Anaerobe 77 (2022) 102509

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Anaerobe
journal homepage: www.elsevier.com/locate/anaerobe

Review Article

Urinary tract infections: Should we think about the anaerobic cocci?

Lyudmila Boyanova a, *, Yulia Marteva-Proevska b, Rumyana Markovska a,
Daniel Yordanov a, Raina Gergova a
a
Department of Medical Microbiology, Medical University of Sofia, Sofia, Bulgaria
b
University Alexander Hospital, Medical University of Sofia, Sofia, Bulgaria

a r t i c l e i n f o a b s t r a c t

Article history: Anaerobic cocci are common anaerobic isolates. Numerous genera of anaerobic cocci have been reported
Received 30 November 2021 in both urinary tract microbiota, mainly of females, and in cases of urinary tract infections (UTIs), pre-
Received in revised form dominantly in patients with comorbidities, when no facultatively anaerobic bacteria were detected from
28 December 2021
the urine samples. UTIs caused by anaerobic cocci have been reported in >7% in some studies. As the
Accepted 30 December 2021
routine diagnostic methods may be insufficient to detect and identify the anaerobic cocci in patients with
Available online 4 January 2022
UTIs, enhanced quantitative urine culture (EQUC) can give better results. EQUC is performed by plating
Handling Editor: Elisabeth Nagy urine samples onto different media to be incubated in both aerobic and anaerobic conditions with a
prolonged incubation time. Other newer methods such as 16S rRNA gene sequencing, qualitative PCR and
Keywords: Next Generation Sequencing can also be considered. Anaerobic cocci such as Peptoniphilus, Parvimonas,
Anaerobic cocci Anaerococcus and Finegoldia spp. were found in patients with bacteremia of urinary source. A fatal
Urinary tract infections outcome has been reported in a diabetic patient with emphysematous pyelonephritis caused by Fine-
Detection goldia magna and Candida parapsilosis due to a delay in seeking hospital care during the COVID-19
Enhanced quantitative urine culture
pandemic. In specific cases such as of chronic infections, immunosuppression, comorbidity, advanced
Treatment
age, following urological tract manipulations and negative culture results for usual uropathogens, it may
be advisable to use suprapubic aspiration cultured in both aerobic and anaerobic condition or EQUC
using media which support the relative slow growing anaerobic cocci as well.
© 2022 Elsevier Ltd. All rights reserved.

1. Introduction cocci in urinary tract microbiota and UTIs. The keywords “anaerobic
cocci”, “urinary tract infections”, “urinary tract microbiota”, “uri-
Anaerobic bacteria can cause different types of urinary tract nary tract microflora”, “diagnosis”, “antibiotic susceptibility”,
infections (UTIs), such as cystitis, pyelitis, pyelonephritis, peri- “treatment” and “urine sample” were searched in PubMed, Scopus
nephric abscess etc. [1]. Anaerobic bacteriuria has been common in and Google Scholar. In this review, we encompassed data from 28
catheterized patients in intensive care units [2]. Anaerobic cocci are articles, most (n ¼ 19, about 70%) of which published in 2017e2021
part of the skin, respiratory, oral, gastrointestinal and urogenital as well as our recent case of UTI caused by two species of anaerobic
microbiota of the human body and common causative agents of cocci in a patient with comorbidity and following a urological
infections, since up to 1/3 of clinical anaerobic isolates have been procedure.
Gram-positive anaerobic cocci (GPAC), [3,4]. The anaerobic cocci
involve a large number of genera such as Finegoldia, Parvimonas,
2. Anaerobic cocci in urinary tract microbiota
Peptostreptococcus, Anaerococcus, Peptoniphilus, Murdochiella, Veil-
lonella and others [3,5].
Numerous genera of anaerobic cocci were found in urinary tract
The aim of the present review was to summarize and discuss
microbiota. Akgül and Karakan [6] encompassed data of four
data on the spectrum, prevalence and significance of the anaerobic
studies on urinary tract microbiota of totally 150 healthy adult
women (Table 1). The detected GPAC belonged to different genera
such as Anaerococcus, Peptoniphilus, Finegoldia and Fannyhessea
* Corresponding author.
(Atopobium), and Gram-negative anaerobic cocci of Veillonella
E-mail addresses: l.boyanova@hotmail.com, boyanova_lbg@medfac.mu-sofia.bg genus were detected as well [6]. In these studies, anaerobic cocci
(L. Boyanova). were identified by 16S rRNA gene sequencing or enhanced

https://doi.org/10.1016/j.anaerobe.2021.102509
1075-9964/© 2022 Elsevier Ltd. All rights reserved.
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al. Anaerobe 77 (2022) 102509

Table 1
Anaerobic cocci in urinary tract microbiota (UTM) and in urinary tract infections (UTIs).

In Country Group of subjects/patients Samples Methods No of No. of % of Genera/species Strain susceptibility/ Reference
patients isolates isolates (numbers) treatment

UTM Several Healthy adult women Catheter 16S rRNA gene 150 NA NA Fannyhessea NA 6
(data of (bladder) or sequencing (Atopobium),
four midstream and/or EQUC Anaerococcus,
studies) urine Peptoniphilus,
Finegoldia, Veillonella
UK Asymptomatic female and Voided urine Quantitative 16 NA NA Parvimonas, NA 7
male volunteers aged 26 PCR of 16S Anaerococcus,
e90 years rRNA genes Finegoldia,
Murdochiella,
Peptoniphilus,
Negativicoccus
China Elderly and non-elderly Urine 16S rRNA 50 12 12.0 Peptoniphilus and NA 8
women sequencing elderly Parvimonas
and 50
non-
elderly
women
UTIs Germany Consecutive patients for Urine Culture, PCR, 1449 NA NA Anaerococcus NA 24
UTI examination 16S rDNA lactolyticus,
sequencing, Anaerococcus
DHPLC (Peptostreptococcus)
vaginalis,
Fannyhessea
(Atopobium) vaginae,
F. magna,
Peptoniphilus sp.
Hungary Symptomatic children and Suprapubic ANC cards or 54 4 7.4 F. magna (2), NA 11
adult patients bladder MALDI TOF MS samples Peptococcus niger (1),
aspirates Peptoniphilus indolicus
(1)
Sweden Patients with GPAC Blood cultures Blood culture, 229 21 9.2 Peptoniphilus (9), Susceptible to IMP and 9
bacteremia MALDI- TOF Parvimonas (8), TZP; resistance to PEN
MS, 16S rRNA Anaerococcus (3), (1.8%), MTZ (2.7%) and
gene Finegoldia (1) CLI (7.3%), EUCAST
sequencing, E breakpoints
tests
Canada Postmenopausal women Transurethral 16S rRNA gene 17 5 of 15 33.3 F. magna 5-fold more Local estrogen 28
with or without recurrent urine sequencing (rUTIs), before before common in rUTI group treatment (LET)
UTIs (rUTIs) 20 LET, LET, before LET than
(controls) 6 of 15 6.7% following LET, absent
after after in controls.
LET, LET,
0 in 0.0 in
controls controls
USA Women before Catheter Culture, 16S 126 NA NA F. vaginae and F. NA 16
urogynecologic surgery (bladder) rRNA gene magna abundance
urine sequencing associated with
symptom severity
USA A patient aged Urine Culture 1 (case 1 NA F. magna (1) VAN, TZP, nephrectomy, 17
62 years with diabetes, report) retroperitoneal
obesity, nephrolithiasis, debridement, (fatal
prostatic hypertrophy, outcome)
emphysematous
pyelonephritis and
urosepsis
USA A woman with Calcium Culture 1 1 NA Veillonella sp. (1) Nephrostomy, 13
nephrolithiasis and phosphate nephrolithotomy,
urosepsis urinary stone antibiotics
Canada A woman aged 47 years Catheter urine Culture, 1 1 NA Veillonella parvula (1) Susceptible to MTZ, PEN, 14
with recurrent UTIs and MALDI- TOF IMP and TET.
multiple comorbidities MS, 16S rRNA Treatment: MTZ (7 days)
sequencing, E and CRO (5 days)
test
Japan A pregnant woman aged 21 Voided urine Culture 1 1 NA Veillonella sp. (1) Susceptible to AMP, CLI, 15
years with hydronephrosis and blood CTX, IMP, resistant to
and urosepsis. cultures VAN. Treatment:
cefotiam i.v.
(empirically), then AMP
i.v.
Spain A 15-year-old girl with Catheter Culture 1 1 NA Peptoniphilus sp. AMX (i.v. for 3 days, then 12
cutaneous vasculitis and urine, blood orally for up to 1 week)
UTI. culture
Bulgaria Voided urine 1 1 NA

2
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al. Anaerobe 77 (2022) 102509

Table 1 (continued )

In Country Group of subjects/patients Samples Methods No of No. of % of Genera/species Strain susceptibility/ Reference
patients isolates isolates (numbers) treatment

A 73-year woman with Culture, F. magna and AMC i.v. for 5 days and Boyanova
diabetes, rheumatoid MALDI- TOF Peptoniphilus then orally for 7 days. (unpublished)
arthritis and frequent UTIs MS, E tests asaccharolyticus
following percutaneous
nephrostolithotomy

GPAC- Gram-positive anaerobic cocci, NA-not available or not appropriate; NGS-16S rRNA rapid next-generation gene sequencing; UTM-urinary tract microbiota; UTIs-
urinary tract infections, DHPLC-denaturing high-performance liquid chromatography, EQUC- expanded quantitative urine culture. LET-local estrogen treatment.
Antibiotics: AMP-ampicillin; AMX-amoxicillin, AMC- amoxicillin/clavulanate; CIP-ciprofloxacin; CLI-clindamycin; CRO-ceftriaxone; CTX-cefotaxime; IMP- imipenem; MTZ-
metronidazole; PEN-penicillin; TET-tetracycline; TZP- piperacillin/tazobactam; VAN-vancomycin.

quantitative urine culture (EQUC, see below), [6]. anaerobic chamber and were identified by ANC cards (bioMe rieux
Lewis et al. [7] evaluated clean catch urine samples of 16 Hunga ria Ltd., Budapest, Hungary) or Microflex MALDI Biotyper
asymptomatic female and male volunteers aged 26e90 years by (Bruker Daltonics, Bremen, Germany), [11].
16S rRNA gene amplification and amplicons analysis of the samples Esteban-Zubero et al. [12] observed a case of UTI and cutaneous
with 454 pyrosequencing. The authors found four strictly anaerobic vasculitis caused by Peptoniphilus spp. in a 15-year-old girl. The
genera, including Jonquetella, Saccharofermentans and Proteiniphi- isolate was susceptible to ampicillin, amoxicillin and moxifloxacin
lum spp. and the anaerobic cocci belonging to genus Parvimonas to [12].
be specific for the urinary tract microbiota of subjects older than 70 Recently, we isolated two GPAC species, F. magna and Peptoni-
years [7]. Therefore, the authors speculated that it is possible for philus asaccharolyticus from the voided urine sample of a 73-year
these anaerobic bacteria to cause infections in elderly patients, woman with diabetes, rheumatoid arthritis and frequent UTIs.
however, more studies are needed to prove the assumption [7]. The patient was treated with tocilizumab and methotrexate. In
Liu et al. [8] evaluated urinary microbiota in women aged 61e85 2019, the patient developed macroscopic hematuria. Klebsiella
years in comparison with that in a group of 28e60-year aged pneumoniae bacteriuria (103 colony-forming units, CFU/ml),
women and found some interesting age-dependent differences. thereafter treated with intravenous piperacillin/tazobactam, and a
Frequency of GPAC was 33.3% (10/30) in the urinary samples of the kidney stone with a diameter of 20e25 mm were detected. In
group of women aged >70 years, lower (20.0%, 2/10) in those of January 2020, a percutaneous nephrostolithotomy was performed.
66e70-year-old women and 0% in those of women aged 61e65 In July 2020, a routine follow-up revealed anemia, creatinine con-
years. Moreover, asymptomatic bacteriuria was associated with centration of 180 mmol/L, normal level of C reactive protein and
lower levels of anaerobic cocci of Peptoniphilus genus and anaerobic 5  107 leukocytes and 1.7  109 erythrocytes in the urine sedi-
rods of Dialister genus [8]. The authors concluded that female uri- ment. Urine examination showed the presence of Morganella
nary microbiota differs according to the age, presence of diabetes morganii (104 CFU/ml), Staphylococcus aureus (104 CFU/ml), and
and in patients with asymptomatic bacteriuria [8]. Escherichia coli (103 CFU/ml). According to the susceptibility testing
results, treatment with ciprofloxacin for 7 days and cefuroxime for
7 days was administered and was successful at the follow-up
3. Anaerobic cocci in urinary tract infections (UTIs)
evaluations. However, the creatinine concentration further
increased to 240 mmol/L. In September 2020, due to retention of
Underdiagnosing or overlooking of anaerobes, including the
inflammatory markers (erythrocyte sedimentation rate, ESR), C
anaerobic cocci from routine urine culture testing is owing to their
reactive protein (16.4 mg/dL) and creatinine, a microbiological
relatively low pathogenic potential in the urinary tract and the lack
urine evaluation was performed and revealed no growth of facul-
of anaerobic diagnostics in many laboratories and centers. How-
tative anaerobes, including Mycoplasma spp., despite the presence
ever, in patients with comorbidities such as immune suppression,
of leukocyturia and hematuria (6 leukocytes and 30 erythrocytes
diabetes and pelvic infections, the UTIs associated with the anaer-
per high power field) and ESR of 100 mm/h. Suprapubic bladder
obic cocci can cause bacteremia [9,10], (Table 1).
aspiration is the recommended method for diagnosing anaerobes
In Sweden, Badri et al. [9] assessed 229 cases of bacteremia with
in UTIs [11]. In our case, the anaerobic cocci (104 CFU/ml) were
involvement of GPAC and revealed that urinary tract was the focus
detected in a voided urine sample, however, they were the only
of the infection in 21 (9.2%) of the cases. The authors used BACTEC
rieux) blood culture isolates from the sample and the treatment according to the sus-
FX (Becton Dickinson) and BacT/Alert (bioMe
ceptibility testing data was successful (see below). The urine sam-
systems incubated for up to 120 h, the positive of which were
ples were plated onto Anaerobe basal agar (Oxoid, Basingstoke, UK)
plated onto Fastidious anaerobe agar and incubated in an anaerobic
with 5% sheep blood and were identified with routine methods and
chamber. Microflex MALDI-TOF MS (Bruker Daltronics) was used
MALDI TOF MS (Vitek MS, bioMe rieux, Marcy l’Etoile, France).
for identification of the isolates, and 16S rRNA genes were
Veillonella spp. are Gram-negative anaerobic cocci that have
sequenced in case of insufficient determination by MALDI-TOF MS
seldom been isolated from urine specimens. However, a case report
[9]. The anaerobic cocci in GPAC bacteremia cases, originating from
of Veillonella detection from a calcium stone culture of a woman
urinary tract infections, involved isolates of the genera Peptoni-
aged 56 years with nephrolithiasis and urosepsis has been recently
philus (9 isolates), Parvimonas (8), Anaerococcus (3) and Finegoldia
reported [13]. Berenger et al. [14] have also observed a case of
(1), [9].
Veillonella parvula UTI in a 47-year-old woman with recurrent UTIs,
In the study of Gajdacs et al. [11], 54 urine samples obtained by
urinary retention and multiple comorbidities such as a past stroke,
suprapubic bladder aspiration were evaluated for anaerobic bac-
gastroesophageal reflux disease, hypothyroidism and substance
teria and in 4 (7.4%) of the samples, anaerobes belonging to the
abuse. Growth of V. parvula was observed on a cystine-lactose-
anaerobic cocci (two Finegoldia magna isolates, one Peptococcus
electrolyte deficient (CLED) medium (Orion Diagnostica, Oy,
niger isolate and one Peptinophilus indolicus isolate) were identified.
Finland). The causative agent (108 CFU/ml) was isolated by
The samples for anaerobic diagnostics were incubated in an
3
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al. Anaerobe 77 (2022) 102509

anaerobic incubation on Fastidious anaerobic agar and thio- Imirzalioglu et al. [24] evaluated urine samples from 1449 pa-
glycolate broth for 24 and 48 h and was identified by Vitek® MS tients for UTI examination in a German university hospital by
(bioMe rieux, Marcy L'Etoile, France) and 16S rRNA gene sequencing routine urine culture, 16S rDNA PCR and denaturing high-
[14]. Yagihashi and Arakaki [15] have described a Veillonella UTI in a performance liquid chromatography (DHPLC) analysis. Fastidious
36-week pregnant Japanese woman aged 21 years with urosepsis bacteria, mostly anaerobes, were frequent (22.4%) causative agents
and hydronephrosis. The Gram-negative cocci were isolated from of UTIs and notably, they were detected only by the molecular
both the urine samples on the anaerobic plate after 7-day incuba- methods. The anaerobic cocci detected by PCR were of different
tion and the blood culture samples after 8-day incubation [15]. genera such as Anaerococcus, Finegoldia, Peptoniphilus and Fanny-
Therefore, the growth of the anaerobic cocci may require a pro- hessea [24].
longed incubation.
Fok et al. [16] evaluated overactive bladder symptom severity in
5. Treatment approach
126 women with stress urinary incontinence and pelvic organ
prolapse before and following urogynecologic surgery. The authors
Anaerobic cocci display different antibiotic susceptibility pat-
used 16S rRNA gene sequencing to assess bladder urine, vaginal and
terns according to the type of the infection, the bacterial genus and
perineal microbiota of the patients and found that the higher
species, the country and both national and individual antibiotic
preoperative abundance of F. magna and Fannyhessea (Atopobium)
consumption. Moreover, multidrug resistance was also observed
vaginae in the catheterized bladder urine samples was significantly
among the anaerobic cocci such as F. magna and Veillonella spp [25].
associated with a higher severity of symptoms. The authors sug-
In France, in the recent study of Gue rin et al. [4] on 133 GPAC iso-
gested a possible association of bladder microbiota with the risk of
lates, susceptibility to metronidazole, linezolid and imipenem was
persistent symptoms in certain patient groups [16].
100%, however, high resistance rates to amoxicillin (in 45% of
Severe UTIs such as emphysematous pyelonephritis with fatal
Peptostreptococcus anaerobius isolates) were found and those to
outcomes can occur in patients with diabetes mellitus. Krol et al.
cefotaxime, clindamycin, moxifloxacin and rifampin (in different
[17] have reported a severe emphysematous pyelonephritis and
GPAC species) were variable [4]. Minimal inhibitory concentrations
urosepsis caused by F. magna and Candida parapsilosis in a diabetic
(MICs) were analyzed according to CA-SFM/EUCAST breakpoints
man aged 62 years. The patient also had obesity, nephrolithiasis
except for cefotaxime [4]. Veloo et al. [26], evaluating resistance in
and prostatic hypertrophy. The fatal outcome in this case was
anaerobes from different countries with E tests and EUCAST
associated with the development of sepsis due to a three-week
breakpoints, have reported high amoxicillin-clavulanic acid resis-
delay of the treatment caused by fearing a risk of getting a severe
tance rates in Peptostreptococcus spp. in Kuwait (45%) and Slovenia
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection
(8.6%), resistance to piperacillin-tazobactam in Turkey and Ger-
during hospitalization [17]. This case report shows the serious
many, and to metronidazole in half (6/12) of Peptostreptococcus
consequences of the delay in seeking medical help due to concerns
isolates in Croatia. In the study of Badri et al. [9] on 229 cases of
related to COVID-19 for the patients with UTIs and comorbidity.
GPAC bacteremia, including 21 cases of urinary tract origin, peni-
cillin resistance was found in 1.8% (4/220 isolates) and resistance
4. Diagnostic methods rates to metronidazole and clindamycin were 2.7% (6/222) and 7.3%
(16/219), respectively, using EUCAST breakpoints. The average time
Urine samples can be obtained as midstream clean-catch urine for intravenous treatment and follow-up oral therapy was 6 and 7
or by a transurethral catheter, or by suprapubic aspiration [18]. days, respectively [9].
Given that >30% of UTI's can be polymicrobial [10,19,20] and the In our case, F. magna and P. asaccharolyticus susceptibility was
choice of antibiotics for therapy requires reliable identification of tested with E tests (Liofilchem, Roseto degli Abruzzi, Italy) ac-
the causative agents, multiplex PCR can detect mixed infections cording to EUCAST breakpoints [27]. Both isolates were susceptible
[10,19]. For the diagnosis, both routine and newer methods such as to amoxicillin (MIC, 0.12 mg/l), metronidazole (MICs, 2 mg/l),
qualitative PCR (SeptiFast real-time PCR), EQUC and Next Genera- clindamycin (MICs, 0.5 mg/l) and resistant to levofloxacin (MICs,
tion Sequencing (NGS) can be implemented [18,21]. Quantitative >10 mg/l) and differed in susceptibility to tetracycline,
PCR assay detecting 16S rRNA genes in urine specimens was used P. asaccharolyticus being resistant to the agent (MIC, 256 mg/l). The
for comparative evaluation of bacterial numbers [7]. patient was successfully treated with amoxicillin/clavulanic acid
Unlike standard urine culture which detects fast-growing intravenously (1000 mg/200 mg b.i.d.) for 5 days and thereafter
facultative anaerobes such as E. coli and Proteus spp. at concentra- orally (500 mg/125 mg t.i.d.) for 7 days. The risk of anaerobic UTIs
tion of 103 CFU/ml, the EQUC can detect bacteria at concentration of such as those involving anaerobic cocci in immunocompromised
only 10 CFU/ml, involving fastidious and slow growing aerobic and patients after urological procedures merits further evaluation.
anaerobic species [20]. The EQUC technique with plating three Esteban-Zubero et al. [12] successfully treated a girl with cuta-
volumes such as 1, 10 and 100 ml of the urine sample onto multiple neous vasculitis and UTI caused by Peptoniphilus sp. with amoxi-
media, incubated in both aerobic and anaerobic conditions has cillin (1 g t.i.d., parenterally for 3 days and orally thereafter) and
been successful for diagnosing UTIs in children [20]. For the an- corticosteroids.
aerobes, urine volumes of 100 ml can be plated onto suitable rich In the case report of Berenger et al. [14], V. parvula was sus-
media such as CDC Anaerobe Blood Agar and thereafter can be ceptible to penicillin, imipenem, metronidazole and tetracycline
incubated anaerobically for 48 h [22]. according to CLSI breakpoints and the associated UTI was treated by
The NGS performed directly on the urine sample is based on PCR metronidazole for 7 days, followed by ceftriaxone for 5 days. In the
and high throughput sequencing of essential 16S ribosomal RNA case report of Yagihashi and Arakaki [15], the Veillonella UTI in a
genes and does not require bacterial growth, moreover, this pregnant woman was treated by insertion of a ureteral stent and
method can be used to detect antibiotic resistance genes as well intravenous cefotiam empirically (for seven days), later changed to
[18,23]. intravenous ampicillin since the in vitro testing revealed

4
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al. Anaerobe 77 (2022) 102509

susceptibility to ampicillin, imipenem, cefotaxime and clindamycin doi.org/10.1111/1574-6976.12005.

[4] F. Gue rin, L. Dejoies, N. Degand, H. Guet-Revillet, F. Janvier, S. Corvec,
as well as vancomycin resistance [15].
O. Barraud, T. Guillard, V. Walewski, E. Gallois, V. Cattoir, On Behalf of the Gmc
In postmenopausal women with recurrent UTIs involving Study Group. In vitro antimicrobial susceptibility profiles of Gram-positive
F. magna infections, a local (vaginal) estrogen therapy and use of anaerobic cocci responsible for human invasive infections, Microorganisms
probiotics have been reported as a useful non-antibiotic approach. 9 (2021) 1665, https://doi.org/10.3390/microorganisms9081665.
[5] J.J. Zambon, V.I. Haraszthy, Other anaerobic bacteria: Bacteroides, Porphyr-
Anglim et al. [28] have recently reported the effect of vaginal es- omonas, Prevotella, Tannerella, Fusobacterium, and gram-positive anaerobic
trogen therapy on urinary bladder microbiota and detected pres- cocci, in: Practical Handbook of Microbiology, CRC Press, 2021, pp. 595e612.
ence/abundance of F. magna in 33.3% (5/15) of the urine sample of [6] T. Akgül, T. Karakan, The role of probiotics in women with recurrent urinary
tract infections, Turk J. Urol. 44 (2018) 377e383, https://doi.org/10.5152/
the postmenopausal women evaluated before the local estrogen tud.2018.48742.
treatment with Premarin (containing conjugated estrogens) or [7] D.A. Lewis, R. Brown, J. Williams, P. White, S.K. Jacobson, J.R. Marchesi,
Vagifem (containing estradiol) tablets for 3e6 months versus only M.J. Drake, The human urinary microbiome; bacterial DNA in voided urine of
asymptomatic adults, Front. Cell. Infect. Microbiol. 3 (2013) 41, https://
6.7% (1/15) after the treatment. F. magna was detected in controls doi.org/10.3389/fcimb.2013.00041.
neither before nor after the local estrogen treatment [28]. [8] F. Liu, Z. Ling, Y. Xiao, Q. Yang, L. Zheng, P. Jiang, L. Li, W. Wang, Character-
The data show that UTIs caused by anaerobic cocci can be suc- ization of the urinary microbiota of elderly women and the effects of type 2
diabetes and urinary tract infections on the microbiota, Oncotarget 8 (2017)
cessfully treated if they are taken into consideration on time. 100678e100690, https://doi.org/10.18632/oncotarget.21126. PMID:
29246012; PMCID: PMC5725054.
6. Conclusion [9] M. Badri, B. Nilson, S. Ragnarsson, E. Senneby, M. Rasmussen, Clinical and
microbiological features of bacteraemia with Gram-positive anaerobic cocci: a
population-based retrospective study, Clin. Microbiol. Infect. 25 (2019)
In conclusion, diagnosis of anaerobic bacteria, including anaer- 760.e1e760.e6, https://doi.org/10.1016/j.cmi.2018.09.001.
obic cocci is justified in patients with chronic infections, immune [10] R. Xu, N. Deebel, R. Casals, R. Dutta, M. Mirzazadeh, A New Gold Rush: a re-
view of current and developing diagnostic tools for urinary tract infections,
suppression, comorbidity and elderly people in whom the causative
Diagnostics (Basel) 11 (2021) 479, https://doi.org/10.3390/
agent of the persistent or recurrent UTI was not established. diagnostics11030479.
However, since the routine methods for diagnosing UTIs are not [11] M. Gajda  o
cs, M. Abr k, A. L
az n, Microbiology of urine samples ob-
ar, K. Buria
appropriate to identify all the anaerobes, including the anaerobic tained through suprapubic bladder aspiration: a 10-year epidemiological
snapshot, Develop. Health Sci. 2 (2019) 76e78, https://doi.org/10.1556/
cocci, suprapubic aspiration and culture in both aerobic and 2066.2.2019.012.
anaerobic atmosphere using media supporting the slow growing [12] E. Esteban-Zubero, R. Castejo n-Moreno, M.A. Alatorre-Jime nez, D. Barbera-
Perez, Cutaneous vasculitis as a first sign of isolated Peptoniphilus spp in
anaerobic cocci can be of help. Newer methods and techniques such
urinary tract infection: a Case Report, Mathews J. Case Rep. 2 (2017), 031.
as EQUC with incubation in both anaerobic and aerobic conditions, [13] R. Karani, G. Imani, S. Tapiero, R.V. Clayman, Stone culture positive Veillonella
16S rRNA gene amplification, qualitative PCR and NGS can be in analysis of calcium-based stones: a case report, J. Endourol. Case Rep. 6
considered as well. The risk of anaerobic UTIs in immunocompro- (2020) 396e398, https://doi.org/10.1089/cren.2020.0140.
[14] B.M. Berenger, L. Chui, A. Borkent, M.C. Lee, Anaerobic urinary tract infection
mised patients following urological procedures deserves further caused by Veillonella parvula identified using cystine-lactose-electrolyte
evaluation. deficient media and matrix-assisted laser desorption ionization-time of
flight mass spectrometry, IDCases 2 (2015) 44e46, https://doi.org/10.1016/
j.idcr.2015.02.002.
Ethical approval [15] Y. Yagihashi, Y. Arakaki, Acute pyelonephritis and secondary bacteraemia
caused by Veillonella during pregnancy, 2012, BMJ Case Rep. (2012), https://
Written informed consent was obtained from the patient of our doi.org/10.1136/bcr-2012-007364. bcr-2012-007364.
[16] C.S. Fok, X. Gao, H. Lin, K.J. Thomas-White, E.R. Mueller, A.J. Wolfe, Q. Dong,
observation. L. Brubaker, Urinary symptoms are associated with certain urinary microbes
in urogynecologic surgical patients, Int. Urogynecol. J. 29 (2018) 1765e1771,
Funding https://doi.org/10.1007/s00192-018-3732-1.
[17] B.C. Krol, A.K. Hemal, E.M. Fenu, H.T. Blankenship, R.A. Pathak, A rare case of
emphysematous pyelonephritis caused by Candida parapsilosis and Finegoldia
This research did not receive any specific grant from funding magna complicated by medical care avoidance, CEN Case Rep 10 (2021)
agencies in the public, commercial, or not-for-profit sectors. 111e114, https://doi.org/10.1007/s13730-020-00531-4.
[18] M.L. Neugent, N.V. Hulyalkar, V.H. Nguyen, P.E. Zimmern, N.J. De Nisco, Ad-
vances in understanding the human urinary microbiome and its potential role
Declaration of competing interest in urinary tract infection, mBio 11 (2020) e00218ee00220, https://doi.org/
10.1128/mbio.00218-20.
[19] E.E. Hilt, K. McKinley, M.M. Pearce, A.B. Rosenfeld, M.J. Zilliox, E.R. Mueller,
The authors declare that they have no known competing
L. Brubaker, X. Gai, A.J. Wolfe, P.C. Schreckenberger, Urine is not sterile: use of
financial interests or personal relationships that could have enhanced urine culture techniques to detect resident bacterial flora in the
appeared to influence the work reported in this paper. adult female bladder, J. Clin. Microbiol. 52 (2014) 871e876, https://doi.org/
10.1128/JCM.02876-13.
[20] J. Thapaliya, P. Khadka, S. Thapa, C. Gongal, Enhanced quantitative urine
Appendix A. Supplementary data culture technique, a slight modification, in detecting under-diagnosed pedi-
atric urinary tract infection, BMC Res. Notes 13 (2020) 5, https://doi.org/
10.1186/s13104-019-4875-y.
Supplementary data to this article can be found online at
[21] L.E. Lehmann, S. Hauser, T. Malinka, S. Klaschik, S.U. Weber, J.C. Schewe,
https://doi.org/10.1016/j.anaerobe.2021.102509. F. Stüber, M. Book, Rapid qualitative urinary tract infection pathogen identi-
fication by SeptiFast real-time PCR, PLoS One 6 (2011), e17146, https://
doi.org/10.1371/journal.pone.0017146.
References
[22] T.K. Price, T. Dune, E.E. Hilt, K.J. Thomas-White, S. Kliethermes, C. Brincat,
L. Brubaker, A.J. Wolfe, E.R. Mueller, P.C. Schreckenberger, The clinical urine
[1] I. Brook, Urinary tract and genito-urinary suppurative infections due to culture: enhanced techniques improve detection of clinically relevant mi-
anaerobic bacteria, Int. J. Urol. 11 (2004) 133e141, https://doi.org/10.1111/ croorganisms, J. Clin. Microbiol. 54 (2016) 1216e1222, https://doi.org/
j.1442-2042.2003.00756.x. 10.1128/JCM.00044-16.
[2] K.L. Rozenfeld, O. Nitzan, A. Peretz, Presence of anaerobic bacteria in the [23] M. Gasiorek, M.H. Hsieh, C.S. Forster, Utility of DNA Next-Generation
urinary tract of catheterized ICU patients, Eur. J. Clin. Microbiol. Infect. Dis. 37 Sequencing and expanded quantitative urine culture in diagnosis and man-
(2018) 2131e2136, https://doi.org/10.1007/s10096-018-3349-9. agement of chronic or persistent lower urinary tract symptoms, J. Clin.
[3] E.C. Murphy, I.M. Frick, Gram-positive anaerobic cocci–commensals and Microbiol. 58 (2019) e00204ee00219, https://doi.org/10.1128/JCM.00204-19.
opportunistic pathogens, FEMS Microbiol. Rev. 37 (2013) 520e553, https://

5
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al. Anaerobe 77 (2022) 102509

[24] C. Imirzalioglu, T. Hain, T. Chakraborty, E. Domann, Hidden pathogens un- joint ESGAI study, Anaerobe 61 (2020), 102111, https://doi.org/10.1016/
covered: metagenomic analysis of urinary tract infections, Andrologia 40 j.anaerobe.2019.102111.
(2008) 66e71, https://doi.org/10.1111/j.1439-0272.2007.00830.x. [27] EUCAST-The European Committee on Antimicrobial Susceptibility Testing,
[25] L. Boyanova, R. Markovska, I. Mitov, Multidrug resistance in anaerobes, Future Breakpoint tables for interpretation of MICs and zone diameters. Version 11.0.
Microbiol. 14 (2019) 1055e1064, https://doi.org/10.2217/fmb-2019-0132. http://www.eucast.org, 2021.
PMID: 31469008. [28] B. Anglim, C. Phillips, O. Shynlova, M. Alarab, The effect of local estrogen
[26] A.C.M. Veloo, H.B. Tokman, H. Jean-Pierre, Y. Dumont, S. Jeverica, R. Lienhard, therapy on the urinary microbiome composition of postmenopausal women
A. Novak, A. Rodloff, V. Rotimi, I. Wybo, E. Nagy, ESGAI study group. Anti- with and without recurrent urinary tract infections, Int. Urogynecol. J. (2021
microbial susceptibility profiles of anaerobic bacteria, isolated from human May 18), https://doi.org/10.1007/s00192-021-04832-9.
clinical specimens, within different European and surrounding countries. A