Increased resistance of gram-negative urinary pathogens after kidney transplantation

Toward an optimization of empirical antibiotic therapy in acute graft pyelonephritis: A retrospective multicenter study

OBJECTIVE

Acute graft pyelonephritis (AGPN) is the most frequent infectious complication in kidney transplant recipients (KTR). The treatment of acute community-acquired (CA) pyelonephritis is based on third-generation cephalosporins (3GC) and fluoroquinolones. Cefepime or a piperacillin-tazobactam combination are more often used in healthcare-associated (HCA) infections. However, these recommendations do not consider the resistance observed in KTRs. The objective of our study was to define the most appropriate empirical antibiotherapy for AGPN in KTRs according to the CA and HCA settings. To answer this question, we assessed the prevalence of resistance to different antibiotics usually recommended for urinary tract infections (UTIs) in the general population.

METHODS

Observational, retrospective, multicenter study covering all episodes of AGPN occurring in hospitalized KTRs in 2019.

RESULTS

A total of 210 patients were included in 7 centers and 244 episodes of AGPN were analyzed (158 CA-AGPN and 86 HCA-AGPN). The prevalence of 3GC and fluoroquinolone resistance was 23 % (n = 36) and 30 % (n = 50) in CA infections (n = 158), and 47 % (n = 40) and 31 % (n = 27) in HCA infections (n = 86), respectively. Cefepime resistance rate was 19 % (n = 30) in CA-AGPN and 29 % (n = 25) in HCA-AGPN. Piperacillin-tazobactam combination had resistance rates > 15 % in both CA and HCA infections. The only antimicrobials with resistance rates < 10 % were aminoglycosides and carbapenems.

CONCLUSION

None of the antibiotics recommended in empirical treatment in UTIs has shown a resistance rate of less than 10% with regard to AGPN. Therefore, none of them should be used as monotherapy. A combination therapy including amikacin could be an appropriate strategy in this setting.

Diagnosing and Managing Urinary Tract Infections in Kidney Transplant Recipients

In the article, the authors review antibiotic treatment options for both acute uncomplicated UTI and complicated UTI. In addition, they review alternative regimens which are needed in the setting of drug-resistant pathogens including vancomycin-resistant Enterococcus, -extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales, and carbapenem-resistant Pseudomonas, which are encountered with more frequency.

Treatment of asymptomatic bacteriuria in the first 2 months after kidney transplant: A controlled clinical trial

BACKGROUND

The incidence of urinary tract infections (UTIs) in the first 2 months postrenal transplantation (pRT) is very high. We evaluate the efficacy of asymptomatic bacteriuria (AB) screening and treatment on the incidence of UTI in the first 2 months pRT METHODS: We conducted a randomized controlled clinical trial. A urine culture was obtained in all patients on the day of the bladder catheter removal, on week three, and before removal of the ureteral catheter. The intervention group received treatment for AB. The control group did not receive treatment. The primary outcomes were the cumulative incidence of UTI and/or graft pyelonephritis and the time to the first episode of UTI and/or graft pyelonephritis RESULTS: Eighty patients were randomized, 40 in each group, and the median follow-up was 63 days (IQR 54-70). The average age was 29.8 years and 33.7% (n = 27) were women. The incidences of UTI (n = 10, 25 % vs. n = 4, 10%, p = .07) and pyelonephritis (n = 6, 15% vs. n = 1, 2.5%, p = .04) were greater in the intervention group, as also shown in the survival analysis: UTI (HR2.8, 95% CI 0.8-9.1, p = .07) and pyelonephritis (HR 6.5, 95% CI 0.8-54.7, p = .08), respectively. The most commonly isolated bacterium was Escherichia coli (n = 28, 59.5%), and over half were E. coli with extended-spectrum beta-lactamases (n = 15). A major limitation was not obtaining the calculated sample size due to a delay in patient recruitment resulting from the COVID-19 pandemic CONCLUSION: Treatment of AB in the first 2 months pRT does not decrease the incidence of UTI or graft pyelonephritis and may actually increase their frequency. Routine treatment of AB during the first months after renal transplantation should not be a standard procedure.

Construction of a nursing solution to prevent and control urinary tract infection in the early stages of kidney transplantation

Background

To construct a nursing solution for the prevention and control of urinary tract infection (UTI) in the early stage after kidney transplantation, and to provide systematic and standardized nursing intervention measures for patients in the early stage after kidney transplantation.

Methods

The preliminary draft of intervention plan was formulated based on risk factor analysis research results of early UTI after kidney transplantation, combined with theoretical research, literature review, and research group meeting. The Delphi method was used to consult 15 experts for two rounds, and the entries were modified according to the opinions of the experts.

Results

After two rounds of consultation, the expert opinions tended to be consistent, and expert authority coefficient was 0.87. The Kendall harmony coefficient of importance and feasibility indexes of the two rounds of consultation were 0.407, 0.651 and 0.545, 0.686, respectively, with statistically significant differences (P<0.001). The nursing solution consisted of eight first-level indexes and 35 second-level indexes. The eight first-level indexes included admission symptom evaluation, UTI monitoring, health education, sports intervention, nutrition intervention, ward management, risk factor prevention and nursing, and psychosocial intervention.

Conclusions

This study constructed a scientific and reliable nursing solution for the prevention and control of early UTI after kidney transplantation, which is hugely important for guiding clinical nursing work.

Antibiotic Resistance and Virulence Genes of Escherichia coli Isolated from Patients with Urinary Tract Infections After Kidney Transplantation from Deceased Donors

Objective

This study aimed to determine the prevalence of antibiotic resistance and virulence genes of Escherichia coli strains among patients with urinary tract infections (UTIs) after kidney transplantation from deceased donors.

Methods

Between January 2014 and June 2018, 64 patients who received kidney transplants from deceased donors at our institution developed a UTI due to E. coli. Polymerase chain reaction was used to detect virulence genes in E. coli strains. The Kirby–Bauer method was used to evaluate the antibiotic susceptibility pattern of the isolates.

Results

Among the study cohort, 46 (71.9%) UTIs were community-acquired (CA), and 18 (28.1%) were hospital-acquired (HA). The percentages of isolated E. coli strains that showed antibiotic resistance were as follows: 92.2% to ampicillin, 76.6% to cefalotin, 81.3% to carbenicillin, 29.7% to ciprofloxacin, 62.5% to cotrimoxazole, 35.9% to gentamicin, 34.4% to levofloxacin, 28.1% to norfloxacin, 68.8% to pefloxacin, 57.8% to trimethoprim/sulfamethoxazole, and 20.3% to amikacin. HA E. coli showed higher resistance to ciprofloxacin, cotrimoxazole, trimethoprim/sulfamethoxazole and amikacin, compared with CA E. coli (P<0.05). The most prevalent virulence genes among the E. coli strains were fim (64.1%), followed by irp2 (56.3%), iroN (46.9%), pap GII (45.3%), sfa (31.3%), pap (25%), iuc (23.4%), pap GI (15.6%), pap GIII (14.1%), hly (9.4%), and cnf (4.7%). The irp2 and iroN genes were found more frequently in the HA E. coli than in the CA E. coli (P<0.05).

Conclusion

The E. coli strains, especially HA E. coli, isolated from UTI patients after kidney transplantation from deceased donors showed resistance to multiple antibiotics and harbored numerous virulence genes. These findings provide insight for genetic characterizations and epidemiological studies of E. coli strains causing UTIs in patients after kidney transplantation from deceased donors.

Caracterización de la infección urinaria y resistencia antimicrobiana en receptores de trasplante renal de un centro colombiano

La infección del tracto urinario (ITU) es una de las principales complicaciones postrasplante renal, los datos a nivel nacional en ese grupo poblacional son limitados.

Objetivos caracterizar la microbiología de las ITU presentadas en receptores de trasplante renal (TxR) en un centro colombiano durante el periodo 2017–2019, los factores relacionados con la resistencia antimicrobiana y el impacto de la ITU en la función del injerto renal.

Métodos estudio de corte transversal ejecutado mediante el análisis de la base de datos de ingresos hospitalarios por urgencias de pacientes receptores de TxR con sospecha clínica de ITU en una institución de cuarto nivel en Bogotá, Colombia. El análisis de datos se ejecutó en STATA 13.0.

Resultados La ITU causó 12,69% de visitas a urgencias en pacientes trasplantados. Los microorganismos aislados fueron: Escherichia coli 52,22%, Klebsiella pneumoniae 16,67%, Pseudomonas aeruginosa 4,44%, Salmonella spp 4,44%, Proteus mirabilis 3,33%, Serratia marcescens 2,22%, Klebsiella oxytoca 2,22%, Citrobacter koseri 1,11%, Enterobacter cloacae 1,11%, otros 2,22%; El urocultivo fue negativo en 10% de los casos. El 28,39% (n:23) de gérmenes aislados fue multisensible mientras que el 71,60% (n:58) expresó algún tipo de patrón de resistencia distribuido así: 68,96% productor de betalactamasa de espectro extendido (BLEE), 15,52% productor de carbapenemasas, 12,06% productor de betalactamasa tipo IRT, 3,45% fue catalogado como multirresistente. 17,78% de los pacientes presentó criterios de urosepsis, no se registró ningún caso de mortalidad asociada a la ITU. La creatinina sérica tuvo un incremento promedio de 0,46 mg/dl durante el episodio de ITU (p: <0,0001) y el antecedente de diabetes mellitus se relacionó con la ITU causada por gérmenes resistentes (p: 0,008).

Conclusiones La ITU es una causa frecuente de atención en urgencias para pacientes receptores de TxR; la Escherichia coli es el microorganismo causal más frecuente y cerca del 70% de los gérmenes aislados presentó algún patrón de resistencia antimicrobiana.

Temporal trends, risk factors and outcomes of infections due to extended-spectrum β-lactamase producing Enterobacterales in Swiss solid organ transplant recipients between 2012 and 2018

Background

The burden of antimicrobial resistance is high in solid organ transplant (SOT) recipients. Among Swiss SOT recipients, we assessed temporal trends of ESBL-producing Enterobacterales (ESBL-E), identified risk factors for ESBL-E, and assessed the impact of resistance on patient outcome.

Methods

Data from the Swiss Transplant Cohort Study (STCS), a nationwide prospective cohort of SOT-recipients, were analysed. Temporal trends were described for ESBL-detection among Escherichia coli and non-Escherichia coli. In a nested case–control study, cases with ESBL-E infection were 1:1 matched (by time since transplantation, organ transplant, pathogen) to controls infected with non-ESBL-E. Factors associated with resistance and with unfavourable 30-day outcome (death, infection relapse, graft loss) were assessed.

Results

From 2012 to 2018, we identified 1′212 infection episodes caused by Enterobacterales in 1′074 patients, thereof 11.4% (138/1′212) caused by ESBL-E. The proportion of ESBL-production among Escherichia coli remained stable over time (p = 0.93) but increased for non-E. coli (p = 0.02) Enterobacterales. In the case–control study (n = 102), antibiotic pre-treatment was independently associated with ESBL-production (aOR = 2.6, 95%-CI: 1.0–6.8, p = 0.046). Unfavourable outcome occurred in 24/51 (47%) cases and 9/51 (18%) controls (p = 0.003). Appropriate empiric antibiotic therapy was the only modifiable factor associated with unfavourable outcome.

Conclusions

In Swiss SOT-recipients, proportion of infections with ESBL-producing non-E. coli Enterobacterales increased in recent years. Antibiotic pre-treatment represents a risk factor for ESBL-E. Improving appropriateness of empiric antibiotic treatment might be an important measure to reduce unfavourable outcome, which was observed in almost half of SOT-recipients with ESBL-E infections.

A middle east systematic review and meta-analysis of bacterial urinary tract infection among renal transplant recipients; Causative microorganisms

UTI has been reported as the most prevalent infectious complication after-kidney transplantation. This study aimed to evaluate the bacterial urinary tract infection among renal transplant recipients, and causative microorganisms from the Middle East. We searched literatures reporting the prevalence of UTI, bacterial pathogens, and antibiotic resistance pattern from January 1, 2010-May 10, 2020 for patients with renal transplant recipients from the Middle East in international databases. Terms used were; "Urinary tract infection", "UTI", "bacterial pathogens", "bacterial infection", "renal transplant", "kidney transplant", post - renal transplant, "antibiotic resistance", "Middle East", Turkey, Iran, Jordan, Kuwait, Bahrain, Lebanon, United Arab Emirates, Qatar, Cyprus, Yemen, Iraq, Egypt, Palestine, and Syria. Data analyzed using CMA software. The prevalence of UTI among renal transplant recipients from the Middle East varied between 4.5 and 85%. The combined prevalence of UTI was reported by 37.9% (95% Cl: 28.3-48.5). The most prevalent organisms recovered from urine samples of patients with UTI were E. coli and Klebsiella with prevalence rate of 57.5%, and 15%, respectively. Also, Coagulase negative Staphylococcus (15%), and Enterococci (11.2%) were the most predominant among Gram positive microorganisms. The most resistance among Gram negative microorganisms belonged to Ceftazidime with frequency of 90% followed by Carbenicillin and Cephalexin with prevalence of 87.3%, and 84%, respectively. The effective antibiotic was Imipenem (15.2%). Regarding the high UTI rate in renal transplant recipients from the Middle East, and the significant presence of both Gram negative and Gram positive microorganisms as the most prevalent uropathogens after renal transplantation should be considered when selecting empirical antibacterial therapy.

Analysis of Susceptibility to Selected Antibiotics in Klebsiella pneumoniae, Escherichia coli, Enterococcus faecalis and Enterococcus faecium Causing Urinary Tract Infections in Kidney Transplant Recipients over 8 Years: Single-Center Study

Background: Urinary tract infections (UTIs) are the most common bacterial infections among kidney transplant (KTX) recipients. The purpose of this study was to analyze antimicrobial resistance (AMR) in four most common pathogens responsible for UTIs in KTX recipients and determine risk factors (RF) for resistance in the same group. Methods: Analyzed antibiograms were based on urine samples positive for bacterial growth of 10⁵ colony-forming units (CFU)/mL obtained from hospitalized adult KTX recipients presenting with UTI symptoms upon admission to the center in years 2011–2018. Results: In total, 783 antibiograms were analyzed for Klebsiella pneumoniae (258 samples, 33.0%), Escherichia coli (212, 27.0%), Enterococcus faecalis (128, 24.0%), and Enterococcus faecium (125, 16.0%). The decrease in susceptibility of E. coli to amoxicillin/clavulanic acid (62.9% vs. 40.0%) and ciprofloxacin (100% to 40.0%) was observed. Susceptibility to gentamicin increased from 33.3% to 92.9% in E. faecium. Susceptibility to tigecycline remained 100% through all years in case of E. faecalis and E. faecium. Male gender was a RF for resistance to amoxicillin/clavulanic acid (p = 0.008), ciprofloxacin (p = 0.0003), trimethoprim/sulfamethoxazole (p = 0.00009), ceftriaxone (p = 0.0001), and cefuroxime axetil (p = 0.00038) in K. pneumoniae and against gentamicin in E. faecalis (p = 0.015). Higher resistance to ampicillin in E. faecalis (p = 0.012) and to ciprofloxacin (p = 0.0003), trimethoprim/sulfamethoxazole (p = 0.007), piperacillin/tazobactam (p = 0.003), ceftriaxone (p = 0.001), and cefuroxime axetil (p = 0.013) in K. pneumoniae was observed in higher age groups of patients. Diabetes as a cause of kidney insufficiency (p = 0.026) and kidney-pancreas transplantation (p = 0.014) was RF for resistance to ceftriaxone in K. pneumoniae. Conclusions: AMR in uropathogens from KTX recipients fluctuated. There were identifiable RFs for resistance in the examined bacteria–antibiotic combinations. We recommend continuous mapping of site-specific microorganisms as etiology and susceptibility may vary between institutions and over time.

Antibiotic therapy in case of positive cultures of kidney transplant preservation fluid: a nationwide survey of prescribing practices

Our survey aimed to describe current prescribing practices for perioperative antibiotic prophylaxis in French kidney transplant centers. We conducted a nationwide cross-sectional clinical vignette-based survey that we sent via email to hospital practitioners involved in perioperative management of kidney transplant patients (KTR). Nearly half of practitioners contacted (182/427, 42.6%) were respondents. A total of 167 getting enough kidney transplant activity were eligible for the survey. The response rate was 50.7% (68/134) among interns and 33.8% (99/293) among seniors. Positive perfusion fluids (PF) cultures for methicillin-susceptible Staphylococcus aureus were associated with antibiotic prescribing in 35% of cases, with no difference in prescribing in patients with diabetes, obesity, or delayed graft function. Antibiotic prescribing was most frequent with Pseudomonas aeruginosa (67%) and Klebsiella pneumoniae strains producing extended spectrum β-lactamases (57%). About 77%, 16%, and 13% of respondents, respectively, reported the existence of local practice guidelines for surgical antibiotic prophylaxis, a standardized approach for antibiotic prescribing in case of positive kidney transplant PF cultures, and local practice guidelines for systematical antibiotic prophylaxis in the early post-transplant period. In France, antibiotic prophylaxis practices in the perioperative kidney transplant period are very heterogeneous. To prevent unnecessary prescribing and bacterial resistance, evidence-based practice guidelines should be developed.

Prevalence and Antimicrobial Resistance of Bacterial Uropathogens Isolated from Iranian Kidney Transplant Recipients: A Systematic Review and Meta-Analysis

BACKGROUND

Urinary tract infection (UTI) is a major complication in patients who receive the kidney transplant. We aimed to evaluate the prevalence and antimicrobial resistance of bacterial uropathogens isolated from Iranian kidney transplant recipients.

METHODS

We searched according to Prisma protocol for UTI infection, prevalence, occurrence and distribution of bacteria and their pattern of antibiotic resistance among Iranian patients who receive kidney transplant through online electronic databases with MeSh terms and text words in published references in both Persian and English languages during 1990-2017. Data analysis was performed using Comprehensive meta-analysis software (CMA) by Cochrane Q and I2 Random Effects Model.

RESULTS

Eleven studies met the eligible inclusion criteria. The prevalence of UTI among kidney transplant patients varied from 11.7% to 67.5%. The combined prevalence of UTI was 32.6%. Among Gram-negative pathogens causing UTI, E. coli was the most dominant followed by Klebsiella pneumonia with prevalence 41.3% and 11.9%, respectively. Also, amongst Gram-positive bacteria, the highest prevalence belonged to Enterococcus spp. (9.8%) and coagulase-negative Staphylococci (9.4%). Also in Gram-negative pathogens, the most resistance was to ampicillin (91.2%), followed by ceftazidime (89.5%). The minimum resistance was against imipenem with prevalence 14.3%.

CONCLUSION

The combined prevalence of UTI was 32.6%. Gram-negative pathogens especially E. coli were the most agents of UTI in Iranian patients who receive kidney transplant. Also, in gram-negative pathogens, the most resistance was to ampicillin that it needs a new strategy for prophylaxis and treatment of UTI after the kidney transplant.

Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe

Background

Asymptomatic bacteriuria is frequent in kidney transplant recipients (KTRs). However, there is no consensus on diagnosis or management. We conducted a European survey to explore current practice related to the diagnosis and management of asymptomatic bacteriuria in adult KTRs.

Methods

A panel of experts from the European Renal Association-European Dialysis Transplant Association/Developing Education Science and Care for Renal Transplantation in European States working group and the European Study Group for Infections in Compromised Hosts of the European Society of Clinical Microbiology and Infectious Diseases designed this cross-sectional, questionnaire-based, self-administered survey. Invitations to participate were e-mailed to European physicians involved in the care of KTRs.

Results

Two hundred and forty-four participants from 138 institutions in 25 countries answered the survey (response rate 30%). Most participants [72% (176/244)] said they always screen for asymptomatic bacteriuria in KTRs. Six per cent (15/240) reported never treating asymptomatic bacteriuria with antibiotics. When antimicrobial treatment was used, 24% of the participants (53/224) said they would start with empirical antibiotics. For an episode of asymptomatic bacteriuria caused by a fully susceptible microorganism and despite no contraindications, a majority of participants (121/223) said they would use a fluoroquinolone (n = 56), amoxicillin/clavulanic acid (n = 38) or oral cephalosporins (n = 27).

Conclusions

Screening for and treating asymptomatic bacteriuria are common in KTRs despite uncertainties around the benefits and harms. In an era of antimicrobial resistance, further studies are needed to address the diagnosis and management of asymptomatic bacteriuria in these patients.

Microbiological epidemiology of preservation fluids in transplanted kidney: a nationwide retrospective observational study

OBJECTIVES

Kidney transplant recipients are at high-risk for donor-derived infections in the early post-transplant period. Transplant preservation fluid (PF) samples are collected for microbiological analysis. In case of positive PF cultures, the risk for the recipient is unknown and there is no consensus for prescribing prophylactic antibiotics. This nationwide observational study aimed to determine the epidemiology of bacterial and fungal agents in kidney transplant PF cultures and identify risk factors associated with positive PF cultures.

METHODS

We performed a retrospective observational study on the following data collected from a national database between October 2015 and December 2016: characteristics of donor, recipient, transplantation, infection in donor and PF microbiological data.

RESULTS

Of 4487 kidney transplant procedures, including 725 (16.2%, 725/4487) from living donors, 20.5% had positive PF cultures (living donors: 1.8%, 13/725; deceased donors: 24.1%, 907/3762). Polymicrobial contamination was found in 59.9% (485/810) of positive PF cultures. Coagulase-negative staphylococci (65.8%, 533/810) and Enterobacteriaceae (28.0%, 227/810) were the most common microorganisms. Factors associated with an increased risk of positive PF cultures in multivariable analysis were (for deceased-donor kidney transplants): intestinal perforation during procurement (OR 4.4, 95% CI 2.1-9.1), multiorgan procurement (OR 1.4, 95% CI 1.1-1.7) and en bloc transplantation (OR 2.5, 95% CI 1.3-4.9). Use of perfusion pump and donor antibiotic therapy were associated with a lower risk of positive PF cultures (OR 0.4, 95% CI 0.3-0.5 and OR 0.6, 95% CI 0.5-0.7, respectively).

CONCLUSION

In conclusion, 24% of deceased-donor PF cultures were positive, and PF contamination during procurement seemed to be the major cause.

Perioperative prophylaxis with ertapenem reduced infections caused by extended-spectrum betalactamase-producting Enterobacteriaceae after kidney transplantation

Backgound

In recent years we have witnessed an increase in infections due to multidrug-resistant organisms in kidney transplant recipients (KTR). In our setting, we have observed a dramatic increase in infections caused by extended-spectrum betalactamase-producing (ESBL) Enterobacteriaceae in KTR. In 2014 we changed surgical prophylaxis from Cefazolin 2 g to Ertapenem 1 g.

Methods

We compared bacterial infections and their resistance phenotype during the first post-transplant month with an historical cohort collected during 2013 that had received Cefazolin.

Results

During the study period 110 patients received prophylaxis with Cefazolin and 113 with Ertapenem. In the Ertapenem cohort we observed a non-statistically significant decrease in the percentage of early bacterial infection from 57 to 47%, with urine being the most frequent source in both. The frequency of infections caused by Enterobacteriaceae spp. decreased from 64% in the Cefazolin cohort to 36% in the Ertapenem cohort (p = 0.005). In addition, percentage of ESBL-producing strains decreased from 21 to 8% of all Enterobacteriaceae isolated (p = 0.015). After adjusted in multivariate Cox regression analysis, male sex (HR 0.16, 95%CI: 0.03–0.75), cefazolin prophylaxis (HR 4.7, 95% CI: 1.1–22.6) and acute rejection (HR 14.5, 95% CI: 1.3–162) were associated to ESBL- producing Enterobacteriaceae infection.

Conclusions

Perioperative antimicrobial prophylaxis with a single dose of Ertapenem in kidney transplant recipients reduced the incidence of early infections due to ESBL-producing Enterobacteriaceae without increasing the incidence of other multidrug-resistant microorganisms or C. difficile.

Updates on urinary tract infections in kidney transplantation

Urinary tract infection (UTI) represents the most common infection after kidney transplantation; it is associated with an increased risk for acute kidney rejection and impaired graft function in the early post-transplant period. Kidney transplant recipients with UTIs are often clinically asymptomatic due to the immunosuppressive therapy; however, asymptomatic bacteriuria may progress to acute pyelonephritis, bacteremia and urosepsis, particularly in the early post-transplant period, that are independent risk factors for short and long-term graft and patient survival. This article reviews the definitions, incidence, risk factors and the management of UTI in kidney transplant recipients; furthermore, the main controversial and still unanswered questions, regarding the causes of recurrent UTIs, adequate use of antibiotics to avoid antibiotic resistance, dosing and timing for prophylaxis and treatment of symptomatic infections, are also discussed. The emerging definition of urinary microbiota introduces new concepts in understanding the complexity of the disease and might represent the future target for therapeutic interventions.

Clinical Significance of Gastrointestinal Carriage of Klebsiella Pneumoniae-Producing Extended-Spectrum Beta-Lactamases in Kidney Graft Recipients

The burden of Klebsiella pneumoniae (KP) producing extended-spectrum beta-lactamases (ESBL+) urinary tract infections (UTIs) is a growing problem after kidney transplantation (KTX). The study was aimed at evaluating the incidence of KP ESBL+ gut colonization in KTX recipients and its correlation with clinical outcomes with special regard to UTIs. The study included all KTX patients hospitalized in our department between January 2014 and December 2016. During this period 2018 KTX patients were admitted: 605 in 2014, 750 in 2015, and 663 in 2016, respectively. Screening for drug-multiresistant Enterobacteriaceae gut carriage was performed in 104 patients (2014), 122 (2015), and 166 (2016). In 2014, 2015, and 2016, 18 (17.3%), 26 (21.3%), and 30 (18.1%) patients had positive test results, and 44 (42.3%), 36 (29.5%), and 45 (27.4%) KTX patients were diagnosed with KP ESBL+ UTI. In 2014, KP ESBL+ UTI was diagnosed in 30 (34.9%) cases with negative anal swab and in 14 patients (77.8%) with positive test result (P = .0008). In 2015, KP ESBL+ UTI was diagnosed in 21 patients (21.9%) with negative anal swab and in 15 (57.7%) with positive test result (P = .0004). In 2016, KP ESBL+ UTI was diagnosed in 24 patients (17.8%) with negative anal swab and in 21 (72.4%) with positive test result (P = .000001). In conclusion, we have revealed a strong association between gut K. pneumoniae colonization, female sex, and MPA intake and KP ESBL+ urinary tract infections in kidney transplant recipients. Our results indicate the very important role of KP ESBL+ screening, while strategies of identified carriers require further research.