Groups of soy based foods and health supplements
\r\n\tThe overall objective of the book is to propose a methodological/ technological state of play and an operational assessment on the complex issues regarding the management and optimization of the multiple components of a transportation system: users, infrastructures, technologies and services.
\r\n\r\n\tThe book welcomes topics such as smart mobility, smart transportation systems, smart vehicle, smart infrastructures, smart people: citizens and users.
",isbn:"978-1-83880-823-5",printIsbn:"978-1-83880-802-0",pdfIsbn:"978-1-83880-824-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"ef80dab7f0350ea7cb28f40eedea2b35",bookSignature:"Prof. Stefano de Luca, Dr. Roberta Di Pace and Dr. Chiara Fiori",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9872.jpg",keywords:"Transportation, Intelligent Information Systems, Smart Vehicles, Vehicle Management, Driving Assistance Technologies, Smart Infrastructures, Smart Transportation Systems, Sustainable Transportation Systems, Vehicle Routing, Travel Demand Modeling, Life Cycle Assessment, Environmental Impacts Modeling",numberOfDownloads:891,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:1,numberOfTotalCitations:1,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 6th 2020",dateEndSecondStepPublish:"May 27th 2020",dateEndThirdStepPublish:"July 26th 2020",dateEndFourthStepPublish:"October 14th 2020",dateEndFifthStepPublish:"December 13th 2020",remainingDaysToSecondStep:"9 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Scientific coordinator of the Transportation Planning and Modelling laboratory, a consultant for the Italian Ministry of Transportation, the Transport commission of Campania Region, of Salerno and Avellino Transportation Departments and member of the IEEE Intelligent Transportation Systems Society.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"271061",title:"Prof.",name:"Stefano",middleName:null,surname:"de Luca",slug:"stefano-de-luca",fullName:"Stefano de Luca",profilePictureURL:"https://mts.intechopen.com/storage/users/271061/images/system/271061.jpeg",biography:"Stefano de Luca is a full professor of Transportation Planning and Transportation Systems Theory in the Department of Civil Engineering at the University of Salerno, in Salerno, Italy. Currently he is director of the “Transportation Systems Analysis” laboratory, Rector’s delegate for Transport and Mobility, and Department’s delegate for the Technological Transfer. His research focus includes transportation planning techniques, choice modelling, signal settings design, traffic assignment models, and freight/passenger terminal simulation and optimization. He advises city, regional, and national governments on transportation planning issues, and serves on the Editorial Advisory Board for Transportation Research part F, the Journal of Advanced Transportation and Sustainability. He has authored more than 100 book chapters and journal articles, and has coordinated several national and international projects. He is a consultant for the Italian Ministry of Transportation, the Transport commission of Campania Region, and Salerno and Avellino Transportation Departments. His main research interests include transportation planning techniques, travel demand modeling, users’ behavior modeling, signal settings design, traffic assignment models, and air transportation. He is a member of the IEEE Intelligent Transportation Systems Society, the Italian Society of Transport Academicians (SIDT) and the Italian Society of Transport Policy (SIPOTRA).",institutionString:"University of Salerno",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Salerno",institutionURL:null,country:{name:"Italy"}}}],coeditorOne:{id:"271713",title:"Dr.",name:"Roberta",middleName:null,surname:"Di Pace",slug:"roberta-di-pace",fullName:"Roberta Di Pace",profilePictureURL:"https://mts.intechopen.com/storage/users/271713/images/system/271713.jpeg",biography:"Roberta Di Pace received both the MSc degree and the Ph.D. degree in transportation engineering from the University of Naples 'Federico II,” Naples, Italy, in 2005 and 2009, respectively. She is an assistant professor in Transportation Engineering at the Department of Civil Engineering of the University of Salerno (Italy). She is an aggregate professor of Technique and Transport Economics (BSc, Civil Eng. and Environmental Eng) and Transportation Systems Design (MSc, Civil Eng). Since 2010 she is a member of the Transportation Planning and Modelling Laboratory. Her main research fields include the development of analytical tools for advanced traveler information systems, the traffic flow modeling, the network signal setting design, the advanced traffic management systems. 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She was Visiting Scientist at the European Commission, Joint Research Center, Directorate for Energy, Transport and Climate Change, Ispra, Italy, from 2017 to 2018. Moreover, from 2015 to 2016 she was Visiting Scientist at the Center for Sustainable Mobility of the Virginia Tech Transportation Institute, USA, and, in 2013, Visiting Scholar at the Center for Automotive Research of the Ohio State University, USA. Her research interests include: sustainable mobility; modeling and simulation for the functional and environmental efficiency improvement of container terminals; integration of microscopic energy consumption model for EVs with traffic control systems; energy consumption modeling and simulation of hybrid and electric powertrains; integration of traffic and energy consumption modeling at microscopic scale; impact assessment of emerging powertrain technologies on route choice behaviors and development of eco-routing strategies for personal and freight mobility; impact assessment of emerging powertrain technologies and charging systems on power electric infrastructure; electric freight logistics, electrification of ports and port operations; well-to-wheels analysis of conventional, hybrid and electric vehicles; impact assessment of emerging railway services (e.g. High Speed/High Capacity services); energy systems, alternative fuels, hydrogen and renewable sources.",institutionString:"University of Salerno",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Salerno",institutionURL:null,country:{name:"Italy"}}},coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"11",title:"Engineering",slug:"engineering"}],chapters:[{id:"73624",title:"BIM Approach for Smart Infrastructure Design and Maintenance Operations",slug:"bim-approach-for-smart-infrastructure-design-and-maintenance-operations",totalDownloads:144,totalCrossrefCites:0,authors:[null]},{id:"73595",title:"Advanced Vehicles: Challenges for Transportation Systems Engineering",slug:"advanced-vehicles-challenges-for-transportation-systems-engineering",totalDownloads:25,totalCrossrefCites:0,authors:[null]},{id:"73941",title:"Towards Shared Mobility Services in Ring Shape",slug:"towards-shared-mobility-services-in-ring-shape",totalDownloads:44,totalCrossrefCites:0,authors:[null]},{id:"74201",title:"Attitudes and Behaviours in Relation to New Technology in Transport and the Take-Up amongst Older Travellers",slug:"attitudes-and-behaviours-in-relation-to-new-technology-in-transport-and-the-take-up-amongst-older-tr",totalDownloads:41,totalCrossrefCites:0,authors:[null]},{id:"73973",title:"Models and Methods for Intelligent Highway Routing of Human-Driven and Connected-and-Automated Vehicles",slug:"models-and-methods-for-intelligent-highway-routing-of-human-driven-and-connected-and-automated-vehic",totalDownloads:88,totalCrossrefCites:0,authors:[null]},{id:"74412",title:"Centralised Traffic Control and Green Light Optimal Speed Advisory Procedure in Mixed Traffic Flow: An Integrated Modelling Framework",slug:"centralised-traffic-control-and-green-light-optimal-speed-advisory-procedure-in-mixed-traffic-flow-a",totalDownloads:73,totalCrossrefCites:0,authors:[null]},{id:"74333",title:"Transit Signal Priority in Smart Cities",slug:"transit-signal-priority-in-smart-cities",totalDownloads:118,totalCrossrefCites:0,authors:[null]},{id:"73356",title:"Optimal Management of Electrified and Cooperative Bus Systems",slug:"optimal-management-of-electrified-and-cooperative-bus-systems",totalDownloads:83,totalCrossrefCites:0,authors:[null]},{id:"73240",title:"Recent Progress in Activity-Based Travel Demand Modeling: Rising Data and Applicability",slug:"recent-progress-in-activity-based-travel-demand-modeling-rising-data-and-applicability",totalDownloads:184,totalCrossrefCites:0,authors:[null]},{id:"73821",title:"Driver Assistance Technologies",slug:"driver-assistance-technologies",totalDownloads:91,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"297737",firstName:"Mateo",lastName:"Pulko",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/297737/images/8492_n.png",email:"mateo.p@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"38361",title:"Possible Risks in Caucasians by Consumption of Isoflavones Extracts Based",doi:"10.5772/47837",slug:"possible-risks-in-caucasians-by-consumption-of-isoflavones-extracts-based",body:'With the increase in human life expectancy many health concerns start to be important, which raises the need for more and different therapeutic solutions.
One of the emerging issues that attracted the attention of research teams looking for new and better medicines is prevention of hormonal dependent tumors in both genders and the relief of climacteric symptoms in post-menopausal women, as the prevention of cardiovascular diseases (CVD).
For both of the above situations testosterone, estrona and estradiol metabolism are fundamental for a possible cardiovascular effect or a desoxinucleic acid (DNA) damage in breast cancer. Phytoestrogens, as isoflavones, in a first approach, seems to be potentially useful solutions. These compounds have the ability to mimic estrogens and induce an estrogen-like effect dependent on their affinity for alpha and beta estrogen receptors (ERs) [1], and this is related to their chemical structures.
Phytoestrogens were discovered by Bennetts et al, who were trying to identify the cause of a specific sheep breeding problem in Western Australia. They implicated equol, a metabolite of daidzin that is an isoflavone existing in subterranean clover pastures [2]. Four decades later, in 1984, this compound was identified in human Urine by Setchell et al [3] and related to consumption of soy and further implicated in a possible prevention of hormonal dependent tumors, cardiovascular diseases and osteoporosis.
At that time, the world was focused on the French Paradox (data collected with French population) that claimed the ingestion of antioxidants, mainly from red wine as the alcohol itself, could be a panacea for cancer prevention and cardiovascular diseases. According to data from the world\'s largest study of heart disease, conducted by the World Health Organization (WHO), during the past decade in 21 countries with 10 million men and women, French heart disease statistics appeared to have been under-estimated and the "French Paradox" overestimated. The French rate of heart disease was actually similar to that of the Italians, Spanish, and the Germans (mainly southern Germany), but still lower than many other countries.
Despite that, other researchers looking in a different way for the same reasons made epidemiological studies on Asian populations in the \'90s that revealed a possible relationship between the ingestion of soy and the prevention of hormonal dependent tumors and also a lower incidence of climacteric symptoms in postmenopausal women. These results, known as the "Japanese Paradox" (data collected with Japonese population), induced Western people to consume soy and soy derivatives rich in isoflavones as genistein, daidzein, glycitein and the respective glucosidic forms (genistin, daidzin and glycitin). A large number of studies have attempted to demonstrate that soy consumption decreases the risk of developing several chronic diseases, in particular, cancer, osteoporosis [4, 5], cardiovascular diseases [6], and also the relief of climacteric symptoms [7]. Up until now however, the majority of these benefits have not been proven [for review see 9].
These two epidemiologic studies are mainly focus on prevention of cardiovascular diseases and cancer, using phenolic compounds as the targets for this bioactivity. The firstone, French paradox, fail and leave behind an important side effect, cirrhosis, in people that increase the intake of wine all over this last decades. Related to the "Japanese Paradox", the scientific community starts to have data enough to think that this concept needs to be evaluated with caution to prevent a future failure.
Until now, in Europe isoflavones are considered as food compounds, nevertheless they are antinutrient compounds, and is the European Food Safety Authority (EFSA)that is responsible for the risk assessment evaluation of them. They recognize the potential importance for human health of the issue of isoflavones from food digestion, but should the alleged beneficial or detrimental health effects be scientifically proven. The Isoflavones ESCO working group evaluates the relevant scientific information available. This includes inter alia:to assess the potential of isolated isoflavones to trigger adverse human health effects;the possible human health benefits of the use of isolated isoflavones for the general population and particularly for women with complaints during and after the menopausal period; whether there is any scientific basis for differences concerning the hazard assessment of isolated isoflavones from soy and/or red clover in comparison with soy or red clover extracts. The final document will be public and available at EFSA web site soon (http://www.efsa.europa.eu/en/esco/escoisoflavones.htm).
For this reason in the present chapter we’ll not focus an overview of the isoflavones, as that isthe current work of, but we’ll discuss other points of view that can contribute for understanding of the topic especially for cancer and relief of climacteric symptoms. In this last point, recently (2010) Rebbeck et al [12] presented a study were theyevaluated whether genes involved in the metabolism of steroid hormones are associated with hormone levels or menopausal symptoms. They used a population-based prospective sample of 436 African American (AA) and European American (EA) women who were premenopausal at enrollment and were followed longitudinally through menopause. Evaluation of the relationship between steroid hormone metabolism genotypes at catechol O-methyltransferase (COMT), cytochrome P450(CYP) as the isoformes CYP1A2, CYP1B1, CYP3A4 and CYP19, Sulfotransferase 1A1 (SULT1A1), and SULT1E1 with hormone levels and menopausal features were carried out. The results show in EA women, SULT1E1 variant carriers had lower levels of dehydroepiandrosterone sulfate, and SULT1A1 variant carriers had lower levels of estradiol, dehydroepiandrosterone sulfate, and testosterone compared with women who did not carry these variant alleles. In AA women, CYP1B1*3 genotypes were associated with hot flashes (odds ratio [OR], 0.62; 95% CI, 0.40-0.95). Interactions of CYP1A2 genotypes were associated with hot flashes across menopausal stage (P = 0.006). Interactions of CYP1B1*3 (P = 0.02) and CYP1B1*4 (P = 0.03) with menopausal stage were associated with depressive symptoms. In EA women, SULT1A1*3 was associated with depressive symptoms (OR, 0.53; 95% CI, 0.41-0.68) and hot flashes (OR, 2.08; 95% CI, 1.64-2.63). There were significant interactions between SULT1A1*3 and hot flashes (P < 0.001) and between SULT1A1*2 and depressive symptoms (P = 0.007) on menopausal stage, and there were race-specific effects of SULT1A1*2, SULT1A1*3, CYP1B1*3, and CYP3A4*1B on menopause. These results suggest that genotypes are associated with the occurrence of menopause-related symptoms or the timing of the menopausal transition [10].
Isoflavones as we’ll explain later in this chapter will interfere with most of these enzymes and Caucasians and Asians present polymorphic changes, in some of them, that can change the bioactive response to various situations, from compounds metabolism to cancer induction or prevention.
Isoflavones are biologically active heterocyclic phenolic compounds (subgroup of isoflavonoids) (Figure 1) that are absorbed by the intestine, circulate systemically, and are eliminated by the kidneys and liver [11].In plants isoflavones occur predominantly as β-glucosides (genistin, daidzin, glycitin), or as acetyl-β-glucosides and malonyl-β-glucosides [12, 13]. Genistein is the more abundant isoflavone in the majority of soy products and also the most active of these compounds, and being able to interact with the estrogenic receptors [14].
Traditionally the main food sources of isoflavones are soy and other beans and pulses,and also fermented soy foods, where the glucosides have been transformed into aglycones which are absorbed more efficiently than glucosides.
In the past these have been more commonly consumed by Asian populations, but are growing in popularity in Europe. Similarly, in recent decades a new generation of soy products have entered the market (e.g. yogurts, cheeses, soy milk drinks, infant formula’s) and commonly consumed food products incorporating soy flour (e.g. bakery products) and protein isolates (e.g. meat products and soy meatless products such as soyburgers). More recently, the development of nutritional supplements rich in isoflavones has targeted niche markets in response to scientific research, that is still controversial, but that suggests a beneficial effect from these food components.
Isoflavones were first discovered in the 1930’s, as a bioactive agent, following the disruption of estrogen action and increased infertility in sheep that had been grazing on red clover, thereby earning the often used name ‘phytoestrogens’.Subsequently isoflavones have been shown to bind to, or indirectly interact with several key nuclear receptors, including hormonal (estrogen receptors alpha and beta [ERs], progesterone and androgen receptors), xenobiotic sensing receptors (Pregnane X receptors [PXR] and Peroxisome proliferator activated receptors [PPARs], and steroidogenic and hypothalamus-pituitary-thyroid (HPT) axis pathways. Isoflavones are structurally similar to the endogenous estrogen 17-beta estradiol, but much less potent on binding to the ERs, although genistein, the more active isoflavone, have a greater binding affinity for ER beta (43.9% related to 100% for estradiol [15]).
These compounds, as other phytoestrogens, are molecules with the ability to mimic estrogenpharmacological action through the linkage with ERs, and because of that are called estrogen-like molecules [15].
The benefits and the inherent risks associated to the ingestion of estrogen-like molecules are related to their binding affinity to beta-ERs and to alpha-ERs.
Chemical structures of iso-flavone equivalents
Beta-ERs are mainly located in bones, brain, thymus, bladder, and the cardiovascular system. Its activation by estrogenic compounds or estrogen-like compounds can probably improve or prevent conditions such as osteoporosis and cardiovascular diseases [16, 17]. In the other hand, alpha-ERs appear to predominate in breast, uterus and ovary; some authors report that linkage between estrogen or estrogen-like molecules and alpha-ERs is potentially dangerous. In breast cancer, for example, it could promote proliferation of damaged DNA [18,19]; and it can also lead to endometrial hyperplasia, as concluded in a randomized, double-blind, placebo-controlled study evaluating the safety of a long-term treatment (up to 5 years) with soy isoflavones. Although no cases of malignancy were detected, the hyperplasia called into question the long-term safety of phytoestrogens with regard to the endometrium [8].
Another important issue indicates a possible relationship between low doses of isoflavones and an increase in tumor proliferation, as it was pointed out by some authors.The same authors also concluded that, genistein and daidzein could not only stimulate pre-existing tumors, but also antagonize the effects of the tamoxifen (antitumour agent). Thus, women with breast cancer or with a history of a previous breast cancer event should be made aware of the risks of potential tumor proliferation while taking soy products [20]. Previously, Hsieh et al, also pointed out the possibility that lower amounts of genistein could stimulate alpha – receptors and influence the proliferation of breast cancer cells [22].
It is furthermore of particular relevance the fact that genistein can be estrogenic and antiestrogenic in human body. Clarify these mechanisms, as it was done for tamoxifen, can becrucial to the understanding of a possible benefit/risk ratio. For example, although tamoxifen has been useful both in treating breast cancer patients and in decreasing the risk of getting breast cancer in women at high risk, it also has some serious side effects.These side effects arise from the fact that while tamoxifen acts as an antiestrogen that blocks the effects of estrogen on breast cells, it mimics the actions of estrogen in other tissues such as the uterus. Its estrogen-like effects on the uterus stimulate proliferation of the uterine endometrium and increase the risk of uterine cancer [23]. The same was refered before in the data from, Unfer et al, (2004) [8].
The relevance of ethnic metabolism will be crucial to clarify some misunderstandings. As an example of the ethnic importance of polymorphic enzymes in metabolic pathways a meta-analysis conducted combining the data with 34 published studies that included 11 962 cancer cases and 14 673 controls in diverse cancers was carried out. The SULT1A1*2 revealed contrasting risk association for UADT cancers (OR=1.62, 95% CI: 1.12, 2.34) and genitourinary cancers (OR=0.73, 95% CI: 0.58, 0.92). Furthermore, although SULT1A1*2 conferred significant increased risk of breast cancer to Asian women (OR=1.91, 95% CI: 1.08, 3.40), it did not confer increased risk to Caucasian women (OR=0.92, 95% CI: 0.71, 1.18). Thus risk for different cancers in distinct ethnic groups could be modulated by interaction between genetic variants and different endogenous and exogenous carcinogens [24].
Even all these results were carried out with Europeans (which don´t consume soy very often) andothers with Asians ( which included this food many years ago in their normal diet plan), it isn’t frequent to discuss their metabolic pathways.
As it is known, populations vary genetically and differ in the occurrence and frequency of particular genetic polymorphism depends on the time when the mutation occurred in relation to human migrations. If it occurred after the populations split, it will be unique to one population and its descendants. If it happened in the ancestor population, it is possible present in all descendent groups. A well-known example is the frequent ALDH2 deficiency in Asian individuals which is rarely found in Caucasians. As metabolizing enzymes are involved in the detoxification on endogenous and xenobiotic toxins, in the activation of procarcinogens, in the formation of reactive intermediates and in their neutralization, many studies have been undertaken concerning the correlation between genetic polymorphisms and metabolizing enzymes and cancer risk [25].
Ethnic differences in metabolism are a consequence of various factors as, for example, adaptation to different environments, differences in nutrition, behavior and cultural differences. This genetic polymorphism of metabolizing enzymes cause differences in effects and toxicity of the ingested compounds between individuals and all population. The so called “idiosyncratic drug interactions” are now explained on the basis of genetic polymorphisms. Beside the genetic variability differences can appear after enzyme induction or inhibition by the affected compound itself or by others or xenobiotics, e.g., from foods [25].
In Phase I metabolization, genistein, daidzein and equol (important metabolite of daidzein-7-O-glucoside) inhibit the Cytochrome P450 (CYP) 1A2, 1B2, 2E1, 3A4 and in phase II they induce UDP glucuronosyl transferase (UGT), Glutathione-S-Transferase (GST) and Quinone Redutase (QR);SULT1A1, SULT1A3 andSULT1E1 are inhibited for all of them [26].
CYP 1A2, for example, is important for estrogen metabolization (E1 and 2) in 2- or 4-OH E1 and 2 followed of the 4-OH E1 and 2 sulphate metabolite by SULT1A1*2 and *3, or to 2- and 4-OCH3 E1 and 2 by COMT. The inhibition of CYP 1A2 and SULT1A1, SULT1A3,probably can induce E1 and E2 to be metabolized by CYP 3A4 (*1B) to 16-alpha OH E1 and 2.
Rebbeck et al, also observedrace-specific associations with CYP1B1, CYP1A2, and SULT1A1 on menopausal symptoms; race-specific effects of SULT1A1*2, SULT1A1*3, CYP1B1*3, and CYP3A4*1B on time to late premenopause, early menopausal transition, and menopause; and interactions of race with SULT1A1*2 and SULT1A1*3 ontime to menopause [10].
The involvement of all these enzymes in the different ethnic groups constitutes a gap in the understanding of what can be used with benefit from other continents. The controversy persists regarding the role of a low ratio of 2-hydroxyestrone/16alpha-hydroxyestrone (2-OHE1)/(16 -OHE1) as a potential estrogenmetabolism marker of increased risk for breast cancer[27]. Was suggested that soy consumption increases this ratio only in women who are equol producers given a possible protection against breast cancer [28].
The European American women that carry the CYP3A4*1B allele important in these last steps of metabolization of estrogens were indicated for a early menopause independent of the SULT1A1*2 or *3 type. The SULT1A1*2 (Arg213His) have a frequency of ca 30% for Caucasians and African Americans but only 8-17% for Asians [25].
GST present important genetic differencesand is induce by isoflavones. The consequences of polymorphic GST isoenzymes are probably more relevant for carcinogenesis and for the detoxication of toxic xenobiotics and of chemotherapeutics than for drug metabolism in general. For example, 44-64% of the Asians present a GSTT1*0 polymorphism against 10-36% in Caucasians with the consequent difference in the metabolizing behavior [25].
This is also important for possible interactions between those molecules and some medicines, special in polimedicated patients. Daidzein, one of the principal isoflavones in soybean,can inhibit CYP1A2 activity and alter the pharmacokinetics of theophylline in healthy volunteers. Theophylline is a bronchodilator with a narrow therapeutic index (5–20 mg/L), and it is primarily eliminated by hepatic metabolism mediated by CYP1A2. [26].
Steroid hormone metabolism genes are not generally responsible for interindividual variation in steroid hormone levels or with changes in these levels across the menopausal transition. However a better understanding of all these mechanisms will be important to prevent future damage if we ingest compounds that will change the natural equilibrium of ethnic groups.
If these associations are confirmed, they may provide information about the prediction ofmenopausal symptoms and allow clinicians to individualize and target hormone therapy in women experiencing menopausal symptoms. Because hormone exposures, genotypesinvolved in hormone metabolism, and the phenotypic manifestations of these factors onsymptoms are all associated epidemiologically with risk of cancer and other diseases, abetter understanding of the role of genotypes and intermediate phenotypes such as hormonelevels may ultimately assist our understanding of steroid hormone– related disease etiology and prevention [10].
So although, until now, the risk assessment for soy products is not clear enough to consider their consumption safe, humans are increasingly being exposed to isoflavones in soy and soy derivatives (other products containing isoflavones from different sources aren’t so rich). Thus better information about the safety of these soy phytoestrogens is urgently needed.
In this section is provided an overview (not exhaustive but presenting some discuss points) of the potential benefit/risk impact of nutritional products and supplements, that include isoflavones in their composition and that are recommended mainly for climacteric relief symptoms in post-menopausal women and/or prostatic cancer prevention in man and CVD prevention.
The European Prospective Investigation into Cancer and Nutrition (EPIC) study evaluated in 2002 the consumption of soy products in 10 European countries [29]. Results from this study revealed that soy consumption at that time was low in Western Europe and that non-dairy substitutes were the most frequently consumed items.
In this section we’ll demonstrate the wide variation of isoflavone levels that these products may provide to the consumer. Because thereare not recommendations of the optimal isoflavone consumption,the information displayed in these products should be clearly specified, especially in the case of health supplements. This is essential for accurate risk assessment studies, where knowing the exposure level of the population to these products and more specifically the exposition to each isoflavone is fundamental.
Nowadays, over the counter (OTC) tablet preparations [30, 31], nutraceuticals and various supplements with isoflavones extracted from soy [32] and other plants are sold in various countries. These products are often used by postmenopausal women to do hormonal therapy replacement as another option to allopathic medicines with oestrogen derivatives, and also with the claim of cancer prevention. However, the impact of that exposure in Caucasian women health is underestimated.
As a result of the promising scientific findings related to isoflavones, the soy-processing industry has grown worldwide from manufacturing alternative dairy products and milk-free infant formulas to provide a wider range of products embracing all types of tastes and consumer health concerns. These new products, sometimes named as second generation soy foods, are based in the inclusion of soy ingredients (soy pieces, soy powder, soy flour, soy protein, etc) among the ingredient list of food items commonly consumed by western populations.
Development of new soy products is especially important in Europe where the population does not accept the characteristic soybean flavor. Some years ago, only a few traditional soy foods were common items in European markets, and among those, soy nuts, soy sauce, tofu and soymilk were easily found, but the recent appearance of the so-called second-generation of soy foods; products made by adding soy ingredients (soy protein) to a wide variety of manufactured foods resulting in products which generally simulate familiar dishes [32].
A number of soy protein-based products are included, mainly meat substitutes (texturised soy protein) in a number of forms, as well as dairy-products substitutes. Same protein is added to enrich a number of foods commonly present in European diets: bread, cookies and soups or dietary supplements (powders) and energy bars used to complement sport diets. The latest version to use soy protein or isoflavone isolates appeared in the form of capsules or tablets directed, and labelled, to promote the claimed health benefits of soy isoflavones between the consumers [32].
It is well known that isoflavone levels in soy-based products depend primarily upon the soybean variety used.Isoflavone content within a single variety can differ three times from year to year[33]. In some studies, this variability has been attributed to climatic and environmental factors [34].Moreover, soybean processing and storage conditions usually lead to a significant isoflavone loss in soy-based products [35]. In addition, isoflavone glucoside conjugates are easily alterable during extraction and cooking[36], and it has been even shown variations between products included in the same batch[32].
In some cases the presence of isoflavones is intended and therefore its concentration is known, but in the majority of the soy foods the levels of isoflavones need to be quantified in order to evaluate the possible health effect of these products.
Results from our previous work with some of the above cited products, selected soy-foods produced and distributed within Europe (Table 1), provide total isoflavone values for a possible evaluation of the potential exposure to these molecules [32].
Groups of soy based foods and health supplements
In this work a total of 115 soy-based products were purchased at local retailers and natural health food stores in Finland, Spain, UK and Portugal during the years 2002-2005. Commercial availability and European manufacture were the only selection criteria. The selected items belong to different groups of soy foods and a classification was needed in order to allow the comparison between levels of isoflavones provided by the different products. Items were divided into four different groups: 1) Traditional soy foods, 2) Non-dairy soy products, 3) Meat analogues, 4) Second-generation soy foods and 5) Health supplements. Food samples were (when necessary) freeze-dried, homogenized and stored at -70 °C until analysis [32].
Soy isoflavones in samples were quantified as previously reported [30, 38, 39] using a HPLC systemsequipped with a Coularray detector or diode array detection. Peaks corresponding to soy isoflavones were confirmed by LC/MS-MS as previously reported [39]. Synthetic standards were used for quantification through calibration curves, and control samples, were introduced between run to assure repeatability was acceptable (CV <15%) over the analysis time. All reagents were from major suppliers and HLPC-grade.Results are mean values of triplicate analyses, and were only accepted when coefficient of variation (CV) between the replicates was <15%. Only values above the limits of quantification of the method for each isoflavone (1 ppm, depending on the analyte) are reported[39].All values are expressed as aglycone equivalents.
Isoflavonemeans in Traditional soy foods, no-dairy soy products and meat analogues analised as examples of European consume.
In Figure 2, from our previous data [32], genistein was found to be the most prevalent isoflavone in Traditional soy foods, no-dairy soy products and meat analogues. In second generation soy foods, daidzein was the most prevalent isoflavones. However differences between the various products were considerable.
Diverse studies have been conducted in different countries in order to analyze the isoflavone content in soy products. Chan et al determined the concentrations and distribution of isoflavones in 47 soy-based foods [40]. They alsostudied the conjugation pattern of isoflavones and found that varied within and between food groups as influenced by the types of soybeans and the processing or cooking techniques used. The authors found very high values in certain foods and concluded that might not be safe, supporting the relevance of the risk assessment for the recommendation of safe intake levels. Similar results were obtained by Boniglia et al [41].
Three years ago, Boniglia et al, achieved similar results. These authors presented a study of the isoflavone content of 14 soy-based Italian dietary supplements – indicated for the improvement of perimenopausal and menopausal symptoms. The objective was to quantify soy isoflavones fraction after hydrolysis into free aglycones. They noticed that, in the examined products, the amounts of isoflavones were frequently expressed ambiguously. None of the products stated whether the isoflavone content of the product was expressed as aglycones or as conjugates. Even worse, each product revealed a different aglycone concentration profile. They also concluded that this difference was probably related to the different sources of raw materials and methods used in the processing and preparation of extracts. They also observed that in more than half the supplements tested, the actual values contained were below those stated and below those expected to relief perimenopausal and menopausal symptoms [41].
Similarly, our study of a 59 selected soy health supplements shown a large variation in the composition, and a wide difference between the content of isoflavones analyzed and that reported in the product [32].
Our study demonstrates,as the others cited before, the wide variation of isoflavone levels that these products may provide to the consumer. Because thereare not recommendations of the optimal isoflavone consumption,the information displayed in these products should be clearly specified, especially in the case of health supplements. This is essential for accurate risk assessment studies, where knowing the exposure level of the population to these products and more specifically the exposition to each isoflavone is fundamental.
Despite the predominant isoflavone forms in soybeans [38] and non-fermented soyproducts (like soy protein or soy milk derivates) are glucosides [42]; fermented soy foods(like soy sauce) contain mainly aglycones [43].The form in which isoflavones are present in soy-based foods and health supplements is important to assess the bioavailability of these products [36], Considering that genistein is, in a theoretical point of view [15,44], about 1000 times more active that daidzein the heath benefit and/or the toxicity could be different in two apparently identical products.
For this confusing data our previous proposition was, and still is, applying the calculation of “Theoretical Efficacy (of isoflavones) Related to Estradiol (TERE) [44]. Like that it is possible evaluate the theoretical impact of exposure to estrogen-like activity of isoflavones in various countries from all the data of different studies already published [44]. This theoretical calculation estimates the “Theoretical Efficacy (TE)” of a mixture with different bioactive compounds in a way to obtain a “Theoretical Efficacy Related to Estradiol (TERE)”. The theoretical calculation that was proposed for some of the authors of this chapter integrates different knowledge about this subject and sets methodological boundaries that can be used to analyse data already published. The outcome should set some consensus for new clinical trials using isoflavones (isolated or included in mixtures) that will be evaluated to assesstheir therapeutically activity.
To do the theoretical calculation [44] the amounts of isoflavones were multiply for the “ERs binding affinities” based on the values obtained in literature [15]. After applying the proposed model, "Theoretical efficiency related to estradiol (TERE), for each mixture of isoflavones, the" Theoretical Efficiency (TE) was estimated which can be used to compare the potential bioactivity [44].
Daidzein and genistein do not have the same binding affinity to alpha- and/or beta-ERs [15]. Also known and frequently mentioned by several authors is that the linkage of oestrogens or oestrogenic compounds to alpha-ERs could be dangerous with breast cancers because it could aid the proliferation of damaged DNA in tumours [45, 46]. The amounts theoretical linked from the different isoflavones to the alpha- oestrogen receptors as an add benefit (when added to the beta-receptors affinity) but also as a potential risk to be under evaluation.
However, it is also accepted that beta-ERs are mainly located in bones, brain, thymus, bladder, cardiovascular system and its activation by estrogenic compounds, or compounds with the ability to mimic estrogenic molecules, such as phytoestrogens, can improve and prevent conditions like osteoporosis and cardiovascular diseases [17, 47] and this will be used as the benefit parameter.
In global terms the total efficacy of the TERE will be determined adding these two values. However the amount linked to the alpha-receptors will be consider as a possible risk limitation, which that needs to be evaluated when the increased dose will induce an improved TERE but the risk assessment for the toxicity can be a handicap. Ultimately, different extracts could be compared, even when the relative amounts present in the extracts are very different.
The example of TERE calculation for samples show in Figure 2 is presented in Table 2, using“Second generation soy foods” data.
Second generation soy foods | Receptor Type | ||
Intake(mg/100g) | Alpha-ERs | Beta-ERs | |
daidzein | 29,2 | (29.2 x 0.031/100) 0.009 | (29.2 x 0.020/100) 0.006 |
genistein | 22,09 | (22.09 x 0.86/100) 0.19 | (25 x 43.9/100) 9.7 |
Total | 51.79 | 0.199 | 9.706 |
TE | 9.9 | (= 0.199 + 9.706) | |
TERE | (100 total linkage to ERs/9.9 TE) = 1/10.1 of the theoretical activity of the estradiol | ||
RISK | ~ 2% | ||
BENEFIT | ~ 98% |
Example of TERE calculation with mean values for Second generation soy foodsusing the “Estrogen Receptor affinity binding values”with daidzein and genistein.
From the total values in Figure 3 and 4 is possible evaluate the amount of daidzein and genistein linked to both receptors and have an idea about the Theoretical Efficacy (TE) of these components if related to estradiol (TERE), Figure 5.
“Estrogen Receptor affinity binding values”for daidzein and genistein content in samples of Group I to IV.
TEvalues for samples of Group I to IV.
With the exception of Non-dairy soy products that present very low bioactivity related to estradiol the other three groups have values between 7 and almost 14% of the estradiol bioactivity.
Nevertheless the apparent majority of benefice related to risk, as was pointed out above, the low amounts of isoflavones linked to alpha receptors can increase the possibility of proliferation in hormonal dependent tumours and the safe amounts were not evaluated yet.
If the same analysis is made with health supplements the values are absolutely different. In Figure 6 it is shown the TE for the highest values of daidzein and genistein found in our samples (daidzein 371.48 and genistein 172,47 mg/g of pill) [32]. The pill with the content of 172,47mg of genistein also had 208.41mg of daidzein. The TE for this product is almost 80% of the bioactivity of estradiol with a clear uncertainty of influence in the bioability of these compounds in human body.
The exposure risk of all those products is unknown and needs to be evaluated in a near future even no enough data for now make sense.
The data presented herein intend to demonstratethe wide range of isoflavone levels that different products may provide to the consumer, even when recommended for the same therapeutic effect and still if the product keeps the same isoflavones profile all the time. Its relevant to mention that the majority of the soy suppliers breed a wide range of soy cultivars, which results in a different mixture of compounds, and consequently in a variable final product composition and hazard [19, 38].
The Europeans, as can be seen in results presented recently by Konar et al, in 2012 consumed legumes with low levels of dietary isoflavones. In this study, 6 legumes (chickpea, red kidney bean, haricot bean, yellow lentil, red lentil and green lentil) were analysed to determine their contents for 10 different isoflavones (both free and conjugated). Methanolic extracts obtained by ultrasound-assisted extraction were analysed by triple quadrupole LC-MS/MS. Chickpeas were the best source of isoflavones (3078 372 mu g/kg total content), with a significant amount of biochanin A and its conjugated form, sissotrin. Kidney beans had the second highest concentration of isoflavones (1076 mu g/kg) and were particularly rich in genistin (946.4 +/- 228.5 mu g/kg). The total isoflavone concentrations of yellow split lentils, green lentils, red lentils and haricot beans were each below 200.0 mu g/kg. However it was determined that the legumes commonly consumed in Western diets (those analyzed in this study) are not so concentrated as soy and soy products as sources of Isoflavones [48].
As it was explained and discussed in the previous section the metabolic pathways and the genetic polymorphic enzymes involved in detoxication of the ingested compounds in our body can conduce to a different bioactivities and consequent risk impact in the various ethnic groups. Only a full risk assessment will prevent the danger or will help to understand the benefit of an increase in the isoflavone intake by Caucasians that for the moment is absolutely out of control.
TEREvalues for samples of Group I to IV.
TEvalues for samples of Group V (only for highest daidzein and genistein content).
The above findings emphasize the need for a thorough correct risk assessment to be carried out to evaluate the differences between the various isoflavones, their relative levels in formulations (dietetic supplements, foods soy based, etc) and their safety profile, in order to establish limits for safe therapeutic effects. Various interactions with conventional medicines have already been published and it is important to alert already medicated patients who are also consuming soy or soy based products. The relationship between this intake and cancer and or cardiovascular diseases prevention is unclear moreover the danger of a cancer improvement.
Without such a risk assessment ad libitum consumption of these compounds could be hazardous.
The authors wish to thank to "Projeto Estratégico - PEst-OE/SAU/UI0177/2011”.
UTI affects approximately 150 million people worldwide, which is most common infection with female predominance [1]. Around 15–25% hospitalized patients receiving indwelling urinary catheter develops CAUTI with prolonged catheterization and in among 40% nosocomial UTI, 80% is due to CAUTI [2]. CAUTI causes about 20% of episodes of health-care acquired bacteraemia in intensive care facilities and over 50% in long term care facilities [3]. The microbiology of biofilm on an indwelling catheter is dynamic with continuing turnover of organisms in the biofilm. Patients continue to acquire new organisms at a rate of about 3–7%/day. In long term catheterization that is by the end of 30 days CAUTI develops in 100% patients usually with 2 or more symptoms or clinical sign of haematuria, fever, suprapubic or loin pain, visible biofilm in character or catheter tube and acute confusion all state [4]. In CAUTI the incidence of infection is Escherichia coli in 24%, Candida in 24%, Enterococcus in 14% Pseudomonas in 10%, Klebsiella in 10% and remaining part with other organisms [5]. Bacteraemia occurs in 2–4% of CAUTI patients where case fatality is three times higher than nonbacteremic patients [6]. Adhesions in bacteria initiate attachment by recognizing host cell receptors on surfaces of host cell or catheter. Adhesins initiate adherence by overcoming the electrostatic repulsion observed between bacterial cell membranes and surfaces to allow intimate interactions to occur [7]. A biofilm is an aggregate of micro-organisms in which cells adhere to each other on a surface embedded within a self-produced matrix of extracellular polymeric substance [8]. In biofilm micro-organisms growing in colonies within an extra-cellular mucopolysaccharide substance which they produce. Tamm-Horsfall protein and magnesium and calcium ions are incorporated into this material. Immediately after catheter insertion, biofilm starts to form and organisms adhere to a conditioning film of host proteins along the catheter surface. Both the inner and outer surfaces of catheter are involved. In CAUTI biofilms are initially formed by one organism but in prolonged Catheterization multiple bacteria’s are present. In biofilm main mass is formed by extra cellular polymeric substance (EPS) within which organisms live. So there are three layers in biofilm, where deeper layer is abiotic, than environmental zone and on surface biotic zone [9]. Growth of bacteria in biofilms on the inner surface of catheters promotes encrustation and may protect bacteria from antimicrobial agents and the consequence is more drug resistance of biofilm organisms. When antibiotic treatment ends the biofilm can again shed bacteria, resulting recurrent acute infection. The patients may present as asymptomatic bacteriuria or symptomatic. In symptomatic bacteriuria patient present with fever, suprapubic or costovertebral angle tenderness, and systemic symptoms such as altered mentation, hypotension, or evidence of a systemic inflammatory response syndrome. In asymptomatic CAUTI diagnosis is made with presence of 105 cfu/mL of one bacterial species in a single catheter urine specimen [10]. In symptomatic CAUTI bacteriological criteria is present with clinical symptoms.
It is recommended that urine specimens be obtained through the catheter port using aseptic technique or, if a port is not present, puncturing the catheter tubing with a needle and syringe in patients with short term catheterization [11]. In long term indwelling catheterization, the ideal method of obtaining urine for culture is to replace the catheter and collect the specimen from the freshly placed catheter. In a symptomatic patient, this should be done immediately prior to initiating antimicrobial therapy. Culture specimens from the urine beg should not be obtained [10, 12]. Urine sample can be collected from suprapubic puncture also. Biofilm can be cultured from the catheter, for this swab is taken from inner side of catheter.
Catheter Associated Asymptomatic Bacteriuria (CA-ASB) is diagnosed when one or more organisms are present at quantitative counts ≥105 cfu/mL from an appropriately collected urine specimen in a patient with no symptoms [13]. Lower quantitative counts may be isolated from urine specimens prior to ≥105 cfu/mL being present, but these lower counts likely reflect the presence of organisms in biofilm forming along the catheter, rather than bladder bacteriuria [14]. Thus, it is recommended that the catheter be removed and a new catheter inserted, with specimen collection from the freshly placed catheter, before antimicrobial therapy is initiated for symptomatic infection [13]. In biofilm culture, most biofilm contains mixed bacterial communities meaning polymicrobial colonization.
Patients who remain catheterized without having antimicrobial therapy and who have colony counts ≥10 2 cfu/mL (or even lower colony counts), the level of bacteriuria or candiduria uniformly increases to >105 cfu/mL within 24–48 h [14]. Given that colony counts in bladder urine as low as 102 cfu/mL are associated with symptomatic UTI in non-catheterized patients [15], untreated catheterized patients and those who have colony counts ≥102 cfu/mL or even lower, the level of bacteriuria or candiduria uniformly increases to >105 cfu/mL within 24–48 h [10, 16]. Colony counts as low as 102 cfu/mL in bladder urine may be associated with symptomatic UTI in non-catheterized patients. Whereas low colony counts in catheter urine specimens are likely to be contaminated by periurethral flora, and the colony counts will increase rapidly if untreated. Low colony counts in catheter urine specimens are also reflective of significant bacteriuria in patients with intermittent catheterization [14].
Pyuria is usually present in CA-UTI, as well as in CA-ASB. The sensitivity of pyuria for detecting infections due to enterococci or yeasts appears to be lower than that for gram-negative bacilli. Dipstick testing for nitrites and leukocyte esterase was also shown to be unhelpful in establishing a diagnosis in catheterized patients hospitalized in the ICU [17].
It is the most common cause of CAUTI in 24–60% patients [5, 18]. In CAUTI the source of this organism is usually patients own colonic flora. E. coli is large and diverse group of bacteria found in environment, foods and intestine of human and animal. Among many species of E. coli only a few causes disease in human being. It is beneficial in that it prevents the growth and proliferation of other harmful species of bacteria. Even it plays an important role in current biological engineering.
E. coli was discovered in 1885 by Theodor Escherich, German bacteriologist, is gram negative rod, lactose fermenter, composed of one circular chromosome which is common facultative anaerobes in colon and farces of human. Distribution is diverse and most of them are harmless belonging to genus Escherichia. Harmful species causes infection of urinary tract, gastrointestinal tract, respiratory system and rarely bacteraemia and septicemia. Phylogenetic analysis of E. coli showed majority of the strains responsible for UTI belongs to the phylogenetic group B2 and D, while in smaller percentage belong to A and B1 [19].
It has three antigens O-cell was antigen, H- flagella antigen and k- Capsular antigen. It has pili—a capsule, fimbriae, endotoxins and exotoxins also. Uropathogenic E. coli use P fimbriae (pyelonephritis-associated pili) to bind urinary tract endothelial cells. Vast majority of catheter-colonizing cells (up to 88%) express type 1 fimbriae and around 73% in E. coli causing CAUTI [20]. In UPEC fimbrial genes are ygiL, yadN, yfcV, and c2395 [21]. Pathogenesis of CAUTI initiated with UPEC colonization in periurethral and vaginal areas. Then it ascends to bladder lumen and grows as planktonic cells in urine. Sequentially adherence to bladder epithelium, then biofilm formation and invasion with replication and kidney colonization and finally bacteremia [22] (Figure 1).
Gram stain picture and morphology of E. coli. Adapted from CCBC faculty web. BIOL 230 Lab Manual: gram stain of E. coli and infection landscapes: Escherichia coli. http://faculty.ccbcmd.edu/courses/bio141/labmanua/lab16/gramstain/gnrod.html.
Diagnosis of E. coli infection is simple, by isolation and laboratory identification of bacterium from urine or biofilm. Laboratory diagnosis by culture of specimen—urine or catheter biofilm in blood agar, MacConkey’s agar or eosin-methylene blue agar (which reveal lactose fermentation). Immunomagnetic separation and specific ELISA, latex agglutination tests, colony immunoblot assays, and other immunological-based detection methods are other ways for diagnosis of E. coli.
Proteus species, member of the Enterobacteriaceae family of gram-negative bacilli are distinguishable from most other genera by their ability to swarm across an agar surface [23, 24]. Proteus species are most widely distributed in environment and as other enterobacteriaceae, this bacteria is part of intestinal flora of human being [25, 26]. Proteus also found in multiple environmental habitats, including long-term care facilities and hospitals. In hospital setting, it is not unusual for proteus species to colonize both the skin and mucosa of hospitalized patient and causing opportunistic nosocomial infections. It is one of the common causes of UTI in hospitalized patients undergoing urinary catheterization [26, 27].
UTIs are the most common manifestation of Proteus infection. Proteus infection accounts for 1–2% of UTIs in healthy women and 5% of hospital acquired UTIs. Catheters associated UTI have a prevalence of 20–45%. Proteus mirabilis causes 90% of proteus infection and proteus vulgaris and proteus penneri also isolated from long-term care facilities and hospital and from patients with underlying disease or specialized care. Most common age group is 20–50 years. More common in female group and the ratio between male female begins to decline after 50 years. UTI in men younger than 50 are usually caused by urologic abnormalities. Patients with recurrent infections, those with structural abnormalities of the urinary tract, those who have had urethral instrumentation or catheterization have an increase frequency of infection caused by proteus species [28].
Proteus mirabilis produces an acidic capsular polysaccharide which was shown from glycose analysis, carboxyl reduction, methylation, periodate oxidation and the application high resolution nuclear magnetic resonance techniques. Proteus species possess an extracytoplasmic outer membrane, a common feature shared with other gram-negative bacteria. Infection depends upon the interacting organism and the host defense mechanism. Various component of the membrane interplay with the host to determine virulence. Virulence factors associated with adhesion, motility, biofilm formation, immunoavoidance, nutrient acquisition and as well as factors that cause damage to the host [29, 30] (Figure 2).
Gram stain picture and morphology of Proteus. Adapted from CCBC faculty web. BIOL 230 Lab Manual: gram stain of Proteus mirabilis and Proteus vulgaris bacteria (SEM) | Macro & Micro: Up Close and Personal | Pinterest | Microbiology, Bacteria shapes and Fungi. https://www.pinterest.com › pin.
Certain virulence factors such as adhesin, motility and biofilm formation have been identified in Proteus species that has a positive correlation with risk of infection. After attachment of Proteus with urothelial cells, interleukin 6 and interleukin 8 secreted from the urothelial cells causes apoptosis and mucosal endothelial cell desquamation. Urease production of proteus also augments the risk of UTI. Urease production, together with the presence of bacterial motility and fimbriae or pili, as well as adhesins anchored directly within bacterial cell membrane may favor the upper urinary tract infection. Once firmly attached on the uroepithelium or catheter surface, bacteria begin to phenotypically change, producing exopolysaccharides that entrap and protect bacteria. These attached bacteria replicate and form microcolonies that eventually mature into biofilms [31, 32]. Once established, biofilms inherently protect uropathogens from antibiotic and the host immune response [33, 34]. Proteus mirabilis as with other uropathogens is capable of adapting to the urinary tract environment and acquiring nutrients. And this is accomplished by the production of degradative enzymes such urease and proteases, toxins such as Haemolysin Hpm A and iron nutrient acquisition proteins.
The infection with Proteus can be diagnosed by taking a urine sample for microscopy and culture which is sufficient in most of the cases except in few cases where advanced diagnostic tools are used. If the urine is alkaline, it is suggestive of infection with Proteus sp. The diagnosis of Proteus is made on swarming motility on media, unable to metabolized lactose and has a distinct fishy door. Ultrasound or CT scan to identify renal stone (Struvite stone) or to visualized kidneys or surrounding structures. It will allow to exclude other possible problems, mimicking symptoms of urinary tract infection [35, 36].
Pseudomonas is a gram-negative bacteria belonging to the family Pseudomonadaceae and containing 191 validly described species [37]. Because of their widespread occurrence in water and plant seeds, the pseudomonas was observed in early history of microbiology. Pseudomonas is flagellated, motile, aerobic organism with Catalase and oxidase-positive. Pseudomonas may be the most common nuclear or of ice crystals in clouds, thereby being of utmost importance to the formation of snow and rain around the world [38]. All species of Pseudomonas are strict aerobes, and a significant number of organisms can produce exopolysaccharides associated with biofilm formation [39]. Pseudomonas is an opportunistic human pathogen that is especially adept at forming surface associated biofilms. Pseudomonas causes catheter associated urinary tract infection(CAUTIs) through biofilm formation on the surface of indwelling catheters, and biofilm mediated infection including ventilator associated pneumonia, infections related to mechanical heart valves, stents, grafts, sutures, and contract lens associated corneal infection [40].
Pseudomonas is third ranking causes nosocomial UTI about 12%, where E. coli remain on the top [41]. CAUTI is directly associated with duration of catheterization. Within 2–4 days of catheterization 15–25% patients develop bacteriuria [42].
Pseudomonas aeruginosa is a gram-negative, rod shaped, asporogenous and monoflagellated, noncapsular bacterium but many strains have a mucoid slime layer. Pseudomonas has an incredible nutritional versatility. Pseudomonas can catabolize a wide range of organic molecule including organic compounds such as benzoate. This, then make Pseudomonas a very ubiquitous microorganism and Pseudomonas is the most abundant organism on earth [43] (Figure 3).
Gram stain picture and morphology of Pseudomonas aeroginosa. Adapted from Science News. A new antibiotic uses sneaky tactics to kill drug-resistant Pseudomonas aeruginosa illustration and Pseudomonas Aeruginosa Stock Photos & Pseudomonas Aeruginosa Stock Images—Alams. https://www.alamy.com › stock-photo.
Pseudomonas is widely distributed in nature and is commonly present in moist environment of hospitals. It is pathogenic only when introduce into areas devoid of normal defense such as disruption of mucous membrane and skin, usage of intravenous or urinary catheters and neutropenia due to cancer or in cancer therapy. Its pathogenic activity depends on its antigenic structure, enzymes and toxins [44]. Among the enzymes Catalase, Pyocyanin, Proteases, elastase, haemolysin, Phospholipase C, exoenzyme S and T and endotoxin and endotoxin A play role in disease process and as well as immunosuppression. Pseudomonas can infect almost any organ or external site. Pseudomonas in invasive and toxigenic. It attached to and colonized the mucous membrane of skin. Pseudomonas can invade locally to produce systemic disease and septicemia. Pseudomonal UTs are usually hospital acquired and are associated with catheterization, instrumentation and surgery. These infections can involve the urinary tract through an ascending infection or through bacteriuria spread. These UTIs may be a source of bacteraemia or septicemia [45].
Identification of bacterium with microscopy is simple method of identification of pseudomonas. Culture and antibiotic sensitivity pattern can be done in most laboratory media commonly on blood agar or eosin-methylthionine blue agar. Pseudomonas has inability to ferment lactose and has a positive oxidase reaction. Fluorescence under UV light is helpful in early identification of colonies. Fluorescence is also used to suggest the presence of pseudomonas in wounds [46].
Urinary catheters are standard medical devices utilized in both hospital and nursing home settings are associated with a high frequency of catheter-associated urinary tract infections (CAUTI). The contribution of Klebsiella spp. in CAUTI is near about 7.7% [47].
Klebsiella pneumoniae is a gram-negative pathogenic bacterium, is part of the Enterobacteriaceae family. It has got polysaccharide capsule attached to the bacterial outer membrane, and it ferments lactose. Klebsiella species are found ubiquitously in nature, including in plants, animals, and humans. They are the causative agent of several types of infections in humans. It has a large accessory genome of plasmids and chromosomal gene loci. This accessory genome divides K. pneumoniae strains into opportunistic, hyper virulent, and multidrug-resistant groups [48] (Figure 4).
Gram stain picture and morphology of Klebsiella pneumonie. Adapted from studyblue.com. Microbio Lab Practical I—Microbiology 101 with Johnson at University of Vermont—StudyBlue. Study 368 Microbio Lab Practical I flashcards from Tess H. on StudyBlue and Klebsiella Pneumoniae Stock Photos and Pictures. Getty Images https://www.gettyimages.com › photos.
The source of Klebsiella causing CAUTI can be endogenous typically via meatal, rectal, or vaginal colonization or exogenous, such as via equipment or contaminated hands of healthcare personnel. They typically migrate along the outer surface of the indwelling urethral catheter, until they enter the urethra.
Migration of the Klebsiella along the inner surface of the indwelling urethral catheter occurs much less frequently, compared with along the outer surface Internal (intraluminal) bacterial ascension occurs by Klebsiella tend to be introduced when opening the otherwise closed urinary drainage system, ascend from the urine collection bag into the bladder via reflux, biofilm formation occurs.
A critical step in progression to CAUTI by Klebsiella is to adhere to host surfaces, which is frequently achieved using pili (fimbriae) [49]. Pili are filamentous structures extending from the surface of Klebsiella. They can be as long as 10 μm and between 1 and 11 nm in diameter. Among the two types of pili—type 1 (fim) pili and type 3 (mrk) pili, type 1 aids virulence by their ability to adhere with mucosal surfaces and type 3 pili strongly associated with biofilm production [50]. Both fim and mrk pili are considered part of the core genome [51]. It is thought that both types of pili play a role in colonization of urinary catheters, leading to CAUTI [52]. In addition to fim and mrk pili, a number of additional usher-type pili have been identified in Klebsiella with an average of ~8 pili clusters per strain. Based on varying gene frequencies, some of these appear to be part of the accessory genome. Immediately after catheterization Klebsiella starts biofilm production on the inner as well as outer surface of the catheter and on urothelium. Biofilm augments migration of Klebsiella into urethra and urinary bladder. Biofilm formation on the catheter surface by Klebsiella pneumoniae causes severe problem. Type 1 and type 3 fimbriae expressed by K. pneumoniae enhance biofilm formation on urinary catheters in a catheterized bladder model that mirrors the physicochemical conditions present in catheterized patients. These two fimbrial types does not is expressed when cells are grown planktonically. Interestingly, during biofilm formation on catheters, both fimbrial types are expressed, suggesting that they are both important in promoting biofilm formation on catheters [53]. The biofilm life cycle illustrated in three steps: initial attachment events with inert surfaces type 1 and type 3 fimbriae encoded by the mrk ABCDF gene cluster within K. pneumoniae promotes biofilm formation [54, 55]. Detachment events by clumps of Klebsiella or by a ‘swarming’ phenomenon within the interior of bacterial clusters, resulting in so-called ‘seeding dispersal’.
Modifiable risk factor are prolonged catheterization, lack of adherence to aseptic catheter care, insertion of the indwelling urethral catheter in a location other than an operating room, presence of a urethral stent, feecal incontinence. Non-modifiable risk factor—renal disease (i.e., serum creatinine >2 mg/dL), diabetes mellitus, older age (i.e., age > 50 years old), female sex, malnutrition and severe underlying illness [53]. For infection several virulence factors such as surface factors (fimbriae, adhesins, and P and type 1 pili) and extracellular factors toxins, siderophores, enzymes, and polysaccharide coatings are necessary for initial adhesion with colonization of host mucosal surfaces for tissue invasion overcoming the host defense mechanisms, and causing chronic infections [55].
Diagnosis of klebsiella infection is by isolation and laboratory identification of bacterium from urine or biofilm. Laboratory diagnosis can be done by culture of specimen—urine or catheter biofilm in blood agar, MacConkey’s agar. Specific ELISA, latex agglutination tests, PCR and other immunological-based detection methods are sophisticated alternatives for diagnosis of klebsiella. Determination of a gene on capsule of Klebsiella is rapid and simple method for the determination of the K types of most K. pneumoniae clinical isolates [56].
Enterobacter species, particularly Enterobacter cloacae and Enterobacter aerogenes, are important nosocomial pathogens responsible for about 1.9–9% CAUTI, rarely causes bacteremia [57, 58]. Enterobacter cloacae exhibited the highest biofilm production (87.5%) among isolated pathogens [53].
Enterobacter bacteria are motile, rod-shaped cells, facultative anaerobic, non-spore-forming, some of which are encapsulated belonging to the family Enterobacteriaceae. They are important opportunistic and multi-resistant bacterial pathogens. As facultative anaerobes, some Enterobacter bacteria ferment both glucose and lactose as a carbon source, presence of ornithine decarboxylase (ODC) activity and the lack of urease activity. In biofilms they secrete various cytotoxins (enterotoxins, hemolysins, pore-forming toxins. Though it is microflora in the intestine of humans, it is pathogens in plants and insects. Amp C β-lactamase production by E. cloacae is responsible for cephalosporin resistance. They possess peritrichous, amphitrichous, lophotrichous, polar flagella. E. aerogenes flagellar genes and its assembly system have been acquired in bloc from the Serratia genus [59] (Figure 5).
Gram stain picture and morphology of Enterobacter species. Adapted from Gram Stain Kit | Microorganism Stain | abcam.comAdwww.abcam.com/ and Science Prof Online. Gram-negative Bacteria Images: photos of Escherichia coli, Salmonella & Enterobacter and Enterobacter aerogenes | Gram-negative microorganism—HPV Decontamination | Hydrogen Peroxide Vapour—Bioquellhealthcare.bioquell.com › microbiology.
The most important test to document Enterobacter infections is culture. Direct gram staining of the specimen is also useful. In the laboratory, growth of Enterobacter isolates is occurs in 24 h or less; Enterobacter species grow rapidly on selective (i.e., MacConkey) and nonselective (i.e., sheep blood) agars.
Enterococci are gram-positive facultative anaerobic cocci, two species are common commensal organisms in the intestines of humans: Enterococcus faecalis (90–95%) and Enterococcus faecium (5–10%) [60]. Though normally a gut commensal, these organisms are commonly responsible for nosocomial infection of urinary tract, biliary tract and blood, particularly in intensive care units (ICU) [61]. E. coli is usually the most frequent species isolated from bacteremic catheter associated urinary tract infections (CAUTI). However, Enterococcus spp. (28.4%) and Candida spp. (19.7%) were also reported to be most common [62]. In another study, E. coli was found the commonest (36%) followed by Enterococcus spp. (25%), Klebsiella species (20%) and Pseudomonas spp. (5%) [63].
The most important cause of bacteriuria is the formation of biofilm along the catheter surface [64]. Enterococcus is gram positive bacteria often found in pairs or short chains. Broadly, Enterococcus is in two groups—faecalis and non-faecalis (E. gallinarum and E. casseliflavus). Enterococcus faecalis formerly classified as part of the group D Streptococcus is a gram-positive, commensal bacterium inhabiting the gastrointestinal tracts of humans and other mammals, survive harsh environmental conditions including drying, high temperatures, and exposure to some antiseptics [65]. E. faecalis has the important characteristics of complex set of biochemical reactions, including fermentation of carbohydrates, hydrolysis of arginine, tolerance to tellurite, and motility and pigmentation. Presence of the catheter itself is essential for E. faecalis persistence in the bladder, E. faecalis depends on the catheter implant for persistence via an unknown mechanism that more than likely involves its ability to produce biofilms on the silicone tubing and immune-suppression [66].
E. faecalis produce a heteropolymeric extracellular hair-like fimbrial structure called the endocarditis- and biofilm-associated pilus-Ebp, having three components the organelle (EbpC), a minor subunit that forms the base of the structure (EbpB) and a tip-located adhesin (EbpA) [67]. EbpA is responsible for adhesion in urothelial and catheter surface for biofilm production (Figure 6).
Morphology of Enterococcus. Adapted from Science Photo Library/Alamy Stock Photo Image ID: F6YBC3.
Urine sample and biofilm microscopy can identify this gram positive organism. Culture yields the growth of E. faecalis in appropriate media. Advanced diagnostic methods like immunological-based detection methods and PCR are rarely needed for diagnosis.
One of the common causes of catheter associated urinary tract infection is fungal infection. Bacterial infections are accounted for 70.9% of catheter associated urinary infection. E. coli is the most commonly isolated organism (41.6%) whereas fungal infections are accounted for 16.6% and mixed fungal and bacterial infections accounted for 12.5% [68]. The National nosocomial infections surveillance (NNIS) data indicated that C. albicans caused 21% of catheter-associated urinary tract infections, in contrast to 13% of non-catheter-associated infections [69]. In one study 24% of the cases showing fungal yeast growth. Candida spp. was the commonest. Non-albicans Candida (86%) isolated more commonly than Candida albicans (14%) [70]. Candida are commensals, and to be pathogenic, interruption of normal host defenses is crucial which is facilitated in conditions like immunocompromised states as AIDS, diabetes mellitus, prolonged broad spectrum antibiotic use, indwelling devices, intravenous drug use and hyperalimentation fluids [71]. Diabetes mellitus has been reported as the most common risk factor for fungal infection [72, 73]. The duration of catheterization is also an important risk factor as the duration increases the incidence of fungal infection is increased [74].
Candida albicans is an oval, budding yeast, which is a member of the normal flora of mucocutaneous membrane. Twenty species of Candida yeasts can cause in human infection but most common is Candida albicans. Sometimes it can gain predominance and can produce disease. Other candida species that can cause disease occasionally are Candida parapsilosis, Candida tropicalis and Candida krusei [75]. Although Candida albicans are common isolates in CAUTI, Candida tropicalis is increasingly reported in CAUTI [76]. The majority of Candida albicans infections are associated with biofilm formation on host or abiotic surfaces such as indwelling medical devices, which carry high morbidity and mortality [63, 77]. Several factors and activities contribute to the pathogenesis of this fungus which mediate adhesion to and invasion into host cells, which are in sequences are the secretion of hydrolases, the yeast-to-hypha transition, contact sensing and thigmotropism, biofilm formation, phenotypic switching and a range of fitness attributes [78] (Figure 7).
Morphology of Candida albicans. Adapted from biomedik8888, Aug 24, 2011. http://www.BioMedik.com.au3.
Urine and materials removed from catheter are needed. Microscopic examinations of gram-stained specimen showed pseudohyphae and budding cells. Culture on Sabouraud’s agar at room temperature and at 37°C showed typical colonies and budding pseudomycelia [79].
It is facultative anaerobic bacilli gram-negative rod of Enterobacteriaceae family considered opportunistic human pathogen but not a component of human facial flora. It is capable of producing a pigment called prodigiosin, which ranges in color from dark red to pale pink. It is ubiquitously spent in nature and has preference for damp conditions. Though previously known as nonpathogenic, but since 1970s it is associated with multi drug resistant infection due to presence of R factor—a plasmid. A study in Japan showed 6.8% incidence of UTI with this organism [80]. It also causes bacteraemia rarely. Diagnosis is confirmed by culture of the urine specimen or catheter biofilm. Automated bacterial identification systems and Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) is the other modality for diagnosis of serratia as well as other enterobacteriaceae [81].
This non-fermentative gram-negative rod discovered as plant growth-promoting bacterium and potential biocontrol agent against plant pathogens. Infection with this uncommon organism in CAUTI occurs in combination with commonest bacteria E. coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. D. tsuruhatensis and E. coli coexist and tend to co-aggregate over time and also cooperate synergistically [82]. D. tsuruhatensis metabolized citric acid more rapidly leaving more uric acid available in the medium to be used by E. coli for dynamic growth of both organisms. Identification of this organism is not confirmatory with culture, so molecular methods are more reliable [83].
Achromobacter denitrificans is gram negative bacterium formerly known as Alcaligenes denitrificans. Infection with this organism predominantly observed in elderly patients with predisposing factors as urological abnormalities, malignancies and immune-suppression. Rarely it causes bacteraemia. This bacterium has high level of antibiotic resistance [84].
In polymicrobial biofilm, Achromobacter xylosoxidans cohabits with common organisms E. coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Diagnosis is by bacterial culture and molecular methods.
Staphylococci (methicillin-sensitive Staphylococcus aureus [MSSA] and methicillin-resistant S. aureus [MRSA], Staphylococcus saprophyticus. These are the common gram positive bacteria usually responsible for skin and soft tissue infections but rarely cause CAUTI and bacteraemia [85].
The incidence of Staphylococcal UTI as well as CAUTI is increasing and the organisms carry wide variety of multidrug-resistant genes on plasmids, which augment spread of resistance among other species [86].
Diagnosis is easy, gram stain of the sample, culture is sufficient. Advanced techniques rarely needed (Figure 8).
Morphology of Staphylococcus aureus. Adapted from abcam.comAdwww.abcam.com/ pharmacist-driven intervention improves care of patients with S aureus Bacteremia/Staph aureus. Nebraska Medicine https://asap.nebraskamed.com.
CAUTI is one of the most nosocomial Infection worldwide resulting from rational as well as sometimes irrational use of indwelling urinary catheter. Cause of CAUTI is formation of pathogenic biofilm commonly due to UPEC, Proteus, Klebsiella, Pseudomonas, Enterobacter rarely Candida and other uncommon opportunistic organisms. CAUTI has got high impact on morbidity and mortality as biofilm producing organisms are more antibiotic resistant. Antibiotic resistance is a global problem. Early detection of CAUTI is simple by examination of urine and catheter biofilm with microscopy as well as culture with antibiogram. It is easy and cost effective with early diagnosis and treatment for good clinical outcome. Advanced and sophisticated methods like Immunomagnetic separation, specific ELISA, colony immunoblot assays and PCR for diagnosis of CAUTI is seldom necessary.
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