Providencia stuartii infections: a review of 117 cases over an eight year period

Socialization of Providencia stuartii Enables Resistance to Environmental Insults

Providencia stuartii is a highly social pathogen responsible for nosocomial chronic urinary tract infections. The bacterium indeed forms floating communities of cells (FCC) besides and prior-to canonical surface-attached biofilms (SAB). Within P. stuartii FCC, cells are riveted one to another owing to by self-interactions between its porins, viz. Omp-Pst1 and Omp-Pst2. In pathophysiological conditions, P. stuartii is principally exposed to high concentrations of urea, ammonia, bicarbonate, creatinine and to large variations of pH, questioning how these environmental cues affect socialization, and whether formation of SAB and FCC protects cells against those. Results from our investigations indicate that FCC and SAB can both form in the urinary tract, endowing cells with increased resistance and fitness. They additionally show that while Omp-Pst1 is the main gateway allowing penetration of urea, bicarbonate and ammonia into the periplasm, expression of Omp-Pst2 enables resistance to them.

Providencia Causing UTIs: Are We Reaching a Dead End!!!

Background

Materials and methods

Results

Conclusion

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Porin self-association enables cell-to-cell contact in Providencia stuartii floating communities

The gram-negative pathogen Providencia stuartii forms floating communities within which adjacent cells are in apparent contact, before depositing as canonical surface-attached biofilms. Because porins are the most abundant proteins in the outer membrane of gram-negative bacteria, we hypothesized that they could be involved in cell-to-cell contact and undertook a structure-function relationship study on the two porins of P. stuartii, Omp-Pst1 and Omp-Pst2. Our crystal structures reveal that these porins can self-associate through their extracellular loops, forming dimers of trimers (DOTs) that could enable cell-to-cell contact within floating communities. Support for this hypothesis was obtained by studying the porin-dependent aggregation of liposomes and model cells. The observation that facing channels are open in the two porin structures suggests that DOTs could not only promote cell-to-cell contact but also contribute to intercellular communication.

Providencia stuartii form biofilms and floating communities of cells that display high resistance to environmental insults

Biofilms are organized communities of bacterial cells that are responsible for the majority of human chronic bacterial infections. Providencia stuartii is a Gram-negative biofilm-forming bacterium involved in high incidence of urinary tract infections in catheterized patients. Yet, the structuration of these biofilms, and their resistance to environmental insults remain poorly understood. Here, we report on planktonic cell growth and biofilm formation by P. stuartii, in conditions that mimic its most common pathophysiological habitat in humans, i.e. the urinary tract. We observed that, in the planktonic state, P. stuartii forms floating communities of cells, prior to attachment to a surface and subsequent adoption of the biofilm phenotype. P. stuartii planktonic and biofilm cells are remarkably resistant to calcium, magnesium and to high concentrations of urea, and show the ability to grow over a wide range of pHs. Experiments conducted on a P. stuartii strain knocked-out for the Omp-Pst2 porin sheds light on the role it plays in the early stages of growth, as well as in the adaptation to high concentration of urea and to varying pH.

Activation of the 2'-N-acetyltransferase gene [aac(2')-Ia] in Providencia stuartii by an interaction of AarP with the promoter region

The aac(2')-Ia gene in Providencia stuartii encodes a 2'-N-acetyltransferase capable of acetylating both peptidoglycan and certain aminoglycoside antibiotics. Regulation of the aac(2')-Ia gene is influenced in a positive manner by the product of the aarP gene, which encodes a small transcriptional activator of the AraC (XylS) family. In this study, we demonstrate the sequence requirements at the aac(2')-Ia promoter for AarP binding and activation.

A regulatory cascade involving AarG, a putative sensor kinase, controls the expression of the 2'-N-acetyltransferase and an intrinsic multiple antibiotic resistance (Mar) response in Providencia stuartii

A recessive mutation, aarG1, has been identified that resulted in an 18-fold increase in the expression of beta-galactosidase from an aac(2')-lacZ fusion. Transcriptional fusions and Northern blot analysis demonstrated that the aarG1 allele also resulted in a large increase in the expression of aarP, a gene encoding a transcriptional activator of aac(2')-Ia. The effects of aarG1 on aac(2')-Ia expression were mediated by aarP-dependent and -independent mechanisms. The aarG1 allele also resulted in a multiple antibiotic resistance (Mar) phenotype, which included increased chloramphenicol, tetracycline and fluoroquinolone resistance. This Mar phenotype also resulted from aarP-dependent and -independent mechanisms. Sequence analysis of the aarG locus revealed the presence of two open reading frames, designated aarR and aarG, organized in tandem. The putative AarR protein displayed 75% amino acid identity to the response regulator PhoP, and the AarG protein displayed 57% amino acid identity to the sensor kinase PhoQ. The aarG1 mutation, a C to T substitution, resulted in a threonine to isoleucine substitution at position 279 (T279I) in the putative sensor kinase. The AarG product was functionally similar to PhoQ, as it was able to restore wild-type levels of maganin resistance to a Salmonella typhimurium phoQ mutant. However, expression of the aarP and aac(2')-Ia genes was not significantly affected by the levels of Mg2+ or Ca2+, suggesting that aarG senses a signal other than divalent cations.

aarC, an essential gene involved in density-dependent regulation of the 2'-N-acetyltransferase in Providencia stuartii

The 2'-N-acetyltransferase [AAC(2')-Ia] in Providencia stuartii has a dual function where it is involved in the acetylation of peptidoglycan and certain aminoglycosides. A search for negative regulators of the aac(2')-Ia gene has resulted in the identification of aarC. A missense allele (aarC1) resulted in an 8.9-fold increase in beta-galactosidase accumulation from an aac(2')-lacZ transcriptional fusion. Northern blot analysis demonstrated an increase in aac(2')-Ia mRNA accumulation that was specific to cells at high density. In addition, the aarC1 allele also resulted in a substantial increase in the expression of aarP, a transcriptional activator of the aac(2')-Ia gene. The wild-type aarC gene was isolated by complementation and encodes a predicted protein of 365 amino acids with a molecular mass of 39,815 Da. The predicted AarC protein exhibited 88% amino acid homology to the previously identified GcpE protein of Escherichia coli and 86% homology to a gene product from Haemophilus influenzae. The E. coli gcpE gene was able to functionally complement the aarC1 allele in P. stuartii. The aarC1 allele was identified as a T to G transversion that resulted in a valine to glycine substitution at position 136 in the AarC protein. The aarC gene appears to be essential for cell viability as construction of a disrupted copy (aarC::lacZ) was possible only in cells that carried an episomal copy of aarC or gcpE.

Molecular epidemiology of catheter-associated bacteriuria in nursing home patients

Urine samples from 19 nursing home patients with long-term urinary catheters were cultured every 3 months for 18 months. Providencia stuartii, present in 74% of the elderly and in 59% of urine specimens, was the most frequently isolated bacteria. The persistence of P. stuartii was significantly higher among females than among males. In order to study the epidemiology of bacteriuria in this nursing home, bacteria were characterized by biochemical tests, antibiotic susceptibility pattern, and restriction fragment length polymorphism (RFLP) analysis. The antibiotic susceptibility pattern indicated that each patient had two to three different strains of P. stuartii during the 18 months of follow-up. In contrast, the RFLP analysis revealed that a specific strain had persisted in the urinary tract of the patient during the entire follow-up period. According to the biochemical profile, 74% of the patients had the same bacteria in urine cultures, pointing to a common source of transmission. RFLP analysis, however, demonstrated different patterns of RFLP, suggesting concomitant multiple sources of infection.

A species-specific DNA probe for Providencia stuartii identification

A DNA probe is described that can be used for identification of Providencia stuartii by means of filter hybridization assays. The probe, which is a fragment of the P. stuartii phoN gene coding for an acid phosphatase, appeared to be able to recognize only P. stuartii strains in slot-blot hybridization experiments performed with total DNA extracted from 545 strains of 64 different Gram-negative bacterial species, including all the major representatives of the family Enterobacteriaceae. Owing to the problems that may be often encountered for correct identification of P. stuartii at the species level when using commercial identification systems, this probe may result useful for fast and reliable identification of P. stuartii strains for taxonomical, epidemiological and diagnostic studies.

Modified MacConkey medium which allows simple and reliable identification of Providencia stuartii

This work describes a modified MacConkey medium (MCP medium) enabling the simple identification of Providencia stuartii, an emerging nosocomial pathogen. A total of 813 strains, belonging to the families Enterobacteriaceae and Pseudomonadaceae, were tested on MCP medium; all P. stuartii strains were phosphatase positive, as were 97.5% of Morganella morganii strains, in contrast with all other tested organisms. A simple discriminating test, such as the ornithine or citrate test, allowed identification of strains of these species. We have also compared the reliabilities of P. stuartii identification by commercial kits (API 20E system) by using a standard MacConkey or MCP medium. Sixteen and three-tenths percent of P. stuartii strains were misidentified by using the former procedure, while with the latter all strains were correctly identified. Finally, the MCP medium was used over a 6-month period in our routine clinical laboratory. Of a total of 1,278 seeded urine samples from elderly patients, we isolated 103 P. stuartii strains which were all correctly identified by coupling MCP medium and the API 20E system. Seventeen and one-half percent of these strains were misidentified when the API 20E system was used in combination with standard MacConkey medium.

Clinical correlates of bacteremia in a Veterans Administration extended care facility

Little is known about bacteremia in long-term care facilities. We have conducted a retrospective study during a 12-month period analyzing the clinical correlates of bacteremia in 533 chronically institutionalized, predominantly male patients, with an average age of 69 years. Thirty-four men had forty-two bacteremic illnesses during this period. The incidence rate was 0.30 episodes per 1000 patient care days, and the mortality rate was 21%. The urinary tract was the most frequently identified tissue source (56%), followed by respiratory tract (7%) and skin (7%). Providencia stuartii was the most common gram-negative organism, while Staphylococcus aureus, Streptococcus pneumoniae and enterococcus were the frequent gram-positive microbes. Gram-negative bacteremia accounted for 63% of the episodes (15% mortality rate), and gram-positive bacteremia accounted for 27% (18% mortality rate); 10% of the bacteremias were polymicrobial (25% mortality rate). Most of the isolated organisms were sensitive to available antimicrobial agents. The leading risk factor for bacteremia was an indwelling urinary catheter (odds ratio 39, 95% confidence limits 16 to 97). Patients with urinary catheters at the beginning of the study constituted only 5% of the population, but accounted for 40% of the gram-negative bacteremias during the year of observation.

Commercial identification systems often fail to identify Providencia stuartii

We tested 145 clinical isolates in an attempt to evaluate some of the most widely used commercial identification systems in Europe in terms of their ability to identify Providencia strains. Two manual miniaturized systems (API 20E and Enterotube II) and three mechanized-automated systems (Cobas-Bact, Sceptor System, and Titertek-Enterobac-Rapid Automated System) were evaluated. Providencia alcalifaciens and Providencia rettgeri strains were correctly identified by all systems in all cases, and in most cases identification was achieved without the aid of supplementary tube tests. By contrast, Providencia stuartii was identified without the aid of supplementary tube tests for only 42.5% (API 20E), 37.5% (Enterotube), 68.7% (Sceptor), and 71.2% (Cobas-Bact) of the isolates. The overall misidentification rates were 16.3, 11.3, 11.3, and 10%, respectively. The Titertek-Enterobac-Rapid Automated System failed to identify only 1 of 80 strains (1.3%) and required supplementary tests in 2 other cases (2.5%). Since four of the multitest systems examined often failed to correctly identify P. stuartii, we conclude that supplementary conventional tube tests should always be used to distinguish this species from the other taxa of the Proteeae tribe.

The resistance of urinary tract pathogens to chlorhexidine bladder washouts

Isolates of Providencia stuartii, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae and Streptococcus faecalis from urinary-tract infections in spinally-injured patients together with Escherichia coli 10418 were challenged with chlorhexidine (200 mg l-1) in a model of a catheterized bladder under conditions which simulate the bladder washout technique. All species survived the antiseptic. Organisms growing on the wall of the bladder model appeared to be particularly resistant and electron microscopy showed that these cells were embedded in a protective glycocalyx. The effect of chlorhexidine bladder washouts on the bacterial flora in the urine of patients was also observed and shown to be minimal and temporary. Examination of urinary sediments from patients revealed the presence of micro-colonies of bacteria embedded in a polysaccharide matrix. We conclude that bladder washouts with chlorhexidine are not likely to eliminate established infections with organisms that occur in patients with indwelling bladder catheters.

Survey of multiply resistant Providencia stuartii in a chronic care unit

Providencia stuartii was cultured over a 4-year period from the urinary tract, throat, perineum, axilla and stools of patients in a long-term chronic care unit, the most common site of colonization being the urinary tract. A total of 17 patients had Prov. stuartii bacteraemia and manipulation of the urinary tract preceded bacteraemia in 10 cases. Eighty-two per cent of the patients had long-term urinary tract colonization from 1 month to 4 years. Although most isolates were resistant to all aminoglycosides except amikacin, the organisms were all susceptible to thienamycin, ceftazidime, cefotaxime, ceftizoxime and moxalactam.

Do clinical microbiology laboratories report complete bacteriology in urine from patients with long-term urinary catheters?

Bacteriuria associated with long-term urinary catheters (those in place for greater than or equal to 30 days) appears to be the most common nosocomial infection in U.S. medical care facilities. This bacteriuria is polymicrobial and dynamic and accompanied by fevers, catheter obstructions, bacteremias, and deaths. We compared the reporting by our research laboratory of bacteria present in urine from long-term-catheterized nursing home patients with that by two commercial laboratories. The commercial laboratories isolated significantly fewer bacterial species at 10(5) CFU/ml of urine specimen. Organisms well recognized as causes of urinary tract infections in noncatheterized patients (Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae) were isolated in comparable frequencies by both the research and commercial laboratories. However, other organisms, including uncommon uropathogens like Providencia stuartii and Morganella morganii, which were actually among the most frequent bacteriuric species in these long-term-catheterized patients, were isolated significantly less frequently by the commercial laboratories. Reasons for the discrepancies are unclear but may involve use of different techniques. More complete reporting may lead to better understanding of the polymicrobial bacteriuria of long-term catheters and its associated complications. This, in turn, may result in improved patient care and infection control in nursing homes.

Molecular analysis of multiple-resistance plasmids transferred from gram-negative bacteria isolated in a urological unit

Forty-one isolates of multiply resistant gram-negative bacteria causing infection in a urological unit of a Dublin hospital were collected during a 6-month period. Twenty-one isolates transferred multiple resistance to an Escherichia coli K-12 recipient in liquid matings. Serratia marcescens, Proteus morganii, Proteus vulgaris, and E. coli isolates harbored similar 120-megadalton IncC plasmids, whereas Enterobacter cloacae strains transferred a 160-megadalton plasmid of a different Inc group. Southern hybridization experiments were performed with purified fragments cloned from one IncC plasmid as probes. They were hybridized to plasmid sequences in total cellular DNA extracts, showing that the IncC plasmids were very closely related. This suggests that the same plasmid has transferred to different bacterial species in the hospital environment.

Prospective survey of fecal, urinary tract, and environmental colonization by Providencia stuartii in two geriatric wards

A prospective survey of fecal, urinary tract, and environmental colonization by Providencia stuartii in two wards was undertaken over a 5-month period. Eight of 53 male patients and 2 of 89 female patients were colonized with the endemic serotype O:63. Two patterns of colonization were found on the male ward. Two patients had persistent urinary tract colonization with no detectable fecal carriage. The other patients had fecal carriage, in some cases persistent, with intermittent urinary tract colonization. The ward environment was in general not contaminated. This study demonstrates that fecal colonization of patients by P. stuartii may be an important and previously underestimated nosocomial reservoir.