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Mani SSR, Thomas A, Alam R, Lalwani M, Valson AT, Yadav B, Eapen JJ, John EE, Yusuf S, Mukha RP, Rajadoss MKP, Mercy D, Alexander S, Varughese S, David VG. Profile, Risk Factors, and Outcomes of Asymptomatic Bacteriuria in Kidney Transplant Recipients with Normal Pretransplant Genitourinary Tract: A Single-Center Experience. Indian J Nephrol 2024; 34:37-44. [PMID: 38645908 PMCID: PMC11003596 DOI: 10.4103/ijn.ijn_407_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/13/2023] [Indexed: 04/23/2024] Open
Abstract
Introduction There is a paucity of studies on asymptomatic bacteriuria (ASB) among kidney transplant recipients (KTR) in developing countries. This study assessed the clinical profile, risk factors, outcomes, and impact of treatment of ASB in KTRs with a normal genitourinary tract. Methods Consecutive KTRs from 2009 to 2018 with no clinical or radiological evidence of obstructive uropathy were included. Urinary tract infection (UTI) after ASB was defined as occurrence of cystitis, pyelonephritis, or urosepsis, with ASB being the first bacteriuric episode. Results Seven hundred ten out of 794 patients with median follow up of 47 months were included. The mean age was 35.5 ± 12 years. Eighty-one patients (11.4%) developed ASB at a median of 25 days (IQR 10, 134.5). Fifty-three percent and 4.9% of ASB episodes were extended-spectrum beta-lactamase (ESBL) positive and carbapenem-resistant organisms, respectively. Eighteen patients (32.1%) with early ASB (<3 months) and 5 (20%) with late ASB developed UTI on follow-up. Fifty-five percent of early and 16% of late ASB episodes were treated, with no significant difference observed in the risk of development of UTI when compared to untreated ASB episodes. Conclusion The incidence of ASB as first bacteriuric episode in our cohort was 11.4%, with there being significant antimicrobial resistance. Female gender, pretransplant UTI, and delayed graft function were independently associated with development of ASB. Treatment of ASB episodes either early or late did not decrease the risk of development of UTI.
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Affiliation(s)
| | - Athul Thomas
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rizwan Alam
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manish Lalwani
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anna T. Valson
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jeethu J. Eapen
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Elenjickal E. John
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sabina Yusuf
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajiv P. Mukha
- Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Deborah Mercy
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Suceena Alexander
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinoi G. David
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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Stohs EJ, Gorsline CA. Opportunities for Antimicrobial Stewardship Interventions Among Solid Organ Transplant Recipients. Infect Dis Clin North Am 2023:S0891-5520(23)00041-7. [PMID: 37280135 DOI: 10.1016/j.idc.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Although antimicrobial stewardship programs have excelled over the past decade, uptake and application of these programs to special populations such as solid organ transplant recipients have lagged. Here, we review the value of antimicrobial stewardship for transplant centers and highlight data supporting interventions that are ripe for adoption. In addition, we review the design of antimicrobial stewardship initiatives, targets for both syndromic and system-based interventions.
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Affiliation(s)
- Erica J Stohs
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA.
| | - Chelsea A Gorsline
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1028, Kansas City, KS, USA
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Codelia-Anjum A, Lerner LB, Elterman D, Zorn KC, Bhojani N, Chughtai B. Enterococcal Urinary Tract Infections: A Review of the Pathogenicity, Epidemiology, and Treatment. Antibiotics (Basel) 2023; 12:antibiotics12040778. [PMID: 37107140 PMCID: PMC10135011 DOI: 10.3390/antibiotics12040778] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Urinary tract infections (UTIs) are among the most common causes of infections worldwide and can be caused by numerous uropathogens. Enterococci are Gram-positive, facultative anaerobic commensal organisms of the gastrointestinal tract that are known uropathogens. Enterococcus spp. has become a leading cause of healthcare associated infections, ranging from endocarditis to UTIs. In recent years, there has been an increase in multidrug resistance due to antibiotic misuse, especially in enterococci. Additionally, infections due to enterococci pose a unique challenge due to their ability to survive in extreme environments, intrinsic antimicrobial resistance, and genomic malleability. Overall, this review aims to highlight the pathogenicity, epidemiology, and treatment recommendations (according to the most recent guidelines) of enterococci.
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Affiliation(s)
- Alia Codelia-Anjum
- Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Lori B Lerner
- Department of Urology, VA Boston Healthcare System, Boston, MA 02132, USA
| | - Dean Elterman
- Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, ON M5T 2SB, Canada
| | - Kevin C Zorn
- Division of Urology, Centre Hospitalier de l'Université de Monstréal, Montreal, QC H2X 0A9, Canada
| | - Naeem Bhojani
- Division of Urology, Centre Hospitalier de l'Université de Monstréal, Montreal, QC H2X 0A9, Canada
| | - Bilal Chughtai
- Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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4
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Gołębiewska JE, Krawczyk B, Wysocka M, Dudziak A, Dębska-Ślizień A. Asymptomatic Bacteriuria in Kidney Transplant Recipients-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020198. [PMID: 36837399 PMCID: PMC9958684 DOI: 10.3390/medicina59020198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Urinary tract infections (UTIs) are the most prevalent complications in kidney transplant (KTx) recipients. The most frequent finding in this group of patients is asymptomatic bacteriuria (ASB). Here, we provide an overview of the available evidence regarding ASB in KTx recipients, including its etiopathology, clinical impact and management. There is a growing body of evidence from clinical trials that screening for and treating ASB is not beneficial in most KTx recipients. However, there are insufficient data to recommend or discourage the use of a "screen-and-treat strategy" for ASB during the first 1-2 months post-transplant or in the case of an indwelling urinary catheter. Despite its frequency, ASB after KTx is still an understudied phenomenon.
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Affiliation(s)
- Justyna E. Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
- Correspondence:
| | - Beata Krawczyk
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, 80-233 Gdańsk, Poland
| | - Magdalena Wysocka
- Digital Experimental Cancer Medicine Team, Cancer Biomarker Centre, CRUK Manchester Institute, University of Manchester, Manchester M13 9PL, UK
| | - Aleksandra Dudziak
- Microbiology Laboratory, University Clinical Center, 80-952 Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
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Bacterial Urinary Tract Infection and Early Asymptomatic Bacteriuria in Kidney Transplantation Still Negatively Affect Kidney Transplant Outcomes in the Era of Modern Immunosuppression and Cotrimoxazole Prophylaxis. Biomedicines 2022; 10:biomedicines10112984. [PMID: 36428552 PMCID: PMC9687497 DOI: 10.3390/biomedicines10112984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/04/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
Risk factors and consequences of urinary tract infection (UTI) post-kidney transplant have been variously reported by studies that were heterogenous in immunosuppressants and prophylactic protocols. We aimed to clarify the risks and consequences of UTI in kidney transplant recipients with post-transplantation cotrimoxazole prophylaxis in the context of modern immunosuppression. This retrospective cohort included kidney transplant recipients receiving tacrolimus, mycophenolate, prednisolone, and cotrimoxazole for bacterial UTI prophylaxis. Recipients were categorized into non-UTI and UTI groups. Asymptomatic bacteriuria (ASB) was screened in the first 3 months and was evaluated for association with UTI. Of 348 kidney transplant recipients, 129 were in the UTI group and 219 in the non-UTI group. UTI risk factors were female sex, body mass index ≥ 25 kg/m2, human leukocyte antigen mismatch, and panel reactive antibody ≥ 50%. Recipients with recurrent UTI had inferior allograft function compared with non-UTI recipients. Patient survival was significantly lower in recipients with UTI in the first post-transplant month. Higher degree of immunosuppressions was associated with recurrent UTI and drug-resistant organisms. In conclusion, UTI continues to negatively affect graft function and survival of kidney transplant recipients. Treating ASB in the first 3 months did not reduce the UTI incidence in the first transplantation year.
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Protus M, Uchytilova E, Indrova V, Lelito J, Viklicky O, Hruba P, Kieslichova E. Sepsis affects kidney graft function and one-year mortality of the recipients in contrast with systemic inflammatory response. Front Med (Lausanne) 2022; 9:923524. [PMID: 35966839 PMCID: PMC9372308 DOI: 10.3389/fmed.2022.923524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background Infections remain a major cause of morbidity and mortality after kidney transplantation. The aim of our study was to determine the effect of sepsis on kidney graft function and recipient mortality. Methods A prospective, observational, single-center study was performed. Selected clinical and biochemical parameters were recorded and compared between an experimental group (with sepsis, n = 34) and a control group (with systemic inflammatory response syndrome, n = 31) comprising kidney allograft recipients. Results Sepsis worsened both patient (HR = 14.77, p = 0.007) and graft survival (HR = 15.07, p = 0.007). Overall one-year mortality was associated with age (HR = 1.08, p = 0.048), APACHE II score (HR = 1.13, p = 0.035), and combination immunosuppression therapy (HR = 0.1, p = 0.006), while graft survival was associated with APACHE II (HR = 1.25, p = 0.004) and immunosuppression. In sepsis patients, mortality correlated with the maximal dose of noradrenalin (HR = 100.96, p = 0.008), fungal infection (HR = 5.64, p = 0.024), SAPS II score (HR = 1.06, p = 0.033), and mechanical ventilation (HR = 5.97, p = 0.033), while graft survival was influenced by renal replacement therapy (HR = 21.16, p = 0.005), APACHE II (HR = 1.19, p = 0.035), and duration of mechanical ventilation (HR = 1.01, p = 0.015). Conclusion In contrast with systemic inflammatory response syndrome, septic kidney allograft injury is associated with early graft loss and may represent a significant risk of mortality.
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Affiliation(s)
- Marek Protus
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czechia
- First Faculty of Medicine, Charles University, Prague, Czechia
| | - Eva Uchytilova
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czechia
- First Faculty of Medicine, Charles University, Prague, Czechia
| | - Veronika Indrova
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jan Lelito
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Ondrej Viklicky
- First Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Petra Hruba
- Transplantation Laboratory, Experimental Medicine Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Eva Kieslichova
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czechia
- First Faculty of Medicine, Charles University, Prague, Czechia
- *Correspondence: Eva Kieslichova,
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7
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So M, Tsai H, Swaminathan N, Bartash R. Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e72. [PMID: 36483373 PMCID: PMC9726551 DOI: 10.1017/ash.2022.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 06/17/2023]
Abstract
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
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Affiliation(s)
- Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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8
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Urinary Tract Infections in Kidney Transplant Recipients-Is There a Need for Antibiotic Stewardship? J Clin Med 2021; 11:jcm11010226. [PMID: 35011966 PMCID: PMC8745876 DOI: 10.3390/jcm11010226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
(1) Background: Urinary tract infections (UTI) are the most common infections after kidney transplantation. Given the risk of urosepsis and the potential threat to the graft, the threshold for treating UTI and asymptomatic bacteriuria with broad spectrum antibiotics is low. Historically fluoroquinolones were prescription favorites for patients that underwent kidney transplantation (KT). After the recent recommendation to avoid them in these patients, however, alternative treatment strategies need to be investigated (2) Methods: We retrospectively analyzed the charts of 207 consecutive adult kidney transplantations that were performed at the department of General, Visceral and Transplantation Surgery of the University Hospital of Tuebingen between January 2015 and August 2020. All charts were screened for the diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infections (UTI) and the patients' clinical characteristics and outcomes were evaluated. (3) Results: Of the 207 patients, 68 patients suffered from urinary tract infections. Patients who developed UTI had worse graft function at discharge (p = 0.024) and at the 12 months follow-up (p < 0.001). The most commonly prescribed antibiotics were Ciprofloxacin and Piperacillin/Tazobactam. To both, bacterial resistance was more common in the study cohort than in the control group. (4) Conclusions: Urinary tract infections appear to be linked to worse graft functions. Thus, prevention and treatment should be accompanied by antibiotic stewardship teams.
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Hernández-Hernández D, Padilla-Fernández B, Ortega-González MY, Castro-Díaz DM. Recurrent Urinary Tract Infections and Asymptomatic Bacteriuria in Adults. CURRENT BLADDER DYSFUNCTION REPORTS 2021; 17:1-12. [PMID: 34868442 PMCID: PMC8634747 DOI: 10.1007/s11884-021-00638-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/14/2022]
Abstract
Purpose of review Our goal was to summarize recent evidence regarding recurrent urinary tract infections and asymptomatic bacteriuria in different adult populations. Recent findings Several research groups are focused on the description of resident bacterial flora in the bladder and urinary dysbiosis in the microbiome era. Even the definitions might change in light of these discoveries. However, the role of urinary microbiome and bacterial interference has still to be determined. Summary Systematic treatment of asymptomatic bacteriuria is not recommended and even classic indications such as asymptomatic bacteriuria in pregnant women are controversial. In fact, its treatment is associated with a higher probability of symptomatic UTI and a higher prevalence of antibiotic-resistant bacteria. Improving the diagnosis of asymptomatic bacteriuria and optimizing the management of recurrent urinary tract infections, especially through non-antibiotics measures, are needed in order to minimise antimicrobial resistance.
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Affiliation(s)
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, La Laguna, Tenerife Spain.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
| | | | - David Manuel Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, La Laguna, Tenerife Spain.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
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10
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Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients. Curr Opin Infect Dis 2021; 33:419-425. [PMID: 33148983 DOI: 10.1097/qco.0000000000000678] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Urinary tract infection (UTI) is the most common infection in kidney transplant recipients (KTRs). Several elements increase the risk of UTI and/or modify its clinical presentation among KTRs (e.g. immunosuppressive therapy, kidney allograft denervation, and use of urinary catheters). Also, KTRs may have UTIs because of difficult-to-identify and/or difficult-to-treat organisms. We provide an overview of the current knowledge regarding bacterial UTIs in KTRs, with a focus on recent findings. RECENT FINDINGS There is accumulating evidence from clinical trials that screening for and treating asymptomatic bacteriuria is not beneficial in most KTRs (i.e. those who are ≥1-2 months posttransplant and do not have a urinary catheter). These patients have a point-prevalence of asymptomatic bacteriuria of only 3% and treating asymptomatic bacteriuria probably does not improve their outcomes. There is no clinical trial evidence to guide the management of symptomatic UTI in KTRs. Several important clinical questions remain unanswered, especially regarding the management of posttransplant pyelonephritis and the prevention of UTI in KTRs. SUMMARY Despite its frequency and associated morbidity, UTI after kidney transplantation is an understudied infection. In an era of increasing antimicrobial resistance and limited resources, further research is needed to ensure optimal use of antimicrobials in KTRs with UTI.
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Almaimani AO. Asymptomatic Bacteriuria in Post Renal Transplant Patients: To Treat or Not? Cureus 2021; 13:e15713. [PMID: 34159042 PMCID: PMC8213437 DOI: 10.7759/cureus.15713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Urinary tract infections (UTIs) can commonly occur within the first few weeks following kidney transplantation procedures. Although the management of asymptomatic bacteriuria and acute graft pyelonephritis is important to reduce the risk of graft rejections following kidney transplantation, the efficacy of antibiotics administration remains controversial among studies in the literature. The aim of this review is to elaborate more on asymptomatic bacteriuria following kidney transplantation and try to formulate proper evidence about the efficacy of antibiotics administration on eliminating the frequency of infections and enhancing the quality of care for patients. Most studies in the literature are observational, which are usually biased in the interventions. However, the current evidence regarding the management and screening of asymptomatic bacteriuria seems to discourage such an approach. Almost all of the included studies reported that antibiotic administration did not significantly lower the rates of secondary symptomatic UTIs or enhance the functions of the graft. In addition, there is no significant impact on mortality and other clinical outcomes. Lastly, the frequent administration of antibiotics can significantly increase the risk of recurrence due to the emergence of novel strains of bacteria that are resistant to the currently administered antibiotics making it unfavorable.
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Affiliation(s)
- Anas O Almaimani
- Department of Urology, King Abdulaziz Airbase Hospital, Dhahran, SAU
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12
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Velioglu A, Guneri G, Arikan H, Asicioglu E, Tigen ET, Tanidir Y, Tinay İ, Yegen C, Tuglular S. Incidence and risk factors for urinary tract infections in the first year after renal transplantation. PLoS One 2021; 16:e0251036. [PMID: 33939755 PMCID: PMC8092797 DOI: 10.1371/journal.pone.0251036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background The most common infections among renal transplant patients are urinary tract infections (UTI). Our main objective in this study is to determine the incidence of UTIs in patients who have undergone renal transplantation in our hospital, to identify the causative microbiological agents, risk factors and determine the effects of UTI on short-term graft survival. Methods Urinary tract infections, which developed within the first year of renal transplantation, were investigated. Patients were compared regarding demographic, clinical, laboratory characteristics and graft survival. Results 102 patients were included in our study. Fifty-three patients (53%) were male and 49 (48%) were female. Sixty-seven urinary tract infection attacks in 21 patients (20.5%) were recorded. Age (p = 0.004; 95% Confidence Interval [CI]: 1.032–1.184), longer indwelling urinary catheter stay time (p = 0.039; 95% Confidence Interval [CI]: 1.013–1.661) and urologic complications (p = 0.006; 95% Confidence Interval [CI]: 0.001–0.320) were found as risk factors for UTI development in the first year of transplantation. Escherichia coli and Klebsiella pneumoniae were the most frequently isolated microorganisms. Of these bacteria, 63.2% were found to be extended spectrum beta lactamase (ESBL) positive. Multidrug resistant microorganisms (MDROs) were more frequent in male patients (32 episodes in males vs. 14 episodes in females, p = <0.001). UTI had no negative impact on short-term graft survival. Conclusion Our study results represent the high incidence of UTI with MDROs in KT recipients. Infection control methods should be applied even more vigorously especially in male transplant patients since a higher incidence of UTI caused by resistant microorganisms was reported in male patients.
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Affiliation(s)
- Arzu Velioglu
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
- * E-mail:
| | - Gokhan Guneri
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Hakki Arikan
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Ebru Asicioglu
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Elif Tukenmez Tigen
- Department of Infectious Disease, Marmara University School of Medicine, Istanbul, Turkey
| | - Yiloren Tanidir
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | - İlker Tinay
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | - Cumhur Yegen
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Serhan Tuglular
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
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13
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Shimizu T, Sugihara T, Kamei J, Takeshima S, Kinoshita Y, Kubo T, Shinzato T, Fujimura T, Yagisawa T. Predictive factors and management of urinary tract infections after kidney transplantation: a retrospective cohort study. Clin Exp Nephrol 2020; 25:200-206. [PMID: 33030613 DOI: 10.1007/s10157-020-01974-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is one of the most common infectious complications in kidney transplant recipients. The aims of our study were to identify possible predictive factors for UTI and advocate for the management of UTI after kidney transplantation (KT). METHODS Between January 2013 and December 2018, 182 adult patients with end-stage kidney disease who underwent KT were retrospectively analyzed. Patients who had urinary symptoms and positive urine culture were diagnosed with UTI. The types of urinary bacteria causing UTIs were also examined. RESULTS UTIs occurred in forty-one patients (25.1%), and the median time to UTI onset (UTI-free survival) after KT was 189 days. The Cox hazard regression analysis showed that the predictive factors for UTI onset were as follows: posttransplant urinary catheterization, including indwelling urinary catheterization and clean intermittent catheterization; a maximum bladder capacity before KT of less than 150 ml; and a low serum albumin level at 1 month after KT. The most common causative agent was Escherichia coli (56.6%), followed by Enterococcus spp. (15.6%) and Klebsiella spp. CONCLUSIONS Kidney transplant recipients with prolonged postoperative malnutrition, posttransplant voiding dysfunction and/or urinary storage disorder had an increased risk of UTI. Bladder function tests, such as uroflowmetry, postvoid residual urine tests, and urodynamic tests, were needed to predict UTI. For patients with malnutrition, care should be taken to ensure sufficient calorie intake. Kidney transplant recipients who develop UTI should be treated as complicated UTI patients.
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Affiliation(s)
- Toshihiro Shimizu
- Department of Renal Surgery and Transplantation, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city, Tochigi, 329-0498, Japan.
| | - Toru Sugihara
- Department of Urology, Jichi Medical University, Shimotsuke-city, Tochigi, Japan
| | - Jun Kamei
- Department of Urology, Jichi Medical University, Shimotsuke-city, Tochigi, Japan
| | - Saki Takeshima
- Department of Renal Surgery and Transplantation, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city, Tochigi, 329-0498, Japan
| | - Yoshitaka Kinoshita
- Department of Renal Surgery and Transplantation, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city, Tochigi, 329-0498, Japan
| | - Taro Kubo
- Department of Renal Surgery and Transplantation, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city, Tochigi, 329-0498, Japan
| | - Takahiro Shinzato
- Department of Renal Surgery and Transplantation, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city, Tochigi, 329-0498, Japan
| | - Tetsuya Fujimura
- Department of Urology, Jichi Medical University, Shimotsuke-city, Tochigi, Japan
| | - Takashi Yagisawa
- Department of Renal Surgery and Transplantation, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city, Tochigi, 329-0498, Japan
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14
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Aydın S, Patil A, Desai M, Simforoosh N. Five compelling UTI questions after kidney transplant. World J Urol 2020; 38:2733-2742. [PMID: 32266510 DOI: 10.1007/s00345-020-03173-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/17/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Urinary tract infection (UTI) is the most common bacterial infection among infectious complications in kidney transplant recipients (KTR). After transplantation, infections can result from surgical complications, donor-derived infections, pre-existing recipient infections, and nosocomial infections. Post-transplant infection is still a major cause of morbidity, mortality, graft dysfunction and rejection. In this paper, we aimed to review a few compelling questions in kidney transplantation (KTX). METHODS To identify relevant clinical questions regarding KTX and UTI a meeting was conducted among physicians involved in the KT program in our hospital. After discussion, several clinically relevant questions related to UTI after KTX. The 5 first rated in importance were judged generalizable to other clinical settings and selected for the purposes of this review. RESULTS Nearly half of the patients present in the first three months of transplant with UTI. The most common uropathogens in post-transplant UTIs are Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Risk factors for UTI include female sex, advanced age, recurrent UTI before transplant, prolonged urethral catheterization, delayed graft function, and cadaveric kidney transplant. CONCLUSION The incidence of post-transplant UTI is similar in both developed and developing countries. E.coli is the most common pathogen in most of studies. Cadaveric donor and post-dialysis transplantation are defined as independent risk factors for post-transplant UTI. Further studies are still required to identify risk factors after kidney transplantation and UTI's importance for graft function and patient outcome.
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Affiliation(s)
- Selda Aydın
- Infectious Diseases and Clinical Microbiology, Medipol Mega Hospital, Istanbul Medipol University School of Medicine, Bağcılar, Istanbul, Turkey.
| | - Abhijit Patil
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Mahesh Desai
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Nasser Simforoosh
- Department of Urology, Shahid Labbafinejad Medical Center, Tehran, Iran
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15
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Gómez-Ochoa SA, Vega-Vera A. Systematic review and meta-analysis of asymptomatic bacteriuria after renal transplantation: incidence, risk of complications, and treatment outcomes. Transpl Infect Dis 2019; 22:e13221. [PMID: 31782870 DOI: 10.1111/tid.13221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/08/2019] [Accepted: 11/24/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Routine treatment for asymptomatic bacteriuria (ASB) after renal transplantation (RT) represents nowadays a controversial topic, being unknown its impact on the overall prognosis of the transplanted patient. METHODS Studies published during 1970-2019 that evaluated the benefit of treating ASB after RT regarding the risk of renal complications were included. The primary outcome was to assess whether the treatment is associated with a lower risk of symptomatic urinary tract infection (UTI) or an improved renal function at the end of the follow-up period. The secondary outcome was the risk of acute graft rejection (AGR). A meta-analysis with a random-effect model was performed. Heterogeneity was assessed with the I2 measure. RESULTS Fifteen studies were included. The incidence of ASB in the first month and the first year after RT was 22% and 30%, respectively. ASB was not correlated to AGR (OR 1.18; 95% CI, 0.78-1.79). Eight studies compared the outcomes of ASB treatment, finding no benefit of treating regarding the risk of symptomatic UTI (OR 1.08; 95% CI, 0.63-1.84; I2 = 35%) or the change in renal function (mean difference in serum creatinine concentration-0.03 mg/dL,95% CI-0.15-0.10; I2 = 53%). CONCLUSIONS Asymptomatic bacteriuria represents a frequent finding after RT, highlighting the need for appropriate management of this condition. Considering that its treatment did not decrease the risk of the studied complications, antibiotic therapy should start to be questioned, as it has been related to higher rates of antimicrobial resistance and high economic costs.
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Affiliation(s)
- Sergio Alejandro Gómez-Ochoa
- GERMINA-UIS Group, School of Medicine, Health Sciences Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Agustín Vega-Vera
- GERMINA-UIS Group, School of Medicine, Health Sciences Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia
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16
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Coussement J, Scemla A, Hougardy JM, Sberro-Soussan R, Amrouche L, Catalano C, Johnson JR, Abramowicz D. Prevalence of asymptomatic bacteriuria among kidney transplant recipients beyond two months post-transplant: A multicenter, prospective, cross-sectional study. PLoS One 2019; 14:e0221820. [PMID: 31490951 PMCID: PMC6730876 DOI: 10.1371/journal.pone.0221820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/15/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND During routine post-kidney transplant care, most European transplant physicians screen patients for asymptomatic bacteriuria. The usefulness of this strategy is debated. To make screening cost-effective, asymptomatic bacteriuria should be prevalent enough to justify the expense, and antibiotics should improve patient outcomes significantly if asymptomatic bacteriuria is detected. Regrettably, the prevalence of asymptomatic bacteriuria among kidney transplant recipients is not well defined. METHODS To determine the prevalence of asymptomatic bacteriuria among kidney transplant recipients, we did a cross-sectional study among kidney transplant recipients undergoing routine surveillance in three outpatient transplant clinics in Belgium and France. We excluded patients who were in the first two months post-transplantation and/or had a urinary catheter. Asymptomatic participants who had a urine culture with one organism isolated at ≥ 105 CFU/mL were asked to provide a confirmatory urine specimen. Asymptomatic bacteriuria was defined per Infectious Diseases Society of America guidelines. RESULTS We screened 500 consecutive kidney transplant recipients. Overall, the prevalence of asymptomatic bacteriuria was 3.4% (17/500 patients). It was similarly low among kidney transplant recipients who were between 2 and 12 months after transplantation (1.3%, 1/76 patients) and those who were farther after transplantation (3.8%, 16/424 patients: p = 0.49). Asymptomatic bacteriuria was significantly associated with female gender (risk ratio 3.7, 95% CI 1.3-10.3, p = 0.007) and older age (mean age: 61 ± 12 years [bacteriuric participants], versus 53 ± 15 years [non-bacteriuric participants], p = 0.03). One participant's colistin-resistant Escherichia coli isolate carried the globally disseminated mcr-1 gene. CONCLUSIONS Among kidney transplant recipients who are beyond the second month post-transplant, the prevalence of asymptomatic bacteriuria is low. Further studies are needed to ascertain the cost-effectiveness of a screen-and-treat strategy for asymptomatic bacteriuria in this population.
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Affiliation(s)
- Julien Coussement
- Division of Infectious Diseases, CUB-Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
- * E-mail:
| | - Anne Scemla
- Service de Néphrologie et Transplantation Adulte, Université Paris Descartes Sorbonne Paris Cité, RTRS Centaure, Labex Transplantex, Paris, France
| | - Jean-Michel Hougardy
- Service de Néphrologie, Dialyse et Transplantation Rénale, CUB-Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
| | - Rebecca Sberro-Soussan
- Service de Néphrologie et Transplantation Adulte, Université Paris Descartes Sorbonne Paris Cité, RTRS Centaure, Labex Transplantex, Paris, France
| | - Lucile Amrouche
- Service de Néphrologie et Transplantation Adulte, Université Paris Descartes Sorbonne Paris Cité, RTRS Centaure, Labex Transplantex, Paris, France
| | - Concetta Catalano
- Service de Néphrologie, Dialyse et Transplantation Rénale, CUB-Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
| | - James R. Johnson
- Minneapolis Veterans Health Care System, Minneapolis, Minnesota, United States of America
| | - Daniel Abramowicz
- Department of Nephrology-Hypertension, Universitair Ziekenhuis Antwerpen and Antwerp University, Antwerp, Belgium
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17
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Tekkarışmaz N, Özelsancak R, Micozkadıoğlu H, Çalışkan K, Demiroğlu YZ, Arslan AH, Haberal M. Risk Factors for Urinary Tract Infection After Kidney Transplant: A Retrospective Analysis. EXP CLIN TRANSPLANT 2019; 18:306-312. [PMID: 31424358 DOI: 10.6002/ect.2019.0081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Urinary tract infections are the most common type of infections in kidney transplant recipients. They are also important factors for increased morbidity and mortality. The aims of this study were to evaluate the number of urinary tract infections, to identify possible donor/receiver-based risk factors, and to evaluate the impact of these infections on graft function. MATERIALS AND METHODS Medical records of patients who had undergone kidney transplant between 2010 and 2017 were retrospectively analyzed. RESULTS Our study included 145 patients (49 women [33.8%] and 96 men [66.2%]), with mean age of 35.2 ± 12.4 years. There were 105 episodes of urinary tract infections in 55 of 145 patients (37.9%) during the first year after transplant. Female sex (P = .001), glomerulonephritis as primary kidney disease (P = .04), pretransplant diabetes (P = .05), and presence of ureteral stent (P = .03) were significant risk factors for the development of urinary tract infections. The most frequent pathogens identified were Escherichiacoli and Klebsiella pneumoniae. Mean glomerular filtration rate t 12 months was significantly lower in patients with urinary tract infection than in patients without infection (80 ± 25 vs 68 ± 28 mL/min; P = .006). CONCLUSIONS In kidney transplant recipients, urinary tract infections are common complications and have negative outcomes on graft function. These infections remain an important disease that requires frequent investigations and new ways of approach for prevention.
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Affiliation(s)
- Nihan Tekkarışmaz
- From the Department of Nephrology, Baskent University Faculty of Medicine, Adana, Turkey
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18
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Kiros T, Asrat D, Ayenew Z, Tsige E. Bacterial urinary tract infection among adult renal transplant recipients at St. Paul's hospital millennium medical college, Addis Ababa, Ethiopia. BMC Nephrol 2019; 20:289. [PMID: 31366333 PMCID: PMC6668100 DOI: 10.1186/s12882-019-1485-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/23/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite significant advances in surgical techniques, immunosuppression protocols, follow up periods and antimicrobial stewardship in modern medicine; post-renal transplantation urinary tract infection remained a major public health problem globally. This multiple serious squeals includes asymptomatic bacteriuria, cystitis and pyelonephritis. Among these, the bacterial origin of infection complications accounts for the most significant clinical, socio-economic impacts in many countries of the world. Therefore, the aim of the study was to investigate the prevalence of bacterial isolates that cause urinary tract infections, assess antibiotic susceptibility pattern among symptomatic and asymptomatic renal transplant recipients attending at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. METHODS A hospital-based cross-sectional study was conducted from December 2017 to August 2018 among 74 renal transplant recipients St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. A first morning voided clean-catch mid-stream urine specimens were collected and 0.001 ml inoculated onto blood and MacConkey agar plates following the standard bacteriological protocols. It was incubated aerobically at 35-37 °C for 24-48 h. Cultural characteristics and series of biochemical tests were used for the identification of isolates to species level based on the standard bacteriological protocols. RESULTS A hospital-based cross-sectional study has shown that significant bacteriuria was found in 11/74 (14.9, 95% CI =8.2-24.7) patients. The prevalence among females 6/32 (18.75%) was higher among males 5/42 (11.9%) without significant association (COR = 2.09, 95% CI = 1.04-8.45, P = 0.253). Urinary tract infection was higher in the age group of 35-49 years old (19.3%). Age was statistically significant and stronger independent associated risk factor with crude odds ratio = 3.67, 95% CI = 2.89-20.07 and P = 0.003, respectively. The most prevalent bacteria isolates were Escherichia coli 2(18.2%), Staphylococcus aureus 2(18.2%), Acinetobacter spp. 2(18.2%), Enterococcus spp. 2(18.2%), Coagulase-negative Staphylococci 2(18.2%) followed by Porteus mirabilis 1(9.1%). The majority (80%) of Gram-negative bacteria were resistant to ciprofloxacin, chloramphenicol, and trimethoprim/sulfamethoxazole. Simultaneously, the multidrug-resistant bacterial isolates accounts for 82% among tested kidney allograft recipients. CONCLUSIONS In conclusion, the overall prevalence of urinary tract infection in the study participants was relatively low with a prevalence of 14.9%. Majority of the study participants were asymptomatic and a higher percentage of females were involved. The multidrug-resistant bacterial isolates in the present study account for 82%.
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Affiliation(s)
- Teklehaimanot Kiros
- Department of Medical Microbiology, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Daniel Asrat
- Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zeleke Ayenew
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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19
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Bonnéric S, Maisin A, Kwon T, Deschênes G, Niel O. Asymptomatic bacteriuria in pediatric kidney transplant recipients: to treat or not to treat? A retrospective study. Pediatr Nephrol 2019; 34:1141-1145. [PMID: 30820703 DOI: 10.1007/s00467-019-04204-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Urinary tract infections (UTI) are common infectious complications in kidney transplant recipients (KTR); asymptomatic bacteriuria (AB) is also frequent. It is unclear whether treatment of AB reduces subsequent UTI in KTR; no guideline is available in pediatric KTR. In this retrospective study, we analyzed the incidence of AB in pediatric KTR and the impact of screening and treating AB on the onset of subsequent UTI. METHODS Thirty-seven pediatric patients were included. Inclusion criteria were the occurrence of one or more episodes of AB between 2 and 24 months post-renal transplantation. Primary outcome was the cumulative incidence of acute pyelonephritis (APN) or lower urinary tract infections (LUTI) occurring between 2 and 24 months post-renal transplantation. RESULTS Thirty-seven patients presented 171 AB episodes. One hundred sixty-four AB episodes were untreated (95.9%); among them, 150 episodes (91.5%) were not followed by a clinical infection. Ten episodes (6.1%) led to APN, and 4 (2.4%) to LUTI. There were 53 episodes of APN: 10 (18.9%) after untreated AB and 43 (81.1%) de novo. There were 11 episodes of LUTI: 4 (36.4%) after untreated AB and 7 (63.6%) de novo. Multi-drug resistant bacteria were present in 27% of the patients and in 20% of patients with pre-existing uropathy. CONCLUSIONS Our results are not in favor of systematic treatment of AB in pediatric KTR. Notably, limitation of antibiotic treatment is an urgent and important health issue in this population, in order to reduce multi-drug resistant bacteria emergence.
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Affiliation(s)
- Stéphanie Bonnéric
- Pediatric Nephrology Department, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France
| | - Anne Maisin
- Pediatric Nephrology Department, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France
| | - Theresa Kwon
- Pediatric Nephrology Department, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France
| | - Georges Deschênes
- Pediatric Nephrology Department, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France
| | - Olivier Niel
- Pediatric Nephrology Department, Robert Debré Hospital, 48 boulevard Sérurier, 75019, Paris, France.
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20
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Sabé N, Oriol I, Melilli E, Manonelles A, Bestard O, Polo C, Los Arcos I, Perelló M, Garcia D, Riera L, Tebé C, Len Ò, Moreso F, Cruzado JM, Carratalà J. Antibiotic Treatment Versus No Treatment for Asymptomatic Bacteriuria in Kidney Transplant Recipients: A Multicenter Randomized Trial. Open Forum Infect Dis 2019; 6:ofz243. [PMID: 31214630 PMCID: PMC6563942 DOI: 10.1093/ofid/ofz243] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 05/20/2019] [Indexed: 12/23/2022] Open
Abstract
Background Whether antibiotic treatment of asymptomatic bacteriuria (AB) can prevent acute graft pyelonephritis (AGP) in kidney transplant (KT) recipients has not been elucidated. Methods In this multicenter, open-label, nonblinded, prospective, noninferiority, randomized controlled trial, we compared antibiotic treatment with no treatment for AB in KT recipients in the first year after transplantation when urinary catheters had been removed. The primary endpoint was the occurrence of AGP. Secondary endpoints included bacteremic AGP, cystitis, susceptibility of urine isolates, graft rejection, graft function, graft loss, opportunistic infections, need for hospitalization, and mortality. Results We enrolled 205 KT recipients between 2013 and 2015. AB occurred in 41 (42.3%) and 46 (50.5%) patients in the treatment and no treatment groups, respectively. There were no differences in the primary endpoint in the intention-to-treat population (12.2% [5 of 41] in the treatment group vs 8.7% [4 of 46] in the no treatment group; risk ratio, 1.40; 95% confidence interval, 0.40–4.87) or the per-protocol population (13.8% [4 of 29] in the treatment group vs 6.7% [3 of 45] in the no treatment group; risk ratio, 2.07, 95% confidence interval, 0.50–8.58). No differences were found in secondary endpoints, except for antibiotic susceptibility. Fosfomycin (P = .030), amoxicillin-clavulanic (P < .001) resistance, and extended-spectrum β-lactamase production (P = .044) were more common in KT recipients receiving antibiotic treatment for AB. Conclusions Antibiotic treatment of AB was not useful to prevent AGP in KT recipients and may increase antibiotic resistance. However, our findings should be regarded with caution, due to the small sample size analyzed.
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Affiliation(s)
- Núria Sabé
- Department of Infectious Diseases, Hospital Universitari de Bellvitge-IDIBELL, Spanish Network for Research in Infectious Diseases (REIPI), and Clinical Sciences Department, Faculty of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Isabel Oriol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge-IDIBELL, Spanish Network for Research in Infectious Diseases (REIPI), and Clinical Sciences Department, Faculty of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Edoardo Melilli
- Department of Nephrology, Hospital Universitari de Bellvitge-IDIBELL, and Clinical Sciences Department, Faculty of Medicine, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Department of Nephrology, Hospital Universitari de Bellvitge-IDIBELL, and Clinical Sciences Department, Faculty of Medicine, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Oriol Bestard
- Department of Nephrology, Hospital Universitari de Bellvitge-IDIBELL, and Clinical Sciences Department, Faculty of Medicine, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Carolina Polo
- Department of Nephrology, Hospital Universitari de Bellvitge-IDIBELL, and Clinical Sciences Department, Faculty of Medicine, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Ibai Los Arcos
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron-VHIR, Spanish Network for Research in Infectious Diseases (REIPI), Barcelona, Spain
| | - Manel Perelló
- Department of Nephrology, Hospital Universitari Vall d'Hebron-VHIR, Barcelona, Spain
| | - Dolors Garcia
- Department of Microbiology, Hospital Universitari de Bellvitge-IDIBELL, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Lluís Riera
- Department of Urology, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Cristian Tebé
- Statistical Assessment Service at Bellvitge Biomedical Research Institute (IDIBELL) and Department of Basic Sciences, Universitat Rovira i Virgili, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Òscar Len
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron-VHIR, Spanish Network for Research in Infectious Diseases (REIPI), Barcelona, Spain
| | - Francesc Moreso
- Department of Nephrology, Hospital Universitari Vall d'Hebron-VHIR, Barcelona, Spain
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari de Bellvitge-IDIBELL, and Clinical Sciences Department, Faculty of Medicine, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge-IDIBELL, Spanish Network for Research in Infectious Diseases (REIPI), and Clinical Sciences Department, Faculty of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Spain
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21
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Hemmersbach-Miller M, Alexander BD, Sudan DL, Pieper C, Schmader KE. Infections after kidney transplantation. Does age matter? Clin Transplant 2019; 33:e13516. [PMID: 30849194 DOI: 10.1111/ctr.13516] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/19/2019] [Indexed: 12/19/2022]
Abstract
Infections threaten successful outcomes after kidney transplantation. Our aim was to determine if the number, types of infections and the risk factors for common infections differed between older compared to younger kidney transplant (KT) recipients in the first year after surgery. We performed a single-center retrospective cohort study. Between 2011 and 2015, 91 KTs were performed in patients ≥65 years of age; these were matched 1:1 (by year of transplantation, sex and race) to controls aged 40-60 years. Over 90% of both groups had an infectious complication. Urinary tract infections (UTIs) and cytomegalovirus (CMV) viremia were significantly more frequent in older recipients. Older adults had more late onset UTIs, including after stent removal. CMV viremia was more frequent in older adults in the 1-6 months post-transplant period. Due to our center-specific protocol utilizing pre-emptive monitoring in the CMV recipient-seropositive population, the higher CMV incidence in the aged recipient was driven by this subpopulation of older adults. No difference in pneumonias or bloodstream infections were found, nor in surgical complications, rejection or graft loss. Mortality was higher at 1-year post-transplant in the older recipients (9.9% vs 1.1%; P = 0.018). Prophylactic and immunosuppressive strategies may need to be altered for older KT recipients.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Infectious Diseases Division, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Barbara D Alexander
- Infectious Diseases Division, Duke University Medical Center, Durham, North Carolina
| | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carl Pieper
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center (GRECC), Durham VA, Durham, North Carolina
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22
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Goldman JD, Julian K. Urinary tract infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13507. [PMID: 30793386 DOI: 10.1111/ctr.13507] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 01/05/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of urinary tract infections (UTI) in solid organ transplantation, focusing on kidney transplant (KT) recipients. KT recipients have unique risk factors for UTI, including indwelling stents and surgical manipulation of the genitourinary tract. KT recipients experience multi-drug antibiotic-resistant infections-UTI prevention and management strategies must consider risks of antimicrobial resistance. Non-antimicrobial prevention strategies for UTI in KT recipients are reviewed. It is important to recognize that some renal transplant recipients with UTI may primarily present with fever, malaise, leukocytosis, or a non-specific sepsis syndrome without symptoms localized to the urinary tract. However, asymptomatic bacteriuria (AB) must be distinguished from UTI because AB is not necessarily a disease state. Accumulating data indicate that there are no benefits of antibiotics for treatment of AB in KT recipients more than 2 months after post-transplant. Further research is needed on management of AB in the early (<2 months) post-transplant period, prophylaxis for UTI in this era of antibiotic resistance, recurrent UTI, non-antimicrobial prevention of UTI, and uropathogens identified in donor urine and/or preservative fluid cultures.
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Affiliation(s)
- Jason D Goldman
- Division of Infectious Diseases, Swedish Medical Center, Seattle, Washington.,Division of Infectious Diseases, University of Washington, Seattle, Washington
| | - Kathleen Julian
- Division of Infectious Diseases, Penn State Hershey Medical Center, Hershey, Pennsylvania
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23
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Imvrios G, Tzitzili E, Pyrpasopoulou A, Miserlis G, Daoudaki M, Fouza A, Mavroudi A, Mouloudi E, Antoniadis N, Salveridis N, Fouzas I. Association of Double-J Stenting in Renal Transplant Patients With Urinary Tract Colonization and Infections in a Multidrug-resistant Microbe Endemic Nosocomial Environment. Transplant Proc 2019; 51:408-412. [PMID: 30879553 DOI: 10.1016/j.transproceed.2019.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE We investigated the association of ureteral stenting after kidney transplantation with the development of urinary tract infections (UTIs) and/or urinary tract colonization, in a hospital environment considered endemic for multidrug resistant (MDR) Gram-negative Enterobacteriaceae. METHODS Seventy-five recipients of deceased donor grafts were divided in groups A and B. Group A (with subgroups A1 and A2) included 45 transplanted patients without urinary stenting, and group B 30 patients with stenting. Subgroup A1 consisted of 30 patients transplanted before 2006, and A2 of 15 patients transplanted after 2006, when MDR, mainly carbapenem-resistant, Enterobacteriaceae, frequency has risen in our hospital. RESULTS The incidence and the number of UTIs per patient were significantly higher in patients without stenting compared to those with stenting. (Group A: 32/45 vs group B: 9/30, P < .001, and group A: 2.86 ± 0.43 vs group B: 0.6 ± 0.19, P < .01 respectively). Patients without stenting tended to have a higher frequency of recurrent UTIs compared to those with stenting (group A: 16/45 vs group B: 4/30, P < .05). Asymptomatic bacteriuria was more frequent in the patients with stent (group A: 8/45 vs group B: 14/30, P < .05). Further sub-comparison of the A1 and A2 subgroups with group B did not change the statistical results. CONCLUSIONS There is no clinically significant association of ureteral stenting after kidney transplantation with the high frequency of MDR Gram-negative bacteria in our hospital.
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Affiliation(s)
- G Imvrios
- Division of Transplantation, Department of Surgery, Hippokration General Hospital, Thessaloniki, Greece
| | - E Tzitzili
- Division of Transplantation, Department of Surgery, Hippokration General Hospital, Thessaloniki, Greece
| | - A Pyrpasopoulou
- Infectious Diseases Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - G Miserlis
- Division of Transplantation, Department of Surgery, Hippokration General Hospital, Thessaloniki, Greece.
| | - M Daoudaki
- Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - A Fouza
- Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - A Mavroudi
- 3rd Paediatric Department, Hippokration General Hospital, Thessaloniki, Greece
| | - E Mouloudi
- Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - N Antoniadis
- Division of Transplantation, Department of Surgery, Hippokration General Hospital, Thessaloniki, Greece
| | - N Salveridis
- Division of Transplantation, Department of Surgery, Hippokration General Hospital, Thessaloniki, Greece
| | - I Fouzas
- Division of Transplantation, Department of Surgery, Hippokration General Hospital, Thessaloniki, Greece
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Marroquin CE. Patient Selection for Kidney Transplant. Surg Clin North Am 2018; 99:1-35. [PMID: 30471735 DOI: 10.1016/j.suc.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The incidence of end-stage renal disease has continued to increase. Similarly, the number of patients living with a functioning renal allograft has also increased. Transplantation has improved with advances in surgical techniques, immunosuppression, and better control of comorbid conditions. Transplantation is transformative and offers the greatest potential for restoring a healthy, productive, and durable life to appropriately selected patients. This article describes factors to address in selection of renal transplant candidates and discusses commonly encountered perioperative events. Paramount to selecting appropriate candidates is the collaboration between a multidisciplinary team focused on a systematic process guided by protocols and common practices.
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Affiliation(s)
- Carlos E Marroquin
- Transplant, Immunology and Hepatobiliary Surgery, Department of Surgery, University of Vermont, 111 Colchester Avenue, Burlington, VT 05401, USA.
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Dagenais R, Leung M, Poinen K, Landsberg D. Common Questions and Misconceptions in the Management of Renal Transplant Patients: A Guide for Health Care Providers in the Posttransplant Setting. Ann Pharmacother 2018; 53:419-429. [PMID: 30345802 DOI: 10.1177/1060028018809318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Once renal transplant recipients are stabilized and require less frequent follow-up with their transplant team, health care providers outside of the transplant setting play an integral role in patients' ongoing medical care. Given renal transplant recipients' inherent complexity, these health care providers often seek consult regarding decisions that may affect transplant-related medications or outcomes. In this review, we discuss answers to 10 of the questions commonly posed to our renal transplant team by other health care providers.
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Kazımoğlu H, Harman R, Mercimek MN, Dokur M, Uysal E. Evaluation of early and late-term infections after renal transplantation: Clinical experiences of Sanko University Medical Faculty Transplantation Center. Turk J Urol 2018; 45:63-69. [PMID: 30201075 DOI: 10.5152/tud.2018.09522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/18/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Infections play an important part in post-transplantation causes of morbidity and mortality. The purpose of this study is to evaluate short-, and long-term infections encountered in after renal transplantations. MATERIAL AND METHODS Two hundred and thirteen cases that consisted of both living and cadaver donors, who suffered from late period renal insufficiency and had renal transplant between June 2011 and January 2016 at the Transplantation Center of Sanko University School of Medicine were included in the study. In this study the short-, and long-term infections seen in post renal transplantation were examined retrospectively. Infection types, frequency and periods of infection, infection agents and predisposing factors were determined as the examination parameters. RESULTS Of the 213 patients who received renal transplant, 139 were males (65.3%) and 74 were women (34.75%) and the mean age was 42±11,8 (range, 14-70) years. Twelve (5.6%) patients exited after renal transplantation. Post-transplant infections were seen in 49 patients (23.1%) within 1-6 months; in 13 patients (6.1%) within 6-12 months; and in 5 patients (2.4%) after the 12th month. The most common infections after renal transplantation were associated with urinary tract (70 patients, 34.3%). The most frequently isolated agents were E. coli (n=66; 30.9%), Kebsiella spp. (n=18; 8.4%) and Enterococci (n=18; 8.4%) respectively. The renal transplants from the cadavers were observed to contract infections 1.78 times more frequently compared to the living donors (OR=1.78, 95% CI=1.03-3.09). CONCLUSION The most common complication after renal transplantation are infections. The majority of the infections are seen within the first year especially between 1-6 months. Post-transplant infections are often related to urinary system. E.coli is the most frequently isolated agent and it may be responsible for urosepsis in renal transplant patients. Infection more often seen in renal transplantations from cadavers.
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Affiliation(s)
- Hatem Kazımoğlu
- Department of Urology, Sanko University School of Medicine, Gaziantep, Turkey
| | - Rezan Harman
- Department of Infectious Diseases, Sanko University School of Medicine, Gaziantep, Turkey
| | | | - Mehmet Dokur
- Department of Emergency Medicine, Biruni University School of Medicine, Istanbul, Turkey
| | - Erdal Uysal
- Department of Transplantation Center, Sanko University School of Medicine, Gaziantep, Turkey
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Yuan X, Liu T, Wu D, Wan Q. Epidemiology, susceptibility, and risk factors for acquisition of MDR/XDR Gram-negative bacteria among kidney transplant recipients with urinary tract infections. Infect Drug Resist 2018; 11:707-715. [PMID: 29785131 PMCID: PMC5957067 DOI: 10.2147/idr.s163979] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Multiple drug resistant/extensively drug resistant (MDR/XDR) Gram-negative urinary tract infections (UTIs) represent a growing threat to kidney transplant recipients. This retrospective study aimed to assess the incidence and microbiological profile of MDR/XDR Gram-negative UTIs, to identify drug susceptibility of MDR/XDR bacteria, and to determine the potential risk factors for MDR/XDR UTIs in kidney recipients. Materials and methods During the study period, 1569 patients underwent consecutive kidney transplantation in two transplantation centers. We studied the demographics, clinical characteristics, and urine culture data from kidney recipients with MDR/XDR Gram-negative UTIs, and verified the risk factors associated with MDR/XDR infections. Results Eighty-one kidney recipients yielded 88 episodes of MDR/XDR Gram-negative UTIs with five patients (6.2%) succumbing to all-cause in-hospital mortality. The most frequently isolated bacterium was Escherichia coli (62.5%). Almost all MDR/XDR Gram-negative bacteria were resistant to first- and second-generation cephalosporin, and monocyclic beta-lactam. They were relatively sensitive to meropenem, amikacin, and tigecycline. As for the 12 XDR bacteria, all of them were resistant to meropenem and 25% of them were resistant to tigecycline. All XDR Acinetobacter baumannii and E. coli were susceptible to tigecycline. Nosocomial infection (odds ratio [OR] = 11.429, 95% CI = 1.311–99.625, P = 0.027) was the only independent predictor of MDR/XDR Gram-negative UTIs. Non-fermenting bacterial infection (OR = 20.161, 95% CI = 3.409–119.240, P = 0.001), polycystic kidney disease (OR = 39.871, 95% CI = 1.979–803.384, P = 0.016), and serum creatinine level > 1.5 mg/dL (OR = 8.688, 95% CI = 1.354–55.747, P = 0.023) were significantly different between XDR and MDR Gram-negative UTIs. Conclusion Meropenem, amikacin, and/or tigecycline can be prescribed for MDR/XDR Gram-negative infections. Tigecycline can also be prescribed for XDR A. baumannii and E. coli. Nosocomial infection was a risk factor for MDR/XDR Gram-negative UTIs, while XDR UTIs were associated with non-fermenting bacterial infection, polycystic kidney disease, and impaired renal function.
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Affiliation(s)
- Xiuhong Yuan
- Psychosomatic Health Institute, the Third Xiangya Hospital of Central South University, Changsha, China
| | - Taohua Liu
- Clinical Medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Di Wu
- Department of Transplant Surgery, the Third Xiangya Hospital of Central South University, Changsha, China
| | - Qiquan Wan
- Department of Transplant Surgery, the Third Xiangya Hospital of Central South University, Changsha, China
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