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A vaccine against Urinary Tract Infections (UTIs) has been one of bioscience’s much sought-after dreams for quite a few years. However, it has proved to be remarkably elusive. To look at the reasons why it is helpful to discuss how vaccines work.
Vaccines programme our immune systems to respond when it encounters an ‘invader’. Once primed in this way, white blood cells are on the lookout, ready to respond.
When these white cells encounter the trigger (or ‘antigen’), they quickly begin to multiply and release antibodies.
Antibodies are very, very specific to the antigen: even to parts of it. They bind to it, to inactivate it, and to signal its removal from our systems.
Often referred to as our Specific or Adaptive immune system, and can provide long-lasting protection against specific pathogens or foreign substances.
Typical administrative routes include oral, intramuscular (most common), nasal sprays, subcutaneous and intradermal (rarest). 
Many people have concerns about Vaccines based on the problem that vaccines do not just contain the ‘active’ ingredient (the antigen)
Typical components include adjuvants, diluents, stabilisers, preservatives and trace components.
The use of gelatine, in particular, as a stabiliser in some vaccines is of concern on religious and ethical grounds and also has the potential to cause anaphylactic allergy reactions, although this is considered rare. For more information on vaccine components see the NCIRS Factsheet :http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/vaccine-components-fact-sheet.pdf
The bladder and the urinary tract is a unique place in your body.
Your specific, adaptive immune system is undoubtedly at work in the urinary tract. Compliment, which activates an immune response, white blood cells, and antibodies, can all be found in urine. 
However, some things get in the way of your immune system working as effectively here as they would, say, in your bloodstream,
So the immune system struggles to reach targets in the bladder as effectively as it can in other places within the body.
The body does have some other tricks to fight bacteria in the UT: The Tamm Horsfall Protein (THP, also known as uromodulin) is made in your kidneys and flows down with the urine. It has been shown to be a defence factor against E.coli  and other uropathogenic bacteria . This glycoprotein is positively bristling with receptors, including mannose, which plays a role in binding to bacteria and flushing them out. It is now known that some people lack THP.
D-Mannose is, in fact, acting in the same way as your body does naturally: by using it you are just supplementing your natural defences without creating bacterial resistance and with no side effects.
When making a vaccine these days it is often the case that a specific ‘target’ will first be identified, this may be a part of the pathogen which we want the resulting antibodies to attack.
(There are other approaches, discussed below in “cocktails: multistrain whole-cell/cell lysate vaccines”) In the case of uropathogenic E.coli (UPEC), a number of such targets have been identified and tried.
Probably the most obvious thing to try. If we could interfere with the lectin ‘anchors’ on the bacterial fimbriae, we would reduce its capacity to hang on and cause infections, right?
Unfortunately, things are not quite so clear-cut in practice.
Further work by the same group, published in 2011 in “Infection and Immunology”  the journal of the American Society for Microbiology resulted in some rather startling facts …
While these examples may sound counter-intuitive, it does explain the lack of success MedImmune had with their vaccine. The Washington team also demonstrated the mechanism for these same effects (discussed later).
Collaborative work between the Seattle team and the Genome Institute of Singapore in 2013 further confirmed these conclusions and the way it works. 
Ref PNAS (Proceedings of the National Academy of Sciences of the United States of America) vol. 110 no. 39 > Drew J. Schwartz, 15530–15537
So, targeting the adhesin ‘grappling-hooks’, it would seem is, counterproductive and unfortunately unlikely to provide the solution many hoped it would and may just replicate the problem with antibiotic therapy which is increased resistance.
Uromune® containing an inactivated bacterial cell suspension of selected strains of Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, and Enterococcus faecalis is now being offered for recurrent cystitis, following a Spanish study on vaccines. These bacteria are introduced to the human body with the sole purpose of stimulating an immune response.
Because of course, the whole premise of vaccination is to provoke an immune response, this has the potential to overstimulate the immune system. It has been suggested that immune systems altered by vaccination are a potential cause of autoimmune diseases. A 2009 study on the possible links between Guillain-Barré and the Gardasil vaccine points out that:
“By their nature, immunisations are intended to stimulate the human immune system, and that stimulation could, at least theoretically, increase the risk of autoimmune diseases.”
Meanwhile, the NCBI (The National Centre for Biotechnology Information advances science and health by providing access to biomedical and genomic information) advises caution in the use of vaccines:
“We suggest that a potential link between vaccines and autoimmune diseases cannot be definitely ruled out and should be carefully explored during the development of new candidate vaccines.”
https://www.ncbi.nlm.nih.gov/pubmed/15196997 Eur J Dermatol. 2004 Mar-Apr; 14(2):86-90.
Like all Gram-negative bacteria, the carbohydrate-rich cell surface of UPEC contains an abundance of various polysaccharides. These again look like they would be a good target, but this turns out not to be the case.
A more recent line of investigation, Siderophores are iron ‘scavenging molecules’ released by UPEC, and they have active ‘portals’ – gateways through the bacterial cell wall to drag them + the iron back in. Blocking these could starve the UPEC of iron.
Encouraging results in studies on mice  have unfortunately not translated to success in humans. REF: Pathogens. 2015 Dec 31;5(1). pii: E1. doi: 10.3390/pathogens5010001.
This highlights another problem: studies comparing experimental UTI in the mouse and active human UTI have identified differences, indicating unsurprisingly that artificial infection of the mouse does not directly equate with natural infection in humans .https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498450/
Vaccinating with whole or lysed fractions of inactivated pathogens can be an effective method to generate protective immunity, and a number of successful vaccines against human pathogens, including Bordetella pertussis (whooping cough), Vibrio cholerae (cholera) and Salmonella Typhi (typhus) contain killed whole bacteria .
One drawback of this approach is the potential for endotoxin toxicity and adverse side effects.
Another problem is that many of the UPEC’s surface antigens are mimics of the host’s surface cell markers. These identify the cells as ‘self’ to the immune system, so they create a weak immunological response, you do not want to start making antibodies against yourself!
Dating back to the 1980’s there have so far been five standardized whole-cell/cell lysate-based vaccines that have been tried for UTI, but with limited success …
OM Pharma, based in Switzerland was developed in 1988 and is currently marketed by Terralab of Croatia in Europe, Canada, and other countries . Notably not the USA.
A daily oral tablet, a full course requires three months to complete.
Only modest protection is afforded by this product .
Initial clinical studies, involving 601 female participants did appear to demonstrate protection against recurrent UTI .
However, a more recent (2015, Justus-Liebig University, Germany) multicentre double-blind control trial of 451 patients showed no significant difference in UTI rates between Uro- Vaxom® and placebo  Urologia Internationalis. 2015; 95: 167-176.
(Solco Basel AG, Birsfelden, Switzerland and Protein Express, Cincinnati, OH, USA) is a suppository vaccine containing a mixture of ten whole-cell, heat-killed uropathogens
Rodent studies were promising, and an early trial of 202 women appeared to show a reduction in recurrent infection in the 12 months following intramuscular injections. .
Subsequent trials delivered Urovac vaginally, to reduce the risk of endotoxin toxicity and adverse side effects, and to stimulate a more robust local immune response .
Phase II and extended Phase II clinical trials found that women who received six total doses of vaccine gained short-term protection from infection, having significant delays to reinfection during the first eight weeks of the study in comparison with women who received placebos [21-24].
However, over the full course of the 6-month study, Urovac immunisation did not provide significant long-term protection from UTI or increase mean levels of UPEC-specific serum, urinary or vaginal antibodies [21-24]
Moreover, even with a vaginal route of delivery, some of the women reported adverse side effects.
SOURCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498450/ Preventing urinary tract infection: progress toward an effective Escherichia coli vaccine
Urvakol/Urostim is the product of a Czech and Bulgarian collaboration (BB-NCIPD Limited). They are seeking approval for a freeze-dried formulation of attenuated uropathogens in a daily oral tablet.
Data from animal and patient studies demonstrate that Urvakol and Urostim have immune-stimulating activity [25-27].
However, the ability of either vaccine to prevent recurrent UTI has not been established as well-structured clinical trials have yet to be completed. 
SOURCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498450/ Preventing urinary tract infection: progress toward an effective Escherichia coli vaccine
The vaccine contains an inactivated bacterial cell suspension of selected strains of uropathogenic bacteria, delivered via an oral tablet. A course of treatment is three months.
A 2013 study by the University of Salamanca , compared 159 patients treated with Uromune® for a period of three months (group A) and 160 with sulfamethoxazole/trimethoprim 200/40 mg/day for a period of 6 months (group B).
The patients receiving Uromune® (group A) experienced a highly significant reduction in the number of infections compared to patients on antibiotics (group B).
A significant reduction was also observed after 9 and 15 months.REF: https://www.ncbi.nlm.nih.gov/pubmed/22806485
Int Urogynecol J. 2013 Jan;24(1):127-34. doi: 10.1007/s00192-012-1853-5. Epub 2012 Jul 18.
Uromune is currently only available in the UK on a ‘named patient’ basis.
A “First Experience” study involving 40 patients at the Royal Berkshire Hospital in Reading ( REF ) has
just been presented ( March 2017 ) at the 32nd Annual EAU Congress in London. This ongoing study does show promise, with 87% of women reporting no further UTI’s during the treatment and the subsequent follow-up period. However, that period is still very short to draw any long-term conclusions.
Further studies are required to evaluate the efficacy of this vaccine in a larger group of patients including comparing effectiveness against placebo and antibiotic prophylaxis.
An international multi-centre study is currently underway, and a Randomised Control Trial at the Royal Berkshire centre. The results from both of these studies are awaited.
REF: First experience in the United Kingdom with the novel sublingual vaccine Uromune® in the treatment of women with recurrent urinary tract infections
Eur Urol Suppl 2017; 16(3); e234
Yang B.1, Foley S.2 1Royal Berkshire Hospital, Dept. of Urology, Reading, United Kingdom, 2Royal Berkshire Hospital Reading UK, Dept. of Urology, Reading, United Kingdom
So, we have had close to 30 years of vaccine development: some products, lots of trials, and although there are hopeful signs, we are not there yet, and we may never be there entirely.
UPEC has some pretty neat tricks up its sleeve when it comes to protecting itself. It has had millions of years to evolve survival strategies. Here’s a few we know about which are relevant to antibody attack, and therefore vaccination.
Molecular Mimicry: Camouflage: Many of UPEC’s surface polysaccharides mimic the host’s cell surface markers, and are thus ‘overlooked’ by the immune system! 
Capsid Cloaking: UPEC can protect themselves from antibody attack.
Recent work suggests that the polysaccharides in UPEC’s capsid (outer layer) may ‘cloak’ the bacterial cell surface, obscuring it from recognition by host antibodies. .
Antibody Shedding: The lectin (FimH) has two shapes, or ‘conformations’. By switching the shape, attached antibodies become un-stuck! So, UPEC can ‘shake-off’ antibodies directed against these areas.
Even more bizarrely, many of the antibodies directed at the FimH seem to ‘lock’ it into a shape that has higher affinity for mannose, actually making it more likely to stick! [10,11]
Strain Diversity: Variability of expression of “virulence factors”: There are many, many factors which assist UPEC and other uropathogenic bacteria to cause infection. Hundreds have been identified already. The problem is, they are not expressed consistently, either by any one strain or across strains.
“A required core set of virulence factors common to all UPEC isolates has yet to be identified” None offer “knock-out blows” 
Biofilm formation: UPECs can at times produce a ‘mucus’ of glycoproteins and polysaccharides which physically protects them from outside attack. The host’s natural defences, white cells, antibodies, compliment, and even chemicals like antibiotics, find it hard to get through this sticky, protective layer. The biofilm can be a ’refuge’, from which they can re-emerge when conditions are less hostile. [31,32]
‘Hiding’ by epithelial cells: UPECs sometimes appear to persuade host epithelial cells to ‘engulf’ them, wrapping around them protectively. This apparently strange behaviour is little understood at this time.
There’s already been a great deal of work in this quest, and we have a long way still to go.
UIT’s and specifically UPEC have an amazing repertoire of tricks and defences, almost certainly more we have not discovered yet.
The search for an effective, safe, long-lasting vaccine is still going on.
Remember, though, that while the scientists continue their quest, there are simple, safe and cost-effective treatments available right now, D-Mannose.
Author: Dermot Boylan - Microbiologist
Dermot worked as a microbiologist in vaccine production for Hoechst before taking up a career in laboratory automation.
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8. Preventing urinary tract infection: progress toward an effective Escherichia coli vaccine Ariel R Brumbaugh and Harry LT Mobley* NCBI - National Centre for Biotechnology Information Expert Rev Vaccines. 2012 Jun; 11(6): 663–676. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498450/
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28. Evaluation of a therapeutic vaccine for the prevention of recurrent urinary tract infections versus prophylactic treatment with antibiotics. Lorenzo-Gómez MF1, Padilla-Fernández B, García-Criado FJ, Mirón-Canelo JA, Gil-Vicente A, Nieto-Huertos A, Silva-Abuin JM. 1 Servicio de Urología, Complejo Asistencial Universitario de Salamanca, Paseo San Vicente 58-182, Instituto de Investigación Biomédica de Salamanca, 37007, Salamanca, Spain. Int Urogynecol J. 2013 Jan;24(1):127-34. doi: 10.1007/s00192-012-1853-5. Epub 2012 Jul 18.[Pubmed]
29. First experience in the United Kingdom with the novel sublingual vaccine Uromune® in the treatment of women with recurrent urinary tract infections. Yang B.1, Foley S.2 1Royal Berkshire Hospital, Dept. of Urology, Reading, United Kingdom, 2Royal Berkshire Hospital Reading UK, Dept. of Urology, Reading, United Kingdom. Eur Urol Suppl 2017; 16(3);e234 http://www.eusupplements.europeanurology.com/article/S1569-9056(17)30206-3/pdf
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