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Bacterial factors associated with long-term persistence in the colon have not been defined. Individual Escherichia coli strains in the colonic flora of 13 schoolgirls with asymptomatic bacteriuria were identified by electromorphic typing of chromosomally encoded enzymes and defined as resident or transient. The strains were characterized as to serotype, receptor specificity, and adherence to the human colonic epithelial cell line HT-29. Colonic resident strains expressed P fimbriae, adhered to colonic epithelial cells via a mannose-resistant mechanism, and expressed the uropathogenic serotypes O1, O2, O6, O7, O18, O25, or O75 more often than did the transient strains, which were often nontypeable. The serotype and hemagglutination pattern were generally retained during intestinal carriage, in contrast to the loss of such properties upon prolonged colonization of the urinary tract. P fimbriae with Galα1→4Galβ-specific adherence may, in fact, have evolved to increase persistence in the colon.

OBJECTIVE--To compare the outcome of pregnancy in women with and without renal scarring after childhood urinary infections with that in unmatched controls. DESIGN--Retrospective study of pregnancies in women prospectively followed up from their first recognised urinary infection. SETTING--Tertiary referral centre in Gothenburg. SUBJECTS--111 Women attending an outpatient clinic for women with urinary infection during 1975-83, of whom 41 (65 pregnancies) were studied (19 women with renal scarring (32), 22 without scarring (33)), and 65 controls (65) randomly selected and matched for parity, age, smoking habits, and date of delivery. MAIN OUTCOME MEASURES--Urinary infections and complications in pregnancy. RESULTS--The incidence of bacteriuria during first pregnancies was significantly greater in women with (9, 47%) and without (6, 27%) renal scarring after childhood urinary infection than in controls (1, 2%) (p less than 0.001, 0.01 respectively). Symptomatic infections were seen only among women with a history of urinary infection: four women with renal scarring (three of whom had vesicoureteric reflux) developed pyelonephritis and three cystitis, and one woman without scarring developed pyelonephritis. Mean blood pressure was higher among women with severe renal scarring than controls (4/11 v 3/44; p less than 0.05) before and during pregnancy. There was no significant difference in the incidence of pre-eclampsia, operative delivery, prematurity, or birth weight. CONCLUSIONS--Women with a history of previous urinary infections had a high incidence of bacteriuria during pregnancy, and those with renal scarring and persistent reflux were prone to develop acute pyelonephritis. The risk of serious complications in pregnancy, however, was not increased in women with severe renal scarring, possibly owing to their continuous clinical supervision.

We report the detection and progression of renal scars in girls prospectively followed from their first recognized urinary tract infection. There were 107 infection-prone subjects with a median age of 7.1 years at the first and 21.7 years at the last urography. Of 51 females who ultimately had lesions, 38 had established scars at the first urography. In 18 subjects, new scars were found in previously undamaged kidneys, 5 already with unilateral scarring. There had been a normal urography after the 5th birthday in 8 of those with later scarring. Worsening of scarring was seen in 10 of the 38 subjects with established scars. The renal damage was in most cases slight or moderate. By stepwise logistic regression analysis, grade of reflux and number of pyelonephritic attacks correlated with scarring, and number of pyelonephritic attacks with new scars and worsening of the lesions. In summary, of the females who ultimately had renal lesions, one-third developed new scars. In most of those with established scars at the first urography, the focal character of lesions suggests that most were also acquired. Since reflux and number of pyelonephritic attacks were identified as risk factors, prevention of renal deterioration should be possible.

The properties of 709 strains of Escherichia coli isolated from feces of healthy schoolchildren were compared with those of 115 strains from the urine of girls with asymptomatic bacteriuria (ABU) detected in a screening program. These fecal strains were also compared with 45 strains that caused asymptomatic reinfections and 10 that caused symptomatic reinfections in the same group of girls. Typing of O antigen was done by direct bacterial agglutination, and K typing was done with a serum agar technique. Hemolytic capacity was assessed in solid medium. Sensitivity to the bactericidal effect of normal serum and minimal inhibitory concentrations of ampicillin were also determined. The strains isolated from girls who had reinfections of ABU were found to be a random sample of the fecal flora, but the strains from children with symptomatic reinfection were not. Strains from index patients with ABU differed from the other groups in a way that was indicative of adaptive changes in the structure of cell envelopes.

The faecal flora was studied in eight children admitted to hospital for treatment of a first urinary infection with sulphonamides. The original, sulphonamide-sensitive Escherichia coli organisms were found to disappear, to be replaced by other E. coli serotypes that were almost invariably resistant to sulphonamides. Some of these serotypes carried R-factors for multiple antibiotic resistance. Possibly some urinary infections with antibiotic-resistant organisms may be due to faecal organisms whose resistance has been changed by previous antibiotic treatment. Hence it is important to study the effects of individual antibiotics on the faecal flora.