Research

Malone Lee, J (2021) Cystitis Unmasked, pp. 119-150, tfm Publishing Ltd, Shrewsbury. UK.
James Malone-Lee is an Emeritus Professor of Medicine at University College London (UCL) and the author of Cystitis Unmasked. “For 37 years as a clinical scientist at UCL he studied lower urinary tract symptoms. His research group made discoveries that challenged numerous strongly held beliefs about lower urinary tract disease, particularly infection. For many years this new knowledge was rejected by many, but in the wake of corroborative evidence from others around the world, this new thinking is becoming more widely accepted.”

Chapter 6 examines NHS data showing trends in the presentation of cystitis and IC/BPS/PBS over 18 years; describes the pathophysiology of UTI and chronic UTI (with illustrations and confocal micrograph images) and what this means to patients.

May 2020
Research is now shedding light on why an initial UTI may be a precursor for recurrent UTIs. “Most women will experience at least one UTI in their lifetime,” said senior author Soman Abraham, Ph.D., a professor in the departments of Pathology, Immunology and Molecular Genetics and Microbiology at Duke University School of Medicine. “In a substantial proportion of these women, UTIs become recurrent with painful frequency.”

August 2010
When uropathogenic Escherichia coli (UPEC) were introduced to the bladders of mice, the acute infection either resolved or evolved into chronic cystits. The development of chronic cystitis was found to be ‘preceded by biomarkers of local and systemic acute inflammation’, including bladder inflammation with injury to the mucosa. Researchers concluded that it is this severe acute inflammatory response which subsequently predisposes individuals to recurrent cystitis.

December 2013
Using advanced imaging techniques, urothelial cells shed in response to bladder inflammation were inspected for bacterial invasion and pathology. Researchers found strong evidence of intracellular E. faecalis in the cells harvested from LUTS patients, thereby implicating this bacteria in the development of chronic LUTS.

Sept 2015
This review examines emerging evidence for a role of intracellular bacterial communities (IBC) in human infection. Occult and recurrent urinary tract infection is thought be due to the invasion of the bladder wall by uropathogenic Escherichia coli (UPEC) and the formation of biofilm-like IBCs. Infection is frequently undetected due to the concentrations of bacteria in the urine falling short of the threshold used in standard urine culture techniques.

August 2000
This early study describes how strains of uropathogenic Escherichia coli (UPEC) can counter host defences upon entering the urinary tract by attaching to the bladder epithelial cells, where they can replicate or persist in a quiescent state. The invasion of the cells can trigger immune responses such as cytokine production, inflammation and the exfoliation of infected bladder wall cells. Despite host defences and antibiotic treatment, they can persist within the bladder tissue and possibly serve as a reservoir for recurrent infections.

December 2006
This paper demonstrates how during acute stages of infection, uropathogenic Escherichia coli (UPEC) can invade cells in the bladder wall to avoid innate defences (immune or antibiotic attack), where they form biofilm-like intracellular bacterial communities (IBC). They go on to colonise the surrounding epithelium and generate further IBC and quiescent intracellular reservoirs (QIRs)

October 2017
It is known that the most significant risk factor for developing a UTI is a prior history of urinary infection. This study shows that, in mice, an initial e coli UTI leaves a long-lasting molecular imprint on the tissue of the bladder wall which alters the pathophysiology and allows for subsequent infection. This new knowledge could lead to the development for new treatments for recurrent urinary infections.

Malone Lee, J (2021) Cystitis Unmasked, pp. 97-118, tfm Publishing Ltd, Shrewsbury. UK.
Chapter 5 explains the history and current use of urinary dipsticks and MSU cultures, the introduction of genomics in urinary tract research and other commonly used tests such as renal tract ultrasound, CT scan, MRI scan, urodynamic studies and cystoscopy.

July 2023
This article discusses the problems with current UTI testing and diagnosis and the importance of improving on techniques that have not changed in many decades. This outdated and simplistic approach to diagnosis is no longer appropriate, despite many continuing to argue that current UTI care is adequate.

July 2013
Studies of acute urinary tract infection have indicated that it is likely that urothelial cells are invaded by bacteria such as Escherichia coli, with persistence of long-term bacterial reservoirs (persisters), but the role of infection in chronic lower urinary tract symptoms (LUTS) is unknown. This large prospective study with eligible patients with LUTS and controls over a three year period compared routine urine cultures of planktonic bacteria with cultures of shed urothelial cells concentrated in centrifuged urinary sediments, revealing that large numbers of bacteria are undetected by standard urine cultures.

January 2017
This study describes the important role of bladder epithelial cells in fighting infection and regulating bladder volume. When other mechanisms have failed to clear the intracellular bacteria, the last resort action is activated. There will be deliberate exfoliation of epithelial cells in order to rapidly decrease bacterial load, and many of these cells are shed carrying a load of adherent bacteria.

May 2016
In this Schreckenberger et al article, the enhanced urine culture (EQUC) technique is evaluated for detecting microorganisms found in urine specimens usually reported as ‘no growth’ by standard culture methods. The EQUC protocol achieved 84 percent uropathogen detection relative to 33 percent detection by standard urine culture. The streamlined EQUC protocol improves detection of uropathogens that are likely relevant for symptomatic women, giving clinicians the opportunity to receive additional information not currently reported using standard urine culture techniques.

In this soundbite from the USANZ 2017 conference, Dr Curtis Nickel, Professor of Urology, Queen’s University, Canada speaks about limitations with current testing technology to diagnose UTI: “We make our clinical decisions in infectious disease in urology based on technology that’s over 100-years-old. We’re still taking urine samples, plating it on an AGAR, and putting it in 24 hours in an incubator and then making a decision. We now know that we grow less than one percent of potential uropathogens by this technique; we don’t culture biofilm bacteria; and we miss 99.9 precent of possible microorganisms that are in the environment that might be related to infectious disease.”

In this interview with Dr Evann Hilt, Dr Paul Schreckenberger and Alan Wolfe of Loyola Urinary Education and Research Collaborative (LUEREC), Loyola University, USA, they speak about discovering the urobiome after it had been overlooked for decades due to testing limitations. The interview ends with a Q&A session by colleagues:  “That’s another myth, the fact that infections are present only when the bacteria are present at 10^5 or greater. And that was never the intent of Kass’ original report. The amount of bacteria in people that have UTI varies. When you get up the urine has been concentrated during the night, sure it can be 10^5. But when you’ve had coffee and urinated it can be 10^2 and that’s also significant. But labs aren’t culturing at 10^2. We miss a lot of true UTIs by setting cut-off limits based on dogma that we think needs to be trashed.”

Helen O’Connell (President USANZ, Australia’s first female urologist and medical researcher) (2023) comments that “Epithelial shedding as a marker of #cUTI is an important paradigm shift @prasadika @anitahclarke @urologyworks. Before it was recognised these are urothelial cells, we were taught they were evidence of contamination ie worthless sample which is not true”

Malone Lee, J (2021) Cystitis Unmasked, pp. 151-198, tfm Publishing Ltd, Shrewsbury. UK.

James Malone-Lee is an Emeritus Professor of Medicine at University College London (UCL) and the author of Cystitis Unmasked. “For 37 years as a clinical scientist at UCL he studied lower urinary tract symptoms. His research group made discoveries that challenged numerous strongly held beliefs about lower urinary tract disease, particularly infection. For many years this new knowledge was rejected by many, but in the wake of corroborative evidence from others around the world, this new thinking is becoming more widely accepted.”

January 2018
Published online on 20 March 2018, this paper instantly became the most popular paper in the history of the International Urogynecology Journal & Pelvic Floor Dysfunction and in the top five percent of nearly one million research outputs ever tracked by Altmetric. This paper covers a large case series of 624 women, spanning data collected over 10 years, demonstrating that patients with chronic lower urinary tract symtpoms (LUTS) and pyuria experience symptom regression [improvement] and a reduction in urinary tract inflammation [pyuria] associated with antimicrobial therapy. Disease regression was achieved with a low frequency of Adverse Effects (AE).

December 2018
This research measures the effect of an unplanned treatment cessation with 210 female and 11 male patients from a UK specialist clinic who were undergoing long-term antibiotic treatment chronic painful lower urinary tract symptoms (LUTS) coupled with pyuria and negative standard UTI tests. The paper shows that after the sudden withdrawal of treatment, 199 patients (90%; female = 188; male = 9) reported deterioration. Symptom scores and signs of inflammation recovered on reinitiating treatment.

March 2022
This multicentre, randomised trial tested and compared the efficacy of methenamine hippurate (Hiprex) for prevention of recurrent urinary tract infections with the current standard prophylaxis of a daily low dose antibiotic. It was found that prophylactic treatment with methenamine hippurate could be appropriate for women with a history of recurrent episodes of urinary tract infections, given the demonstration of non-inferiority to daily antibiotic prophylaxis seen in this trial.

April 2014
This article discusses the place of methenamine (Hiprex) in the management of recurrent urinary tract infection and suggests it should be used when recurrent UTIs are not suppressed by more commonly used antibiotics.

November 2022
This Norwegian study found that methenamine (Hiprex) had a significant preventive effect in women aged 40 and older with a history of recurrent UTIs for longer than two years.

December 2020
“Estrogen depletion at any age has direct implications on genitourinary health and lower urinary tract function. It is often in the perimenopausal age group that GSM and recurrent UTIs become prevalent, driving women to the urologist for evaluation and treatment. Urinary tract evaluation with imaging and cystoscopy is often of low yield and can be frustrating for both the patient and the clinician. Vaginal estrogen therapy is safe and extremely efficacious in treating these symptoms and lowering the risk of UTIs. It can be used safely in most women, even in those already on systemic HRT.”

June 2013
“The female hormone estrogen may protect against urinary tract infections in postmenopausal women by improving two of the body’s defense mechanisms, a new study found.” The researchers found that the body’s natural antimicrobial proteins were triggered by the hormone, as well as the creating a tightening effect on the surface layer of the bladder epithelium.

May 2023
US urologist Dr. Rachel Rubin discusses the importance of vaginal hormone treatments for women over 45. “The take-home message is that as a practicing urologist, you should be treating genitourinary syndrome of menopause and giving any woman over 45 vaginal hormones, whether in the form of vaginal estrogen or vaginal DHEA,” says Rachel S. Rubin, MD.

May 2022
Experts discuss the role of hormones in UTI and the benefits of vaginal hormone treatments in preventing and managing UTI.

November 2015
This article is one of the first to highlight that the commonly held belief that the bladder is a sterile organ can no longer be accepted. Modern testing (expanded quantitative urine culture and 16S ribosomal RNA gene sequencing) can detect previously unrecognised organisms, making it possible to answer previously intractable scientific and clinical questions. Available data indicates that the urinary bacterial population is strongly linked with urinary symptoms.

March 2014
In this ground breaking study, researchers used a modified culture protocol that included plating larger volumes of urine, incubation under varied atmospheric conditions, and prolonged incubation times to demonstrate that many of the organisms identified in urine by 16S rRNA gene sequencing can be cultured using an expanded protocol. The most prevalent genera isolated were Lactobacillus (15%), followed by Corynebacterium (14.2%), Streptococcus (11.9%), Actinomyces (6.9%) and Staphylococcus (6.9%). Other genera commonly isolated include Aerococcus, Gardnerella, Bifidobacterium, and Actinobaculum. The study demonstrates that urine contains colonies of living bacteria that comprise a resident female urine microbiota.

An interview with the Loyola University research team at the American Society for Microbiology’s 114th Annual Meeting, Boston, USA, May 2014. Representatives from the Loyola Urinary Education and Research Collaborative (LUEREC) team, Alan Wolfe, Evann Hilt and Paul Schreckenberger discuss their discovery of the female urinary microbiome (FUM) and what this could mean for the future of UTI testing and treatment.

February 2020
The presence of chronic disease and infections are commonly linked to the role of biofilms, as biofilm-residing bacteria can be resistant to both the immune system, antibiotics, and other treatments. Biofilm diseases occur in many bodily systems, including the urinary system. The current knowledge on how biofilm may contribute to the pathogenesis of disease indicates a number of different mechanisms. These include the biofilm acting as a reservoir of pathogenic bacteria or creating an inflammatory response. Observations also indicate that biofilm can be formed within the living cells as well as outside the cell. Understanding the role of biofilm is essential to the development of effective treatments for such infections.

An interview with Scott Hultgren and Alan Wolfe at the International Continence Society (ICS) 2015 Conference. Professor Scott Hultgren answers questions and discusses with Professor Alan Wolfe his research team’s work with immunity, biofilms and clinical prevention of recurrent urinary tract infections.

March 2014
This study looks at the significant role of bacterial biofilms in UTIs, causing persistent infections, relapses and prostatitis. Treating such conditions is challenging and the study looks at a number of therapeutic approaches, as well as highlighting the need for new antimicrobial drugs that inhibit biofilm formation and the associated bacterial virulence.

September 2020
This work investigates the use of nitrofurantoin loaded poly (lactic-co-glycolic acid) (PLGA) particles to improve delivery to intracellular targets for the treatment of chronic UTI. The particles were able to deliver the drug to cells through multiple layers of a 3D human bladder organoid model causing minimal cell toxicity, displaying superior killing of bacterial reservoirs harboured within bladder cells compared with unencapsulated drug and were able to kill bacterial biofilms more effectively than the free drug.

December 2013
This paper looks into a prototype of a new encapsulated drug delivery system to treat chronic UTI by delivering high-dose antibiotics direct into the bladder where they can permeate cells and eradicate intracellular bacterial reservoirs. The study encapsulated Gentamicin in a polmeric carrier and these capsules killed Enterococcus faecalis in vitro in a dose-responsive, slow-release manner, which suggested this treatment could prove to be successful for recalcitrant UTI.

December 2019
This article reports the treatment of a renal transplant patient who developed a recurrent urinary tract infection with an extended-spectrum β-lactamase (ESBL)-positive Klebsiella pneumoniae strain in the first month post transplant. The infection recurred despite repeated meropenem treatment. The patient developed epididymitis and was then successfully treated with meropenem and bacteriophages.

Developed within University College London (UCL) Encapsulation Research Group and based on a novel implementation of electro-hydrodynamic processing. AtoCap Technology enables the encapsulation of patient-specific combinations of generic drugs such as antibiotics and chemotherapeutics into a multi-layered capsule. CapFuran®, enables time-release killing of a variety of patient-derived uropathogenic bacterial species, including E. coli, by a well-known and frequently-used generic antibiotic encapsulated using innovative methodology. In pre-clinical experiments, CapFuran® eradicated bacteria buried deep within a multi-layered human bladder organoid model and also killed bacterial biofilms.

July 2021
This Australian study tested the action of NAC against biofilm producing bacteria. It was found to inhibit bladder endothelial cell invasion and biofilm formation by E. coli and E. faecalis, thereby showing potential for enhancing the therapeutic effects of antibiotics in treating UTI.

May 2020
This study systematically reviewed available research to determine the role of vaccines in the treatment of recurrent UTI. Researchers concluded that the vaccines available currently do appear to have a role in the prevention of recurrent UTI while producing tolerable side effects. They determined that more work is required with regard to longer term benefits for this patient group, and also the role of vaccines in other high-risk patient groups, with the potential for an increasing role in the future.

March 2023
This study found that the sublingual vaccine MV140 appeared to safely prevent or reduce the risk of UTI. Resulting benefits are a reduction in antibiotic use and overall disease burden for patients suffering from recurrent UTI.

March 2021
This study tested intravesical vaccination with one or more uropathegenic E.coli antigens in mice, compared with subcutaneous administration. It was found to be effective and represented a superior strategy to treat UTI, particularly in subjects with aberrant bladder immune responses.

April 2023
The National Institute of Allergy, Immunology, and Infectious Diseases has awarded Soman Abraham, PhD, and Herman Staats, PhD, a two-year R21 grant titled “A Novel Vaccination Strategy to Curb Recurrent UTIs”

Monash University, Melbourne, Australia
Program Director: Dr Malcolm Starkey
Theme Leader: Dr Iain Abbott
Website: https://www.monash.edu/medicine/ccs/research/bladder-and-kidney-health
Email: ccs.bladderkidneydisovery@monash.edu

The Bladder and Kidney Health Discovery program has more than 50 world-class scientists and clinicians working to improve the understanding of conditions that impact the urinary tract and finding improved ways to diagnose, manage, prevent and treat these complex conditions. Their program unites expertise from immunology, microbiology, infectious diseases, sexual health, diabetes, renal medicine and urology.

University of Queensland, Brisbane, Australia
Group Leader:  Professor Mark Schembri
Website: https://imb.uq.edu.au/research-groups/schembri
Contact:  m.schembri@uq.edu.au

Professor Mark Schembri is a prominent microbiologist at the University of Queensland with experience in combating the global health crisis presented by antibiotic resistant bacteria that cause UTI. Professor Schembri’s expertise on the genetics, genomics and virulence of uropathogenic E. coli aims to improve the outcomes of the >400 million individuals that suffer from UTIs each year across the globe.

School of Medical Sciences, Sydney Infectious Dieases Institute,
The Charles Perkins Centre, Faculty of Medicine and Health,
The University of Sydney, Sydney NSW, Australia

Centre Lead: Associate Professor Jim Manos
Website: https://sydney.edu.au/medicine-health/about/our-people/academic-staff/jim-manos.html
Email: Jim.manos@sydney.edu.au

The research team has been studying how harmful bacteria, like Pseudomonas aeruginosa, Proteus mirabilis, and Staphylococcus aureus, cause infections in the human body for over 15 years. What they have discovered is that the more dangerous strains of these bacteria tend to create stronger biofilms. These biofilms act like protective shields, making it difficult for antibiotics to reach and kill the bacteria, leading to persisting infections.

The team’s focus has been on urinary tract infections (UTIs), and they have been working closely with urology clinicians in major hospitals to analyse clinical samples. Their research has unveiled variations in the composition of the biofilm matrix, the protective layer formed by bacteria, in UTI-causing strains like Uropathogenic E.coli (UPEC), as well as strains of P. aeruginosa, P. mirabilis, and Enterobacter faecalis.

In collaboration with their industry partner, Whiteley Corporation, they are dedicated to developing and testing combined treatments. These treatments aim to disrupt the biofilm matrix, allowing antibiotics to effectively reach and eliminate the underlying bacteria. Their combined approach, involving antioxidants, antibiotics, and adjuvants, has shown promising results in both catheter-associated and non-catheter-associated bladder infections, based on our innovative glass bladder model.

Their ongoing partnership with Whiteley Corporation chemists is helping us expand the range and improve the composition of the combination treatments. The goal is to cover various types of UTI-causing bacteria, ensuring safety and meeting other requirements for eventual approval by regulatory agencies like the Therapeutic Goods Administration (TGA). Their ultimate aim is to provide an effective treatment for urinary tract infections.

Relevant publications:

1. Manoharan et al. N-acetylcysteine prevents catheter occlusion and inflammation in catheter associated-urinary tract infections by suppressing urease activity Frontiers in Cellular and Infection Microbiology 2023 1 doi.org/10.3389/fcimb.2023.1216798.
2. Manoharan et al. N-acetylcysteine protects bladder epithelial cells from bacterial invasion and displays antibiofilm activity against urinary tract bacterial pathogens Antibiotics 2021 10 900 doi.org/10.3390 /antibiotics10080900. PMID:34438950.
3. Das et al. Conditions Under Which Glutathione Disrupts the Biofilms and Improves Antibiotic Efficacy of Both ESKAPE and Non-ESKAPE Species Frontiers in Microbiology 2019 doi:10.3389/fmicb.2019.02000 PMID:31543871.

University of Technology Sydney (UTS), Sydney, Australia
Theme Leader:  Dr Iain Duggin  
Duggin Lab : https://sites.google.com/view/dugginlab/home
Website:  https://www.uts.edu.au/research/australian-institute-microbiology-infection
Contact:  Iain.Duggin@uts.edu.au

Dr Duggin’s team uses and develops methods for model microorganisms. The have led the development of Haloferax volcanii (archaea found in salt lakes) as a powerful model for cell biology that is particularly useful for comparative and evolutionary studies. They also study Escherichia coli, particularly Uropathogenic E. coli (UPEC) that cause urinary tract infections (UTI). The applications of their research include biotechnology and vaccine and drug design/delivery. Their work is improving our understanding of the pathogenesis of UTI and its diagnosis/treatment.

Hudson Institute of Medical Research, Melbourne, Australia
Research Group Head: Dr Samuel Forster  
Website:  www.hudson.org.au/research-group/microbiota-systems-biology
Contact: sam.forster@hudson.org.au

Research at the Microbiota and Systems Biology laboratory applies genomics, computational and systems biology, microbiology, and immunology to develop an understanding of bacterial community structures that could relate to autoimmune diseases, cancers and infections, their genomes and reciprocal interactions with the human immune system that lead to disease or maintain health. Their research focuses on developing new therapeutic options for many conditions and diseases.  Dr Forster recaps his urinary tract infection research, where research needs to head next, and how further research could find a breakthrough treatment in this article:  https://www.hudson.org.au/news/treating-utis-where-to-from-here/

Department of Renal Medicine
University College London (UCL), United Kingdom
Principal Investigators: Drs Rajvinder Khasriya and Harry Horsely
Website: https://twitter.com/BIIG_UCL
Email:  h.horsley@ucl.ac.uk

The Bladder Infection and Immunity Group at University College London, part of the Centre for Kidney & Bladder Health, The Eastman Dental Institute: Microbial diseases is at the forefront of research into urinary tract infections (UTIs). The team is dedicated to unravelling the complexities of chronic and recurrent UTIs, focusing on innovative diagnostics, treatments and overcoming antibiotic resistance. You can read more about BIIG’s research here.

Centre for Urological Biology

University College London (UCL), United Kingdom
Centre Lead:  Professor Jennifer Rohn
Website: https://www.ucl.ac.uk/nephrology/research-centres/centre-urological-biology
Email: j.rohn@ucl.ac.uk

The Chronic UTI group focuses primarily on the cell biology, microbial diversity and host/pathogen interactions of recalcitrant and recurrent urinary tract infection in patients. They have a special interest in how chronic/recurrent UTI differs from uncomplicated acute UTI, and favour human model systems over animal studies. To facilitate this research, the group has been designing innovative human organoid models to study the biology of infection and to use as a test-bed for assessing new treatments. They are investigating how protected bacterial reservoirs might facilitate recurrence and antibiotic resistance.  Their work encompasses microbiology, molecular cell biology, immunology, tissue engineering, metagenomics, high-resolution imaging and biofilm biology.  They work closely with clinicians to study the causative bacteria in patient populations, including renal transplant recipients, the chronically infected elderly and younger recurrent UTI patients.  They also collaborate with engineers, materials scientists and industry partners to develop novel therapeutics and diagnostic tools with an emphasis on circumventing antibiotic resistance. The Chronic UTI Group is about to commence clinical trials on their most mature therapy design.

Loyola University, Chicago, USA
Headed by Professor Alan Wolfe
Website: http://ssom.luc.edu/luerec/
Email:  awolfe@luc.edu

The Loyola research team was the first to publish the discovery of the female urinary microbiota (FUM) in 2012 and continues to make in-roads in developing an understanding of the urinary microbiota and how it relates to health and disease. Once they have a clear understanding of the urinary microbiota, they hope to develop innovative treatments for various LUTS conditions and syndromes that are, at present, misunderstood.

Duke University, North Carolina, USA
Headed by Dr Soman Ninan Abraham
Website: https://abrahamlab.wixsite.com/abrahamlab
Email:  soman.abraham@duke.edu

The Abraham laboratory is focused on developing innovative approaches for curbing microbial infections through the study of the molecular interactions occurring between pathogenic bacteria and prominent immune and epithelial cells. They believe there is a significant amount of crosstalk occurring between bacteria and host cells during infection and that the outcome of this interaction dictates both how quickly the infection is cleared and the severity of the pathology associated with the infection. They also believe that through deciphering this crosstalk they should be able to selectively promote certain beneficial interactions while abrogating the harmful ones.   In this Youtube interview, Dr Abraham explains the immune system response to urinary tract infection and how the vaccine his team is working on addresses this:  https://www.youtube.com/watch?v=HCwh5KLV3bg

Washington University School of Medicine, USA
Headed by Dr Scott Hultgren
Website: www.cwidr.wustl.edu
Website:  https://hultgrenlab.wustl.edu/
Email:  hultgren@wustl.edu

The Center for Women’s Infectious Disease Research (cWIDR) is investigating common and often overlooked infections affecting women, such as acute and chronic urinary tract infections, interstitial cystitis and sexually transmitted diseases. The research combines women’s health, microbiology, immunology and infectious diseases, and has made significant progress with acute, recurrent and chronic UTI with the discoveries and understanding of uropathogenic E. coli (UPEC), intracellular bacterial communities (IBC) and biofilm infection.