Microorganisms UTI & STI

SUNARYATI SUDIGDOADI
&
USEP ABDULLAH HUSIN
DEPT. OF MICROBIOLOGY
MEDICAL FACULTY
PADJADJARAN UNIVERSITY
INTRODUCTON
 Urinary tract infections (UTIs) : cause
of morbidity and health care in persons
of all ages
 Sexually active young women are
affected, but several other populations,
including :
elderly persons and those undergoing
genitourinary instrumentation or
catheterization, are also at risk
INTRODUCTON
 An estimated 40 percent of
women report having had a
UTI at some point in their lives
 UTIs are the leading cause of
Gram negative bacteremia
 Microbes usually enter the
urinary system through the
urethra
NORMAL MICROBIOTA
 Urinary bladder and upper urinary

tract sterile
 Lactobacilli predominant in the
vagina
 >1,000 bacteria/ml or 100
coliforms/ml of urine indicates
infection
DEFENSE MECHANISM OF THE
URINARY TRACT
1. Urine factor :
 Urea concentration and high
osmolarity
 Low pH of urine  kill bacteria
2. Hydrokinetic factor :
 Periodic urinary flow
 Dilution of rest urine cause of urinary
flow from kidney
 Bladder emptying
3. Mucosal factor :
 Mucosa of the bladder consist of more

than one layer cells
 Mucosa of the urinary tract and bladder
covered by mucus  prevent
microorganism attachment
 Prostatic secretion : has an
antibacterial effect
 Secretion of local IgA  prevent
attachment of microorganism on
uroepithelium later and neutralize toxin
produce by microorganism
 Perioxidase on the mucosal layer  has
a bactericidal effect
CLINICAL MANIFESTATION
LOWER URINARY TRACT INFECTIONS
 Acute cystitis : a superficial inflammation of the
bladder and urethra
 Acute prostatitis occurs when bacteria invade
the prostate
UPPER URINARY TRACT INFECTIONS

 Acute pyelonephritis is due to bacterial invasion
of the renal tissue with inflammation and
swelling, sometimes cause renal dysfunction
ETIOLOGY
 Escherichia coli, which is responsible for 80 % of
infections that are acquired outside of hospitals
 Other Gram-negative rods such as Klebsiella,
Enterobacter, and Proteus spp. are relatively
common, each accounting for
3 to 5 % of infections
 Within the hospital environment, Pseudomonas
aeruginosa, Serratia marscesens, and other
Gram positive bacteria such as Enterococcus
faecalis, and Staphylococcus epidermidis are
more resistant, common hospital-acquired
pathogens
ETIOLOGY
 Gram-positive organisms, particularly
coagulase-negative staphylococci and
enterococci, cause some infections
 Staphylococcus saprophyticus
causes about 10 % of UTI in young
women
 Candida albicans is also a frequent
pathogen in hospitalized patients,
particularly if diabetes is present
ETIOLOGY
Anaerobes and fastidious organisms rarely
cause urinary infections
A number of viruses, particularly mumps
virus, cytomegalovirus, and coxsackieviruses,
can be present in the kidneys and urine,
but rare
A number of sexually transmitted pathogens
(e.g., Neisseria gonorrhoeae) may invade
the urethra. Chlamydia trachomatis and
herpes simplex can present with symptoms
that mimic acute cystitis in both men and
women
PATHOGENESIS
A. Entry is normally by ascent from the

urethra
Bacteria invade the urinary tract by
ascending route through the urethra
to infect the bladder and renal pelvis
is the most common.
Occasionally with hematogenous
spread
B. Host factors
 The larger number of UTI's present in women than
in men is probably due to the much shorter urethra
and the much closer association of the urethra to
the anus
 Sexual intercourse contributes to the increased
number of UTI's seen in women
 Any anatomic obstruction, or neurological disorder
leading to the failure to completely eliminate the
urine can lead to UTI
 Men in their 40's have problems with the prostate
gland enlarging resulting in obstruction of the
urethra followed by incomplete elimination of urine
from the bladder and UTI's
C. Bacterial factors
The most important virulence factor of
bacteria is the enhanced ability to adhere to
uroepithelial cells. This attachment is mediated
by specific pilus adhesins on the surface of E
coli.
Pseudomonas infections are both invasive and
toxinogenic
S. aureus expresses many potential virulence
factors such as proteins, enzymes and toxins
D. Spread to the kidney
Infection of the kidney is due to ascent from the lower

urinary tract and so any factor leading to
retrograde flow of the urine to the kidney will
predispose the host to pyelonephritis.
Such factors include:
1. Reflux of urine to the kidney
2. Physiological malfunctions
3. Urethral catheters
4. Urinary tract stones
Escherichia coli
 Member of the normal intestinal flora
 Motile, possess polysaccharide capsule
 Grow on nonselective media
 Red colonies on Mac Conkey agar
 An isolate from urine can be identified by
its hemolysis on blood agar
 Temperature for growth : 15 – 450C
 Some strains more resistant to heat
viable at 600 C, 15 minutes
550 C, 60 minutes
E. coli - URINARY TRACT
INFECTION
 The most common cause of UTI
 Accounts approximately 80 % of
first UTI in young women
 UTI can result in bacteremia with
clinical signs of sepsis
 Nephropathogenic E. coli typically
produce hemolysin
PATHOGENESIS
The organisms are propelled into the
bladder from the periurethral region
during sexual intercourse.
With the aid of specific adhesins they are
able to colonize the bladder.
The adhesin that has been most closely
associated with uropathogenic E. coli is
the P fimbria (or pyelonephritis-
associated pili [PAP] pili).
Klebsiella pneumoniae
 The most clinically important species This
bacterium produces large sticky colonies when
plated on nutrient media
 Klebsiella's pathogenicity can be attributed to
its production of a heat-stable enterotoxin
 K. pneumoniae urinary tract infections are
common in catheterized patients
 In fact, K. pneumoniae is second only to E. coli
as a urinary tract pathogen.
ENTEROBACTER
 Previously : Aerobacter, similar
characteristics to Klebsiella,
differ in motility
 The organisms has small capsule
 E. aerogenes may be found free-
living as well as in the intestinal
tract
 E. aerogenes & E. cloacae causes
UTI & sepsis
PROTEUS
 Infection in humans only when bacteria
leave the intestinal tract
 Found in UTI, produce bacteremia,
focal lesions in debilitated patients or
receiving i.v infusions
 P. vulgaris & M. morganii
important nosocomial pathogens
PROTEUS
 P. mirabilis UTI, occasionally
other infection
 Produces a typical “swarming”
growth on blood agar
 Is primarily an opportunist,
transmitted via catheters
 Produces a powerfull urease that
hydrolyzes urea to ammonia and CO2
 Results in stones and calculi, leading
to urinary tract obstruction
SERRATIA
 S. marscescens : is common
opportunistic pathogen in hospitalized
patient
 Causes pneumonia, UTI, meningitis,
wound infections, bacteremia &
endocarditis especially in narcotics
addicts & hospitalized patients
 Often multiply resistant to
aminoglycosides & penicillins
 Infections can be treated with 3rd
generation cephalosporins
CHARACTERISTICS
 Gram negative rods
 Motile with peritrichous
flagella, or nonmotile
 Grow on peptone or meat
extract media without
addition NaCl or other
supplements
 Grow well on Mac Conkey’s
agar, aerobically/
facultative anaerobes
 Ferment rather than
oxidize glucose, often with
gas production
CHARACTERISTICS
 Facultative anaerobes or
aerobes
 Ferment a wide range of
carbohydrates
 Possess a complex antigenic
structure
 Produce a variety toxins & other
virulence factors
Pseudomonas aeruginosa
 Opportunistic pathogen of humans.
 The bacterium almost never infects
uncompromised tissues, yet there is hardly any
tissue that it cannot infect, if the tissue defenses
are compromised in some manner
 Pseudomonas aeruginosa is a Gram-negative,
aerobic rod, belonging to the bacterial family
Pseudomonadaceae
CHARACTERISTICS
P. aeruginosa isolates may produce three colony types.
 Natural isolates from soil or water : small, rough colony.

 Clinical samples, in general, smooth colony types.
 One type has a fried-egg appearance which is large, smooth,
with flat edges and an elevated appearance.
 Another type, has a mucoid appearance, which is attributed to
the production of alginate slime.
The smooth and mucoid colonies are presumed to play a role

in colonization and virulence.
P. aeruginosa produces two types of soluble
pigments, pyocyanin and (fluorescent)
pyoverdin.
The latter is produced abundantly in media
of low-iron content, and could function in
iron metabolism in the bacterium.
Pyocyanin (from "pyocyaneus") refers to
"blue pus" which is a characteristic of
suppurative infections caused by
Pseudomonas aeruginosa.
BACTERIAL PRODUCTS
 COLICINS (BACTERIOCINS)
Bactericidal, produced by certain strains of bacteria,
active against some other strains of the same or
closely related species
Their production is controlled by plasmid
Colicins : produced by E. coli
Marcescins : produced by serratia
Pyocins : produced by pseudomonas
 TOXINS & ENZYMES
Endotoxins : have a variety of pathophysiologic effects
Many bacteria also produce exotoxins of clinical
importance
Staphylococcus
Staphylococci are Gram-positive spherical bacteria
that occur in microscopic clusters resembling grapes
Taxonomically, the genus Staphylococcus is in the
bacterial family Micrococcaceae
Staphylococci are facultative anaerobes
The bacteria are catalase-positive and oxidase-
negative, can grow at a temperature range of 15 to
450C and at NaCl concentrations as high
as 15 %
Staphylococcus
S. aureus forms a fairly large yellow
colony on rich medium; often hemolytic
on blood agar
Nearly all strains produce the enzyme
coagulase
S. epidermidis has a relatively small white
colony, non hemolytic, nearly all strains
lack the coagulase enzyme
S. saprophyticus
Is non hemolytic if culture on blood agar,
coagulase-negative, novobiocin-
resistant.
Lacks protein A
Enterococcus faecalis
 The enterococci are facultative anaerobes,
produce a small gray colony after 24 hour
incubation at 35°C on sheep blood agar
 The enterococci are catalase-negative or (more
commonly) weak positive,
 A small gray colony that is slightly or -
hemolytic and sometimes β-hemolysis, weakly
catalase-positive is a typical presentation for
Enterococcus
 Microscopically, Gram-positive cocci occurring in
chains or pairs with individual cells being
somewhat elongated can be presumed to be
streptococci or enterococci
 The enterococci do bear the Lancefield
Group D antigen, but Enterococcus is a
genus separate from Streptococcus
 Like Group D streptococci, Enterococcus is
able to grow in the presence of 40% bile and
to hydrolyze esculin, while other
streptococci are not
 Unlike Group D streptococci, Enterococcus
produces a positive PYR test (red color
produced after addition of N,N methyl
aminocynnamaldehyde reagent after
exposure to L-pyrrolidonyl-beta-
naphthylamide (PYR) substrate), and can be
identified by these tests.
Microbiological diagnosis
 Specimen has to be taken under strict

precautions as lower part of urethra is
colonized by fecal flora
 Thus catheterization is forbidden
 Midstream urine is the primary choice, while
suprapubic puncture are alternatives
 In special cases after surgery on the kidney,
urine is taken by renal catheter.
 Urine must be chilled and processed within 2
hours
Four stages of microbiological examination for
UTI are diagnosis important
 Screening for WBC

 Cultivation
Plate dilution method

Calibrated loop method
Dip-slide method
 Interpretation
 Susceptibility testing of isolated bacteria
The aim of culture is to find if the concentration
exceeds the value 105 cfu/ml that is significant for
infection
(In some infections (acute UTI in women with pyuria,

chronic pyelonephritis) the concentration may be
lower).
DIAGNOSIS
The diagnosis of UTI : based on a quantitative
urine culture : > 100,000 colony-forming
units (105 CFU) per ml of urine, was termed
"significant bacteriuria."
This value was chosen because of its high
specificity for the diagnosis of true infection,
even in asymptomatic persons.
However, several studies have established
that one third or more of symptomatic women
have CFU counts below this level (low-
coliform-count infections).
They have also shown that a bacterial count
of 100 CFU per mL of urine has a high positive
predictive value for cystitis in symptomatic
women
Bacteriuria indicate UTI
Criteria of UTI
1. Bacteriuria with quantitative >100.000 cfu/ml
2. Bacteriuria with quantitative <100.000 cfu/ml and
lekocyturia
3. Bacteriuria with quantitative <100.000 cfu/ml in
repeated culture, and same kind of bacteria was
found
4. Bacteriuria with quantitative <100.000 cfu/ml, only
one species of bacteria, with definite clinical
symptoms
5. If the result of culture is > 1000 cfu of fungus/ ml
 indicate fungal infection
Sexually Transmitted Infections
 Bacteria
 Neisseria gonorrhoeae
 Yeasts and fungi
 Chlamydia trachomatis  Candida albicans
 Treponema pallidum  Candida glabrata
 Haemophilus ducryei
(chancroid)  Candida tropicalis
 Lymphogranuloma
 Mycoplasma
 Ureaplasma  Parasites
 Calymmatobacterium  Trichomonas
granulomatis
vaginalis
 Gardnerella vaginalis
 Viruses  Entamoeba
 Herpes simplex II histolytica
 Hepatitis B  Giardia lamblia
 Hepatitis C
 Sarcoptes scabiei
 HIV
 Papillomavirus  Phitirius pubis
NEISSERIA GONORRHOEAE
General characteristics :
 oxidase-positive, gram-
negative diplococcus,
a”kidney bean”
morphologic appearance
 epidemic, the highest

incidence in the most
sexually active groups
(age 15-25 years).
Virulence factor
1. Capsule
2. Pili
3. Cell-wall protein
4. Lipopolysaccharide
5. IgA protease
Classification
1. N. gonorrhoeae does not use maltose,
which distinguishes it from Neisseria
meningitidis.
2. Differentiation is by auxotyping (nutritional

requirements) or colonial morphology (types
1 and 2 are virulent; types 3, 4, and 5 are
much less virulent)
Pathogenicity
 Produces IgAase that degrades IgA1; this
antibody probably plays a key early role
in mucosal infections. (IgAase is also
found in Haemophilus and streptococcal
organisms).
 Possesses a plasmid that codes for
penicillinase production.
 Possesses pili, which are protein surface
fibrils that mediate attachment to the
mucosal epithelium.
Pathogenicity
1. Pili undergo phase variation (on/off
switch of pili production). Nonpiliation
greatly reduces virulence.
2. Pili also exhibit antigenic variation and

have the capacity to produce millions of
variants, which is partly responsible for
the lack of protection against
subsequent infection.
Pathogenicity
 Possesses outer membrane proteins that
form porins (PI and PIII) and that determine
-
clumping (PII) or opacity. PII strains are
isolated from disseminated forms. Pili and
PII play major roles in adherence
 Possesses endotoxin activity that damages

mucosal cells. Unlike most LPSs, N.
gonorrhoeae lacks lengthy O-antigenic side
chains and is termed lipo-oligosacharide
(LOS)
CHLAMYDIA TRACHOMATIS
 Chlamydia trachomatis infection is one of

the most common sexually transmitted
infections world wide
 Occurring in men and women under the
age of 25.
 This is most likely an underestimate, since
half of people with chlamydia likely have
gonorrhea too.
Chlamydia trachomatis
• Serovars L1-L3 • Lymphogranuloma venereum
Trachoma
• Serovars A, B, Ba,C (hyperendemic blinding)
• Inclusion conjunctivitis (newborn)
• Neonatal pneumonia
• Urethriti
• Serovars D-K •
•
Cervicitis
Pelvic inflammatory disease
• Association with cervical cancer
•Pneumonia (human psittacosis,

Chlamydia psittaci avian chlamydiosis)
Chlamydia pneumoniae
•Pneumonia
(TWAR strain)
PHYSIOLOGY AND STRUCTURE
A. Elementary bodies (EB) - EB are the small (0.3 -
0.4 µm) infectious form of the chlamydia.
 Possess a rigid outer membrane, extensively
cross-linked by disulfide bonds
 Resistant to harsh environmental conditions
encountered when the chlamydia are outside of
their eukaryotic host cells
 Bind to receptors on host cells and initiate infection
 Most chlamydia infect columnar epithelial cells but

some can also infect macrophages.
B. Reticulate bodies (RB) - RB are the non-
infectious intracellular from of the chlamydia.
 They are the metabolically active replicating

form of the chlamydia.
 They possess a fragile membrane lacking
the extensive disulfide bonds characteristic
of the EB.
CHLAMYDIA LIFE CYCLE
TREPONEMA PALLIDUM
General characteristics
 is a corkscrew-shaped, motile organism with
unusual morphologic appearance of the outer
envelope, three axial filaments, a cytoplasmic
membrane-cell wall complex with endotoxin, and a
protoplasmic cylinder.
 causes chronic, painless infections that may last 30
to 40 years if untreated.
 decreases in number as host defenses are
stimulated, causing disappearance of symptoms;
subsequently, organisms multiply and symptoms
reappear.
MYCOPLASMA & UREAPLASMA
1. Mycoplasma hominis
2. Mycoplasma genitalium
3. U. urealyticum is a prokaryote that lacks
a cell wall and can be cultured in the lab.
However, this organism is often seen in
normal individuals and culturing the
organism has questionable value in
diagnosing NGU.
GARDNERELLA VAGINALIS
G. vaginalis is a rod
shaped gram
variable bacteria
which more
commonly causes
vaginitis but can
on occasion cause
NGU in males.
Diagnosis
Three of the four criteria should be positive

 thin homogeneous discharge
 pH of discharge >4.5.
 Clue cells in saline wet mount or Gram stain
of vaginal discharge
 Mixture of vaginal discharge and 10% KOH
liberates an "amine-like" or "fishy" odor.
Haemophilus ducreyi
Chancroid or soft
chancre disease is an
acute sexually
transmitted disease
characterized by genital
ulceration and
suppuration
Ducrey's bacillus) is a
Gram(-) rod which grows
in chains.
Gram-negative bacilli, intra- and extracellularly
dispersed, with "school of fish" distribution (see arrows).
Pathology and pathogenesis
 The organism enters the body through
skin abrasions.
 It induces a papule or vesicle which
ulcerates.
 There is a dense inflammatory exudate
with PMNs but not mononuclear cells.
 Incubation period of 1-14 days after
exposure before you get the development
of the characteristic lesion, the soft
chancre. SUNARYATI SUDIGDOADI
Calymmatobacterium granulomatis
Granuloma inguinale (also called lupoid
ulceration granuloma of the pudenda and
granuloma contagiosa) is a chronic, indolent,
ulcerative, granulomatous disease of the
skin and lymphatics.
Gram -rod with characteristic bipolar staining

so they have a safety pin-like appearance in
stained tissue preparation : Donovan
bodies
Pathology and pathogenesis
 The organism gains entry by direct

inoculation through skin abrasions or
mucous membranes.
 One or more indurated papules form which
progress to characteristic ulceration.
 The most important sign is the presence of
mononuclear cells with intra cytoplasmic
vacuoles packed with the bacteria or
Donovan bodies as they are called.

Microorganisms UTI &amp; STI

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SUNARYATI SUDIGDOADI

 Urinary bladder and upper urinary

 Mucosa of the bladder consist of more

UPPER URINARY TRACT INFECTIONS

A. Entry is normally by ascent from the

Infection of the kidney is due to ascent from the lower

 Natural isolates from soil or water : small, rough colony.

The smooth and mucoid colonies are presumed to play a role

 Specimen has to be taken under strict

 Screening for WBC

Plate dilution method

(In some infections (acute UTI in women with pyuria,

 epidemic, the highest

2. Differentiation is by auxotyping (nutritional

2. Pili also exhibit antigenic variation and

 Possesses endotoxin activity that damages

 Chlamydia trachomatis infection is one of

• Serovars L1-L3 • Lymphogranuloma venereum

•Pneumonia (human psittacosis,

 Most chlamydia infect columnar epithelial cells but

 They are the metabolically active replicating

Three of the four criteria should be positive

Gram -rod with characteristic bipolar staining

 The organism gains entry by direct

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