Introduction

Staphylococcus saprophyticus is a Gram-positive, coagulase negative, non-hemolytic coccus that

is a common cause of uncomplicated urinary tract infections (UTIs), particularly in young
sexually active females. Less commonly, it is responsible for complications including acute
pyelonephritis, urethritis, epididymitis, and prostatitis.[1][2]
An acute uncomplicated UTI is characterized by dysuria and frequency in an immunocompetent,
non-pregnant adult female and is the most common bacterial infection in women. A complicated
infection typically involves a patient that is immunocompromised, elderly, male, pregnant,
diabetic, and/or with urologic abnormalities such as indwelling catheters or kidney disease.
S. saprophyticus can be differentiated from another coagulase-negative staphylococcus by its
resistance to Novobiocin. Like other uropathogens, S. saprophyticus utilizes urease to produce
ammonia. However, unlike many of these organisms, it cannot reduce nitrate.
S. saprophyticus is part of the normal human flora that colonizes the perineum, rectum, urethra,
cervix, and gastrointestinal tract. It has also been found that S. saprophyticus is a common
gastrointestinal flora in pigs and cows and thus may be transferred to humans through eating
these respective foods.
Go to:

Etiology
S. saprophyticus is the second most common cause of community-acquired urinary tract
infections, after Escherichia coli. In females ages 16 to 25, it causes up to 42% of all infections.
Over 40% of all young, sexually active women contain S. saprophyticus as part of their normal
genitourinary flora.[3][4][5]
Patients with nosocomial UTIs, the elderly, pregnant patients, and those with urinary
catheterization have an increased incidence S. saprophyticus colonization. Men have a lower
incidence of S. saprophyticus infections.
General risk factors for UTI’s include history of recurrent UTIs, female sex, recent sexual
intercourse, pregnancy, neurogenic bladder, indwelling catheter, and benign prostatic
hypertrophy.[6][7]
S. saprophyticus is also a common culprit involved in polymicrobial UTIs. Polymicrobial
infections are more likely to occur in patients that are immunocompromised, elderly, those who
have diabetes, have indwelling catheters, HIV, and/or malignancies. Polymicrobial infections are
less common in young, healthy, sexually active females.
Go to:

Epidemiology
In the United States, urinary discomfort is a common complaint in patients seeking medical
attention. UTIs are one of the top 10 diagnoses made in emergency departments annually. Nearly
half of all women will experience a UTI in their lifetime, and between 5% and 20% of non-
hospitalized patients, the infection will be due to S. saprophyticus. Despite highly successful
treatment rates, up to 60% of all patients will experience a recurrent UTI within one year.
Go to:

Pathophysiology
Bacterial colonization of the bladder and ureter epithelium by S. Saphrophyticus occurs via
several different types of adhesins. These include hemagglutinins with autolytic and adhesive
properties, as well as surface-associated lipase that forms fimbria-like surface appendages,
helping the bacteria to maintain tight adherence to these surfaces.
It is suspected that the high survivability of S. saprophyticus inside the urinary tract is in part due
to the adhesins anchored within the cell wall, allowing the organism to effectively adhere and
colonize the uroepithelium, together with urease, which contributes to the persistent growth of
the infection.
Some strains of S. Saprophyticus have the ability to create biofilms, increasing their virulence,
especially in patients with catheters. Once biofilms have been produced, antibiotic resistance is
exacerbated. In these cases, S. Saprophyticus may be resistant to vancomycin and only
effectively treated via linezolid.
Go to:

History and Physical

The characteristic history of dysuria, urinary frequency, urinary urgency, and suprapubic pain
will be common in symptomatic UTI patients. In those patients with pyelonephritis, back or
flank pain, nausea, and fever or chills may also be present.
Physical examination may reveal suprapubic tenderness, in 10% to 20% of cases, and should
include urine specimen for analysis. However, in most cases of uncomplicated UTI, a physical
examination is unremarkable. In complicated cases or pyelonephritis, patients may present with
fever, tachycardia, and/or costovertebral angle tenderness.
Go to:

Evaluation
The diagnosis of S. saprophyticus requires a confirmatory urine culture. A positive culture is
indicated by greater than 100,000 colony forming units per mL, with a sensitivity and specificity
of more than 90%.
UTI, in general, may be diagnosed more cost-effectively with a urine dipstick alone. A dipstick
that is positive for leukocytes esterase and/or nitrites is the most simplistic method of UTI
diagnosis. In cases of negative dipstick results, and high clinical suspicion, a bacterial urine
culture should also be obtained.[8][9]
  An adequate urine sample should be obtained from a mid-stream catch or straight
catheterization, which more effectively avoids contamination.
Imaging is not necessary for cases of uncomplicated UTIs. If renal pathology, such as
pyelonephritis, is suspected a CT scan is the most sensitive modality for demonstrating
complications such as hydronephrosis or renal abscess.
Go to:

Treatment / Management
Treatment with outpatient antibiotics is indicated in symptomatic or complicated UTIs and
pyelonephritis. It is important to take into consideration specific local resistance patterns when
choosing appropriate antibiotic coverage.[10]
The antibiotic of choice in uncomplicated S. saprophyticus UTIs is nitrofurantoin (Macrobid)
100 mg orally twice daily for five days, or for seven days in complicated cases. Trimethoprim-
sulfamethoxazole (TMP-SMX) 160 mg/800 mg by mouth twice daily for three days may be
given alternatively in uncomplicated cases.
Symptomatic treatment for pain and nausea should also be addressed. Acute uncomplicated
UTIs are unlikely to cause renal injury. Thus NSAIDs are a preferred analgesic. Pyridium may
also be given to alleviate associated dysuria. Ondansetron or Promethazine are commonly
prescribed anti-emetics. Most patients will notice symptomatic relief within 36 hours from
antibiotic treatment alone.
Patients who are hemodynamically unstable, have associated kidney injury, abscess formation, or
emphysematous pyelonephritis, have failed outpatient treatment, have intractable nausea,
vomiting, or pain, are unable to tolerate oral intake, or are unable to comply with medical
treatment may require admission.
Go to:

Differential Diagnosis
Other diagnoses include non-S. saprophyticus UTI or cystitis, urethritis, pyelonephritis, or
nephrolithiasis.
Go to:

Prognosis
The majority of S. saprophyticus infections can be adequately treated with antibiotics. However,
if left untreated, they may progress to pyelonephritis. Untreated pyelonephritis may lead to
further complications, such as renal insufficiency.
Go to:

Pearls and Other Issues

It is important to note that the diagnosis of UTI based on the combination of both leukocyte
esterase and nitrites, will miss cases caused by S. saprophyticus. Like most other gram-positive
uropathogens, S. saprophyticus does not reduce nitrate to nitrite.
S. saprophyticus has resistance to antibiotic regimes commonly prescribed and effective for E.
coli induced UTIs, including ampicillin, ceftriaxone, cephalexin, and ciprofloxacin. In cases
where UTI symptoms persist following treatment with one of the previously mentioned
antibiotics, S. saprophyticus should be highly suspected.
Go to:

Enhancing Healthcare Team Outcomes

UTIs are usually managed by the primary care provider, nurse practitioner, and an internist.
however, not all UTIs are due to gram-negative organisms. In some cases, the organism may be
S.Saprophyticus, which can only be identified following culture. While culture is not routine in
all patients with a UTI, when the patient fails to improve, one must suspect a different organism
and send the urine for culture.
Treatment with outpatient antibiotics is indicated in symptomatic or complicated UTIs and
pyelonephritis. It is important to take into consideration specific local resistance patterns when
choosing appropriate antibiotic coverage.
Patients who are hemodynamically unstable, have associated kidney injury, abscess formation, or
emphysematous pyelonephritis, have failed outpatient treatment, have intractable nausea,
vomiting, or pain, are unable to tolerate oral intake, or are unable to comply with medical
treatment may require admission. These patients may need IV antibiotics and radiological studies
to determine the extent of the infection.
When treated promptly, most patients have good outcomes.[11] (Level V)
Go to:

Questions
To access free multiple choice questions on this topic, click here.
Go to:

References
1.
Argemi X, Hansmann Y, Prola K, Prévost G. Coagulase-Negative Staphylococci
Pathogenomics. Int J Mol Sci. 2019 Mar 11;20(5) [PMC free article] [PubMed]
2.
Pinault L, Chabrière E, Raoult D, Fenollar F. Direct Identification of Pathogens in Urine
by Use of a Specific Matrix-Assisted Laser Desorption Ionization-Time of Flight
Spectrum Database. J. Clin. Microbiol. 2019 Apr;57(4) [PMC free article] [PubMed]
3.
Natsis NE, Cohen PR. Coagulase-Negative Staphylococcus Skin and Soft Tissue
Infections. Am J Clin Dermatol. 2018 Oct;19(5):671-677. [PubMed]
4.
Lala V, Minter DA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan
23, 2019. Acute Cystitis. [PubMed]
5.
Hur J, Lee A, Hong J, Jo WY, Cho OH, Kim S, Bae IG. Staphylococcus saprophyticus
Bacteremia originating from Urinary Tract Infections: A Case Report and Literature
Review. Infect Chemother. 2016 Jun;48(2):136-9. [PMC free article] [PubMed]
6.
Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections:
epidemiology, mechanisms of infection and treatment options. Nat. Rev. Microbiol. 2015
May;13(5):269-84. [PMC free article] [PubMed]
7.
Becker K, Heilmann C, Peters G. Coagulase-negative staphylococci. Clin. Microbiol.
Rev. 2014 Oct;27(4):870-926. [PMC free article] [PubMed]
8.
Stock I. [Nitrofurantoin--clinical relevance in uncomplicated urinary tract
infections]. Med Monatsschr Pharm. 2014 Jul;37(7):242-8. [PubMed]
9.
Mirone V, Franco M. Clinical aspects of antimicrobial prophylaxis for invasive
urological procedures. J Chemother. 2014 Oct;26 Suppl 1:S1-S13. [PubMed]
10.
Widerström M, Wiström J, Sjöstedt A, Monsen T. Coagulase-negative staphylococci:
update on the molecular epidemiology and clinical presentation, with a focus on
Staphylococcus epidermidis and Staphylococcus saprophyticus. Eur. J. Clin. Microbiol.
Infect. Dis. 2012 Jan;31(1):7-20. [PubMed]
11.
Stuart JI, John MA, Milburn S, Diagre D, Wilson B, Hussain Z. Susceptibility patterns of
coagulase-negative staphylococci to several newer antimicrobial agents in comparison
with vancomycin and oxacillin. Int. J. Antimicrob. Agents. 2011 Mar;37(3):248-
52. [PubMed]