JOURNAL OF CLINICAL MICROBIOLOGY, Apr. 2000, p. 1703–1705 Vol. 38, No.

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Copyright © 2000, American Society for Microbiology. All Rights Reserved.

Aerococcus urinae in Urinary Tract Infections

QING ZHANG,1 CHRISTOPHER KWOH,2 SILVIA ATTORRI,1 AND JILL E. CLARRIDGE III1,3,4*
Department of Pathology1 and Department of Microbiology and Immunology,3 Baylor College of Medicine,
Baylor College of Medicine,2 and Pathology and Laboratory Medicine Service,
Veterans Affairs Medical Center,4 Houston, Texas
Received 8 November 1999/Returned for modification 31 December 1999/Accepted 21 January 2000

Aerococcus urinae is a rarely reported pathogen, possibly due to difficulties in the identification of the
organism. A. urinae is a gram-positive coccus that grows in pairs and clusters, produces alpha-hemolysis on
blood agar, and is negative for catalase and pyrrolidonyl aminopeptidase. Some of these characteristics and its
being absent from the databases of most commercial identification systems could allow A. urinae to be
misidentified as a streptococcus, enterococcus, or staphylococcus. We report two cases of urinary tract infection
(UTI) caused by A. urinae and characterize these isolates by morphology, biochemical testing, whole-cell fatty
acid analysis, 16S rRNA gene sequencing, and antibiotic susceptibilities. Most patients infected with A. urinae
are elderly males with predisposing conditions who present initially with UTI. Because A. urinae is resistant to
sulfonamides, treatment could be inappropriate, with infections resulting in serious complications, including
death. It is important for the clinician and the microbiologist to consider A. urinae a potential pathogen and
proceed with thorough microbiological identification.

CASE REPORTS with normal vital signs and a large, tender prostate on physical
exam. Urinalysis revealed 4 to 6 WBCs/HPF, no bacteria, trace
Case 1. An 80-year-old male with preexisting coronary artery amounts of leukocyte esterase, and negative results for nitrites,
disease, left-sided hemiparesis (the residual effect of a stroke), protein, ketones, bilirubin, and blood. He was diagnosed clin-
and multiinfarct dementia was admitted to the hospital for ically with prostatitis and treated with tetracycline due to a
altered mental status. The patient developed slowly worsening history of ciprofloxacin allergy. The patient developed a rash
urinary symptoms, including nocturia and frequency, over the
3 weeks prior to admission.
On admission the patient was afebrile with normal vital
TABLE 1. Biochemical results of the present clinical isolates
signs. The physical examination was unremarkable except that compared with the literature values for A. urinae and A. viridans
a marked disorientation to place and time and a left-sided (adapted from references 1, 2, 4, 5, 6, and 7)
hemiparesis (the residual effect of a previous stroke) were
observed. Urinalysis showed white blood cells (WBCs) too Result fora:
numerous to count, 8 red blood cells/high power field (HPF), Test Present clinical
many bacteria, a specific gravity of 1.017, and a pH of 5.0, with A. urinae A. viridans
isolates
negative results for protein, ketones, and bilirubin. The patient
had a serum WBC count of 6.6 (64% neutrophils, 19% lym- Hydrolysis of:
Hippurate ⫹ ⫹ NA
phocytes, 9% monocytes, 7% eosinophils, and 1% basophils) Arginine ⫺ ⫺ NA
and a hemoglobin and a hematocrit of 10.6 g/dl and 31.5%, Acid production from:
respectively. Serum chemistries including electrolytes, glucose, Glucose ⫹ ⫹ NA
liver, renal, and thyroid function tests were all reported as Sucrose ⫹ ⫹ ⫹
normal. Chest X-ray was normal except for an elevated right Maltose ⫺ ⫺ ⫹
hemidiaphragm. Computed tomogram of the head revealed a Sorbitol ⫹ ⫹ ⫺
previous infarct in the distribution of the right middle cerebral Lactose ⫺ ⫺ ⫹
artery as well as hypodensity consistent with diffuse small ves- Trehalose ⫺ ⫺ ⫹
sel disease. The patient was treated empirically with intrave- Mannitol ⫹ ⫹ V
Inulin ⫺ ⫺ NA
nous ciprofloxacin for presumed urinary tract infection (UTI). Starch ⫺ NA NA
Urine cultures grew ⬎105 CFU of Aerococcus urinae, the only Glycogen ⫺ ⫺ NA
isolate, per ml. His urinary symptoms resolved and his mental Ribose ⫹b ⫹b V
status improved by hospital day 3. The patient was discharged, L-Arabinose ⫺ ⫺ NA
having had oral ciprofloxacin prescribed. Results of repeated Enzyme production
urinalysis after discharge were normal. ␤-Glucosidase ⫺ ⫺ NA
Case 2. A 58-year-old white male with adequately treated ␤-Glucuronidase ⫹ ⫹ ⫺
hypothyroidism presented at the Veterans Affairs Medical ␤-Galactosidase ⫺ ⫺ ⫹
Center outpatient clinic with several days of dysuria, increased ␣-Galactosidase ⫺ ⫺ NA
Alkaline phosphatase ⫺ ⫺ NA
urinary frequency, and nocturia. He was afebrile at the time, Leucine arylamidase ⫹ ⫹ ⫺
Pyrrolidonyl aminopeptidase ⫺ ⫺ ⫹
Urease ⫺ NA NA
* Corresponding author. Mailing address: Pathology and Laboratory Nitrite reductase ⫺ ⫺ NA
Medicine Service (113), Veterans Affairs Medical Center, 2002 Hol-
combe Blvd., Houston, TX 77030. Phone: (713) 794-7336. Fax: (713) a
NA, not available; V, variable; ⫹, positive; ⫺, negative.
794-7657. E-mail: jillc@bcm.tmc.edu. b
Acid production was slow.

1703
1704 CASE REPORTS J. CLIN. MICROBIOL.

TABLE 2. Antibiotic susceptibilities of present isolates, together

with those of A. urinae and A. viridans (adapted from

Did not return for follow-up

references 3, 4, and 10)a

Septic shock, endocarditis,

Sepsis, endocarditis, death

Result of treatment
Result for:

Endocarditis, death

Endocarditis, death
Present isolates
Antibiotic A. A.
Disk
diffusion E-testc urinae viridans

Recovered

Recovered

Recovered
testb

Unknown
death
Penicillin G S (40, 40) S (0.016, 0.064) S R

PR, present report; M, male; F, female; CIP, ciprofloxacin; TET, tetracycline; TMP, trimethoprim; AMP, ampicillin; GEN, gentamicin; CXM, cefuroxime; SULFA, sulfamethizole.
Trimethoprim- R (0, 0) R (0, 0) R S
sulfamethoxazole
Vancomycin S (26, 25) S (0.75, 0.75) S S

Initial treatment
Ciprofloxacin S (30, 30) S (0.25, 0.25) NA NA

AMP, GEN

AMP, GEN
Gentamicin R (0, 0) ND R S

Unknown
SULFA
Tetracycline S (32, 32) S (0.25, 0.5) S S

CXM

TMP
TET
CIP

CIP
a
S, susceptible; R, resistant; NA, not available; ND, not done.
b
Standard disks recommended by National Committee for Clinical Labora-

TABLE 3. Summary of clinical features of our two cases and previously reported casesa
tory Standards guidelines were used. Values in parentheses are inhibitory zone
sizes (in millimeters) for the isolates from cases 1 and 2 (in that order).

No sign of sepsis

2 of 2 positive at
c
Values in parentheses are MICs (in micrograms per milliliter) of the respec-

Blood culture

Positive for 17
2 of 2 positive
tive drugs for the isolates from cases 1 and 2 (in that order).

result

Not septic

patients
3 days
Positive
Positive

Positive

Positive
and discontinued the antibiotic after 2 days of treatment. He

Case 9 was a study of 63 patients (34 female patients and 29 male patients). The age listed is the median age (range, 3 to 97 years).
returned to the clinic 2 weeks later, still complaining of urinary
symptoms, and was febrile at 100.1°F. A second urinalysis
Urine culture

Negative

Negative
demonstrated 20 to 30 WBCs/HPF, 1 to 3 red blood cells/HPF,

Normal
resultc

⬎105
5

⬎105

⬎105
⬎105

5
⬎10

⬎10
a moderate level of leukocyte esterase, and negative urine
chemistries. The urine culture on the second urine sample later
grew ⬎105 CFU of A. urinae, the only isolate, per ml. The
patient was lost to follow-up.
Nocturia, urinary frequency,

Fever, symptoms of a UTI,

Dysuria and large, tender
Main symptoms and signs

Fever, hematuria, dysuria

Dysuria, testicular pain,

altered mental status

Antecedent UTI, heart

incontinence, pyuria

Fever, dysuria, pyuria,

Fever, heart murmur

Sepsis, fever, urinary

Microbiology. We compared two strains of A. urinae from

heart murmur

incontinence
the present cases and two blood isolates of Aerococcus viridans

septicemia
from our stock for growth on Trypticase soy agar with 5%

Values given are in CFU per milliliter. The result for case 4 was obtained with a dipstick.
murmur
prostate

sheep blood, with incubation at 35°C in three different atmo-

spheres. At 24 h, the diameters of colonies of A. urinae grown
in ambient air, air plus 8% CO2, or anaerobic conditions were
0.1, 0.5, or 0.5 mm, respectively. At 48 h all colonies were
larger, but at 24 h, A. viridans grew to 0.7- and 1-mm diameters
Coronary artery disease, alcoholism

Diabetes mellitus, prostatic disease,

in air and in air plus 8% CO2, respectively, and showed no

growth under anaerobic conditions. A. viridans growth in an-
Alcoholism, hepatic cirrhosis,

aerobic conditions was barely visible at 48 h. The colonies of

Underlying disease(s)

cerebrovascular disease

both species produce alpha-hemolytic reactions on blood agar.

Coronary artery disease,

The two A. urinae strains are catalase negative and pyrroli-

chronic pancreatitis

indwelling catheter

donyl aminopeptidase (PYR) test negative. Biochemical iden-

tification was performed by the API 20 Strep system (bio-
Hypothyroidism

Prostate cancer

Prostate cancer
Not identified

Meriéux, Marcy l’Etoile, France), the Rapid CB Plus system

Meningioma

(Remel, Lenexa, Kans.), and an automated identification sys-

tem (Vitek 120; bioMeriéux, Hazelwood, Mo.) according to
the manufacturers’ instructions. The results shown in Table 1
are consistent with the results reported by Christensen et al.
(4). The API biotype number (3442300) is appropriate for A.
M, F

urinae but is not in the code book. The Vitek gave a unique
Sex

M
M

M
M

code number (52025410000 or 50025410200) that is also not in

the code book. The whole-cell fatty acid (CFA) analysis was
age (yr)
Patient

performed on isolates grown on blood agar plates for 48 h at

80

58

78
43

81
63

81

80

74

35°C in 8% CO2 (Hewlett-Packard HP 5890 II microbial iden-

tification system [MIDI, Inc., Newark, Del.]), which gave no
match or called the isolate Streptococcus equinus at a 0.291
(reference)
Case no.

1 (PR)

2 (PR)

similarity index. The major CFAs were hexadecanoic acid

3 (10)

7 (13)

b
4 (7)

5 (2)
6 (2)

8 (8)

9 (4)

(16:0) (24%), octadecenoic acid (18:1 omega 9 cis) (21%),

a
b
c

octadecanoic acid (18:0) (17.5%), hexadecenoic acid (16:1

VOL. 38, 2000 CASE REPORTS 1705

omega 9 cis) (12%). However, A. viridans was correctly named 24 h the colony morphology resembles that of an alpha-hemo-
by all these biochemical identification systems. The nucleotide lytic streptococcus or lactobacillus; at 48 h it is similar to that
sequences of 16S rRNA were determined (MicroSeq 16S of an enterococcus. The Gram stain should be differential, as
rRNA gene kit; Perkin-Elmer Applied Biosystems, Foster City, A. urinae forms pairs, tetrads, and clusters. However, since A.
Calif.). The two isolates were identified as A. urinae by 16S urinae shows smaller cocci and fewer tetrads than A. viridans
rRNA gene sequencing, with a 0.2 to 0.4% difference from the does, it could be confused with pediococci or densely packed
type strain. A. urinae demonstrated a 7 to 8% difference from streptococci or enterococci.
A. viridans, which indicates a genetic diversity similar to that We characterized our isolates by macroscopic and micro-
found among other well-described genera and does not sup- scopic appearance, biochemical profiles, CFA analysis, 16S
port Facklam and Elliott’s assertion that these organisms, rRNA gene sequencing analysis, and antibiotic susceptibilities.
which they call Aerococcus-like organisms, belong in a separate However, according to our study and previous reports (3, 4,
genus (6). 5, 6), the most important routine tests are detection of leucine
Antibiotic susceptibility was tested by the disk diffusion arylamidase, ␤-glucuronidase, PYR, hydrolysis of hippurate
method using Mueller-Hinton blood agar, and the MICs were (Table 1), and antibiotic susceptibility patterns (Table 2).
determined by E-test. National Committee for Clinical Labo- Rapid PYR testing is useful for distinguishing between A.
ratory Standards guidelines for Staphylococcus spp. were used viridans or enterococci (both PYR positive) and A. urinae
for susceptibility testing (11). Our strains of A. urinae are (PYR negative). A Gram stain should be carefully examined
resistant to trimethoprim-sulfamethoxazole and gentamicin for the characteristic arrangement in clusters and tetrads to
but susceptible to penicillin (Table 2). rule out lactobacillus and other streptococcus. Pediococci are
Discussion. There are currently three described species of PYR negative and have a Gram stain morphology similar to
the genus Aerococcus: A. viridans, Aerococcus christensenii, and that of A. urinae; however, they differ in their resistance to
A. urinae. A. viridans is more commonly isolated from blood vancomycin and in their positive bile esculin test result. Other
and has been associated with granulocytic bacteremia (9) and newly described genera that are rarely encountered in the
endocarditis (12). The recently characterized species A. chris- clinical laboratory can be differentiated by the characteristics
tensenii (5) has not been reported as a human pathogen. A. listed in Table 1 (6).
urinae, previously known as Aerococcus-like organism, is an
uncommon pathogen. Previous reports from European coun-
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