International Journal of Antimicrobial Agents 22 (2003) S29
/S33

www.ischemo.org

Virulence factors of uropathogenic Escherichia coli

L. Emody *, M. Kerenyi, G. Nagy
Department of Medical Microbiology and Immunology, University Medical School of Pecs, Szigeti ut 12, H-7624 Pecs, Hungary

Abstract
Virulence factors of Escherichia coli are of two main types; those produced on the surface of the cell and those produced within
the cell and then exported to the site of action. Those on the surface include different sorts of fimbriae that have a role in adhesion to
the surface of host cells but may also have additional roles such as tissue invasion, biofilm formation or cytokine induction. The
activities of cell wall components are discussed and several exported virulence factors are described that have anti host cell activities.
Others virulence factors enable the bacteria to grow in an environment of iron restriction.
# 2003 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
Keywords: Virulence factors; Fimbriae; Adhesion; Cytotoxicity

1. Introduction
Escherichia coli is by far the most common pathogen
isolated from urinary tract infections (UTI), and frequently originates from the patients own intestinal
flora. However, only some members of the normal flora
elicit an infection in persons without local or general
predisposing conditions to UTI. E. coli clones present in
the large intestine are not equally able to initiate and
maintain the infectious process in the urinary tract.
Special components or products, called virulence factors, enable E. coli cells to colonise selectively the
mucosal uro-epithelium, evoke an inflammatory reaction and eventually proceed from the lower urinary tract
to the renal cavities and tissues.

2. Surface virulence factors

Surface virulence factors of the pathogen (Table 1)
include various adhesins mainly of fimbrial nature. Type
1 fimbriae (called also type 1 pili) may promote bacterial
adhesion, invasion and growth as a biofilm [1
/3]. These
fimbriae recognise manno-oligosaccharides naturally
presented on glycoprotein molecules of the host cell

* Corresponding author. Tel.: /36-72-536-252; fax: /36-72-536253.

E-mail address: levente.emody@aok.pte.hu (L. Emody).

surface. Allelic variations of the FimH adhesin subunit

determine the fine sugar specificity of these fimbriae.
Pathoadaptive mutations play an important role in
tissue tropism and infectivity of type 1 fimbriated E.
coli [1
/6].
P fimbrial lectins recognise a digalactoside component
of the P blood group antigen also abundantly positioned
on the surface of urinary epithelial cells [7]. Molecular
contact between the mucosal surface and the pathogen
induces lipopolysaccharide (LPS) independent transmembrane signalling and epithelial cell activation.
Concomitant interleukin (IL-6 and IL-8) production
promotes the development of local inflammation [8,9].
S fimbriae and F1C fimbriae have also been implicated in the process of UTI. They both show binding
efficiency to epithelial and endothelial cell lines derived
from the lower human urinary tract and kidney [10,11].
Thin aggregative fimbriae [12], also called curli, are
expressed on about 50% of urinary E. coli isolates. They
are optimally expressed at ambient temperature and in
this way they may promote colonisation of the perineal
area initiating a subsequent UTI [13].
All the above fimbriae producing species are also able
to bind to various matrix components facilitating tissue
invasion by the pathogen [14]. Minor subunits positioned proximal to the adhesin subunit are responsible
for this function in the case of P and S fimbriae.
Flagellar motility contributes to the virulence of
Proteus mirabilis in ascending UTI [15]. Mouse studies
using a pyelonephritis model suggest that swarm cell

0924-8579/03/$30 # 2003 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
doi:10.1016/S0924-8579(03)00236-X

S30

L. Emody et al. / International Journal of Antimicrobial Agents 22 (2003) S29
/S33

production is involved in tissue invasion [16]. It is

obvious that flagellar motility enhances the ability of
E. coli by adaptive responses to attractive or repellent
environmental stimuli but no data are available at
present as to whether motility promotes tissue invasion.
Further virulence factors located on the bacterial
surface include the capsular material and the endotoxic
LPS molecules. The capsule provides protection against
phagocytic engulfment and complement mediated bactericidal effect in the host. Certain capsular types (K1
and K5) show a molecular mimicry to tissue components, preventing a proper humoral immune response by
the infected host [17
/19].
LPS with its well known effects on cytokine synthesis
(IL-1, TNFa) enhances the inflammatory response. It
induces the synthesis of specific antibodies to the
somatic antigen. Certain antigenic types of LPS are
also involved in resistance of the pathogen to the killing
effect of the normal human serum. As a polyclonal B
cell mitogen, the LPS molecule exerts an immunoadjuvant effect that promotes the humoral immune
response to other antigens of the pathogen [20
/22].
Outer membrane proteins may also contribute to
virulence functions. They may be involved in the
secretory machinery of exported virulence factors. The
role of TolC protein in the transfer of the a-haemolysin
toxin across the outer membrane of E. coli cells is well
documented [23].
Uropathogenic E. coli (UPEC) strains may gain
access to iron from iron containing host components
like haemin by specific receptor molecules. The outer
membrane haemin receptor protein ChuA is an example
for this function [24].

3. Exported virulence factors (Table 1)

The most important exported virulence factor of
urinary E. coli pathogens is a-haemolysin [25]. It is a
pore-forming toxin of the repeat toxin (RTX) family
[26,27] with a promiscuous target cell spectrum including not only erythrocytes but also leukocytes, endothelial- and renal epithelial cells [28]. a-Haemolysin has
been proven to contribute to nephropathogenicity when
mice were infected transurethrally or inravesically with
toxin producer and non-producer isogenic clone pairs of
E. coli [29]. Similarly to streptolysin-O, E. coli ahaemolysin elicits the synthesis of specific antibodies
during infection. The presence of high titre anti-ahaemolytic antibodies could be detected in patients
suffering from infection caused by a-haemolytic E. coli
[30]. This pathogen has been incriminated as the
causative agent of acute haemolytic crisis in the immunocompromised host [31].
A candidate uropathogenic toxic virulence factor is
the cytotoxic necrotising factor 1 (CNF1) [32]. In vitro

studies show that it interferes with polymorphonuclear

phagocytosis, and evokes apoptotic death of bladder
epithelial cells [33].
Secreted autotransporter toxin (SAT), a serine protease autotransporter, is associated with pyelonephritic
E. coli strains, and has toxic activity against cell lines of
bladder or kidney origin [34].
Production of cytolethal distending toxin (CDT) [35]
and cytolysin A [36] has also been detected in UPEC
strains. The former arrests the cell cycle, and the latter
causes apoptosis of host cells. Their pathogenetic role,
however, has not yet been elucidated.
Growth under iron restricted conditions needs bacterial mechanisms to compete successfully for iron in the
host. Low molecular weight siderophores like aerobactin, enterobactin and yersiniabactin are involved in this
process [37
/39]. These compounds are exported from
the bacterial cell to gain ferric iron from iron chelator
molecules of the host. As mentioned above, receptor
molecules in the bacterial outer membrane organize the
transport and utilisation of siderophore bound iron.

4. Genetic information and regulation of virulence

A high plasticity is characteristic of the UPEC
genome. Virulence factors are frequently encoded by
flexible genetic elements called pathogenicity islands
(PAI) [40,41]. PAIs are mobile DNA regions holding
mobility sequences, and are inserted in the vicinity or
within tRNA genes. Their G/C content differs from
that of the core regions of the chromosome. Horizontal
transfer of PAIs is an important tool in the evolution of
UPEC virulence. PAIs may encode adhesins, toxins,
iron uptake systems, secretion mechanisms and capsules
[41,42]. UPEC strains have been shown to harbour
several PAIs. For example, E. coli isolate 536 possesses
at least five PAIs [42]. Genetic information for the same
phenotypic character may simultaneously be present on
more than one of these PAIs. For example, both PAI I
and II of E. coli 536 code for a-haemolysin production
[43]. However, discrete inhomologies in the structural
DNA sequences or differences in the cis regulatory
regions may influence the quantitative expression and
functionality of the gene products. Sequence analysis
and identification of phage integrase genes in flanking
regions of PAIs may help in revealing the archetypes
and the direction of horizontal gene transfer.
Regulation of gene expression is also an important
aspect in the manifestation of UPEC virulence. Environmental signals like temperature, availability of nutrients and iron, etc. are important environmental
conditions involved. Expression of adhesive fimbriae is
under thermoregulation [44]. Type 1-, P- and S-fimbriae
are synthesised at the body temperature of the host
while curli fimbriae */in a large majority of the

L. Emody et al. / International Journal of Antimicrobial Agents 22 (2003) S29
/S33

S31

Table 1
Factors of E. coli involved in urinary tract virulence
Virulence factor

Localisation

Function

Reference

Type 1 fimbriae

Bacterial
surface
Bacterial
surface
Bacterial
surface
Bacterial
surface
Bacterial
surface
Bacterial
surface
Bacterial
surface
Bacterial
surface
Bacterial
surface
Exported
Exported
Exported
Exported
Exported
Exported
Exported
Exported

Adhesion to mucosal epithelium and tissue matrix, invasion, biofilm formation

[1
/5]

Adhesion to mucosal epithelium and tissue matrix, cytokine induction

[7
/9,14]

Adhesion to mucosal and endothelial cells, and to tissue matrix

[10,14]

Adhesion to mucosal and endothelial cells

[11]

Adhesion to mucosal cells and matrix, biofilm formation

[12
/14]

Motility, adaptation, fitness

[15,16]a

Antiphagocytic, anticomplement effect, serum resistance, evasion of immune

recognition
Endotoxic effects, O-antigen, cytokine induction, serum resistance, immunoadjuvant
Receptor and transport function

[17
/19]
[20,21]

Cytotoxicity, haemolysis
Interference with phagocytosis and apoptosis
Cytotoxicity
Cytotoxicity
Cytotoxicity
Growth under iron restriction
Growth under iron restriction
Growth under iron restriction

[25
/31]
[32,33]b
[34]b
[35]b
[36]b
[37,38]
[37,38]
[39]

P fimbriae
S fimbriae
F1C fimbriae
Thin aggregative fimbriae (curli)
Flagellum
Capsule
Lipopolysaccharide
Outer membrane proteins
a-Haemolysin
Cytotoxic necrotising factor 1
Secreted autotransporter toxin
Cytolethal distending toxin
Cytolysin A
Enterobactin
Aerobactin
Yersiniabactin
a
b

[23,24]

Role in invasiveness proven for P. mirabilis but not for E. coli .

Putative virulence factors, role in human infections not yet proven.

strains */at ambient temperature [13]. Siderophores and

outer membrane ferric-siderophore receptors are expressed in response to iron restriction. Thus, not only
the structural evolution but also the regulation of
virulence genes reflects a patho-adaptation. This adaptation capacity enables the virulent bacterial population
to survive and initiate pathological processes under
selective environmental conditions in defined organ
systems in the host. At the same time, this selective
expression mechanism is energetically very economical
for the microbe as virulence factors are synthesised when
and where necessary.
Concerted expression of virulence factors may be
mediated by global regulators simultaneously affecting
the appearance of a set of bacterial properties involved
in the pathogenetic process. leuX is a tRNA gene with
influence on a-haemolysin, type 1 fimbriae, flagellum
and aerobactin synthesis [43]. RfaH protein regulates
the expression of O-antigen, capsular material, ahaemolysin and ChuA haemin receptor [45]. Both these
global regulators have been shown to contribute to
UPEC virulence in various mouse models.
Expression of certain virulence traits may also be
influenced in trans by unlinked virulence gene clusters.

An example for this regulatory cross-talk is, the

complementation of S fimbrial regulatory mutation by
Prf fimbrial regulators [46].
It has recently been recognised that bacteria are able
to sense and respond to their own population density.
This phenomenon is called quorum sensing and has an
influence on expression of virulence properties through
the function of transcriptional regulators [47]. Quorum
sensing is an important regulatory mechanism in
enteropathogenic (EPEC) and enterohaemorrhagic
(EHEC) E. coli virulence [48]. Biofilm production,
synthesis of capsular material and flagella motility
have been shown to be influenced by population density
in several Gram-negative bacteria [49]. Further studies
may elucidate if quorum sensing mechanisms are also
involved in the expression of these properties in UPEC,
and if so, how these regulatory mechanisms influence
their pathogenicity.

5. Conclusion
Net virulence of individual UPEC strains in a given
infection is determined by the presence and actual

S32

L. Emody et al. / International Journal of Antimicrobial Agents 22 (2003) S29
/S33

expression of the virulence factors they have, and also

by the environmental conditions present in the host
organism. That is, the infectious process can be interpreted only as a series of complicated events determined
by host-parasite and possibly host
/host interactions. A
molecular approach involving experiments with isogenic
bacterial clone pairs and in vivo expression technology
(IVET) may help to gain a deeper insight into these
complicated events [50].
Accumulation of theoretical knowledge through virulence studies allows practical applications. Identification
of virulence factors and mechanisms may facilitate the
application of more precise approaches in phenotypic
(i.e. proteome analysis) or molecular (i.e. DNA array
technique) diagnosis and epidemiology. As a result, new
targets will be recognised for antimicrobial intervention.
Finally, the perspectives of prevention may improve by
utilisation of receptor analogues or vaccine candidate
monovalent/polyvalent antigens.

Acknowledgements
This work was supported by grants OTKA T037833
and ETT 086/2001 to L.E.

References
[1] Ofek I, Doyle RJ. Bacterial adhesion to cells and tissues. New
York, London: Chapman and Hall, 1994:513
/61.
[2] Schembri MA, Klemm P. Biofilm formation in a hydrodynamic
environment by novel FimH variants and ramifications for
virulence. Infect Immun 2001;69:1322
/8.
[3] Martinez JJ, Mulvey MA, Schilling JD, et al. Type 1 pilusmediated bacterial invasion of bladder epithelial cells. EMBO J
2000;19:2803
/12.
[4] Oelschlaeger TA, Dobrindt U, Hacker J. Virulence factors of
uropathogens. Curr Opin Urol 2002;12:33
/8.
[5] Sokurenko EV, Courtney HS, Ohman P, et al. FimH family of
type 1 fimbrial adhesins: functional heterogeneity due to minor
sequence variations among fimH genes. J Bact 1994;176:748
/55.
[6] Sokurenko EV, Hasty DL, Dykhuizen DE. Pathoadaptive mutations: gene loss and variation in bacterial pathogens. Trends
Microbiol 1999;7:191
/5.
[7] Leffler H, Svanborg-Eden C. Chemical identification of a glycosphingolipid receptor for Escherichia coli attaching to human
urinary tract epithelial cells and agglutinating human erythrocytes. FEMS Microbiol Lett 1980;8:127
/34.
[8] Hedlund M, Wachtler M, Johansson E, et al. P fimbriae
dependent, LPS independent activation of epithelial cytokine
responses. Mol Microbiol 1999;33:693
/703.
[9] Godally G, Bergsten G, Frendeus B, et al. Innate defences and
resistance to Gram-negative mucosal infection. Adv Exp Med
Biol 2000;485:9
/24.
[10] Marre R, Kreft B, Hacker J. Genetically engineered S and F1C
fimbriae differ in their contribution to adherence of Escherichia
coli to cultured renal tubulus cells. Infect Immun 1990;58:3434
/7.
[11] F1C Fimbriae, Hacker J, Morschhauser JS. In: Klemm P, editor.
Fimbriae, Adhesion, Genetics, Biogenesis, and Vaccines. Boca
Raton: CRC Press, 1994:27
/36.

[12] Collinson SK, Emody L, Trust TJ, Kay WW. Thin aggregative
fimbriae from diarrheagenic Escherichia coli . J Bact
1992;174:4490
/5.
[13] Patri E, Szabo E, Pal T, Emody L. Thin aggregative fimbriae on
urinary Escherichia coli isolates. Adv Exp Med Biol
2000;485:219
/24.
[14] Westerlund B, Korhonen TK. Bacterial proteins binding to the
mammalian extracellulat matrix. Mol Microbiol 1993;9:687
/94.
[15] Harmon RC, Rutherford RL, Wu HM, Collins MS. Monoclonal
anti-body-mediated protection and neutralization of motility in
experimental Proteus mirabilis infection. Infect Immun
1989;57:1936
/41.
[16] Allison C, Emody L, Coleman N, Hughes C. The role of swarm
cell differentiation and multicellular migration in the uropathogenicity of Proteus mirabilis . J Infect Dis 1994;169:1155
/8.
[17] Horwitz MA, Silverstein SC. Influence of the Escherichia coli
capsule on complement fixation, phagocytosis and killing by
human phagocytes. J Clin Invest 1980;65:82
/94.
[18] Finne J. Occurrence of unique polysialosyl carbohydrate units in
glycoproteins of developing brain. J Biol Chem 1982;257:11966
/
70.
[19] Vann VF, Schmidt MA, Jann B, Jann K. The structure of
capsular polysaccharide (K5 antigen) of urinary tract-infective
Escherichia coli O10:K5:H4. A polymer similar to desulfoheparin. Eur J Biochem 1981;116:359
/64.
[20] Morrison DC, Ryan JL. Endotoxins and disease mechanisms.
Annu Rev Med 1987;38:417
/32.
[21] Brade H, Brade L, Rietschel ET. Structure-activity relationships
of bacterial lipopolysaccharides (endotoxins). Zentralbl Bakteriol
Microbiol Hyg [A] 1988;268:151
/79.
[22] Rietschel ET, Brade H, Holst O, et al. Bacterial endotoxin:
chemical constitution, biological recognition, host response, and
immunological detoxification. Curr Top Microbiol Immunol
1996;216:39
/81.
[23] Wandersman C, Deleplaire P. TolC, an Escherichia coli outer
membrane protein required for hemolysin secretion. Proc Natl
Acad Sci USA 1990;87:4776
/80.
[24] Torres AG, Payne SM. Haem iron-transport system in enteroheamorrhagic Escherichia coli O157:H7. Mol Microbiol
1997;23:825
/33.
[25] Smith HW. The haemolysins of Escherichia coli . J Pathol
Bacteriol 1963;85:197
/211.
[26] Ebrspracher B, Hugo F, Bhakdi S. Quantitative study of the
binding and hemolytic efficiency of Escherichia coli hemolysin.
Infect Immun 1989;57:983
/8.
[27] Welch R. Pore-forming cytolysins of gram-negative bacteria. Mol
Microbiol 1991;5:521
/8.
[28] Keane WF, Welch R, Gekker G, Peterson PK. Mechanism of
Escherichia coli a-hemolysin induced injury to isolated renal
tubular cells. Am J Pathol 1987;126:350
/7.
[29] van den Bosch JF, Emody L, Ketyi I. Virulence of haemolytic
strains of Escherichia coli in various animal models. FEMS
Microbiol Lett 1982;13:427
/30.
[30] Emody L, Batai I, Kerenyi M, et al. Anti-Escherichia coli alphahaemolysin in control and patient sera, Lancet 1982;ii:986.
[31] Emody L, Molnar L, Kellermayer M, et al. Urinary Escherichia
coli infection presenting with jaundice. Scand J Infect Dis
1989;21:579
/82.
[32] Caprioli A, Falbo V, Ruggeri FM, et al. Cytotoxic necrotizing
factor production by hemolytic strains of Escherichia coli causing
extra-intestinal infections. J Clin Microbiol 1987;25:758
/61.
[33] Fiorentini C, Fabbri A, Matarrese P, et al. Hinderance of
apoptosis and phagocytic behaviour: induced by Escherichia coli
cytotoxic necrotizing factor (CNF1): two realted activities in
epithelial cells. Biochem Biophys Res Commun 1997;241:341
/6.
[34] Guyer DG, Radulovic S, Jones FE, Mobley HLT. Sat, the
secreted autotransporter toxin of uropathogenic Escherichia coli ,

L. Emody et al. / International Journal of Antimicrobial Agents 22 (2003) S29
/S33

[35]

[36]

[37]
[38]

[39]

[40]

[41]
[42]

is a vacuolating cytotoxin for bladder and kidney epithelial cells.

Infect Immun 2002;70:4539
/46.
Toth I, Oswald E, Szabo B, et al. Virulence markers of human
uropathogenic Eschericha coli strains isolated in Hungary. Adv
Exp Med Biol 2000;485:335
/8.
Lai XH, Arencibia I, Johansson A, et al. Cytocidal and apoptotic
effects of the ClyA protein from Escherichia coli on primary and
cultured monocytes and macrophages. Infect Immun
2000;68:4363
/7.
Guerinot ML. Microbial iron transport. Ann Rev Microbiol
1994;48:743
/72.
Braun V, Hantke K, Kostler W. Bacterial iron transport:
mechanisms, genetics, and regulation. In: Sigel A, Sigel H, editors.
Metal ions in biological systems. New York: Marcel Dekker, Inc.,
1998:67
/145.
Schubert S, Picard B, Gouriou S, et al. Yersinia high-pathogenicity island contributes to virulence in Escherichia coli causing
extraintestinal infections. Infect Immun 2002;70:5335
/7.
Blum G, Ott M, Lischewski A, et al. Excision of large DNA
regions termed pathogenicity islands from tRNA-specific loci in
the chromosome of an Escherichia coli wild-type pathogen. Infect
Immun 1994;62:606
/14.
Hacker J, Kaper JB. Pathogenicity islands and the evolution of
microbes. Ann Rev Microbiol 2000;54:641
/79.
Oelschlaeger TA, Dobrindt U, Hacker J. Pathogenicity islands of
uropathogenic E. coli and the evolution of virulence. Int J
Antimicrob Agents 2002;19:517
/21.

S33

[43] Ritter A, Blum G, Emody L, et al. tRNA genes and pathogenicity

islands: influence on virulence and metabolic properties
of uropathogenic Escherichia coli . Mol Microbiol 1995;17:109
/
21.
[44] de Graaf FK, Mooi FR. The fimbrial adhesins of Escherichia coli .
Adv Microbiol Physiol 1986;28:65
/143.
[45] Nagy G, Dobrindt U, Schneider G, et al. Loss of regulatory
protein RfaH attenuates virulence of uropathogenic Escherichia
coli 2002;70:4406
/13.
[46] Morsschauser J, Vetter V, Emody L, Hacker J. Adhesin
regulatory genes within large, unstable DNA regions of pathogenic Escherichia coli : cross-talk between different adhesin gene
clusters. Mol Microbiol 1994;11:555
/66.
[47] Kievit TR, Iglewski BH. Bacterial quorum sensing in pathogenic
relationship. Infect Immun 2000;68:4839
/49.
[48] Sperandio V, Mellies JL, Nguyen W, et al. Quorum
sensing controls expression of the type III secretion gene
transcription and protein secretion in enterohemorrhagic and
enteropathogenic Escherichia coli . Proc Natl Acad Sci USA
1999;96:15196
/201.
[49] Sperandio V, Torres AG, Kaper JB. Quorum sensing Escherichia
coli regulators B and C (QseBC): a novel two-component
regulatory system involved in the regulation of flagella and
motility by quorum sensing. Mol Microbiol 2002;43:809
/21.
[50] Lee SH, Butler SM, Camilli A. Selection for in vivo regulators of
bacterial virulence. Proc Natl Acad Sci USA 2001;98:6889
/94.