google Scholar 

  6. 6

    Mulvey, M. A. et al. Induction and evasion of host defenses by type 1-piliated uropathogenic Escherichia coli. Science 282, 1494–1497 (1998).

    CAS  Article  Google Scholar 

  7. 7

    Anderson, G. G. et al. Intracellular bacterial biofilm-like pods in urinary tract infections. Science 301, 105–107 (2003).

    CAS  Article  Google Scholar 

  8. 8

    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).

    PubMed  Google Scholar 

  9. 9

    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).

    Article  Google Scholar 

  10. 10

    Hannan, T. J. et al. Inhibition of cyclooxygenase-2 prevents chronic and recurrent cystitis. EBioMedicine 1, 46–57 (2014).

    Article  Google Scholar 

  11. 11

    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).

    CAS  Article  Google Scholar 

  12. 12

    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).

    Article  Google Scholar 

  13. 13

    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).

    CAS  Article  Google Scholar 

  14. 14

    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).

    CAS  Article  Google Scholar 

  15. 15

    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).

    CAS  PubMed  PubMed Central  Google Scholar 

  16. 16

    Andersson, P. et al. Persistence of Escherichia coli bacteriuria is not determined by bacterial adherence. Infect. Immun. 59, 2915–2921 (1991).

    CAS  PubMed  PubMed Central  Google Scholar 

  17. 17

    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).

    CAS  Article  Google Scholar 

  18. 18

    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).

    Article  Google Scholar 

  19. 19

    Gerdes, S. Y. et al. Experimental determination and system level analysis of essential genes in Escherichia coli MG1655. J. Bacteriol. 185, 5673–5684 (2003).

    CAS  Article  Google Scholar 

  20. 20

    Nissle, A. Über die Grundlagen einer neuen ursächlichen Bekämpfung der pathologischen Darmflora. Dtsch. Med. Wochenschr. 42, 1181–1184 (1916).

    Article  Google Scholar 

  21. 21

    Hansson, S. et al. Follicular cystitis in girls with untreated asymptomatic or covert bacteriuria. J. Urol. 143, 330–332 (1990).

    CAS  Article  Google Scholar 

  22. 22

    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).

    CAS  Article  Google Scholar 

  23. 23

    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).

    CAS  Article  Google Scholar 

  24. 24

    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).

    CAS  Article  Google Scholar 

  25. 25

    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).

    CAS  Article  Google Scholar 

  26. 26

    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).

    Article  Google Scholar 

  27. 27

    Robino, L. et al. Intracellular bacteria in the pathogenesis of Escherichia coli urinary tract infection in children. Clin. Infect. Dis. 59, e158–e164 (2014).

    CAS  Article  Google Scholar 

  28. 28

    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).

    CAS  Article  Google Scholar 

  29. 29

    Langermann, S. et al. Prevention of mucosal Escherichia coli infection by FimH-adhesin-based systemic vaccination. Science 276, 607–611 (1997).

    CAS  Article  Google Scholar 

  30. 30

    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).

    CAS  Article  Google Scholar 

  31. 31

    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).

  32. 32

    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).

    CAS  Article  Google Scholar 

  33. 33

    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).

    CAS  Article  Google Scholar 

  34. 34

    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).

    Article  Google Scholar 

  35. 35

    Gágyor, I. et al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial. Br. Med. J. 351, h6544 (2015).

    Article  Google Scholar 

  36. 36

    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).

    CAS  PubMed  Google Scholar 

  37. 37

    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).

    Article  Google Scholar 

  38. 38

    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).

    CAS  Article  Google Scholar 

  39. 39

    Rasko, D. A. & Sperandio, V. Anti-virulence strategies to combat bacteria-mediated disease. Nat. Rev. Drug Discov. 9, 117–128 (2010).

    CAS  Article  Google Scholar 

  40. 40

    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).

    CAS  Article  Google Scholar 

  41. 41

    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).

    CAS  PubMed  PubMed Central  Google Scholar 

  42. 42

    Hung, C. S., Dodson, K. W. & Hultgren, S. J. A murine model of urinary tract infection. Nat. Protoc. 4, 1230–1243 (2009).

    CAS  Article  Google Scholar 

  43. 43

    Pfaffl, M. W. A new mathematical model for relative quantification in real-time RT-PCR. Nucleic Acids Res. 29, e45 (2001).

    CAS  Article  Google Scholar 

  44. 44

    Shishkin, A. A. et al. Simultaneous generation of many RNA-seq libraries in a single reaction. Nat. Methods 12, 323–325 (2015).

    CAS  Article  Google Scholar 

  45. 45

    Trapnell, C., Pachter, L. & Salzberg, S. L. Tophat: discovering splice junctions with RNA-Seq. Bioinformatics 25, 1105–1111 (2009).

    CAS  Article  Google Scholar 

  46. 46

    Anders, S., Pyl, P. T. & Huber, W. HTSeq—a Python framework to work with high-throughput sequencing data. Bioinformatics 31, 166–169 (2015).

    CAS  Article  Google Scholar 

  47. 47

    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).

    Article  Google Scholar 

  48. 48

    Metcalfe, P. D. et al. Bladder outlet obstruction: progression from inflammation to fibrosis. BJU Int. 106, 1686–1694 (2010).

    Article  Google Scholar 

  49. 49

    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).

    Article  Google Scholar 

  50. 50

    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).

    CAS  Article  Google Scholar 

Download references


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.

Author information




V.P.O. and T.J.H. conceived, designed and performed experiments, analysed data and wrote the manuscript. L.Y. and J.L. performed experiments and analysed data. D.J.S. and S.S. performed experiments. E.D.O.R. analysed data. M.C. conceived experiments. C.L.M., A.L.L. and S.J.H. conceived experiments, analysed data and wrote the manuscript.

Corresponding author

Correspondence to Scott J. Hultgren.

Ethics declarations

Competing interests

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 information

Supplementary information

Supplementary Figures 1–14, legends for Supplementary Tables 1–4 and Supplementary References (PDF 2163 kb)

Supplementary Table 1

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)

Supplementary Table 2

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)

Supplementary Table 3

Pathway analysis showing the canonical pathways enriched in the differentially expressed genes in the RNA-seq experiment. (XLSX 30 kb)

Supplementary Table 4

Broad meta-pathways assembled by Ingenuity IPA from the specific enriched pathways given in Supplementary Table 3. (XLSX 34 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

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

Download citation

Further reading


Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing