Anaerobe 77 (2022) 102509

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Anaerobe
journal homepage: www.elsevier.com/locate/anaerobe

Review Article

Urinary tract infections: Should we think about the anaerobic cocci?

Lyudmila Boyanova a, *, Yulia Marteva-Proevska b, Rumyana Markovska a,
Daniel Yordanov a, Raina Gergova a
a
Department of Medical Microbiology, Medical University of Sofia, Sofia, Bulgaria
b
University Alexander Hospital, Medical University of Sofia, Sofia, Bulgaria

a r t i c l e i n f o a b s t r a c t

Article history: Anaerobic cocci are common anaerobic isolates. Numerous genera of anaerobic cocci have been reported
Received 30 November 2021 in both urinary tract microbiota, mainly of females, and in cases of urinary tract infections (UTIs), pre-
Received in revised form dominantly in patients with comorbidities, when no facultatively anaerobic bacteria were detected from
28 December 2021
the urine samples. UTIs caused by anaerobic cocci have been reported in >7% in some studies. As the
Accepted 30 December 2021
routine diagnostic methods may be insufficient to detect and identify the anaerobic cocci in patients with
Available online 4 January 2022
UTIs, enhanced quantitative urine culture (EQUC) can give better results. EQUC is performed by plating
Handling Editor: Elisabeth Nagy urine samples onto different media to be incubated in both aerobic and anaerobic conditions with a
prolonged incubation time. Other newer methods such as 16S rRNA gene sequencing, qualitative PCR and
Keywords: Next Generation Sequencing can also be considered. Anaerobic cocci such as Peptoniphilus, Parvimonas,
Anaerobic cocci Anaerococcus and Finegoldia spp. were found in patients with bacteremia of urinary source. A fatal
Urinary tract infections outcome has been reported in a diabetic patient with emphysematous pyelonephritis caused by Fine-
Detection goldia magna and Candida parapsilosis due to a delay in seeking hospital care during the COVID-19
Enhanced quantitative urine culture
pandemic. In specific cases such as of chronic infections, immunosuppression, comorbidity, advanced
Treatment
age, following urological tract manipulations and negative culture results for usual uropathogens, it may
be advisable to use suprapubic aspiration cultured in both aerobic and anaerobic condition or EQUC
using media which support the relative slow growing anaerobic cocci as well.
© 2022 Elsevier Ltd. All rights reserved.

1. Introduction
Anaerobic bacteria can cause different types of urinary tract
infections (UTIs), such as cystitis, pyelitis, pyelonephritis, peri-
nephric abscess etc. [1]. Anaerobic bacteriuria has been common in
catheterized patients in intensive care units [2]. Anaerobic cocci are
part of the skin, respiratory, oral, gastrointestinal and urogenital
microbiota of the human body and common causative agents of
infections, since up to 1/3 of clinical anaerobic isolates have been
Gram-positive anaerobic cocci (GPAC), [3,4]. The anaerobic cocci
involve a large number of genera such as Finegoldia, Parvimonas,
Peptostreptococcus, Anaerococcus, Peptoniphilus, Murdochiella, Veil-
lonella and others [3,5].
The aim of the present review was to summarize and discuss
data on the spectrum, prevalence and significance of the anaerobic
* Corresponding author.
E-mail addresses: l.boyanova@hotmail.com, boyanova_lbg@medfac.mu-sofia.bg
(L. Boyanova).
cocci in urinary tract microbiota and UTIs. The keywords “anaerobic
cocci”, “urinary tract infections”, “urinary tract microbiota”, “uri-
nary tract microflora”, “diagnosis”, “antibiotic susceptibility”,
“treatment” and “urine sample” were searched in PubMed, Scopus
and Google Scholar. In this review, we encompassed data from 28
articles, most (n ¼ 19, about 70%) of which published in 2017e2021
as well as our recent case of UTI caused by two species of anaerobic
cocci in a patient with comorbidity and following a urological
procedure.
2. Anaerobic cocci in urinary tract microbiota
Numerous genera of anaerobic cocci were found in urinary tract
microbiota. Akgül and Karakan [6] encompassed data of four
studies on urinary tract microbiota of totally 150 healthy adult
women (Table 1). The detected GPAC belonged to different genera
such as Anaerococcus, Peptoniphilus, Finegoldia and Fannyhessea
(Atopobium), and Gram-negative anaerobic cocci of Veillonella
genus were detected as well [6]. In these studies, anaerobic cocci
were identified by 16S rRNA gene sequencing or enhanced

https://doi.org/10.1016/j.anaerobe.2021.102509
1075-9964/© 2022 Elsevier Ltd. All rights reserved.
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al. Anaerobe 77 (2022) 102509

Table 1
Anaerobic cocci in urinary tract microbiota (UTM) and in urinary tract infections (UTIs).

In Country Group of subjects/patients Samples Methods No of No. of % of Genera/species Strain susceptibility/ Reference
patients isolates isolates (numbers) treatment

UTM Several Healthy adult women Catheter 16S rRNA gene 150 NA NA Fannyhessea NA 6
(data of (bladder) or sequencing (Atopobium),
four midstream and/or EQUC Anaerococcus,
studies) urine Peptoniphilus,
Finegoldia, Veillonella
UK Asymptomatic female and Voided urine Quantitative 16 NA NA Parvimonas, NA 7
male volunteers aged 26 PCR of 16S Anaerococcus,
e90 years rRNA genes Finegoldia,
Murdochiella,
Peptoniphilus,
Negativicoccus
China Elderly and non-elderly Urine 16S rRNA 50 12 12.0 Peptoniphilus and NA 8
women sequencing elderly Parvimonas
and 50
non-
elderly
women
UTIs Germany Consecutive patients for Urine Culture, PCR, 1449 NA NA Anaerococcus NA 24
UTI examination 16S rDNA lactolyticus,
sequencing, Anaerococcus
DHPLC (Peptostreptococcus)
vaginalis,
Fannyhessea
(Atopobium) vaginae,
F. magna,
Peptoniphilus sp.
Hungary Symptomatic children and Suprapubic ANC cards or 54 4 7.4 F. magna (2), NA 11
adult patients bladder MALDI TOF MS samples Peptococcus niger (1),
aspirates Peptoniphilus indolicus
(1)
Sweden Patients with GPAC Blood cultures Blood culture, 229 21 9.2 Peptoniphilus (9), Susceptible to IMP and 9
bacteremia MALDI- TOF Parvimonas (8), TZP; resistance to PEN
MS, 16S rRNA Anaerococcus (3), (1.8%), MTZ (2.7%) and
gene Finegoldia (1) CLI (7.3%), EUCAST
sequencing, E breakpoints
tests
Canada Postmenopausal women Transurethral 16S rRNA gene 17 5 of 15 33.3 F. magna 5-fold more Local estrogen 28
with or without recurrent urine sequencing (rUTIs), before before common in rUTI group treatment (LET)
UTIs (rUTIs) 20 LET, LET, before LET than
(controls) 6 of 15 6.7% following LET, absent
after after in controls.
LET, LET,
0 in 0.0 in
controls controls
USA Women before Catheter Culture, 16S 126 NA NA F. vaginae and F. NA 16
urogynecologic surgery (bladder) rRNA gene magna abundance
urine sequencing associated with
symptom severity
USA A patient aged Urine Culture 1 (case 1 NA F. magna (1) VAN, TZP, nephrectomy, 17
62 years with diabetes, report) retroperitoneal
obesity, nephrolithiasis, debridement, (fatal
prostatic hypertrophy, outcome)
emphysematous
pyelonephritis and
urosepsis
USA A woman with Calcium Culture 1 1 NA Veillonella sp. (1) Nephrostomy, 13
nephrolithiasis and phosphate nephrolithotomy,
urosepsis urinary stone antibiotics
Canada A woman aged 47 years Catheter urine Culture, 1 1 NA Veillonella parvula (1) Susceptible to MTZ, PEN, 14
with recurrent UTIs and MALDI- TOF IMP and TET.
multiple comorbidities MS, 16S rRNA Treatment: MTZ (7 days)
sequencing, E and CRO (5 days)
test
Japan A pregnant woman aged 21 Voided urine Culture 1 1 NA Veillonella sp. (1) Susceptible to AMP, CLI, 15
years with hydronephrosis and blood CTX, IMP, resistant to
and urosepsis. cultures VAN. Treatment:
cefotiam i.v.
(empirically), then AMP
i.v.
Spain A 15-year-old girl with Catheter Culture 1 1 NA Peptoniphilus sp. AMX (i.v. for 3 days, then 12
cutaneous vasculitis and urine, blood orally for up to 1 week)
UTI. culture
Bulgaria Voided urine 1 1 NA

2
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al.
Table 1 (continued )
In Country Group of subjects/patients Samples Methods
A 73-year woman with Culture,
diabetes, rheumatoid MALDI- TOF
arthritis and frequent UTIs MS, E tests
following percutaneous
nephrostolithotomy
GPAC- Gram-positive anaerobic cocci, NA-not available or not appropriate; NGS-16S rRNA rapid next-generation gene sequencing; UTM-urinary tract microbiota; UTIs-
urinary tract infections, DHPLC-denaturing high-performance liquid chromatography, EQUC- expanded quantitative urine culture. LET-local estrogen treatment.
Antibiotics: AMP-ampicillin; AMX-amoxicillin, AMC- amoxicillin/clavulanate; CIP-ciprofloxacin; CLI-clindamycin; CRO-ceftriaxone; CTX-cefotaxime; IMP- imipenem; MTZ-
metronidazole; PEN-penicillin; TET-tetracycline; TZP- piperacillin/tazobactam; VAN-vancomycin.
quantitative urine culture (EQUC, see below), [6].
Lewis et al. [7] evaluated clean catch urine samples of 16
asymptomatic female and male volunteers aged 26e90 years by
16S rRNA gene amplification and amplicons analysis of the samples
with 454 pyrosequencing. The authors found four strictly anaerobic
genera, including Jonquetella, Saccharofermentans and Proteiniphi-
lum spp. and the anaerobic cocci belonging to genus Parvimonas to
be specific for the urinary tract microbiota of subjects older than 70
years [7]. Therefore, the authors speculated that it is possible for
these anaerobic bacteria to cause infections in elderly patients,
however, more studies are needed to prove the assumption [7].
Liu et al. [8] evaluated urinary microbiota in women aged 61e85
years in comparison with that in a group of 28e60-year aged
women and found some interesting age-dependent differences.
Frequency of GPAC was 33.3% (10/30) in the urinary samples of the
group of women aged >70 years, lower (20.0%, 2/10) in those of
66e70-year-old women and 0% in those of women aged 61e65
years. Moreover, asymptomatic bacteriuria was associated with
lower levels of anaerobic cocci of Peptoniphilus genus and anaerobic
rods of Dialister genus [8]. The authors concluded that female uri-
nary microbiota differs according to the age, presence of diabetes
and in patients with asymptomatic bacteriuria [8].
3. Anaerobic cocci in urinary tract infections (UTIs)
Underdiagnosing or overlooking of anaerobes, including the
anaerobic cocci from routine urine culture testing is owing to their
relatively low pathogenic potential in the urinary tract and the lack
of anaerobic diagnostics in many laboratories and centers. How-
ever, in patients with comorbidities such as immune suppression,
diabetes and pelvic infections, the UTIs associated with the anaer-
obic cocci can cause bacteremia [9,10], (Table 1).
In Sweden, Badri et al. [9] assessed 229 cases of bacteremia with
involvement of GPAC and revealed that urinary tract was the focus
of the infection in 21 (9.2%) of the cases. The authors used BACTEC
rieux) blood culture
FX (Becton Dickinson) and BacT/Alert (bioMe
systems incubated for up to 120 h, the positive of which were
plated onto Fastidious anaerobe agar and incubated in an anaerobic
chamber. Microflex MALDI-TOF MS (Bruker Daltronics) was used
for identification of the isolates, and 16S rRNA genes were
sequenced in case of insufficient determination by MALDI-TOF MS
[9]. The anaerobic cocci in GPAC bacteremia cases, originating from
urinary tract infections, involved isolates of the genera Peptoni-
philus (9 isolates), Parvimonas (8), Anaerococcus (3) and Finegoldia
(1), [9].
In the study of Gajdacs et al. [11], 54 urine samples obtained by
suprapubic bladder aspiration were evaluated for anaerobic bac-
teria and in 4 (7.4%) of the samples, anaerobes belonging to the
anaerobic cocci (two Finegoldia magna isolates, one Peptococcus
niger isolate and one Peptinophilus indolicus isolate) were identified.
The samples for anaerobic diagnostics were incubated in an
Anaerobe 77 (2022) 102509
No of No. of % of Genera/species Strain susceptibility/ Reference
patients isolates isolates (numbers) treatment
F. magna and AMC i.v. for 5 days and Boyanova
Peptoniphilus then orally for 7 days. (unpublished)
asaccharolyticus
anaerobic chamber and were identified by ANC cards (bioMe rieux
Hunga ria Ltd., Budapest, Hungary) or Microflex MALDI Biotyper
(Bruker Daltonics, Bremen, Germany), [11].
Esteban-Zubero et al. [12] observed a case of UTI and cutaneous
vasculitis caused by Peptoniphilus spp. in a 15-year-old girl. The
isolate was susceptible to ampicillin, amoxicillin and moxifloxacin
[12].
Recently, we isolated two GPAC species, F. magna and Peptoni-
philus asaccharolyticus from the voided urine sample of a 73-year
woman with diabetes, rheumatoid arthritis and frequent UTIs.
The patient was treated with tocilizumab and methotrexate. In
2019, the patient developed macroscopic hematuria. Klebsiella
pneumoniae bacteriuria (103 colony-forming units, CFU/ml),
thereafter treated with intravenous piperacillin/tazobactam, and a
kidney stone with a diameter of 20e25 mm were detected. In
January 2020, a percutaneous nephrostolithotomy was performed.
In July 2020, a routine follow-up revealed anemia, creatinine con-
centration of 180 mmol/L, normal level of C reactive protein and
5  107 leukocytes and 1.7  109 erythrocytes in the urine sedi-
ment. Urine examination showed the presence of Morganella
morganii (104 CFU/ml), Staphylococcus aureus (104 CFU/ml), and
Escherichia coli (103 CFU/ml). According to the susceptibility testing
results, treatment with ciprofloxacin for 7 days and cefuroxime for
7 days was administered and was successful at the follow-up
evaluations. However, the creatinine concentration further
increased to 240 mmol/L. In September 2020, due to retention of
inflammatory markers (erythrocyte sedimentation rate, ESR), C
reactive protein (16.4 mg/dL) and creatinine, a microbiological
urine evaluation was performed and revealed no growth of facul-
tative anaerobes, including Mycoplasma spp., despite the presence
of leukocyturia and hematuria (6 leukocytes and 30 erythrocytes
per high power field) and ESR of 100 mm/h. Suprapubic bladder
aspiration is the recommended method for diagnosing anaerobes
in UTIs [11]. In our case, the anaerobic cocci (104 CFU/ml) were
detected in a voided urine sample, however, they were the only
isolates from the sample and the treatment according to the sus-
ceptibility testing data was successful (see below). The urine sam-
ples were plated onto Anaerobe basal agar (Oxoid, Basingstoke, UK)
with 5% sheep blood and were identified with routine methods and
MALDI TOF MS (Vitek MS, bioMe rieux, Marcy l’Etoile, France).
Veillonella spp. are Gram-negative anaerobic cocci that have
seldom been isolated from urine specimens. However, a case report
of Veillonella detection from a calcium stone culture of a woman
aged 56 years with nephrolithiasis and urosepsis has been recently
reported [13]. Berenger et al. [14] have also observed a case of
Veillonella parvula UTI in a 47-year-old woman with recurrent UTIs,
urinary retention and multiple comorbidities such as a past stroke,
gastroesophageal reflux disease, hypothyroidism and substance
abuse. Growth of V. parvula was observed on a cystine-lactose-
electrolyte deficient (CLED) medium (Orion Diagnostica, Oy,
Finland). The causative agent (108 CFU/ml) was isolated by
3
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al.
anaerobic incubation on Fastidious anaerobic agar and thio-
glycolate broth for 24 and 48 h and was identified by Vitek® MS
(bioMe rieux, Marcy L'Etoile, France) and 16S rRNA gene sequencing
[14]. Yagihashi and Arakaki [15] have described a Veillonella UTI in a
36-week pregnant Japanese woman aged 21 years with urosepsis
and hydronephrosis. The Gram-negative cocci were isolated from
both the urine samples on the anaerobic plate after 7-day incuba-
tion and the blood culture samples after 8-day incubation [15].
Therefore, the growth of the anaerobic cocci may require a pro-
longed incubation.
Fok et al. [16] evaluated overactive bladder symptom severity in
126 women with stress urinary incontinence and pelvic organ
prolapse before and following urogynecologic surgery. The authors
used 16S rRNA gene sequencing to assess bladder urine, vaginal and
perineal microbiota of the patients and found that the higher
preoperative abundance of F. magna and Fannyhessea (Atopobium)
vaginae in the catheterized bladder urine samples was significantly
associated with a higher severity of symptoms. The authors sug-
gested a possible association of bladder microbiota with the risk of
persistent symptoms in certain patient groups [16].
Severe UTIs such as emphysematous pyelonephritis with fatal
outcomes can occur in patients with diabetes mellitus. Krol et al.
[17] have reported a severe emphysematous pyelonephritis and
urosepsis caused by F. magna and Candida parapsilosis in a diabetic
man aged 62 years. The patient also had obesity, nephrolithiasis
and prostatic hypertrophy. The fatal outcome in this case was
associated with the development of sepsis due to a three-week
delay of the treatment caused by fearing a risk of getting a severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection
during hospitalization [17]. This case report shows the serious
consequences of the delay in seeking medical help due to concerns
related to COVID-19 for the patients with UTIs and comorbidity.
4. Diagnostic methods
Urine samples can be obtained as midstream clean-catch urine
or by a transurethral catheter, or by suprapubic aspiration [18].
Given that >30% of UTI's can be polymicrobial [10,19,20] and the
choice of antibiotics for therapy requires reliable identification of
the causative agents, multiplex PCR can detect mixed infections
[10,19]. For the diagnosis, both routine and newer methods such as
qualitative PCR (SeptiFast real-time PCR), EQUC and Next Genera-
tion Sequencing (NGS) can be implemented [18,21]. Quantitative
PCR assay detecting 16S rRNA genes in urine specimens was used
for comparative evaluation of bacterial numbers [7].
Unlike standard urine culture which detects fast-growing
facultative anaerobes such as E. coli and Proteus spp. at concentra-
tion of 103 CFU/ml, the EQUC can detect bacteria at concentration of
only 10 CFU/ml, involving fastidious and slow growing aerobic and
anaerobic species [20]. The EQUC technique with plating three
volumes such as 1, 10 and 100 ml of the urine sample onto multiple
media, incubated in both aerobic and anaerobic conditions has
been successful for diagnosing UTIs in children [20]. For the an-
aerobes, urine volumes of 100 ml can be plated onto suitable rich
media such as CDC Anaerobe Blood Agar and thereafter can be
incubated anaerobically for 48 h [22].
The NGS performed directly on the urine sample is based on PCR
and high throughput sequencing of essential 16S ribosomal RNA
genes and does not require bacterial growth, moreover, this
method can be used to detect antibiotic resistance genes as well
[18,23].
4
Anaerobe 77 (2022) 102509
Imirzalioglu et al. [24] evaluated urine samples from 1449 pa-
tients for UTI examination in a German university hospital by
routine urine culture, 16S rDNA PCR and denaturing high-
performance liquid chromatography (DHPLC) analysis. Fastidious
bacteria, mostly anaerobes, were frequent (22.4%) causative agents
of UTIs and notably, they were detected only by the molecular
methods. The anaerobic cocci detected by PCR were of different
genera such as Anaerococcus, Finegoldia, Peptoniphilus and Fanny-
hessea [24].
5. Treatment approach
Anaerobic cocci display different antibiotic susceptibility pat-
terns according to the type of the infection, the bacterial genus and
species, the country and both national and individual antibiotic
consumption. Moreover, multidrug resistance was also observed
among the anaerobic cocci such as F. magna and Veillonella spp [25].
In France, in the recent study of Gue rin et al. [4] on 133 GPAC iso-
lates, susceptibility to metronidazole, linezolid and imipenem was
100%, however, high resistance rates to amoxicillin (in 45% of
Peptostreptococcus anaerobius isolates) were found and those to
cefotaxime, clindamycin, moxifloxacin and rifampin (in different
GPAC species) were variable [4]. Minimal inhibitory concentrations
(MICs) were analyzed according to CA-SFM/EUCAST breakpoints
except for cefotaxime [4]. Veloo et al. [26], evaluating resistance in
anaerobes from different countries with E tests and EUCAST
breakpoints, have reported high amoxicillin-clavulanic acid resis-
tance rates in Peptostreptococcus spp. in Kuwait (45%) and Slovenia
(8.6%), resistance to piperacillin-tazobactam in Turkey and Ger-
many, and to metronidazole in half (6/12) of Peptostreptococcus
isolates in Croatia. In the study of Badri et al. [9] on 229 cases of
GPAC bacteremia, including 21 cases of urinary tract origin, peni-
cillin resistance was found in 1.8% (4/220 isolates) and resistance
rates to metronidazole and clindamycin were 2.7% (6/222) and 7.3%
(16/219), respectively, using EUCAST breakpoints. The average time
for intravenous treatment and follow-up oral therapy was 6 and 7
days, respectively [9].
In our case, F. magna and P. asaccharolyticus susceptibility was
tested with E tests (Liofilchem, Roseto degli Abruzzi, Italy) ac-
cording to EUCAST breakpoints [27]. Both isolates were susceptible
to amoxicillin (MIC, 0.12 mg/l), metronidazole (MICs, 2 mg/l),
clindamycin (MICs, 0.5 mg/l) and resistant to levofloxacin (MICs,
>10 mg/l) and differed in susceptibility to tetracycline,
P. asaccharolyticus being resistant to the agent (MIC, 256 mg/l). The
patient was successfully treated with amoxicillin/clavulanic acid
intravenously (1000 mg/200 mg b.i.d.) for 5 days and thereafter
orally (500 mg/125 mg t.i.d.) for 7 days. The risk of anaerobic UTIs
such as those involving anaerobic cocci in immunocompromised
patients after urological procedures merits further evaluation.
Esteban-Zubero et al. [12] successfully treated a girl with cuta-
neous vasculitis and UTI caused by Peptoniphilus sp. with amoxi-
cillin (1 g t.i.d., parenterally for 3 days and orally thereafter) and
corticosteroids.
In the case report of Berenger et al. [14], V. parvula was sus-
ceptible to penicillin, imipenem, metronidazole and tetracycline
according to CLSI breakpoints and the associated UTI was treated by
metronidazole for 7 days, followed by ceftriaxone for 5 days. In the
case report of Yagihashi and Arakaki [15], the Veillonella UTI in a
pregnant woman was treated by insertion of a ureteral stent and
intravenous cefotiam empirically (for seven days), later changed to
intravenous ampicillin since the in vitro testing revealed
L. Boyanova, Y. Marteva-Proevska, R. Markovska et al.
susceptibility to ampicillin, imipenem, cefotaxime and clindamycin
as well as vancomycin resistance [15].
In postmenopausal women with recurrent UTIs involving
F. magna infections, a local (vaginal) estrogen therapy and use of
probiotics have been reported as a useful non-antibiotic approach.
Anglim et al. [28] have recently reported the effect of vaginal es-
trogen therapy on urinary bladder microbiota and detected pres-
ence/abundance of F. magna in 33.3% (5/15) of the urine sample of
the postmenopausal women evaluated before the local estrogen
treatment with Premarin (containing conjugated estrogens) or
Vagifem (containing estradiol) tablets for 3e6 months versus only
6.7% (1/15) after the treatment. F. magna was detected in controls
neither before nor after the local estrogen treatment [28].
The data show that UTIs caused by anaerobic cocci can be suc-
cessfully treated if they are taken into consideration on time.
6. Conclusion
In conclusion, diagnosis of anaerobic bacteria, including anaer-
obic cocci is justified in patients with chronic infections, immune
suppression, comorbidity and elderly people in whom the causative
agent of the persistent or recurrent UTI was not established.
However, since the routine methods for diagnosing UTIs are not
appropriate to identify all the anaerobes, including the anaerobic
cocci, suprapubic aspiration and culture in both aerobic and
anaerobic atmosphere using media supporting the slow growing
anaerobic cocci can be of help. Newer methods and techniques such
as EQUC with incubation in both anaerobic and aerobic conditions,
16S rRNA gene amplification, qualitative PCR and NGS can be
considered as well. The risk of anaerobic UTIs in immunocompro-
mised patients following urological procedures deserves further
evaluation.
Ethical approval
Written informed consent was obtained from the patient of our
observation.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.anaerobe.2021.102509.
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