UTI in Renal Transplant

UTI in Renal Transplant

Background

  • Most common post-renal transplant infection
  • Associated with increased risk of rejection, allograft dysfunction and morbidity/mortality
  • Risk Factors/Unique Considerations for Transplant Patients:
    • Vesicoureteral reflex is common in transplant patients due to short transplant ureter and no valve at vesicoureteral junction
    • Native kidneys/ureteral stumps (particularly if history of PKD), renal calculi, urinary tract abnormalities such as vesicoureteral reflex
    • Catheterization or indwelling urinary stents, defunctionalized bladder (related to prior oliguria/prolonged dialysis), deceased donor transplant, delayed graft function, transplant immunosuppression and/or systemic illness on steroids and immunosuppression (may mask symptoms of sepsis)
  • Common organisms:
    • GNRs: E. Coli most common, Pseudomonas, Enterococcus, Klebsiella
    • Increasing resistance to ciprofloxacin and Bactrim due to frequent use for prophylaxis
  • Prevention:
    • Prophylactic antibiotics: Bactrim DS daily, often used 6 months-1year after transplant
        • If unable to tolerate Bactrim, consider cephalosporins or nitrofurantoin (if GFR>60 and typically for 1 month only) in effort to prevent fluoroquinolone resistance
    • Basic infection prevention measures: hydration, frequent voiding, wiping front to back, voiding after sexual intercourse
    • Removal of indwelling devices/catheters as able
    • Consider post-coital antibiotics for women with recurrent UTI after sexual intercourse
    • Estrogen cream for peri/postmenopausal women (restores epithelial barrier)
    • Inconclusive data on cranberry juice

 

Presentation

  • Simple cystitis: dysuria, frequency/urgency, hematuria, suprapubic tenderness. No systemic symptoms and no indwelling catheters/stents/tubes.
  • Acute pyelonephritis/complicated UTI: above symptoms + fever/chills, malaise, nausea or allograft pain, leukocytosis
    • Also includes urinary tract anomalies and/or indwelling catheters/stents/tubes
  • The transplanted kidney is denervated, and pts may be not have upper urinary symptoms

 

Evaluation 

  • UA with culture (midstream collection or “clean catch”)
  • Examine the native kidneys (CVA tenderness) AND the allograft (RLQ or LLQ)
  • Renal U/S (of both allograft and native kidneys) if: early post-op (1 month), recurrent (2+ episodes in year), history of nephrolithiasis or if sepsis/bacteremia
  • Blood cultures if signs/symptoms of complicated UTI (systemic symptoms) OR if urine culture are consistent w/ hematogenous spread to the bladder (such as Staph aureus)
  • Consider testing for C. urealyticum if UA positive but culture negative

 

Management

  • Always get UA with culture (midstream collection)
  • Remove or replace indwelling catheters
  • Review prior culture susceptibilities (if available)
  • Empiric antibiotic regimens:
      • Simple cystitis: Fluoroquinolones (ciprofloxacin 250 BID or Levaquin 500 mg daily), Augmentin (500 mg BID), 3rd gen cephalosporin (cefpodoxime 100 mg BID or cefixime 400 mg daily) or nitrofurantoin 100 mg BID (if GFR>30)
      • Complicated UTI/Pyelonephritis (cover Pseudomonas, gram negatives and Enterococcus): Rocephin 2g daily (preferred), Cefepime 2g q8hrs or Zosyn 3.75g q6hrs, can also use meropenem 1g q8h (need ID approval)
        • Note, Dr. Langone does not like Rocephin, but prefers: Cefepime if LE+, nitrite +, Zosyn if LE+ and nitrite – (covers enterococcus), or LVQ
      • For stable pts with mild complicated UTI, can consider giving more narrow empiric antibiotics: Augmentin 875 mg BID or ciprofloxacin 500 mg q12h 
      • MDR UTI: Consult transplant ID
        • Options: meropenem-vaborbactam, ceftolozone-tazobactam, ceftazidime-avibactam
      • If pts w/PCKD, include lipophilic antibiotic (such as ciprofloxacin) to penetrate cysts
  • Duration:
      • Simple cystitis: <6 months post-transplant: 10-14 d; >6 months post-transplant: 5-7 d
      • Complicated UTI: 14-21 d
      • Transition to oral if susceptible to Levaquin or Cipro (bioavailable in urinary tract)

 

Additional Information

  • Asymptomatic bacteriuria: no consensus; recommend getting 2nd culture to confirm prior to treating
      • Often treated if <1-3 months since transplant. > 3 months post-transplant likely do not require UA screenings and/or treatment for asymptomatic bacteriuria
  • Positive Blood Cultures Related to UTI
      • Repeat blood cultures are NOT typically indicated for uncomplicated gram negative bacteremia or for bacteremia from a localized source (such as pyelonephritis)
      • Consider repeating cultures when: concern for endovascular involvement, MDR gram negative bacilli, persistence of fever/leukocytosis >72 hours after initiation of appropriate antibiotic regimen, new sepsis, concern for abscess or no source control