Waterborne Urinary Tract Infections: Have We Overlooked an Important Source of Exposure?

Urinary tract infections and antimicrobial susceptibility: A retrospective trend analysis of uropathogens in women in Accra, Ghana (2019-2022)

Urinary tract infections (UTIs) remain a significant public health concern, with evolving patterns in prevalence and antimicrobial resistance. This retrospective study, conducted at the Greater Accra Regional Hospital in Accra, Ghana, analyzed 11,280 urine cultures obtained exclusively from female patients from 2019 to 2022 to assess trends in UTI burden, prevalence stratified by age and month, and antimicrobial susceptibility patterns. In all, urine pathogens were isolated in 4475 (39.67%) of the samples tested. Of the total number of uropathogens isolated, majority of them were bacterial pathogens (94.21%), with an increasing proportion of fungal infections, specifically candida species (5.79%). Irrespective of the year, the highest prevalence of uropathogens were consistently recorded in the month of May, while individuals aged ≥  90 years exhibited the greatest odds of infection in 2020 (aOR: 1.88, p = 0.039). Escherichia coli (30.51%) and Staphylococcus aureus (15.16%) were the most prevalent Gram-negative and Gram-positive pathogens, respectively. Antimicrobial susceptibility testing revealed declining antibiotic effectiveness over time, with notable exceptions for gentamicin (97.4% effectiveness against Enterococcus spp.) and ofloxacin (82.9% against Enterococcus spp.). Alarmingly, most antibiotics exhibited effectiveness rates below 20% by 2022, underscoring the growing resistance challenge. These findings, drawn from a key healthcare facility in Ghana's capital, highlight the dynamic nature of UTIs and the urgent need for targeted interventions, optimized antimicrobial stewardship, and continuous monitoring of resistance patterns to improve patient outcomes.

Population Ecology-Quantitative Microbial Risk Assessment (QMRA) Model for Antibiotic-Resistant and Susceptible E. coli in Recreational Water

Understanding and predicting the role of waterborne environments in transmitting antimicrobial-resistant (AMR) infections are critical for public health. A population ecology-quantitative microbial risk assessment (QMRA) model is proposed to evaluate urinary tract infection (UTI) development due to recreational waterborne exposures to Escherichia coli (E. coli) and antibiotic-resistant extended-spectrum β-lactamase-producing (ESBL) E. coli. The horizontal gene transfer (HGT) mechanism of conjugation and other evolutionary factors were modeled separately in the environment and the gut. Persistence/dilution dominated HGT in the environment; however, HGT highly impacted predicted ESBL populations in the body. Predicted disability life year (DALY) risks from exposure to ESBL E. coli at concentrations consistent with US recreational water criteria were less than the 10-6 pppy benchmark value but greater than the susceptible E. coli DALY risks associated with a UTI health outcome. However, the prevailing susceptible dose-response relationship may underestimate ESBL risk if HGT rates in vivo approach those reported in vitro. A sensitivity analysis demonstrated that DALY values, E. coli/ESBL concentrations, and exposure parameters were influential on predicted risks. The model is a preliminary tool to begin the expansion of the QMRA paradigm to explore the impacts of evolutionary changes in AMR risk assessment.

Phylogenetic groups and extraintestinal virulence genes of inflow Escherichia coli entering a municipal drinking water treatment facility (St. Paul, MN, USA)

Extraintestinal pathogenic Escherichia coli (ExPEC), a leading cause of urinary tract infections, sepsis and neonatal meningitis, circulates between diverse hosts and the environment. Consequently, identifying ExPEC reservoirs and transmission pathways has potentially great public health importance. Here, we used PCR-based methods to characterize 104 E. coli isolates from inflow water to the St. Paul, MN (USA), municipal drinking water treatment plant. Isolates were analysed for major phylogenetic groups and multiple extraintestinal virulence genes. Additionally, from the 65 (of 104) water samples that yielded multiple E. coli colonies, we screened E. coli population DNA for virulence genes. Thirty-three percent of isolates represented virulence-associated groups B2 and D, and 8% (95% CI: 3%, 15%) qualified molecularly as ExPEC. The ExPEC isolates, all from group B2 or D, had a median virulence gene score of 11.0 and collectively contained all but four of the 28 studied extraintestinal virulence genes. Population DNA screening increased the proportion of samples positive for individual virulence genes and, presumptively, for ExPEC [14% (95% CI: 10%, 30%) vs. 8%, P=0.03]. These findings identify a previously underappreciated potential mechanism for community-wide dissemination of ExPEC and underscore the importance of consistent disinfection of municipal drinking water.

Epidemiological trends and predictions of urinary tract infections in the global burden of disease study 2021

Urinary tract infections (UTIs) are prevalent; however, comprehensive and current epidemiological data remain scarce. This study examined the global, national, and regional burden of UTIs by sex, age, and socio-demographic index (SDI) from 1990 to 2021. The 2021 Global Burden of Disease study included age-standardised incidence rate (ASIR), age-standardised prevalence rate (ASPR), age-standardised death rate (ASDR), and age-standardised disability-adjusted life years rate (ASDAR). The estimated annual percentage change was used to depict temporal trends, whereas Pearson correlation analysis explore its correlation with the human development index (HDI), the SDI, and age-standardised rates (ASRs). An autoregressive integrated moving average model forecasted the UTI burden trends. From 1990 to 2021, the number of UTI cases increased by 66.45%, reaching 4.49 billion cases, with an ASIR of 5,531.88 per 100,000 population. The greatest incidence of UTIs was seen in women and older adult men. Tropical Latin America and low-middle SDI regions exhibited the highest ASIR, ASPR, ASDR, and ASDAR, while East Asia showed the lowest. ASDR and ASDAR decreased with higher SDI levels. ASR and HDI were weakly positively correlated with ASDR and ASDAR. ASIR, ASPR, and ASDAR are projected to increase until 2050. The global burden of UTIs is rising and is influenced by geographical location, age, sex, and economic development, crucial for guiding medical practices and forming relevant policies.

Summer temperature and emergency room visits due to urinary tract infection in South Korea: a national time-stratified case-crossover study

BACKGROUND

Although urinary tract infection (UTI) is a common and severe public health concern, and there are clear biological mechanisms between UTI and hot temperatures, few studies have addressed the association between hot temperatures and UTI.

METHODS

We designed a time-stratified case-crossover study using a population-representative sample cohort based on the National Health Insurance System (NHIS) in South Korea. We obtained all NHIS-based hospital admissions through the emergency room (ER) due to UTI (using a primary diagnostic code) from 2006 to 2019. We assigned satellite-based reanalyzed daily summer (June to September) average temperatures as exposures, based on residential districts of beneficiaries (248 districts in South Korea). The conditional logistic regression was performed to evaluate the association between summer temperature and UTI outcome.

RESULTS

A total of 4,436 ER visits due to UTI were observed during the summer between 2006 and 2019 among 1,131,714 NHIS beneficiaries. For 20% increase in summer temperatures (0-2 lag days), the odd ratio (OR) was 1.06 (95% CI: 1.02-1.10) in the total population, and the association was more prominent in the elderly (people aged 65 y or older; OR:1.11, 95% CI: 1.05-1.17), females (OR: 1.12, 95% CI: 1.05-1.19), and people with diabetes history (OR: 1.14, 95% CI: 1.07-1.23). The effect modification by household income was different in the total and elderly populations. Furthermore, the association between summer temperature and UTI increased during the study period in the total population.

CONCLUSIONS

Our results are consistent with the hypothesis that higher summer temperatures increase the risk of severe UTIs, and the risk might be different by sub-populations.

Self-reported urinary tract infection and bacterial vaginosis symptoms among indigenous adolescents during seasonal periods of water scarcity: A cross-sectional study in Bandarban Hill District of Bangladesh

Background and Aims

Water scarcity and poor water quality could lead to suboptimum menstrual hygiene practices, and subsequently urinary tract infection (UTI) and bacterial vaginosis (BV). In this study, we estimate the prevalence of self-reported UTI and BV among indigenous adolescent girls during the water scarcity period in the Bandarban Hill Districts in south-eastern Bangladesh.

Methods

Using a cross-sectional design, a total of 242 indigenous adolescent girls were selected and interviewed during the seasonal water scarcity period (from February to May 2022) in Bandarban. The difference in prevalence of any self-reported UTI or BV symptoms by respondents' characteristics was assessed by χ 2 test. Multivariable logistic regression model was used to observe the associated factors.

Results

The prevalence of self-reported UTI, BV, and any symptoms of UTI or BV among the respondents were 35.54%, 28.93%, and 43.80%, respectively. Ethnicity, studentship status, source of water used for menstrual hygiene, and perceived water quality were significantly associated with the prevalence of any self-reported UTI or BV symptoms.

Conclusion

Findings recommend further research to cross-check the validity of self-reported prevalence and investigate if the episodes of UTI or BV could be attributable to water scarcity and poor water quality in study areas during dry period.

Exposure to industrial hog and poultry operations and urinary tract infections in North Carolina, USA

An increasing share of urinary tract infections (UTIs) are caused by extraintestinal pathogenic Escherichia coli (ExPEC) lineages that have also been identified in poultry and hogs with high genetic similarity to human clinical isolates. We investigated industrial food animal production as a source of uropathogen transmission by examining relationships of hog and poultry density with emergency department (ED) visits for UTIs in North Carolina (NC). ED visits for UTI in 2016-2019 were identified by ICD-10 code from NC's ZIP code-level syndromic surveillance system and livestock counts were obtained from permit data and aerial imagery. We calculated separate hog and poultry spatial densities (animals/km2) by Census block with a 5 km buffer on the block perimeter and weighted by block population to estimate mean ZIP code densities. Associations between livestock density and UTI incidence were estimated using a reparameterized Besag-York-Mollié (BYM2) model with ZIP code population offsets to account for spatial autocorrelation. We excluded metropolitan and offshore ZIP codes and assessed effect measure modification by calendar year, ZIP code rurality, and patient sex, age, race/ethnicity, and health insurance status. In single-animal models, hog exposure was associated with increased UTI incidence (rate ratio [RR]: 1.21, 95 % CI: 1.07-1.37 in the highest hog-density tertile), but poultry exposure was associated with reduced UTI rates (RR: 0.86, 95 % CI: 0.81-0.91). However, the reference group for single-animal poultry models included ZIP codes with only hogs, which had some of the highest UTI rates; when compared with ZIP codes without any hogs or poultry, there was no association between poultry exposure and UTI incidence. Hog exposure was associated with increased UTI incidence in areas that also had medium to high poultry density, but not in areas with low poultry density, suggesting that intense hog production may contribute to increased UTI incidence in neighboring communities.

Virulence Profile, Antibiotic Resistance, and Phylogenetic Relationships among Escherichia coli Strains Isolated from the Feces and Urine of Hospitalized Patients

Extra-intestinal pathogenic Escherichia coli (ExPEC) may inhabit the human gut microbiota without causing disease. However, if they reach extra-intestinal sites, common cystitis to bloodstream infections may occur, putting patients at risk. To examine the human gut as a source of endogenous infections, we evaluated the E. coli clonal diversity of 18 inpatients' guts and their relationship with strains isolated from urinary tract infection (UTI) in the same hospital. Random amplified polymorphic DNA evaluated the clonal diversity, and the antimicrobial susceptibility was determined by disk diffusion. One isolate of each clone detected was sequenced, and their virulome and resistome were determined. Overall, 177 isolates were screened, among which 32 clones were identified (mean of two clones per patient), with ExPEC strains found in over 75% of the inpatients' guts. Endogenous infection was confirmed in 75% of the cases. ST10, ST59, ST69, ST131, and ST1193 clones and critical mobile drug-resistance encoding genes (bla_CTX-M-15, bla_OXA-1, bla_DHA-1, aac(6')-lb-cr, mcr-1.26, qnrB4, and qnrB19) were identified in the gut of inpatients. The genomic analysis highlighted the diversity of the fecal strains, colonization by lactose-negative E. coli, the high frequency of ExPEC in the gut of inpatients without infections, and the presence of β-lactamase producing E. coli in the gut of inpatients regardless of the previous antibiotics' usage. Considering that we found more than one ExPEC clone in the gut of several inpatients, surveillance of inpatients' fecal pathogens may prevent UTI caused by E. coli in the hospital and dissemination of risk clones.

Naturalized Escherichia coli in Wastewater and the Co-evolution of Bacterial Resistance to Water Treatment and Antibiotics

Antibiotic resistance represents one of the most pressing concerns facing public health today. While the current antibiotic resistance crisis has been driven primarily by the anthropogenic overuse of antibiotics in human and animal health, recent efforts have revealed several important environmental dimensions underlying this public health issue. Antibiotic resistant (AR) microbes, AR genes, and antibiotics have all been found widespread in natural environments, reflecting the ancient origins of this phenomenon. In addition, modern societal advancements in sanitation engineering (i.e., sewage treatment) have also contributed to the dissemination of resistance, and concerningly, may also be promoting the evolution of resistance to water treatment. This is reflected in the recent characterization of naturalized wastewater strains of Escherichia coli-strains that appear to be adapted to live in wastewater (and meat packing plants). These strains carry a plethora of stress-resistance genes against common treatment processes, such as chlorination, heat, UV light, and advanced oxidation, mechanisms which potentially facilitate their survival during sewage treatment. These strains also carry an abundance of common antibiotic resistance genes, and evidence suggests that resistance to some antibiotics is linked to resistance to treatment (e.g., tetracycline resistance and chlorine resistance). As such, these naturalized E. coli populations may be co-evolving resistance against both antibiotics and water treatment. Recently, extraintestinal pathogenic strains of E. coli (ExPEC) have also been shown to exhibit phenotypic resistance to water treatment, seemingly associated with the presence of various shared genetic elements with naturalized wastewater E. coli. Consequently, some pathogenic microbes may also be evolving resistance to the two most important public health interventions for controlling infectious disease in modern society-antibiotic therapy and water treatment.