**2.2. P fimbriae**

P-fimbriated *E. coli* are pyelonephritogenic and attach to the carbohydrate structure alpha-D-Galp-(1-4)-beta-D-Galp. In the kidney, they bind strongly to Bowman's capsule, glomerulus, and endothelial cells of vessel walls. This highly organized composite structure is composed of six subunits at least. Once P fimbriae expressed *E. coli* enter the urinary tract, they establish bacteriuria and help to cross the epithelial barrier to enter the bloodstream and can cause hemagglutination of erythrocytes [14]. This type of fimbriae is encoded by *pap* gene cluster (also known as *fso* and *fst*), and *pap +* strains remain longer in the intestinal flora than papstrains [23]. P antigens are expressed in the cell surface of red blood cells and in various cells lining in the urinary tract. P1 (present in glycoproteins in human), P, PK, and LKE antigens act as the receptors for P-fimbriated UPEC. P-fimbriated *E. coli* cannot agglutinate red blood cells that lack P antigen. Isolated P fimbriae can bind to a synthetic analogue of its receptor, and experimental application of that analogue impedes infection process.

**2.3. Dr/Afa adhesins**

**2.4. Other fimbriae as virulence factors**

for the survival of UPEC strains such as F9 fimbriae.

**3. Toxins**

transferase (AST), etc.

Dr blood group antigen is a membrane protein of red blood cells and located on the decay accelerating factor (DAF) that protects red blood cells from being degraded or lysed by autologous complements. Another important function of DAF is to regulate complement cascade [25]. These antigens are recognized by Dr and Afa adhesin family of uropathogenic *E. coli.* There are both fimbrial (F1845 and O75X) and non-fimbrial (AFA I and AFA II) types of adhesins. Immuno-invasion of UPEC by hiding from the host humoral immune response is somehow mediated by Dr family of adhesins [26]. These microscopically invisible fimbriae are present in the cell wall, and their structural and organization properties are quite different from other types of fimbriae [13]. Chloramphenicol can inhibit O75X binding to a specific part of the Dr antigen, but it cannot inhibit other adhesins of this family which indicates that Dr family adhesins can recognize specific sites at the Dr [25]. For years, several studies were conducted to identify specific sites for binging of Dr family hemagglutinins. For instance, a strong affinity of O75X was found to Bowman's capsule, proximal and distal tubules, and the collecting duct basement membranes. In the bladder, they strongly bind to connective tissues.

Virulence Factors of Uropathogenic *E. coli* http://dx.doi.org/10.5772/intechopen.79557 11

F1C is a virulence factor responsible for urinary tract infections, which is encoded by an operon of seven genes, i.e., *focAICDFGH*, where FocA is the major subunit and FocH is the tip adhesin [26]. F1C receptors are present in bladder endothelium and muscular layer. They cannot bind to the epithelium. They bind to glomeruli, distal tubules, collecting ducts, and vascular endothelial cells. Studies show that F1C fimbriae and pyelonephritis are correlated though there is a little difference in the prevalence of type 1 fimbriae in UTI strains and normal fecal isolates. Prevalence of F1C fimbriae in normal fecal isolates is 10% which is 16% in UTI strains [26]. S fimbriae are genetically identical to F1C fimbriae and differ only by the tip adhesin SfaS. Criteria that are needed to be recognized as a virulence factor were determined by different studies regarding S fimbriae. There are some other adhesins that are not crucial

Several toxic substances or proteins secreted by uropathogenic strains of *E. coli* play a consequential role as virulence factors in UTIs. However, toxins have the ability to alter the host cell signaling cascade and modulate inflammatory responses. Several in vitro and in vivo studies showed that toxins also contribute to the stimulation of the host cell death and releasing of necessary nutrients, which provide the ability to access deeper tissues within the urinary tract [27]. In 1987, CDT toxin (cyclomodulins) was first reported as virulent toxin in UPEC [28] which opened a new door in the study of the pathogenesis of UTIs, and then many other toxins in UPEC were reported including α-hemolysin (HlyA), cytotoxic necrotizing factor 1 (CNF1), secreted autotransporter toxin (SAT), cytolysin A, plasmid-encoded toxin (PET), vacuolating autotransporter toxin (VAT), Shigella enterotoxin-1 (ShET-1), arginine succinyl-

There are at least nine genes in the pap gene cluster with two restriction sites at two ends. The regulatory part starts the following Eco R1 consisting of papI and papB. Then papA, papH, papC, papD, papE, papF, and papG are situated, and after these, Bam HI is present. Approximately 1000 of subunits form a P fimbria, being united in a helical manner. Among them the major constituent is the protein subunit PapA (19.5 KD), and minor subunits are PapE (16.5 KD), PapF (15 KD), and PapG (35 KD). In the periplasmic space, PapD (27.5 KD) may be present and can also be incorporated in the structure. Another protein PapC, which is the largest one with 80 KD of mass, assists the process by transporting the subunits outside the part of the cell. Though PapA is the major constituent, it is not mandatory for attachment, and among many serotypes, PapA molecules show high homology with the amino acids of N and C termini. PapA also has an average level of similarity with structural subunits of other *E. coli* fimbriae including type 1 fimbriae. The minor subunits at the tip of fimbria determine the specificity to the receptor. Many mutational analyses revealed that mutation in PapA does not affect the adherence, while mutation in other genes (i.e. *papEFG*) does not hamper fimbrial structural appearance. In the fine structure of P fimbriae, a PapF-PapG complex is formed which is attached to PapA (bulk potion of the structure) subunits through PapE subunits. Finally, PapH terminates the assembly of the fimbriae and attaches thereby [16]. An important thing is that the amino acid sequence of PapG is approximately similar to that of Shiga toxin. Shiga toxin is found in some serotypes of *E. coli.* Another role of PapG was found in some variants of P fimbriae which is they can initiate subunit polymerization [14].

Many experiments show that expression of these fimbriae is not relevant to urinary tract infection, while more sophisticated other experiments have concluded about their role in pathogenesis. However, during infection in immunocompromised patients, less expression of P fimbriae is observed, which indicated that P fimbriae are needed to overcome certain types of host immune attacks. Although P fimbriae can initiate inflammatory responses by activating TLR4 [24], it protects UPEC from human polymorphonuclear leukocytes (hPMNLs). In the rapidly changing environment through the urinary tract, environmental influences affect the expression of P fimbriae. Expression of P fimbriae is favored at 37°C and inhibited at a range of 18–22 °C, but there are some variations in this phenomenon. The temperature-dependent expression is controlled by a region close to *papB* of the pap gene cluster.
