CLINICAL CASE

A 21-year-old woman presents with a 3-day duration of discomfort with urination

and increased urinary frequency. She has noted that her urine has a strong odor as
well. She denies fever, abdominal pain, back pain, vaginal discharge, or skin rash.
She is sexually active and takes oral contraceptive pills.
On examination, she is comfortable appearing and afebrile. She has no
costovertebral angle tenderness. Abdominal exam is notable only for suprapubic
tenderness. Microscopic examination of the sediment of a centrifuged urine sample
reveals 1015 white blood cells per high power field and numerous bacteria.

What type of organism would a Gram stain of the urine most likely
show? 

What is the most common etiologic agent of this infection? 

What is the most likely reservoir of this infection? 

What is the most likely mechanism by which this organism infects

the urinary tract? 

ANSWERS TO CASE 9: Escherichia coli

Summary: A 21-year-old woman has urinary frequency and dysuria. The urinalysis
shows numerous white blood cells.

Organism most likely to be seen on Gram stain: Gram-negative rod 

Most common etiologic agent: Escherichia coli 

Most likely reservoir for the organism: Patients own gastrointestinal

(GI) tract 

Most likely mechanism of introduction of organism into the urinary

tract: Urethral contamination by colonic bacteria followed by ascension of
the infection into the bladder 

CLINICAL CORRELATION 

Escherichia coli is the most commonly found aerobic, gram-negative bacilli in the
GI tract of humans. Escherichia coli is responsible for over 80 percent of all
urinary tract infections (UTIs), along with other clinical diseases including
gastroenteritis, sepsis, and neonatal meningitis.
The E. coli that causes diarrhea is usually acquired from the environment, whereas
most other infections caused by E. coli are acquired endogenously. Much of the
diarrhea resulting from E. coli is acquired in developing countries particularly in
travelers to these countries.
The serotypes that are associated with travelers diarrhea can be grouped based on
their
method
of
pathogenesis:
enterotoxigenic,
enterohemorrhagic,
enteroaggregative, and enteroinvasive strains. These strains produce toxins, which
account for their invasiveness as well as decreased absorption in the GI tract.
Most of these cause a selflimited diarrhea with the exception of enterohemorrhagic
E. coli, frequently associated with E. coli serotype O157:H7, causing a bloody
diarrhea, which is usually acquired from eating poorly cook meat from an
infected cow.
Complications of infection with this organism include hemolytic uremic syndrome
(HUS), which is a triad of hemolytic anemia, thrombocytopenia, and renal failure.
HUS is a significant cause of acute renal failure in children. UTIs caused by E. coli
are associated with organisms from the GI tract or vagina ascending up to the
bladder. These organisms can colonize the vagina and be introduced into the bladder
during instrumentation or sexual intercourse. Those serotypes that produce
adhesions, which mediate adherence of the organisms to epithelial cells in the
urinary tract are more likely to cause infections. The majority of cases of
uncomplicated and complicated pyelonephritis are caused by E. coli, a complication
of a UTI, where the organisms continue to ascend from the bladder to the kidney. 

APPROACH TO SUSPECTED Escherichia coli UTI

Objectives
Know the structure, characteristics, and virulence factors of E. coli. 
Know the pathogenic groups and toxins involved in diarrhea caused by E.
coli. 

Definitions
Pyelonephritis: Infection of the kidney.Cystitis: Infection of the bladder.

Hemolytic uremic syndrome (HUS): A syndrome characterized by

hemolytic anemia, thrombocytopenia (low platelets), and acute renal failure.

DISCUSSION
Characteristics of Escherichia coli
Escherichia coli is a member of the family Enterobacteriaceae (see Table 9-1 for
an abbreviated list). All members of this family have in common the fact that they
ferment glucose, are oxidase negative, and reduce nitrates to nitrites. Many
members of the family Enterobacteriaceae, like E. coli, are normal flora of the
human GI tract.
Escherichia coli produces numerous adhesins, which allow the organism to attach
to cells in the urinary and gastrointestinal tracts. This prevents the bacteria from
being flushed from these organs by the normal passage of urine or intestinal
motility. Escherichia coli also can produce several exotoxins, involved in the
pathogenesis of diarrhea, including shiga toxins, heat-stable toxins, heat-labile
toxins, and hemolysins. Hemolysin HlyA is particularly important in producing an
inflammatory response in the urinary tract, whereas most of the other exotoxins
are more pathogenic in the GI tract.
Escherichia coli are divided into serogroups based on the O antigen found on the
lipopolysaccharide (LPS) of the cell membrane and the H antigen found on the
flagella (Figure 9-1).

Diagnosis
The diagnosis of a UTI is made by urinalysis and urine culture. Complications such
as pyelonephritis would be indicated by fever and flank pain. On urinalysis, the
presence of white blood cells or leukocyte esterase and bacteria are suggestive of a
true infection. Definitive diagnosis of the etiology is made by culture of the urine.
Escherichia coli is easily grown on most culture media. A quantitative urine culture
from a symptomatic patient should demonstrate greater than 105 colony-forming
units (CFUs) bacteria/mL urine to be considered significant. Escherichia coli
would appear as pink colonies on MacConkey agar indicating fermentation of
lactose. A rapid spot indole test would give a preliminary identification of E. coli,
which would be confirmed by biochemical analysis.

Treatment and Prevention

Treatment of UTIs is based on the affecting organism and its susceptibility to
antibiotics. Common antimicrobials chosen include trimethoprim sulfamethoxazole,
or a fluoroquinolone. Most E. coli are resistant to ampicillin and penicillin.

Recurrent UTIs are quite common, particularly in young women. Prevention can
include consumption of large amounts of liquid and attention to totally emptying the
bladder during urination. Fluid and electrolyte replacement should be administered
to patients with E. coli diarrhea; however, antimicrobial treatment should not be
administered. Escherichia coli diarrhea is best prevented by improved hygiene.

MICROBIOLOGY PEARLS
Escherichia coli is the most common cause of UTIs in otherwise healthy
patients.
Escherichia coli can easily be identified following growth of a flat lactose
fermenter on MacConkey agar that is indole positive.
Many serotypes of E. coli are associated with travelers diarrhea.