Levofloxacin Penetration Into a Renal Cyst in a Patient With Autosomal Dominant Polycystic Kidney Disease

Efficacy of Prolonged Antibiotic Therapy for Renal Cyst Infections in Polycystic Kidney Disease

OBJECTIVE

To determine the impact of antibiotic therapy (ATBT) on outcomes of renal cyst infection (CyI) in patients with polycystic kidney disease.

PATIENTS AND METHODS

We undertook a single-center retrospective study of CyI in autosomal dominant polycystic kidney disease (January 1, 2000, through December 31, 2018). Cyst infections were classified as definite (microbiologically proven), probable (radiologic signs), or possible (clinical or biologic signs only). We studied the determinants of ATBT failure (persistence of infection beyond 72 hours of microbiologically adequate initial ATBT, with requirement for ATBT change, cyst drainage, or nephrectomy) and recurrences (>14 days after the end of ATBT).

RESULTS

Among 90 patients, 139 CyIs (11 definite, 74 probable, 54 possible) were compiled. Cultures were positive in 106 of 139 (76%) episodes, with Escherichia coli found in 89 of 106 (84%). Treatment failures and recurrences within 1 year of follow-up were more frequent in definite/probable CyI (20/85 [34%] and 16/85 [19%]) than in possible CyI (2/54 [4%] and 4/54 [7%]; P<.01 and P=.08, respectively). Male sex (odds ratio [OR], 7.79; 95% CI, 1.72 to 46.68; P<.01), peak C-reactive protein level above 250 mg/L (OR, 7.29; 95% CI, 1.78 to 35.74; P<.01; to convert C-reactive protein values to nmol/L, multiply by 9.524), and cyst wall thickening (OR, 7.70; 95% CI, 1.77 to 43.47; P=.01) but not the modalities of initial ATBT were independently associated with higher risk of failure. In a Cox proportional hazards model, kidney transplant recipients exhibited higher risk of recurrence (hazard ratio, 3.76; 95% CI, 1.06 to 13.37; P=.04), whereas a total duration of ATBT of 28 days or longer was protective (hazard ratio, 0.02; 95% CI, 0.00 to 0.16; P<.001), with an inverse correlation between duration and recurrence (81% for treatment <21 days, 47% for 21 to 27 days, 2% for ≥28 days; P<.0001).

CONCLUSION

Initial first-line ATBT had no significant effect on renal CyI treatment failure. Treatment duration of 28 days and longer reduced recurrences.

Cyst infection in autosomal dominant polycystic kidney disease: our experience at Toranomon Hospital and future issues

Cyst infection is a frequent and serious complication of autosomal dominant polycystic kidney disease (ADPKD) that is often difficult to treat and can be fatal. However, much is still unknown about cyst infection. Positron emission tomography (PET) is generally recommended for detecting infected cysts, but it has the disadvantages of limited availability, high cost, and radiation exposure. We have devised magnetic resonance imaging (MRI) diagnostic criteria for cyst infection. Lipid-soluble antibiotics such as fluoroquinolones show good penetration into cysts and are recommended for cyst infection. However, we reported that fluoroquinolone-resistant microorganisms showed a high prevalence in cyst infection. We should, therefore, reconsider the empirical use of fluoroquinolones for ADPKD patients with cyst infection. We have suggested a new antibiotic strategy according to the severity of cyst infection. It may be important to consider the drug half-life in serum in addition to the drug susceptibility when selecting antibiotics Cyst drainage is necessary for some patients with refractory cyst infection; however, cyst drainage can be associated with severe adverse events. We suggest adaptation criteria for cyst drainage in patients with cyst infection in ADPKD. Most causative bacteria of cyst infection are enterobacteria, and hematogenous spread via bacterial translocation in the intestine is considered the main cause of cyst infection. Therefore, intestinal flora may be important for cyst infection. The role of the intestinal flora in cyst infection in ADPKD is unknown and should be explored in future research.

Bacteremic kidney cyst infection caused by Helicobacter cinaedi

Cyst infection is one of the major complications in patients with autosomal dominant polycystic kidney disease (ADPKD). The causative pathogen in kidney cyst infection frequently goes undetected. Although only one case report of kidney cyst infection caused by Helicobacter cinaedi (H. cinaedi) is published in English literature, it may be an important pathogen in kidney cyst infection. Kidney cyst infection and H. cinaedi infection share the common characteristic of tendency to relapse and chronic kidney disease is a major risk factor for H. cinaedi infection. Moreover, a long period is required to detect H. cinaedi in blood cultures, potentially causing false-negative results. After the identification of H. cinaedi, we must carefully select antibiotics and the antibiotic treatment period should be extended to prevent recurrence. Here we present a case of a 58-year-old male with ADPKD who developed bacteremic kidney cyst infection caused by H. cinaedi. He was admitted to our hospital because of fever, lower left back pain, vomiting, and feeling of abdominal enlargement. H. cinaedi was detected from the blood cultures obtained at admission after 4 days of culture. Antibiotics were administered for 8 weeks after confirming negative blood cultures. There was no evidence of kidney cyst infection relapse at 3 months after treatment completion. Nephrologists should regard H. cinaedi as a challenging but important pathogen in kidney cyst infection, particularly when the causative organism is unknown or kidney cyst infection is recurrent.

Cronobacter sakazakii bacteremia in a heart transplant patient with polycystic kidney disease

Infections with Cronobacter sakazakii are mainly described among neonates and infants, with contaminated powdered infant formulas most often incriminated as the cause. We describe here a case of C. sakazakii bacteremia secondary to a suspected cyst infection in a heart-and-kidney transplant patient with polycystic kidney disease.

Management of urinary tract infection in solid organ transplant recipients: Consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

BACKGROUND

Urinary tract infections (UTIs) are one of the most common infections in solid organ transplant (SOT) recipients.

METHODS

Experienced SOT researchers and clinicians have developed and implemented this consensus document in support of the optimal management of these patients. A systematic review was conducted, and evidence levels based on the available literature are given for each recommendation. This article was written in accordance with international recommendations on consensus statements and the recommendations of the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

RESULTS

Recommendations are provided on the management of asymptomatic bacteriuria, and prophylaxis and treatment of UTI in SOT recipients. The diagnostic-therapeutic management of recurrent UTI and the role of infection in kidney graft rejection or dysfunction are reviewed. Finally, recommendations on antimicrobials and immunosuppressant interactions are also included.

CONCLUSIONS

The latest scientific information on UTI in SOT is incorporated in this consensus document.

Successfully treated Escherichia coli-induced emphysematous cyst infection with combination of intravenous antibiotics and intracystic antibiotics irrigation in a patient with autosomal dominant polycystic kidney disease

A 62-yr-old woman with an autosomal dominant polycystic kidney disease (ADPKD) was admitted to our hospital for further evaluation of intermittent fever, nausea and left flank discomfort. The computed tomography (CT) scan revealed a gas-forming, infectious cyst of approximately 8.1 cm in size in left kidney lower pole. Escherichia coli was identified from the cyst fluid culture examination. Her symptoms improved only after the concomitant use of intravenous ciprofloxacin and an intracystic irrigation of ciprofloxacin through a percutaneous cystostomy drainage. Our case presents the successfully treated emphysematous cyst infection with combination of intravenous antibiotics and intracystic antibiotic therapy instead of surgical management.

Renal cyst infection caused by Brucella abortus

A 49-year-old man with a medical history of polycystic kidney disease was presented to the emergency department with fever and left flank pain. Abdominal examination revealed an enlarged and painful left kidney. The C-reactive protein level was significantly high and the magnetic resonance imaging revealed areas of abnormal intensity and fluid-fluid levels in renal cysts. Brucella abortus was yielded from both blood and cyst fluid culture. Standard therapy (rifampicin plus doxycycline) of brucellosis was started, but the clinical and laboratory signs subsided after the addition of ciprofloxacin. There was no need for aspiration of infected cyst fluid. Hereby, according to the medical database search, we report that the first renal cyst infection caused by B. abortus was successfully treated with triple antibiotic therapy.

Hyperbaric oxygen therapy in a patient with autosomal dominant polycystic kidney disease with a perinephritic abscess

A 68-year-old female in hemodialysis due to autosomal dominant polycystic kidney disease underwent resection of cysts in her right kidney via a laparoscopic approach due to abdominal pain. Three weeks after surgery, she was admitted with sepsis. A CT scan showed a large abscess around the right kidney. Percutaneous drainage of abscess was performed. The pus smear showed Gram-positive cocci and the culture contained methicillin-resistant Staphylococcus aureus. Ciprofloxacin, clindamycin and vancomycin were given. In the 3 weeks following admission, she remained febrile and septic and showed a progressive deterioration in her general condition, along with malnutrition and persistent drainage of purulent material from her right flank. The antibiotic therapy was changed to vancomycin, metronidazole and meropenem, but no improvement was observed. Because of the high risk associated with carrying out an open nephrectomy, we decided to use hyperbaric oxygen therapy (HBOT) as a potentially useful measure to control her infection. The patient underwent 26 daily sessions of 100% hyperbaric oxygen (2.5 atm). The use of HBOT induced a notable break in the clinical course of this patient's retroperitoneal infection. She was discharged after day 58 without any signs of inflammatory activity, and she has not presented reactivation of infection since then. We think that this case suggests that this therapy could be a new therapeutic tool in the management of patients with similar clinical features when all other therapeutic measures have failed. We did not find any other reports of the use of HBOT in infections of renal cysts.

Cyst infections in patients with autosomal dominant polycystic kidney disease

BACKGROUND AND OBJECTIVES

Cyst infection is a complex diagnostic and therapeutic issue in patients with autosomal dominant polycystic kidney disease (ADPKD); however, published data regarding the diagnosis and the management of cyst infections in patients with ADPKD are sparse.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A retrospective study was conducted in a referral center for patients with ADPKD in Paris, France. We identified using a computerized database all patients who had ADPKD and were admitted in the nephrology department of Hôpital Necker between January 1998 and August 2008 with likely or definite renal and/or hepatic cyst infection. Medical files of all included patients were reviewed.

RESULTS

Among 389 identified patients with ADPKD, 33 (8.4%) had 41 episodes of cyst infection, including eight definite and 33 likely cases. The incidence of cyst infections in patients with ADPKD was 0.01 episode per patient per year. Microbiological documentation was available for 31 episodes (75%), Escherichia coli accounting for 74% of all retrieved bacterial strains. Positron emission tomography scan proved superior to ultrasound, Computed tomography scan, and magnetic resonance imaging for the detection of infected cysts. Clinical efficacy of initial antibiotic treatment was noted in 71% of episodes. Antibiotic treatment modification was more frequently required for patients who were receiving initial monotherapy compared with those who were receiving bitherapy. Large (diameter >5 cm) infected cysts frequently required drainage.

CONCLUSIONS

Positron emission tomography scan will probably make the diagnosis of cyst infections easier and more accurate. Antibiotic association, including a fluoroquinolone, and the drainage of large infected cysts remain the main treatment for cyst infections.