Itu 2015

REVIEWS
Urinary tract infections: epidemiology,

mechanisms of infection and
treatment options
Ana L.Flores-Mireles*, Jennifer N.Walker*, Michael Caparon and Scott J.Hultgren
Abstract | Urinary tract infections (UTIs) are a severe public health problem and are caused by
a range of pathogens, but most commonly by Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis, Enterococcus faecalis and Staphylococcus saprophyticus. High recurrence rates and
increasing antimicrobial resistance among uropathogens threaten to greatly increase the
economic burden of these infections. In this Review, we discuss how basic science studies are
elucidating the molecular details of the crosstalk that occurs at the hostpathogen interface,
as well as the consequences of these interactions for the pathophysiology of UTIs. We also
describe current efforts to translate this knowledge into new clinical treatments for UTIs.
Pyelonephritis
A kidney infection
characterized by cystitis
symptoms with additional
fever, flank pain, costovertebral-angle tenderness, nausea
and vomiting.
Cystitis
An infection of the bladder
with accompanying symptoms
of dysuria (painful urination),
pain (particularly suprapubic),
urinary frequency, urinary
urgency and haematuria (blood
in urine).
Department of Molecular
Microbiology and Center for
Womens Infectious Disease
Research, Washington
University School of Medicine,
Box 8230, 660 South Euclid
Avenue, St. Louis, Missouri
631101093, USA.
*These authors contributed
equally to this work.
Correspondence to S.J.H.
e-mail:
[email protected]
doi:10.1038/nrmicro3432
Published online 8 April 2015
Urinary tract infections (UTIs) are some of the most

common bacterial infections, affecting 150million people each year worldwide1. In 2007, in the United States
alone, there were an estimated 10.5million office visits
for UTI symptoms (constituting 0.9% of all ambulatory
visits) and 23million emergency department visits24.
Currently, the societal costs of these infections, including health care costs and time missed from work, are
approximately US$3.5billion per year in the United
States alone. UTIs are a significant cause of morbidity in
infant boys, older men and females of all ages. Serious
sequelae include frequent recurrences, pyelonephritis with
sepsis, renal damage in young children, pre-term birth
and complications caused by frequent antimicrobial use,
such as high-level antibiotic resistance and Clostridium
difficile colitis.
Clinically, UTIs are categorized as uncomplicated or
complicated. Uncomplicated UTIs typically affect individuals who are otherwise healthy and have no structural or neurological urinary tract abnormalities5,6; these
infections are differentiated into lower UTIs (cystitis)
and upper UTIs (pyelonephritis)5,7. Several risk factors
are associated with cystitis, including female gender, a
prior UTI, sexual activity, vaginal infection, diabetes,
obesity and genetic susceptibility 3,7. Complicated UTIs
are defined as UTIs associated with factors that compromise the urinary tract or host defence, including urinary
obstruction, urinary retention caused by neurological
disease, immunosuppression, renal failure, renal transplantation, pregnancy and the presence of foreign bodies such as calculi, indwelling catheters or other drainage
devices8,9. In the United States, 7080% of complicated

UTIs are attributable to indwelling catheters10, accounting for 1million cases per year4. Catheter-associated UTIs
(CAUTIs) are associated with increased morbidity and
mortality, and are collectively the most common cause
of secondary bloodstream infections. Risk factors for
developing a CAUTI include prolonged catheterization,
female gender, older age and diabetes11.
UTIs are caused by both Gram-negative and Grampositive bacteria, as well as by certain fungi (FIG.1). The
most common causative agent for both uncomplicated
and complicated UTIs is uropathogenic Escherichia
coli (UPEC). For the agents involved in uncomplicated
UTIs, UPEC is followed in prevalence by Klebsiella
pneumoniae, Staphylococcus saprophyticus, Enterococcus
faecalis, groupB Streptococcus (GBS), Proteus mirabilis,
Pseudomonas aeruginosa, Staphylococcus aureus and
Candida spp.3,6,12,13 (FIG.1). For complicated UTIs, the
order of prevalence for causative agents, following UPEC
as most common, is Enterococcusspp., K.pneumoniae,
Candidaspp., S.aureus, P. mirabilis, P.aeruginosa and
GBS9,1416 (FIG.1).
Patients suffering from a symptomatic UTI are
commonly treated with antibiotics; these treatments
can result in long-term alteration of the normal micro
biota of the vagina and gastrointestinal tract and in the
development of multidrug-resistant microorganisms17.
Theavailability of niches that are no longer filled by the
altered microbiota can increase the risk of colonization
with multidrug-resistant uropathogens. Importantly,
the golden era of antibiotics is waning, and the need
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REVIEWS
Complicated UTI
Uncomplicated UTI
3% 2% 1%
1%
1%
5%
6%
6%
75%
UPEC
K. pneumoniae
S. saprophyticus
Enterococcus spp.
GBS
P. mirabilis
P. aeruginosa
S. aureus
Candida spp.
Risk factors
Female gender
Older age
Younger age
3%
2%
2%
2%
7%
11%
65%
8%
Risk factors
Indwelling catheters
Immunosuppression
Urinary tract abnormalities
Antibiotic exposure
Figure 1 | Epidemiology of urinary tract infections. Urinary tract infections (UTIs) are caused
byReviews
a wide range
of
Nature
| Microbiology
pathogens, including Gram-negative and Gram-positive bacteria, as well as fungi. Uncomplicated UTIs typically affect
women, children and elderly patients who are otherwise healthy. Complicated UTIs are usually associated with indwelling
catheters, urinary tract abnormalities, immunosuppression or exposure to antibiotics. The most common causative agent
for both uncomplicated and complicated UTIs is uropathogenic Escherichia coli (UPEC). For uncomplicated UTIs, other
causative agents are (in order of prevalence) Klebsiella pneumoniae, Staphylococcus saprophyticus, Enterococcus faecalis,
group B Streptococcus (GBS), Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus and Candidaspp. For
complicated UTIs, the other causative agents are (in order of prevalence) Enterococcusspp., K.pneumoniae, Candidaspp.,
S.aureus, P.mirabilis, P.aeruginosa and GBS.
for rationally designed and alternative treatments is

therefore increasing. Recent studies have used RNA
sequencing to directly analyse uropathogens from the
urine of women experiencing symptomatic UTIs. These
studies, together with basic science and improved animal models, have been crucial in enabling us to understand the molecular details of how uropathogens adhere,
colonize and adapt to the nutritionally limited bladder
environment; evade immune surveillance; and persist
and disseminate in the urinary tract. These studies have
therefore revealed key virulence factors that can be targeted to prevent and counteract the pathogenic mechanisms that are important in UTIs7,17,18. In this Review,
we discuss the molecular mechanisms of pathogenesis
during bladder and kidney infection, comparing and
contrasting the virulence factors used by the major
uropathogens UPEC, K. pneumoniae, P. mirabilis,
E.faecalis and P.aeruginosa. Furthermore, we discuss
current antibiotic treatments, antibiotic resistance mechanisms, new combination therapies and future therapeutic interventions that use vaccines and small molecules
to target virulence factors.
Adherence and colonization

Adherence is a key event initiating each step in UTI
pathogenesis. A UTI typically starts with periurethral
contamination by a uropathogen residing in the gut,
followed by colonization of the urethra and subsequent
migration of the pathogen to the bladder, an event that
requires appendages such as flagella and pili (FIG.2). In
the bladder, the consequences of complex hostpathogen

interactions ultimately determine whether uropathogens
are successful in colonization or eliminated.
Multiple bacterial adhesins recognize receptors on
the bladder epithelium (also known as the uroepithelium) and mediate colonization (TABLE1). Uropathogens
such as UPEC survive by invading the bladder epithelium, producing toxins and proteases to release nutrients from the host cells, and synthesizing siderophores
to obtain iron (FIG.2; TABLE1). By multiplying and overcoming host immune surveillance, the uropathogens
can subsequently ascend to the kidneys, again attaching
via adhesins or pili to colonize the renal epithelium and
then producing tissue-damaging toxins (FIG.2; TABLE1).
Consequently, the uropathogens are able to cross the
tubular epithelial barrier to access the blood stream,
initiating bacteraemia.
The uropathogens that cause uncomplicated UTIs,
including UPEC, K.pneumoniae and S.saprophyticus,
have the ability to bind directly to the bladder epithelium, which is composed of the umbrella cells (also
known as superficial facet cells), intermediate cells and
basal cells19 (TABLE1). UPEC and K.pneumoniae bind
to uroplakins, which are the major protein components
of the umbrella cell apical membrane19 and which form
a crystalline array protecting the mammalian bladder
tissue from damaging agents in urine20. In addition to
uroplakins, 31 integrins, which are expressed at the
surface of uroepithelial cells, can also serve as receptors
for UPEC21. By contrast, complicated UTIs are initiated
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REVIEWS
a
Abdominal aorta
Inferior vena cava
Renal
artery
11 Bacteraemia
Host tissue
10 damage by
bacterial toxins
Renal
vein
Colonization of
the kidneys
Kidney
Ureter
8 Ascension to the kidneys

7
Epithelial damage
by bacterial toxins
and proteases
Biolm formation
Bacterial multiplication
and immune system
subversion
Neutrophil inltration
Bladder
Biolm
Neutrophil
Fibrinogen
Urethra
Colonization and
invasion of the
bladder, mediated
by pili and adhesins
Inammatory response
in the bladder and
brinogen accumulation
in the catheter
Uropathogenic
bacteria
2
Colonization of the urethra

and migration to the bladder
Contamination of the
periurethral area with a
uropathogen from the gut
Urinary
catheter
Figure 2 | Pathogenesis of urinary tract infections. a|Uncomplicated urinary tract infections

begin
when
Nature(UTIs)
Reviews
| Microbiology
uropathogens that reside in the gut contaminate the periurethral area (step1) and are able to colonize the urethra.
Subsequent migration to the bladder (step2) and expression of pili and adhesins results in colonization and invasion of
the superficial umbrella cells (step3). Host inflammatory responses, including neutrophil infiltration (step4), begin to
clear extracellular bacteria. Some bacteria evade the immune system, either through host cell invasion or through
morphological changes that result in resistance to neutrophils, and these bacteria undergo multiplication (step5) and
biofilm formation (step6). These bacteria produce toxins and proteases that induce host cell damage (step7), releasing
essential nutrients that promote bacterial survival and ascension to the kidneys (step8). Kidney colonization (step9)
results in bacterial toxin production and host tissue damage (step10). If left untreated, UTIs can ultimately progress to
bacteraemia if the pathogen crosses the tubular epithelial barrier in the kidneys (step11). b|Uropathogens that cause
complicated UTIs follow the same initial steps as those described for uncomplicated infections, including periurethral
colonization (step1), progression to the urethra and migration to the bladder (step2). However, in order for the
pathogens to cause infection, the bladder must be compromised. The most common cause of a compromised bladder is
catheterization. Owing to the robust immune response induced by catheterization (step3), fibrinogen accumulates on the
catheter, providing an ideal environment for the attachment of uropathogens that express fibrinogen-binding proteins.
Infection induces neutrophil infiltration (step4), but after their initial attachment to the fibrinogen-coated catheters, the
bacteria multiply (step5), form biofilms (step6), promote epithelial damage (step 7) and can seed infection of the kidneys
(steps8 and 9), where toxin production induces tissue damage (step10). If left untreated, uropathogens that cause
complicated UTIs can also progress to bacteraemia by crossing the tubular epithelial cell barrier (step11).
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Table 1 | Virulence factors used by the main uropathogens
Uropathogen
Virulence factors
Refs
Adherence
Toxin
Immune evasion
Iron acquisition
Other
UPEC
F1C pili
P pili
S pili
Type1 pili
Dr adhesins
HlyA
CNF1
HlyA
Capsular antigens
CNF1
Yersiniabactin
Aerobactin
Enterobactin
Salmochelin
Yersiniabactin
Antigen43
Flagella
Klebsiella
pneumoniae
Type1 pili
Type3 pili
ND
Capsule
Aerobactin
Enterobactin
ND
Proteusmirabilis
MR/P pili
NAFs
PMFs
AipA adhesin
TaaP adhesin
Haemolysins
(HpmA and
HlyA)
Pta
Capsule
ZapA
Proteobactin
Yersiniabactinrelated
Flagella
Urease
Pseudomonas
aeruginosa
Extracellular DNA
Exopolysaccharides
(alginate, PEL and
PSL)
ND
Capsule
Elastase
ExoS
Phospholipase
Rhamnolipids
Pyochelin
Pyoverdin
Quorum sensing
Staphylococcus
saprophyticus
Aas adhesin
SdrI adhesin
Uaf adhesin
Aas
ND
ND
Urease
Enterococcus
faecalis
Ebp pili
Ace adhesin
Esp adhesin
ND
Epa
ND
Sortase A
SigV
MsrA and MsrB
Enterococcus
faecium
Ebp pili
Esp adhesin
ND
ND
ND
ND
6,33,63,93,
96,141,142
4951,143,144
6,53,97,145
81,86,137,
146,147
84,148,149
54,55,61
54
AipA, adhesion and invasion mediated by the Proteus autotransporter; CNF1, cytotoxic necrotizing factor 1; Ebp, endocarditis- and biofilm-associated; Epa,
enterococcal polysaccharide antigen; Esp, enterococcal surface protein; ExoS, exoenzyme S; F1C pili, type 1-like immunological group C pili; HlyA, -haemolysin;
HpmA, haemolysin; MR/P, mannose-resistant Proteus-like; Msr, methionine sulfoxide reductase; NAF, non-agglutinating fimbria; ND, not determined; PMF,
P.mirabilis-like fimbria; P pili, pyelonephritis-associated pili; Pta, Proteus toxic agglutinin; TaaP, trimeric autoagglutinin autotransporter of Proteus; UPEC,
uropathogenic Escherichia coli.
when the bacteria bind to a urinary catheter, a kidney

stone or a bladder stone, or when they are retained in the
urinary tract by a physical obstruction. Some pathogens
(for example, UPEC) can cause both uncomplicated and
complicated UTIs. However, others such as P.mirabilis,
P.aeruginosa and Enterococcusspp. predominantly
cause complicated UTIs (FIG.2). Subsequently, these
uropathogens often form biofilms that are responsible
for colonization and persistence22,23 (BOX1).
Chaperoneusher pathway pili. Many uropathogens initiate a UTI using pili that mediate adhesion to host and
environmental surfaces, facilitate invasion into the host
tissues and promote interbacterial interactions to form
biofilms2427. For example, numerous Gram-negative
pathogenic bacteria including E.coli, Klebsiellaspp.,
Proteusspp., Pseudomonasspp., Haemophilusspp.,
Salmonellaspp. and Yersiniaspp.16,2729 express a
large, highly conserved family of adhesive fibres called
chaperoneusher pathway (CUP) pili25,26. CUP pili are
assembled by the chaperoneusher molecular machinery 24,25 and are composed of pilin subunits with incomplete immunoglobulin-like folds that lack the typical
carboxyterminal seventh -strand30,31. Briefly, in a process termed donor-strand complementation, a dedicated
periplasmic chaperone donates a strand to complete
the immunoglobulin fold of the subunits, forming a
complex with each subunit and ensuring their proper
folding and stabilization. The chaperonesubunit complex is then targeted to the usher assembly protein in
the outer membrane, where the usher selectively differentiates chaperonesubunit complexes and catalyses the
ordered assembly of pili on the cell surface via a mechanism termed donor-strand exchange. During donorstrand exchange, the final folding of a subunit occurs
as the donated strand of the chaperone is replaced
by an aminoterminal extension on the next incoming
subunit 32. Importantly, understanding the most basic
principles of molecular biology such as how a protein folds into domains that serve as assembly modules
for building large supramolecular structures, and how an
outer-membrane macromolecular machine (the usher)
assembles these structures from individual subunits,
which are delivered as chaperonesubunit complexes
and then transported in a regulated manner across a biological membrane has led to the development of antivirulence compounds that block CUP pilus assembly or
function and that result in the dysregulation of virulence
factors. These compounds have the potential for broadspectrum activity against numerous Gram-negative
bacteria (see below).
Uropathogenic Escherichia coli. Thirty-eight distinct
CUP pilus operons have been identified in E. coli
genomes, and a single UPEC strain can encode more
than 12 different CUP pili25. However, the distribution of
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Box 1 | Biofilms and morphological plasticity
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.
Biofilm formation
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 (FIG.3). Type1 pili, antigen43 and adhesive surface fibres
called curli induce biofilm formation by mediating interbacterial interactions and attachment to surfaces. Transcription
of antigen43 is regulated by oxidative stress regulator (OxyR; also known as hydrogen peroxide-inducible genes
activator)131, whereas type1 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 type1pili35.
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 (FIG.4). 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
biofilmformation. 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 MrpJ leads 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 cellcell 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.
Morphological changes
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 (FIG.3). 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
theouter 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 (FIG.4).
CUP operons is not uniform across different UPECisolates; some operons are found ubiquitously in UPEC,
whereas others are present in only a handful of strains.
The multitude of CUP pili encoded by UPEC are tipped
with different adhesins, some of which are known to
mediate distinct tropisms in the lower and upper urinary tract by recognizing receptors with stereochemical
specificity, notably in the bladder or kidney epithelium33.
Type1 pili and pyelonephritis-associated (P) pili are
the better characterized CUP pili. Type1 pili are essential for colonization, invasion and persistence of UPEC
in the mouse bladder 34 (FIG.3). Type1 pili are tipped with
the adhesin FimH7, which recognizes mannosylated uroplakins and 13 integrins with stereochemical specificity 21,35 to initiate colonization and invasion into umbrella
cells7,21. Type1 pili binding to these cells triggers a signal
transduction cascade that activates Rho GTPases, such
as those from the Rac family, to cause actin rearrange

ment and internalization of UPEC by a zippering mechanism consisting of a plasma membrane sheathe that
engulfs the bacterium36 (FIG.3). Invasion allows UPEC to
subvert certain host defences and become recalcitrant
to antibiotic treatments. However, an innate defence
expulsion mechanism defends the uroepithelium from
UPEC invasion; this expulsion mechanism depends on
Toll-like receptor4 (TLR4) expression by uroepithelial
cells. Lipopolysaccharide (LPS)-mediated activation of
TLR4 stimulates adenylyl cyclase3 (AC3) to produce
cyclic AMP, which induces the exocytosis of vesicular
UPEC into the apical plasma membrane of the umbrella
cells37 (FIG.3). Importantly, by escaping into the cytoplasm (through an unknown mechanism), UPEC can
subvert the expulsion pathway and rapidly multiply,
forming transient biofilm-like intracellular bacterial
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Exfoliation
a
Neutrophil
Kidney
UPEC
UPEC
lament
LPS
Type 1 pilus
Uroplakin
RHO
GTPases
cAMP
UPEC
expulsion
Fe
Iron scavenging
Fe
Fe Fe
Actin
Invasion
Membrane
ruing
UPEC survival
Eux
Actin
RAC
HlyA
Inammation,
apoptosis or
exfoliation
31
integrin
IBC
Tissue
damage
Survival pathways
QIR
Transitional cells
Umbrella cells
IBC
CNF1
TLR4
AC3
BCAM
Actin
bres
Kidney epithelium
Figure 3 | Virulence factors of uropathogenic Escherichia coli b

that contribute to urinary tract infections. a|In the bladder,
uropathogenic Escherichia coli (UPEC) expression of type1 pili
is essential for colonization, invasion and persistence. The
P pilus
type1 pilus adhesin, FimH, binds mannosylated uroplakins and
TLR4
integrins that coat the surface of umbrella cells. Uroplakin
Globosides
PIGR
binding by FimH induces actin rearrangement and bacterial
internalization via unknown mechanisms. FimH31 integrin
interactions induce actin rearrangement via activation of
RHO-family GTPases (such as RAC proteins), resulting in
PIGR expression
bacterial invasion. Inside the host cell, UPEC can subvert
host defences and resist antibiotic treatment. However,
Lamina propria
lipopolysaccharide (LPS) released by UPEC is sensed by Toll-like
IgA
receptor4 (TLR4), which induces cyclic AMP (cAMP) production
via adenylyl cyclase3 (AC3) activation, resulting in exocytosis of
Plasma cells
vesicular UPEC across the apical plasma membrane. UPEC
subverts this innate defence mechanism by escaping into the
cytoplasm, where it then multiplies to form intracellular bacterial communities (IBCs). Maturation
IBCs causes
bacterial
NatureofReviews
| Microbiology
dispersal and allows the invasion of other host cells, which enables UPEC to re-enter the IBC cycle. Alternatively, UPEC can
establish quiescent intracellular reservoirs (QIRs) in the underlying transitional cells. QIRs consist of 410 non-replicating
bacteria within membrane-bound compartments encased in Factin and can remain viable for months. In addition, UPEC
survives within the harsh bladder environment by secreting several factors that are important for nutrient acquisition. The
toxin haemolysin (HlyA) promotes host cell lysis through pore formation, facilitating iron release and nutrient acquisition.
The siderophores expressed by UPEC allow the bacterium to scavenge iron and thus promote survival during a urinary
tract infection (UTI). HlyA also triggers epithelial exfoliation to promote the spread of UPEC to other hosts following urine
expulsion or to expose deeper layers of the uroepithelium for QIRs. Cytotoxic necrotizing factor 1 (CNF1) is also important
for host cell remodelling and functions by binding to the receptor basal cell adhesion molecule (BCAM) on host cells to
induce constitutive activation of the RHO GTPases RAC1, RHOA and cell division control42 (CDC42), resulting in actin
cytoskeletal rearrangements and membrane ruffling. Activation of RAC1 also induces the host cell anti-apoptotic and
pro-survival pathways, preventing apoptosis of colonized epithelial cells and allowing the UPEC population to expand.
The extracellular survival of UPEC also requires evasion of the innate immune system by the adoption of a filamentous
morphology, which renders the bacterium more resistant to neutrophil killing than their bacillary form. b|UPEC
colonization of the kidneys is dependent on expression of pyelonephritis-associated (P) pili, which bind globoside-containing
glycolipids lining the renal tissue. The Ppilus adhesin, PapG, also interacts with TLR4, reducing the expression of polymeric
immunoglobulin receptor (PIGR). This results in impaired immunoglobulinA (IgA) transport across the epithelium, thereby
modulating the local secretory antibody immune response and preventing UPEC opsonization and clearance.
communities (IBCs)38,39 (BOX1; FIG.3). After their maturation, bacteria disperse from the IBC to invade other
cells, where the IBC cycle is repeated3840. IBC formation
is a common mechanism for clinical UPEC isolates and
has been observed in multiple mouse backgrounds

and also in exfoliated uroepithelial cells in the urine of
patients with acute UTIs but not in the cells in urine
from healthy controls41,42. The process of invasion and
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IBC formation provides UPEC with the ability to survive
stringent bottlenecks in the urinary tract, including
TLR4mediated expulsion, umbrella cell exfoliation,
ascension to the kidneys, urination and inflammation7,43. UPEC also establishes quiescent intracellular
reservoirs (QIRs) in underlying transitional cells, within
membrane-bound compartments enmeshed in Factin
(FIG.3). In contrast to the metabolically active IBCs, QIRs
typically contain 410 non-replicating bacteria that can
remain viable for months and can be reactivated to
serve as seeds that initiate a recurrent UTI7. It has been
proposed that during uroepithelial turnover, in which
the underlying immature cells terminally differentiate
into umbrella cells, the redistribution of actin and perhaps other associated signals might trigger UPEC revival
from QIRs, releasing the bacteria back into the bladder
lumen44.
Unlike the mannose-binding adhesin FimH of type1
pili, the adhesin of Ppili, PapG, binds globosides containing glycolipids that are present in the human kidneys33
(FIG.3). In addition, PapG modulates the local secretoryantibody immune response by interacting with TLR4
to reduce polymeric immunoglobulin receptor (PlGR)
expression, thus impairing immunoglobulin A transport
through the lamina propria and epithelial cells to the
kidney lumen45 (FIG.3). By inhibiting immunoglobulin
A transport into the urinary space, UPEC evades a key
host protective mechanism, allowing the establishment
of ascending infection45,46.
Importantly, the initial innate host response to UPEC
colonization and invasion not only dictates the outcome
of the original infection but is also crucial for determining host susceptibility to subsequent infections39. An
increased susceptibility to recurrent UTIs can occur not
because of a deficient host response to UPEC infection,
as is commonly accepted, but rather as a result of an
unrestrained lymphocyte-dependent innate inflammatory response to acute infection, leading to severe acute
injury to the mucosal uroepithelium and potentiating
subsequent infections39.
Globosides
Glycosylceramides containing
acetylated amino sugars and
simple hexoses. These
molecules are found in the
kidneys.
Klebsiella pneumoniae. Similarly to UPEC, K.pneumoniae uses type1 pili for biofilm formation and bladder colonization47 (TABLE1). Interestingly, although the
K.pneumoniae adhesin FimH is highly homologous to
UPEC FimH, they have different binding specificities48.
K.pneumoniae FimH-mediated biofilm formation is
inhibited by heptyl mannose, as opposed to the methyl
mannose-mediated inhibition of UPEC FimH. Moreover,
K.pneumoniae FimH has a weaker adherence to the bladder than UPEC FimH, resulting in significantly lower
K.pneumoniae titers in the mouse bladder and fewer
IBCs than are seen for UPEC. Despite the relatively poor
adhesive properties of K.pneumoniae FimH in the urinary tract, it remains an important virulence factor for
K.pneumoniae during colonization, biofilm formation
and persistence in both UTIs and CAUTIs4850. In addition, K.pneumoniae encodes numerous other CUP pili,
including type3 pili, which also play an important part
in colonization, biofilm formation and persistence during
UTIs and in biofilm formation during CAUTIs35,51,52.
Proteus mirabilis. Following initial attachment, P.mirabilis produces mannose-resistant Proteus-like (MR/P)
pili, which are CUP pili that facilitate biofilm formation
and colonization of the bladder and kidneys, and are
crucial for catheter-associated biofilm formation6,16,23,53
(BOX1; FIG.4). Other CUP pili encoded by P.mirabilis
include P.mirabilis-like fimbriae (PMFs), which are
important for bladder and kidney colonization53, and
non-agglutinating fimbriae (NAFs), which are able
to attach to uroepithelial cells in vitro 53. However,
the invivo mechanistic roles of PMFs, NAFs and their
receptors have not yet been established.
In addition to CUP pili, P. mirabilis encodes
twoautotransporters, TaaP (trimeric autoagglutinin
autotransporter of Proteus) and AipA (adhesion and
invasion mediated by the Proteus autotransporter),
which are important for bladder and kidney infection,
respectively 53. AipA can adhere to human bladder and
kidney cell lines invitro but is only required for kidney infection (and not for bladder infection) in mice.
Conversely, TaaP is required for bladder infection by
P.mirabilis in mice. Importantly, both autotransporters bind to extracellular-matrix proteins invitro: AipA
preferentially binds to collagen I, and TaaP to laminin,
which might provide an explanation for their different
tissue tropisms.
Enterococci. Enterococci encode several adhesion factors, including the collagen adhesin Ace, enterococcal
surface protein (Esp), enterococcal polysaccharide antigen (Epa), and endocarditis- and biofilm-associated
(Ebp) pili54 (TABLE1). Of these, Ebp pili contribute to
CAUTIs5456 and are required for persistence during
infection55,56. Clinical studies have shown that mechanical stress induced by urinary catheterization produces
histological and immunological changes in the bladder,
resulting in a robust inflammatory response, exfoliation, oedema, and mucosal lesions of the uroepithelium
and kidneys57,58. Importantly, a mouse model of CAUTI
seems to recapitulate these immunological changes that
are induced by urinary catheterization, exhibiting catheter-induced inflammation, severe uroepithelial damage, exfoliation and the onset of bladder wall oedema,
which is exacerbated by increased catheterization time59.
Urinary catheters provide a surface for E.faecalis attachment and biofilm formation, which promotes E.faecalis
persistence in the bladder and further dissemination
to the kidneys55 (FIG.4). However, E.faecalis is unable to
bind to catheter material invitro and is unable to grow
in urine60. This apparent paradox was resolved by the
finding that urinary catheterization induces fibrinogen
release into the bladder as part of the inflammatory
response; this fibrinogen subsequently accumulates in
the bladder and is deposited on the implanted catheter 60
(FIGS2,4). Following fibrinogen deposition, the Ebp
pilus adhesin EbpA, which contains an Nterminal
fibrinogen-binding domain mediates catheter colonization and biofilm formation during CAUTIs caused
by E.faecalis 60,61 (FIG.4). Furthermore, E.faecalis can use
fibrinogen for growth, enhancing biofilm formation on
the catheter 60 (FIG.4). This resolution of the paradox has
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REVIEWS
a
Neutrophil
P. mirabilis
Urease
CO2 and
ammonia
pH increase and
crystal formation
Crystalline biolm
Urea
Tissue
damage
Filamentation
Catheter
MR/P pilus
HpmA
Inammation,
apoptosis or
exfoliation
Tissue damage
Exfoliation
Pta
Fe
Fe
Fe
Fe
Fe
Iron scavenging
Fe
Osmotic
pressure
Puncture
Leakage
Actin depolymerization
Transitional cells
Umbrella cells
Uroepithelium colonization
b
E. faecalis
Protease
production
Food source
Fibrinogen deposition
Transitional cells Umbrella cells
Fibrinogen
release
Ebp pilus
Biolm
Fibrinogen accumulation
Inammed uroepithelium
Figure 4 | Mechanisms of pathogenesis during catheter-associated urinary tract infections. a|Catheter-associated

Reviews | Microbiology
urinary tract infections (CAUTIs) mediated by Proteusmirabilis depend on the expression of Nature
mannose-resistant
Proteus-like
(MR/P) pili for initial attachment, and for biofilm formation on the catheter and in the bladder. Subsequent urease production
induces the formation of calcium crystals and magnesium ammonium phosphate precipitates in the urine through the
hydrolysis of urea to carbon dioxide and ammonia, resulting in a high pH. The production of extracellular polymeric substances
by bacteria attached to the catheter traps these crystals, allowing the formation of a crystalline biofilm, which protects the
community from the host immune system and from antibiotics. In addition, these structures prevent proper urine drainage,
resulting in reflux and promoting the progression to pyelonephritis, septicaemia and shock. Finally, production of the bacterial
toxins haemolysin (HpmA) and Proteus toxic agglutinin (Pta) is important for tissue destruction and bacterial dissemination to
the kidneys. HpmA induces pore formation by inserting itself into the cell membrane and destabilizing the host cell, causing
tissue damage, exfoliation and nutrient release. Pta punctures the host cell membrane, causing cytosol leakage and resulting
in osmotic stress and depolymerization of actin filaments, thus compromising the structural integrity of the cell. The release
of nutrients via these toxins also allows the bacteria to scavenge iron using siderophores. b|Enterococcusfaecalis
pathogenesis during CAUTIs depends on catheter implantation, which results in bladder inflammation and causes fibrinogen
release, deposition onto the catheter, and accumulation. E.faecalis takes advantage of the presence of fibrinogen and uses
it as a food source through the production of proteases. E.faecalis also binds fibrinogen through the endocarditis- and
biofilm-associated (Ebp) pilus, allowing the formation of biofilms that protect the bacteria against the immune system.
276 | MAY 2015 | VOLUME 13
REVIEWS
been recapitulated invitro by the demonstration that
E.faecalis attaches to fibrinogen-coated catheters and
grows in urine supplemented with fibrinogen60.
Other virulence factors

The bladder environment is limited in nutrients; thus,
in order to survive and grow within the urinary tract,
uropathogens produce proteases and toxins that damage
the host tissue to release nutrients, while also providing a
niche for bacterial invasion and dissemination (TABLE1).
Lamellopodium
A cytoskeletal actin projection
at the surface of a cell. In some
cases, these actin-powered
protrusions are a key factor
driving cell motility.
Proteases and toxins. UPEC secretes high concentrations of haemolysin (HlyA), which oligomerizes and
integrates in the cholesterol-rich microdomains in the
host cell membrane in a Ca+-dependent manner 62,63.
This results in pore formation in the umbrella cells and
promotes their lysis, which facilitates iron and nutrient
acquisition by the bacteria (FIG.3). HlyA also triggers
exfoliation, exposing deeper layers of the uroepithelium
for colonization and promoting bacterial spread to other
hosts following cell expulsion in the urine6265 (FIG.3).
Furthermore, HlyA is highly expressed in IBCs, suggesting
that it is important during this stage of infection39,63,66.
UPEC also secretes cytotoxic necrotizing factor1
(CNF1), which affects actin remodelling in the host cell
through three small RHO GTPases: RAC1, RHOA and
cell division control 42 (CDC42)67,68. CNF1 enters the
host cell in endocytic vesicles, by binding to the receptor basal cell adhesion molecule (BCAM; also known as
LU)69, and then constitutively activates RHO GTPases
via deamination of a glutamine residue; this causes
actin cytoskeletal rearrangements and membrane ruffling, leading to increased levels of bacterial internalization67,70. In addition, the activation of RAC1GTP
induces the host cell anti-apoptotic and pro-survival
pathways (through the interaction of phosphoinositide
3kinase (PI3K), AKT (also known as PKB) and nuclear
factor-B (NFB)); this prevents apoptosis of the colonized uroepithelium, thus facilitating UPEC survival
and protecting the niche67,71 (FIG.3).
P.mirabilis produce two toxins, haemolysin (HpmA)
and Proteus toxic agglutinin (Pta), which are implicated
in tissue damage and dissemination to the kidneys, initiating acute pyelonephritis16,72. HpmA is a Ca+-dependent
pore-forming cytolysin that destabilizes the host cell by
inserting itself into the cell membrane and causing a
Na+ efflux 16 (FIG.4). By contrast, the surface-associated
cytotoxic protease Pta is functional only in an alkaline
pH, such as that induced by the activity of P.mirabilis
urease73. In the proposed mode of action, Pta punctures
the host cell membrane, causing leakage of the cytosol,
osmotic stress and depolymerization of actin filaments;
the structural integrity of the cell is therefore compromised, resulting in bladder and kidney damage53,73
(FIG.4). Pta also induces bacterial cellcell interaction via
autoaggregation53,73.
P. aeruginosa produces elastases, exoenzyme S
(ExoS) and haemolytic phospholipase C, all of which
have been implicated in UTI initiation and dissemination, and subsequent pyelonephritis74,75 (TABLE1). The
GTPase activity of ExoS downregulates macrophage
RAC1 function, interfering with lamellopodium formation and inducing membrane ruffle formation. The
ADP-ribosyltransfease activity of ExoS targets RHO
family proteins (RAS proteins and RalA), affecting
cell adherence and morphology 76. Elastase induces
tissue destruction through its protease activity, releasing nutrients (including iron) for continued bacterial
growth77. Phospholipase C is an toxin that hydrolyses
phosphatidylcholine from the host cell membrane,
compromising cell integrity and resulting in organ
damage7880. The expression of all of these virulence
factors is regulated by the quorum sensing system81.
Quorum sensing is activated at high cell density by the
accumulation of small molecules called autoinducers.
When a threshold level of autoinducers is reached,
they bind to transcriptional activator proteins and
activate the expression of virulence factors81,82 (BOX1).
Urease. Urease is encoded by several uropathogens,
including P.mirabilis 53,83, S.saprophyticus 84, K.pneumoniae 85 and P. aureginosa 86, and is important for
colonization and persistence during P.mirabilis and
S.saprophyticus UTIs83,84 (FIG.4; TABLE1). This enzyme
catalyses the hydrolysis of urea to carbon dioxide and
ammonia87, resulting in elevated urine pH and the production of calcium crystals (apatite) and magnesium
ammonium phosphate ammoprecipitates (struvite) in
urine and on catheters53 (FIG.4). Importantly, the accumulation of ammonia becomes toxic for the uroepithelial cells, inducing direct tissue damage88. The P.mirabilis
urease, one of the best studied ureases involved in UTIs,
is a Ni2+-dependent metalloenzyme that is essential for
colonization of the bladder and kidneys and promotes
the formation of stones23,53,87. The P.mirabilis urease is
induced by urea and is constitutively expressed during
growth in urine89. This urease is highly active, hydrolysing urea several times faster than those produced by
other species, such as Providencia stuartii, Providencia
rettgeri, Proteus vulgaris and Morganella morganii 90. The
high activity level of the P.mirabilis enzyme induces rapid
crystal formation, and these crystals become trapped
within the polysaccharides produced by attached bacterial cells, forming crystalline biofilms on catheters23,89,91.
The crystalline biofilms provide P.mirabilis with protection from the host immune system and antibiotics88
(BOX1; FIG.4). These structures also block urine drainage from the ureters, potentially resulting in reflux and
promoting progression to pyelonephritis, septicaemia
and shock53.
Iron scavenging. The bladder environment is limited in
iron. Thus, to be able to grow in human urine, uropatho
gens utilize siderophore systems for iron (Fe3+) scavenging; these systems are composed of the siderophore
assembly machinery, a siderophore responsible for binding iron and a membrane receptor that internalizes the
iron bound to the siderophore92 (TABLE1).
UPEC produces several siderophores93, of which two
aerobactin and yersiniabactin are essential in the
urinary tract93 (FIG.3). Aerobactin is highly expressed, stable at low pH and displays higher levels of iron binding
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REVIEWS
than enterobactin94,95. Yersiniabactin is important in biofilm formation in urine and has a protective role against
intracellular killing by copper stress, as it sequesters
host-derived copper 96.
Numerous iron-scavenging siderophore systems are
utilized by other uropathogens: K.pneumoniae produces enterobactin and aerobactin85; P.mirabilis uses
proteobactin and yersiniabactin-related97; and P.aeruginosa produces pyochelin and pyoverdin86 (TABLE1).
Siderophore systems are important potential targets for
vaccine development98 and for designing small molecules
that interfere with their function.
Treatment of urinary tract infections

UTIs result in considerable economic and public health
burdens and substantially affect the life quality of
afflicted individuals17. Currently, antibiotics such as
trimethoprim sulfamethoxazole, ciprofloxacin and ampicillin are the most commonly recommended therapeutics for UTIs4. However, increasing rates of antibiotic
resistance and high recurrence rates threaten to greatly
enhance the burden that these common infections place
on society. Ideally, alternative therapies will be established that will be recalcitrant to the development of
resistance. Many promising approaches are being developed, from leveraging what we have learned about the
basic biology of UTI pathogenesis to specifically target
virulence pathways. These antivirulence therapeutics
should theoretically allow us to effectively neutralize, or
disarm, the capacity of UTI pathogens to cause disease,
without altering the gut commensal microbiota, because
antivirulence therapeutics target processes that are critical for UTI pathogenesis but that are not required for the
essential processes of growth and cell division (which are
the targets of conventional antibiotics).
Below, we discuss the current challenges that have
arisen from the emergence of multidrug-resistant bacterial strains and highlight the progress that is being made
towards the development of antivirulence therapeutics
for UTIs. We also discuss how an understanding of the
evolution of bacterial resistance mechanisms and their
spread is providing new approaches for the modification
and improvement of current therapeutic options.
Multidrug resistance. UTIs are becoming increasingly
difficult to treat owing to the widespread emergence of
an array of antibiotic resistance mechanisms3,4,15,99102 (see
Supplementary information S1(table)). Of particular
concern are members of the family Enterobacteriaceae,
including E.coli and K.pneumoniae, which have both
acquired plasmids encoding extended-spectrum
lactamases (ESBLs). These plasmids rapidly spread
resistance to third-generation cephalosporins as well as
other antibiotics15,99103 (BOX2). Other Enterobacteriaceae
family members produce the class C lactamases
(AmpC enzymes) that are active against cephamycin
in addition to third-generation cephalosporins, and are
also resistant to lactamase inhibitors99102. The expression of AmpC enzymes is also associated with carba
penem resistance in K.pneumoniae strains lacking a
42kDa outer-membrane protein15,99102 (BOX2).
Multidrug resistance is also common among entero

cocci, as they are naturally resistant to trimethoprim,
clindamycin, cephalosporins and penicillins15,101,102.
Recently, Enterococcusspp. have developed high-level
resistance to glycopeptides, including vancomycin, which
is considered to be one of the last lines of defence against
multidrug-resistant organisms. Specifically, enterococci
evolved resistance to glycopeptides through the expression of vancomycin and teicoplanin A-type resistance
(van) genes that encode the penicillin-binding proteins
(PBPs) VanA, VanB, VanD, VanE, VanG and VanL101,102.
The mechanism of resistance for VanA, the most common
PBP expressed by enterococci, is to replace the cell wall
precursor dalaninedalanine with dalaninedlactose,
effectively reducing the binding affinity of vancomycin104.
The troubling trend towards a high prevalence of multi
drug-resistant uropathogens has spurred the development
of alternative control measures and treatment options.
Combination therapies. New antimicrobials that are
resistant to inactivation by ESBLs are under development for use in combination with new classes of
lactamase inhibitors, which target both lactamases
and K.pneumoniae carbapenemases (KPCs)105107. These
combination therapies have been shown to be effective
invitro against carbapenem-resistant members of the
family Enterobacteriaceae. Furthermore, clinical trials
involving complicated UTIs revealed that ceftazidime,
a third-generation cephalosporin that is active against
Gram-positive and Gram-negative organisms, is effective against ESBL- and carbapenemase-producing Gramnegative bacteria when combined with the lactamase
inhibitor avibactam105. Future studies are needed to test
the efficacy of ceftazidimeavibactam against ESBL-,
KPC- and AmpC-producing Gram-negative pathogens
during infection, as the drug combination has the potential to be effective against a broad range of cephalosporinresistant Enterobacteriaceae family members. Although
these antibioticinhibitor combinations are promising,
the development of resistance to lactamase inhibitors
is not well characterized105. Moreover, the effectiveness of
specific antibioticinhibitor therapies is dependent on the
antimicrobial-resistance patterns encoded by each pathogen, as the expression of certain combinations of ESBLs
and carbapenemases can provide resistance to an antibioticinhibitor therapy 105107. For example, the combination of BAL30072BAL29880clavulanate (two lactam
antibiotics and a lactamase inhibitor) is effective against
many carbapenem-resistant Enterobacteriaceae family
members, but K.pneumoniae strains that typically produce KPCs and SHVs (another type of ESBL), or AmpC
enzymes are resistant 106. Therefore, it is crucial to know
which antibiotic mechanisms are available to a specific
uropathogen in order to determine an effective treatment.
Vaccines targeting bacterial adhesion. As adherence has
a key role at nearly every step of UTI pathogenesis, one
attractive strategy for the development of antivirulence
therapies, including vaccines, has been to target CUP pili.
As a general rule, vaccination with whole pili has been
ineffective at generating an antibody response that can
278 | MAY 2015 | VOLUME 13
REVIEWS
Box 2 | Antibiotic resistance
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.
ESBLs
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 resistant101,102.
CTXMs
The plasmids encoding the ESBLs CTXMs form a new plasmid phylum that is
phylogenetically distinct from other plasmid-encoded lactamases. CTXMs 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. CTXMs are the most prevalent
lactamases in community-associated isolates and are typically encoded on plasmids
with other resistance genes102. CTXMs efficiently hydrolyse the lactam ring via
nucleophilic attack of a ring carbonyl carbon by a conserved serine in the lactamase,
resulting in a ring-opened product that is inactive140.
OXAs
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.
AmpC enzymes
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
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 (NDM1), 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.
protect against UTIs. However, adhesin-based vaccines

have been shown to be effective at blocking hostpathogen
interactions, thus preventing the establishment of disease108112. Experiments using mouse and cynomolgus
monkey models of UTIs determined that immunization
with PapDPapG or FimCFimH chaperoneadhesin
complexes protected against UTIs108112. The effectiveness of the FimCFimH vaccine was shown to be due,
in large part, to antibodies that block the function of
FimH in bladder colonization110. Furthermore, the
anti-FimH antibodies did not seem to alter the E.coli
niche in the gut microbiota109. Modifications of this vaccine are currently under development, with the aim of
inducing greater immune stimulation108,112. For example,
one approach has been to fuse FimH to the flagellin FliC
in order to induce a more substantial acute inflammatory
response, which functions through TLR4 signalling via

the MYD88 pathway 112. A PhaseI clinical trial began in
January 2014 to evaluate the efficacy of a FimCFimH
vaccine using a synthetic analogue of monophosphoryl
lipid A as the adjuvant.
In addition to the UPEC adhesins, adhesins from
P.mirabilis and E.faecalis have also been used as vaccine targets60,113. In a mouse model of UTI, vaccination
with the P.mirabilis MR/P pilus adhesin, MrpH, reduced
bacterial burdens compared with those of unvaccinated
controls, similar to the results observed with UPEC
in the FimH vaccine trials110,113. Moreover, a vaccine
strategy that is efficacious against E.faecalis CAUTIs
is being developed based on vaccination with the Ebp
pilus adhesin, EbpA. This strategy induced high antibody titers and reduced bacterial burdens in a mouse
model of CAUTI60. In conclusion, adhesin-based vaccines represent a promising area for the development of
therapeutics against uropathogens. Thus, understanding the molecular basis of hostpathogen interactions
is crucial for vaccine development strategies.
Vaccines targeting bacterial toxins and proteases. The
UPEC pore-forming toxin HlyA has also received attention as a potential vaccine target and was evaluated in
a mouse model of pyelonephritis to assess protection
against renal damage 114,115. Vaccination with HlyA
reduced the incidence of renal scaring compared with
controls; however, it did not protect against UPEC colonization of the kidneys115. In addition, in a mouse model
of UTI, vaccination with the P.mirabilis haemolysin,
HpmA, did not provide protection against bacterial colonization116. However, vaccination with Pta, an alkaline
protease with toxic effects towards epithelial cells, displayed promising results in a mouse model of UTI, protecting against upper UTI, although bacterial burdens
in the bladder remained unaffected116. Thus, although
haemolysins and proteases might provide effective vaccine targets for preventing upper UTIs, additional studies are needed to determine the effectiveness of these
enzymes as targets for vaccines.
Vaccines targeting siderophores. Iron acquisition systems have shown great promise as targets for vaccine
development because uropathogens require a source of
iron during colonization and persistence. Furthermore,
siderophore and haem acquisition systems have been
shown to be upregulated during experimental infection,
as well as in the urine of women with a UTI86,94,97,98. These
parameters sparked vaccine development based on ferric
yersiniabactin uptake receptor (FyuA), haem acquisition
protein (Hma), iron uptake transport aerobactin receptor (IutA) and the siderophore receptor iron-responsive
element A (IreA)98. Vaccination with FyuA and Hma protected mice against pyelonephritis98,117, whereas vaccination with IutA and IreA reduced bladder colonization in
mice, confirming the importance of these proteins during
infection98,117. Interestingly, the differential tissue-specific
protection seen with these four proteins suggests that
these systems have different roles or expression profiles
in different niches, including the bladder orkidneys.
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REVIEWS
Vaccinations with other siderophore systems in mouse
models of UTI, including the iron receptors FitA and
ChuA98, were not protective against infection and were
correlated, to a large extent, with lower antigen-specific
humoral responses during experimental UTI. These studies suggest that effective siderophore-based vaccines function in part by preventing cognate siderophore uptake, as is
the case with FyuA, Hma, IutA and IreA98,117, making this
an exciting area of therapeutic development againstUTIs.
Teratogenicity
The capability of a compound
to cause fetal malformation.
Musculo-integumentary
Refers to the interaction
between the muscular and
integumentary systems. The
muscular system is composed
by the skeletal, smooth and
cardiac muscles, whereas the
skin, hair, nails and other
specialized structures form the
integumentary system.
Small molecules targeting urease. Several urease inhibitors have been developed as potential drugs for UTI
treatment, with varying results89. Many of the early
inhibitors were active against ureases from several different bacterial species, including Helicobacter pylori,
P.mirabilis and S. saprophyticus, and many of these
inhibitors showed great promise, as they had low binding and inhibitory concentrations. The best characterized urease inhibitor, acetohydroxamic acid (AHA),
even had some success in treating UTIs causedby
urease-producing organisms; this inhibitor works
bypreventing urine alkalization and was approvedby
the FDA in 1983 (REF. 89). However, many of these
inhibitors had severe side effects related to toxicity.
For example, AHA resulted in teratogenicity, as well as
psychoneurological and musculointegumentary effects.
Subsequent studies showed that derivatives of AHA
also had considerable inhibitory properties, but again,
these compounds had mutagenic properties that made
them undesirable therapeutics89. Another group of urease inhibitors, the phosphoramidites, exhibited potent
activity against P.mirabilis urease and were effective in
a mouse model of infection. However, this class of compounds displayed low stability in the low pH of gastric
juice, making them impractical89. Finally, the heterocyclic compounds termed benzimidazoles have garnered
much attention because they function as proton pump
inhibitors that irreversibly inactivate ATPase systems118.
These compounds are currently the standard treatment
for peptic ulcers and gastroesophageal reflux disease89.
Benzimidazoles interact with the gastric hydrogen potassium ATPase, thereby inactivating them and effectively
limiting the disease118. Interestingly, benzimidazoles also
bind to the urease metallocentre, effectively blocking
the active site of the enzyme through steric hindrance89.
Benzimidazoles also have a bactericidal activity against
H.pylori, and this is not mediated by urease inhibition,
indicating that these compounds have a more general bactericidal effect89,119. Great strides have been made to identify and characterize urease inhibitors, but more work is
needed to bring these potential treatments to themarket.
Small molecules targeting bacterial adhesion. Our detailed
understanding of pilus assembly and pilusreceptor
binding has opened the door to the development of two
classes of small, rationally designed synthetic compounds
to inhibit pili: mannosides, which inhibit pilus function;
and pilicides, which inhibit pilus assembly. Targeting
CUP pilus function or assembly has therapeutic potential, as it should block UPEC colonization, invasion and
biofilm formation, thus preventing disease30,31,120,121.
Pilicides were originally developed to specifically

inhibit the assembly of UPEC type1 pili. They have a
2pyridone scaffold28,30,31,120 and function by selectively
targeting and interfering with crucial chaperoneusher
interactions. Further studies have been carried out to
investigate their broad spectrum of activity against
other CUP pili122. A recent analysis of 35 Escherichiaspp.
genomes and 132plasmids identified a total of 458CUP
operons, representing 38 distinct CUP pilus types on
the basis of usher phylogeny 25. A single Escherichia sp.
genome can have as many as 16 distinct, intact CUP operons25, suggesting that compounds which target CUP pili
by disrupting their assembly would potentially exhibit
broad-spectrum activity. For example, pilicide ec240
was found to disrupt several virulence-associated pili,
including type1 pili, Ppili and Spili, as well as flagellar
motility 122. The effect of ec240 on the transcriptome and
proteome of the cystitis isolate E.coliUTI89 revealed that
the most downregulated genes after growth in the presence of ec240 were the type1 pilus genes. Type1pilus
expression is controlled by inversion of the type1 fimbriae promoter element (fimS), which can oscillate
between phase ON and phase OFF orientations. ec240
induced the fimS phase OFF orientation and increased
the expression of the transcriptional regulators Sfimbrial
switch regulatory protein (SfaB) and Ppilus regulatory
protein PapB, which have been shown to promote a fimS
phase OFF orientation122. Thus, the potency of pilicide
ec240 is largely due to its ability to induce a phase OFF
orientation of the type1 pilus promoter, rather than
any interference with chaperoneusher interactions.
Additional work revealed that other pilicides also inhibit
the production of Dr pili, another type of UPEC CUP pili
that are known to be important in pyelonephritis in mice
and humans30,33. Furthermore, pilicides have been shown
to disrupt CUP pilus biogenesis in K.pneumoniae and
also in Haemophilus influenzae (a finding that has important implications for otitis media)24,29. Thus, pilicides
represent an exciting class of antivirulence molecules
with the potential to target a broad spectrum of pathogens that utilize CUP pili in attachment and the establishment of infection. Future studies using mouse models
of UTIs and CAUTIs to investigate the role of CUP pili
in Gram-negative bacterial infections, as well as the efficacy and bioavailability of pilicides as therapeutics, will
unravel the potential of this class of molecules.
Mannosides, which are FimH receptor analogues,
have been developed to bind FimH with high affinity
and block FimH binding to mannosylated receptors35,121,123125. Mannosides are potent FimH antagonists
that offer a promising therapeutic opportunity for the
treatment and prevention of UTIs by interrupting key
hostpathogen interactions123125. Studies in mouse models have demonstrated the potential of mannosides as
novel therapeutic strategies against UTIs: mannosides
are orally bioavailable; they are potent and fast-acting
therapeutics in treating and preventing UTIs; they function by preventing bladder colonization and invasion;
they are effective against multidrug-resistant UPEC; they
potentiate antibiotic efficacy; and they are effective
against established UTIs and CAUTIs35,121,124,125.
280 | MAY 2015 | VOLUME 13
REVIEWS
Interestingly, the adhesin FimH undergoes a substantial structural change during transit across the usher
pore, such that the receptor-binding lectin domain bends
approximately 37 with respect to the pilin domain.
Thus, FimH adopts an elongated conformation before
transport across the usher pore32,126, whereas the lectin
domain swings closer to the pilin domain after transport 32. The two forms of the lectin domain have important implications for binding and pathogenesis: the
elongated conformation binds mannose with a significantly higher affinity than the compact form126. Residues
that control these conformational transitions have been
shown to be under positive selection, and pathoadaptive
alleles of FimH have subsequently been identified126128.
Thus, we now understand how proteinprotein interactions and ligand binding can regulate a dynamic conformational equilibrium in the receptor-binding domain
of FimH, and this is revealing unexpected insights into
UTI pathogenesis and potentiating mannoside development. This unravelling of the dynamics of how allostery
governs CUP pilus assembly and function is providing
valuable information about macromolecular protein
assembly and virulence in Gram-negative pathogens
and is spawning new ways of thinking about drug
development.
Outlook
UTIs are some of the most common bacterial infections, resulting in billions of dollars in health care costs
annually 1. Both the numerous uropathogens, which
encode a wide range of virulence factors, and the spread
of antimicrobial resistance threaten the only effective
treatment option available antibiotics15,17. Moreover,
high rates of recurrent UTIs suggest that antibiotics are
not an effective therapy for all UTIs. Intensive studies
have laid the foundations for conducting translational
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research that can identify essential mechanisms of virulence and provide evidence to guide the development
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Acknowledgements
The authors apologize to researchers whose work could not

be included in this Review owing to space limitations. They
thank members of S.J.H.s and M.G.C.s laboratories, especially K.W. Dodson, for their suggestions and comments. This
work was supported by the 1F32DK104516-01 grant to
A.L.F.-M. and the R01-DK051406, R01-AI108749-01 and
P50-DK0645400 grants from the US National Institute of
Allergy and Infectious Diseases (NIAID) and US National
Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK).
Competing interests statement
The authors declare no competing interests.
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REVIEWS

Urinary tract infections: epidemiology,

Urinary tract infections (UTIs) are some of the most

devices8,9. In the United States, 7080% of complicated

NATURE REVIEWS | MICROBIOLOGY

VOLUME 13 | MAY 2015 | 269

for rationally designed and alternative treatments is

Adherence and colonization

the bladder, the consequences of complex hostpathogen

270 | MAY 2015 | VOLUME 13

8 Ascension to the kidneys

Colonization of the urethra

Figure 2 | Pathogenesis of urinary tract infections. a|Uncomplicated urinary tract infections

NATURE REVIEWS | MICROBIOLOGY

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when the bacteria bind to a urinary catheter, a kidney

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as those from the Rac family, to cause actin rearrange

NATURE REVIEWS | MICROBIOLOGY

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Figure 3 | Virulence factors of uropathogenic Escherichia coli b

has been observed in multiple mouse backgrounds

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NATURE REVIEWS | MICROBIOLOGY

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Transitional cells Umbrella cells

Figure 4 | Mechanisms of pathogenesis during catheter-associated urinary tract infections. a|Catheter-associated

276 | MAY 2015 | VOLUME 13

Other virulence factors

NATURE REVIEWS | MICROBIOLOGY

VOLUME 13 | MAY 2015 | 277

Treatment of urinary tract infections

Multidrug resistance is also common among entero

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protect against UTIs. However, adhesin-based vaccines

response, which functions through TLR4 signalling via

NATURE REVIEWS | MICROBIOLOGY

VOLUME 13 | MAY 2015 | 279

Pilicides were originally developed to specifically

280 | MAY 2015 | VOLUME 13

10. Lo,E. etal. Strategies to prevent catheter-associated

NATURE REVIEWS | MICROBIOLOGY

17. Kostakioti,M., Hultgren,S.J. & Hadjifrangiskou,M.

VOLUME 13 | MAY 2015 | 281

44. Blango,M.G., Ott,E.M., Erman,A., Veranic,P. &

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63. Nagamatsu,K. etal. Dysregulation of Escherichia coli

107. Mushtaq,S., Woodford,N., Hope,R., Adkin,R. &

NATURE REVIEWS | MICROBIOLOGY

to invitro and invivo evaluation. J.Med. Chem. 53,

VOLUME 13 | MAY 2015 | 283

The authors apologize to researchers whose work could not

Competing interests statement

The authors declare no competing interests.

284 | MAY 2015 | VOLUME 13

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