6. A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
Asymptomatic bacteruria (whether treatment is necessary or not) treatment in post transplant is controversial.
From my personal opinion, asymptomatic bacteruria is common in ileal conduit & antibiotic treatment is necessary only if patient becomes symptomatic, has graft dysfunction or lab abnormality ( leucocytosis, high CRP).
Patient has no urinary symptoms ,has also ideal conduit in which asymptomatic bacteriuria is common and no need to be treated but in kidney transplant ,Pt is on immunosuppression so better to treat asymptomatic bacteriuria to avoid progression to UTI
How would you manage this patient? This patient with urinary diversion, expected to have bacturia (mixed with intestinal flora) – growth of multiple organism points towards contamination. In general population post-urinary diversion, we don’t screen for it, unless the patient has symptomatic febrile UTI / pyelonephritis. In such cases also, anatomical abnormalities (ureter stricture, stone etc) are important and its correction eliminates further risk of UTI. In transplant recipients ASB may aggravate to pyelonephritis, as the denervated kidney in ileal conduit may not produce classical symptoms of UTI, and IS may mask the inflammatory reactions. But majority of the guidelines don’t recommend treatment of ASB, to aboid antibiotic resistance; unless patient becomes symptomatic / raised CRP / Leucocytosis /graft dysfunction. Routine screening by urinalysis and culture is also not recommended beyond 3months post-transplant. 1) References: 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 Sep;33(9):e13507. doi: 10.1111/ctr.13507. Epub 2019 Mar 28. PMID: 30793386. 2) 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. 2020 Feb;22(1): e13221. doi: 10.1111/tid.13221. Epub 2019 Dec 12. PMID: 31782870. 3) Coussement J, Maggiore U, Manuel O, et al. Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe. Nephrol Dial Transplant. 2018 Sep 1;33(9):1661-1668. doi: 10.1093/ndt/gfy078. PMID: 29635410.
If the patient has no urinary or systemic symptoms, this is an asymptomatic bacteriuria due to ileal conduit and there is no need for treatment unless the patient become symptomatic and shows laboratory abnormalities such as elevated CRP.
· How would you manage this patient?
This patient with urine diversion, expected to have bacteruria as the urine is mixed with intestinal normal flora. Specially the growth of multiple organism will point to contamination.
So in such case, only treatment is offered if there is significant symptoms of UTI.
So no need for treatment in this scenario.
-Management of this case starts by proper history taking and assessment of the reasons that have led to ileal conduit
-Asymptomatic bacteriuria management post transplantation is a point of debate .
-assessment of fever , CBC ,CRP with titer, associated vaginal infections , drug levels of FK and MMF are the keys for proper management.
workup for complications related to ileal conduits. interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients’ renal function and maintain their quality of life. https://pubs.rsna.org/doi/10.1148/rg.2021200067
How would you manage this patient? Ileal conduit urinary diversion (ICUD) is the least complication-prone and most common procedure after radical cystectomy. It is associated with number of complication including UTI, upper tract stones as well as calculi within the diversion segment,and progressive decrease of renal function are noted in most patients during long-term follow-up after radical cystectomy.
Patients who had undergone ICUD had a higher incidence of UTI and UTI with septicaemia during long-term follow-up. The major concern following ICUD is the potential for bacterial colonisation of the intestinal conduit. However, asymptomatic bacterial tolerance is common in patients who have undergone ICUD
The ICUD increases the risk of UTI with septicaemia about fivefold, and the mortality rate of septicaemia increases with age.
– In the index case no data available about the cause of this procedure, other risk factors as DM ,level of IS, and presence of symptomatic or complicated UTI. – Full history about symptoms of UTI (urgency , frequency , dysuria …). – CBC, CRP ,urine culture. – Kidney function. – Blood culture in case of suspected urosepsis. –Perioperative prophylactic antibiotic treatment has been proven to be effective
-asymptomatic UTI antibiotic treatment is unnecessary as this is a chronic complication ,only needs to be monitored. Symptomatic UTI treated according to severity References Liu YL, Luo HL, Chiang PH, Chang YC, Chiang PH. Long-term urinary tract effect of ileal conduit after radical cystectomy compared with bladder preservation: a nationwide, population-based cohort study with propensity score-matching analysis. BMJ Open. 2018 Dec 9;8(12):e023136.
In this case, the diagnosis is asymptomatic bacteriuria, which is also expected due to the fact that the ureter was implanted in the ileal conduit.
After 2 months of transplantation, there is no longer any indication for monitoring urine culture, as there is no longer any impact on the graft.
REFERENCE:
– Robles Garcia et al; Kidney Transplant and ileal conduit diversion on same surgical procedure ;clinical case and review of literature.2020
– 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. 2020;22(1):e13221
the index patient is a 57 year old female patient who received kidney from her sister 6 months ago… The recipient has abnormal bladder and is on an ileal conduit created for urinary diversion…. she has neocystoureterostomy on the ileal conduit…. This is 6 months post transplant and she has excellent graft function with no features of pyelonephritis…. Urine culture shows bacterial count >105 CFU/ml….
this patient has asymptomatic bacteriuria after renal transplant….
The time period of 6months does not warrant treatment with antibiotics for prophylaxis
There is data to show that antibiotic prophylaxis’s is indicated in the first 3 months post renal transplant as there is high incidence of acute pyelonephritis… AST recommend treatment of asymptomatic bacteriuria in the first 3 months of transplant…they do not recommend routine screening or treatment of asymptomatic bacteriuria after 3 months…
There is no evidence to say that asymptomatic bacteriuria is associated with increased graft loss… there is no correlation with long term graft function deterioration also….
A recent meta analysis showed that there is no need to treat Asymptomatic bacteriuria across 8 studies after 1 month of renal transplantation….
This patient, I would like to confirm whether she has symptomatic UTI…with fever, elevated total count and graft tenderness…if none is there I would diagnose her to have asymptomatic bacteriuria…..I would monitor her regularly for symptomatic UTI on her follow up visit
I will not reduce the immunosuppression or give antibiotic prophylaxis’s.
References:
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. 2020;22(1):e13221
Asymptomatic bacteriuria – In the transplant population, can be defined by the presence of >10*5 bacteria (CFU/mL) on urine culture with no symptoms of UTI. · Recurrent UTI – can be defined as Two or more episodes of UTI in six months, or three or more episodes of UTI in one year.
Monitoring for asymptomatic bacteriuria should be limited to the first one to two months post transplant. Most patients who are observed without antibiotic treatment will clear bacteriuria spontaneously .
If two consecutive cultures yield >105 (CFU)/mL of the same pathogen, antibiotic treatment for five days .
· If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
· No Monitoring for asymptomatic bacteriuria after two months since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, allograft rejection and can lead to unnecessary antibiotic administration.
Long term graft & patient survival in illeual conduits is comparable to that in normal transplant population.
Screening and treatment of asymptomatic bacteriuria is not recommended.
As in the foregoing example, patients with anomalous urinary tracts are typically recipients of an ileal conduit. These individuals are prone to recurring asymptomatic or symptomatic UTIs. To determine the severity of the disease, a comprehensive medical history, physical examination, and investigations, including a CBC, RFTs, CRP, DIC profile, and urine culture, are necessary. Whether an antibiotic is prescribed for a symptomatic UTI depends on the infection’s complexity.
Simple urinary tract infections are treated with fluoroquinolones, a third-generation cephalosporin, or amoxicillin-clavulanate, while complicated infections are treated with broad-spectrum antibiotics such as piperacillin-tazobactam, meropenem, etc. Although center-specific, asymptomatic UTIs did not necessitate treatment until the first month after a transplant, A patient with an asymptomatic UTI only needs to be monitored; antibiotic treatment is unnecessary.
Patient recommendations for behavioral therapy should include increasing oral fluid intake, frequent urination, and urination after coitus. The graft and patient survival rates over the long term are comparable to those of the typical transplant population.
Reasons for diversion; malignancy, stricture, trauma to urethra or ureter, neurogenic bladder etc.
Type of urinary diversion ;continent, non continent or orthotopic.
Any symptoms to suggest systemic involvement or pyelonephritis ;nausea, vomiting, fever, pain, dysuria, decreased urine output etc.’
Generally, no antibiotics, nephrectomy or screening required for ASB post urinary diversion as it would hardly change mgt or outcome with exception of a few indications.
It would be vital to monitor the pt and promptly start tx and further workup once she gets symptomatic except in cases of ureas splitting organisms like proteus that can cause stone formation.
Infection from C.glabrata and C.albicans should be treated to prevent local fungal complications.
REF;
Matthew et al; UTI in pts with urinary diversion.ajkd.2005.09.008
Robles Garcia et al; Kidney Transplant and ileal conduit diversion on same surgical procedure ;clinical case and review of literature.2020
How would you manage this patient?This patient has ill conduit this means hat she has voiding problems .
Such conduit is another way of urine voiding in case of bladder dysfucntions .
In case of ileal condiut we may have ASB and UTIS but not affect Grfat fucntion .
screen for ASB: if positive (i.e., 2 consecutive urine cultures yielding >10⁵ CFU/ml of the same pathogen), treat with antibiotics for 5days as guided by the sensitivity pattern; however, if the 2nd culture is negative or grows another organism do not give antibiotics
· use pathogen-specific antibiotics as guided by the culture and sensitivity patterns
· antibiotics prophylaxis should be carefully evaluated to avoid adverse effects and emergence of antibiotic-resistant microorganisms
· management of symptomatic infections: obtain urine sample for m/c/s, then start with empiric therapy awaiting definitive therapy as guided by the sensitivity patterns
6. A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
Issues/ concerns
– 57yo female, LDKTx 6months ago, donor sister
– ureter implanted into the ileal conduit created for urine diversion
– the recipient most probably had an incompetent bladder or a voiding problem which could have directly affected the function of the graft kidney hence the need to have an ileal conduit urinary diversion
– the main complication of ileal conduit urinary diversion in kidney transplantation is ASB and UTIs which do not lead to graft loss
– fortunately, the long-term outcome is comparable to transplantation in healthy native bladders
– further history and physical examination: indication for the ileal conduit, any urological malformations, VUR, history of recurrent UTIs prior to transplant, local and systemic symptoms of infection (frequency, urgency, dysuria, fevers, nausea, flank pain, graft tenderness), antibiotic prophylaxis, ureteric stent
· ultrasound to assess the graft kidney, native kidneys, postvoid residual volume
· non-contrast CT scan of the urinary tract for patients with recurrent UTIs and a normal ultrasound – to assess for strictures, stones, complex cysts
· if CT scan is unrevealing, rule out bladder dysfunction and outflow tract obstruction by measuring urine flow rate and performing urodynamic studies
· flexible cystoscopy to detect abnormalities in the urethra or bladder
– treatment:
· patients with ileal conduits are at increased risk of asymptomatic bacteriuria (ASB)
· screen for ASB: if positive (i.e., 2 consecutive urine cultures yielding >10⁵ CFU/ml of the same pathogen), treat with antibiotics for 5days as guided by the sensitivity pattern; however, if the 2nd culture is negative or grows another organism do not give antibiotics
· use pathogen-specific antibiotics as guided by the culture and sensitivity patterns
· antibiotics prophylaxis should be carefully evaluated to avoid adverse effects and emergence of antibiotic-resistant microorganisms
· management of symptomatic infections: obtain urine sample for m/c/s, then start with empiric therapy awaiting definitive therapy as guided by the sensitivity patterns
– simple cystitis: empiric therapy with a fluoroquinolone or a 3rd generation cephalosporin or amoxicillin-clavulanate or nitrofurantoin (if eGFR >30); duration of therapy 10-14days if the simple cystitis occurs earlier than 6 months posttransplant and 5-7days if it occurs 6 months posttransplant
– complicated UTI: empiric therapy with piperacillin-tazobactam or meropenem or a combination of vancomycin plus cefepime; treat for 14-21days, can switch to oral medications once the patient is symptom free and the antibiotic sensitivity patterns are known
· optimal duration of antimicrobial therapy for recurrent UTIs in kidney transplant recipients remains unknown References
1. Doménech P, Garcia J, Cortés A, Miñana B, Castañé C, Costa D, et al. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature. Transplantation Case Reports. 2020 05/30:1-3.
2. Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, et al. Kidney transplantation into an ileal conduit: a single center experience of 59 cases. The Journal of urology. 2003 Nov;170(5):1727-30. PubMed PMID: 14532763. Epub 2003/10/09. eng.
3. Mitra S, Alangaden GJ. Recurrent urinary tract infections in kidney transplant recipients. Current infectious disease reports. 2011 Dec;13(6):579-87. PubMed PMID: 21870039. Epub 2011/08/27. eng.
4. Bodro M, Linares L, Chiang D, Moreno A, Cervera C. Managing recurrent urinary tract infections in kidney transplant patients. Expert Review of Anti-infective Therapy. 2018 2018/09/02;16(9):723-32.
· transplantation in patients with an abnormal lower urinary tract (LUT), associated with an increased risk of pyelonephritis and thus graft loss
· Thus, in patients with an abnormal LUT, anatomical, and functional evaluations are recommended to detect and treat abnormalities that may impact kidney allograft survival.
· The first case of kidney transplantation into a urinary tract deviation with an intestinal conduit was described in 1966 by Kelly et al.
· In Kidney transplant with drainage into an ileal conduit, long-term graft and patient survival is comparable to that in the normal transplant population.
· Urinary tract infection (UTI) is the most common infection after kidney transplantation.
· UTI is associated with the development of bacteremia, acute T cell-mediated rejection, impaired allograft function, and allograft loss, with increased risk of hospitalization and death.
· Asymptomatic bacteriuria – In the transplant population, this is defined by the presence of >105 bacterial (CFU/mL) on urine culture with no local or systemic symptoms of UTI.
· Recurrent UTI – Two or more episodes of UTI in six months, or three or more episodes of UTI in one year. Risk factors for UTI in kidney transplant recipients
· Female sex
· Advanced age
· Recurrent UTI prior to transplant
· Vesicoureteral reflux
· Urethral catheterization
· Ureteral stent placement
· Deceased-donor kidney transplant
· History of autosomal dominant polycystic kidney disease (ADPKD)
· Delayed graft function
The widespread use of antibiotic prophylaxis among kidney transplant recipients has led to an increased rate of resistance to ciprofloxacin and trimethoprim-sulfamethoxazole
UTIs are associated with significant morbidity among transplant recipients, especially if they occur early after transplantation.
Prophylaxis with TMP-SMX can be administered as one double-strength tablet daily or three times per week or one single-strength tablet daily and continued for six months to one year posttransplant;
Early ureteral stent removal within four weeks of transplant may help to prevent UTI after kidney transplantation.
Monitoring for asymptomatic bacteriuria
· it should be limited to the first one to two months posttransplant
· Most patients who are observed without antibiotic treatment will spontaneously clear bacteriuria
· If the patient has two consecutive cultures that yield >105 (CFU)/mL of the same pathogen, antibiotic treatment for five days may be reasonable (according to culture result).
· If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
· Monitoring for asymptomatic bacteriuria after two months should not be performed since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration
Approach to prevention
· Behavioral changes: increased fluid intake, frequent voiding, postcoital voiding, contraception modification (in sexually active patients), and wiping from front to back
· Some experts administer prophylactic antibiotics to selected patients with recurrent UTI.
· For postmenopausal females, topical estrogen may prevent recurrence of UTIs
· Some transplant programs use methenamine hippurate (1000 mg twice daily) with or without ascorbic acid (1000 mg twice daily) for prevention of recurrent UTI.
MANAGEMENT OF SYMPTOMATIC INFECTIONS Simple cystitis
· An oral fluoroquinolone (ciprofloxacin 250 mg twice daily or levofloxacin 500 mg once daily, or
· A third-generation cephalosporin (eg, cefpodoxime 100 mg twice daily or cefdinir 300 mg twice daily), or
· Amoxicillin-clavulanate (500 mg twice daily).
· Nitrofurantoin (100 mg twice daily) is another option for patients with an eGFR >30 mL/min/1.73 m2.
· Duration of therapy:
1) For that occurs earlier than six months posttransplant, treat for 10 to 14 days.
2) For that occurs more than six months posttransplant, treat for five to seven days. Complicated UTI
· Piperacillin-tazobactam 4.5 g IV every six hours, or
· Meropenem 1 g IV every eight hours, or
· Combination therapy with vancomycin plus cefepime 1 g IV every eight hours.
· Duration of therapy: 14 to 21 days of antibiotic therapy
A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml. How would you manage this patient?
Further hx needed;
Reasons for diversion; malignancy, stricture, trauma to urethra or ureter, neurogenic bladder etc.
Type of urinary diversion ;continent, non continent or orthotopic.
Any symptoms to suggest systemic involvement or pyelonephritis ;nausea, vomiting, fever, pain, dysuria, decreased urine output etc.’
Generally, no antibiotics, nephrectomy or screening required for ASB post urinary diversion as it would hardly change mgt or outcome with exception of a few indications.
It would be vital to monitor the pt and promptly start tx and further workup once she gets symptomatic except in cases of ureas splitting organisms like proteus that can cause stone formation.
Infection from C.glabrata and C.albicans should be treated to prevent local fungal complications.
REF;
Matthew et al; UTI in pts with urinary diversion.ajkd.2005.09.008
Robles Garcia et al; Kidney Transplant and ileal conduit diversion on same surgical procedure ;clinical case and review of literature.2020
asymptomatic bacteruria(>105c CFU/ML in 2 urine samples >24h in between) in the settings of urinary diversion espicially with normal graft function & isolation of different organisms, should be monitored only for symptoms& graft function, it dosent necessiate AB therapy or reduction of immunosupression
Six months post-transplant (donor is the patient sister)
Ureter was implanted into the ileal conduit
On triple therapy as maintenance
Significance urine culture (recurrent)
Management
Further history to elucidate on the UTI symptoms
Renal function test
No treatment is required if renal function is stable and the patients remain asymptomatic and well. Furthermore, this is six months post-transplant, and if no issue with her graft function, perhaps is the best time to reduce the patient’s immunosuppression.
Reference Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, Augustine T. Kidney transplantation into an ileal conduit: a single center experience of 59 cases. J Urol. 2003 Nov;170(5):1727-30. doi: 10.1097/01.ju.0000092023.39043.67. PMID: 14532763.
there is 3 types of operation for urinary divergent includes
–ileal conduit (mostly non continent operation needs ostoma and patient not on CIC) -indiana pouch reservior (patient on CIC) -neobladder with uretheral connection (Patient on CIC)
and another classification according continent( needs CIC and non continent on ostoma)
So, more details are needed about kind of operation and patiient is maintained on what??
and what is the cause for this urinary conversion is needed???
Multiple organism in urine culture in patients post urine divergent is consider normal and usually no need to be treated unless symptomatic
post kidney transplant patient usually symptoms will not be that typical because of immunosuppression medications.
So,clincal examination ,lab investiagtions (dearranged kidney functions ,CBC and CRP) and radiological assessment maybe needed for further evaluation in such specfic group of patients.
In this case i will go for conservative managment unless there is symptoms or signs of sepsis References
1. Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
2. Singh R, Bemelman FJ, Hodiamont CJ, et al. The impact of trimethoprim-sulfamethoxazole as Pneumocystis jiroveci pneumonia prophylaxis on the occurrence of asymptomatic bacteriuria and urinary tract infections among renal allograft recipients: a retrospective before-after study. BMC Infect Dis 2016; 16:90.
3. Horwedel TA, Bowman LJ, Saab G, Brennan DC. Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant. Transpl Infect Dis 2014; 16:261.
4. Hollyer I, Varias F, Ho B, Ison MG. Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study. Transpl Infect Dis 2019; 21:e13063.
Main complication of ill conduits is UTI without significant medium term impact on graft outcome.
Long term graft & patient survival in ill conduits is comparable to that in normal transplant population.
Incidence of asymptomatic bacteriuria after>1 month post transplant reduced to <4% so no need for treatment.
Patients with urinary diversion have not benefit in asymptomatic bacteriuria treatment
Colonization with asymptomatic bacteriuria strain(E. coli 83972) in ill conduits proved protective against symptomatic recurrence in patients who don’t spontaneously develop asymptomatic bacteriuria.
So screening & treatment of asymptomatic bacteriuria is not recommended.
This patient not need treatment.
References:
Gueguen J., Timsit M., Scemla A., Boutin J., Bruyere F., et al. Outcomes of kidney-transplanted patients with history of intestinal reconstruction of the urinary tract. BJUI Compass,2022;3:75-85.
Strohaeker J., Aschke V., Koenigsrainer A., Nadalin S. and Bachmann R. Urinary Tract Infection in Kidney Transplant Recipients-Is There a Need for Antibiotic Stewardship?. J. Clinical. Med. 2020.
Symeonidis E., Falagas M. and Dimitriadis F. Urinary tract infection in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis. Trans. Androl.Urol, 2019;8(4):286-289.
How would you manage this patient? Ileal condiu in kidney transplant recipient is indicated for patients with abnormal urinary tract and commonly complicated with recurrent UTI either symptomatic or not as the intestinal segments used to form the conduit are normally colonized with bacteria . Management of this recurrent UTI depends on presence of symptoms as fever , tachycardia.– Investigations needed include : CBC , CRP ,procalcitonin , KFT, LFT– Antibiotic treatment is largely based on presence of symptomatic classification :1- Asymptomatic bacteriuria : defined as the presence of >100000 CFU/mL on urine culture without assiociated local or systemic symptoms of UTI and should be confirmed with another urine culture growing the same organism before starting treatment.2- Complicated UTI including upper UTI (pelonephritis) or Lower UTI (cystitis) :any symptomatic UTI in kidney transplant recipient is considered complicated . -The presence of >100000 CFU/mL on urine culture associated with with local urinary symptoms as frequency, urgency or dysuria ( acute cystitis ) or with tender graft (pyelonephritis) or with systemic inflammatory symptoms as fever.Symptoms of complicated UTI may be atypical due to denervated graft and immunesuppressive status.Investigations 1- CBC, LFT,KFT2- Inflammatory markers: ESR, CRP, procalcitonon 3- Urine culture and sensitivityManagement :According to presense of symptoms , complicated or not a- For persistent asymptomatic pyuria : 5 days antibiotic course should be considered b- For mild cases : outpatient empiric treatment with oral fluoroquinolone.– For severe and complicated cases: -hospitalization , maintain good hydration , correct any electrolytes disturbance .– Antibiotic treatment bases on culture and sensitivity and start empirical treatment with either fluroquinolone oral or IV or if suspected MDR gram negative organism consider antipseudomonal carbapenem, piperacillin-tazobactam or cefepime
How would you manage this patient?Ileal condiu in kidney transplant recipient is indicated for patients with abnormal urinary tract and commonly complicated with recurrent UTI either symptomatic or not as the intestinal segments used to form the conduit are normally colonized with bacteria . Management of this recurrent UTI depends on presence of symptoms as fever , tachycardia.– Investigations needed include : CBC , CRP ,procalcitonin , KFT, LFT– Antibiotic treatment is largely based on presence of symptomatic classification :1- Asymptomatic bacteriuria :defined as the presence of >100000 CFU/mL on urine culture without assiociated local or systemic symptoms of UTI and should be confirmed with another urine culture growing the same organism before starting treatment.2- Complicated UTI including upper UTI (pelonephritis) or Lower UTI (cystitis) :any symptomatic UTI in kidney transplant recipient is considered complicated . -The presence of >100000 CFU/mL on urine culture associated with with local urinary symptoms as frequency, urgency or dysuria ( acute cystitis ) or with tender graft (pyelonephritis) or with systemic inflammatory symptoms as fever.Symptoms of complicated UTI may be atypical due to denervated graft and immunesuppressive status.Investigations 1- CBC, LFT,KFT2- Inflammatory markers: ESR, CRP, procalcitonon 3- Urine culture and sensitivityManagement :According to presense of symptoms , complicated or not a- For persistent asymptomatic pyuria : 5 days antibiotic course should be considered b- For mild cases : outpatient empiric treatment with oral fluoroquinolone.– For severe and complicated cases: -hospitalization , maintain good hydration , correct any electrolytes disturbance .– Antibiotic treatment bases on culture and sensitivity and start empirical treatment with either fluroquinolone oral or IV or if suspected MDR gram negative organism consider antipseudomonal carbapenem, piperacillin-tazobactam or cefepime
How would you manage this patient?This patient first would be a detailed history- History on indication of the urinary diversion, ileal conduit are usually done to due lower urinary tract abnormalitiesHistory of UTI clinical symptoms.
In this patient absence of any clinical symptoms makes it a diagnosis of asymptomatic bacteriuria which is defined as CFU>105 in 2 urine samples 24 hours apart.
This patient has history of multiple organisms grown hence it would be prudent to know whether the urine sample was collected in a sterile procedure.
Presence of ASB doesn’t affect the overall graft function and survival hence prophylactic antibiotics is not warranted.
Patients with ileal conduit had similar longterm graft function and survival in comparison to patients with no urinary diversion.
Thus antibiotics should be started when there is additional symptoms of tender graft, fever or high inflammatory markers.
Thus in this patient one should look for markers of inflammation like CRP, Procalcitonin and ESR.
There is also no indication of native kidney nephrectomy.
References Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology lecturer on post-renal transplantation urinary tract infection.
According to the guidelines of the European Association of Urology (EAU), UTI after TX might present as:
Asymptomatic bacteriuria
Symptomatic infection
If the recipient develops signs and symptoms of UTI, leucocytes, and CRP, exclude BK/CMV infection, and do ultrasonography for any structural abnormalities
If no fever or other symptoms and with normal kidney function, this transplant recipient has asymptomatic bacteriuria (>105 colony-forming units/mL in two urine samples >24h apart)
Patients with Ileal Conduit:
Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients ESRD due to abnormal lower urinary tracts
Long-term graft and patient survival is comparable to that in the normal transplant population despite pre-existing co-morbidity and the increased complication rate
The presence of constant bacteriuria did not adversely affect survival.
Prophylactic antibiotic treatment is not warranted.
No indication for native nephrectomy, except in selected cases
Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP.
Screening and treatment of ASB:
Not recommended
Experts suggest screening and start treatment for bacteriuria in the early postoperative period and up to 6 months post TX
No recommendation to change immunosuppressive drugs
References
lecture on Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
How would you manage this patient? Introduction;
–Urinary diversion is required following cystectomy for benign or malignant conditions. -Ileal conduit, continent cutaneous diversion, and orthotopic neobladder are the three most commonly used techniques of urinary diversion. -Ileal conduits are the archetypical procedure of incontinent urinary diversions. -Urine is directed from the ureters through a segment of isolated bowel to the surface of the abdominal wall via a cutaneous stoma. -There, urine drains continuously and is collected by an external appliance adhered to the skin surface. Asymptomatic bacteriuria; -In the transplant population, this is defined by the presence of >105 bacterial colony-forming units per milliliter (CFU/mL) on urine culture with no local or systemic symptoms of UTI. Simple cystitis; -The presence of >105 CFU/mL on urine culture with local urinary symptoms, such as dysuria, frequency, or urgency, but no systemic symptoms, such as fever or allograft pain, and no indwelling device (eg, ureteral stent, nephrostomy tube, or chronic urinary catheter). Complicated UTI; -The presence of >105 CFU/mL on urine culture with fever, allograft pain, chills, malaise, or bacteremia with the same organism in urine, or a biopsy with findings consistent with pyelonephritis. Recurrent UTI; Two or more episodes of UTI in six months, or three or more episodes of UTI in one year. Risk factors; -Female sex -Advanced age -Recurrent UTI prior to transplant -Vesicoureteral reflux -Urethral catheterization -Ureteral stent placement -Deceased-donor kidney transplant -History of autosomal dominant polycystic kidney disease (ADPKD) -Delayed graft function Evaluation; -For patients with suspected acute complicated UTI, send urine for both urinalysis (either by microscopy or by dipstick) and culture with susceptibility testing. -Imaging is generally reserved for those who are severely ill, have suspected urinary tract obstruction, have persistent symptoms despite 48 to 72 hours of appropriate antimicrobial therapy, or have recurrent symptoms. Diagnosis; -The diagnosis of acute complicated UTI is made in patients who have consistent clinical findings as well as pyuria and bacteriuria. -UTI is unlikely if pyuria is absent. Indications for hospitalization; -Outpatient management is acceptable for patients with acute complicated UTI of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in an outpatient facility or the emergency department and discharged on oral antimicrobials with close follow-up. Empiric therapy; -The approach to empiric therapy of acute complicated UTI depends on the severity of illness, the risk factors for resistant pathogens, and specific host factors. Critical illness/urinary tract obstruction; -For patients who are critically ill or have urinary tract obstruction, suggest an antipseudomonal carbapenem plus vancomycin. Other hospitalized patients; -For hospitalized patients without critical illness or urinary tract obstruction who have no risk factors for a multidrug-resistant (MDR) gram-negative infection, suggest ceftriaxone or piperacillin-tazobactam . -Oral or parenteral fluoroquinolones are also reasonable options. -For patients who have risk factors for an MDR gram-negative infection, suggest piperacillin-tazobactam, cefepime , or an antipseudomonal carbapenem. -For those with a recent history of an ESBL-producing urinary isolate specifically, use a carbapenem. Outpatients without risk for resistance; -For outpatients without risk factors for an MDR gram-negative infection , suggest an oral fluoroquinolone, such as levofloxacin or ciprofloxacin. -If the community prevalence of E. coli fluoroquinolone resistance is known to be higher than 10%, suggest also a single dose of a long-acting parenteral agent such as ceftriaxone or ertapenem prior to administering the fluoroquinolone. Outpatients with risk for resistance; -For outpatients with risk factors for an MDR gram-negative infection , suggest an initial dose of ertapenem . -Subsequently, an oral fluoroquinolone or daily ertapenem can be used. Directed therapy and duration; -Results of urine culture and susceptibility testing should be used to confirm that the chosen empiric regimen is active and to tailor the regimen, including switching a parenteral regimen to an oral agent once symptoms have improved. -Appropriate oral agents to treat acute complicated UTI include fluoroquinolones (eg, levofloxacin or ciprofloxacin) ciprofloxacin , given for 5 to 7 days) or TMP/SMX (given for 7 to 10 days). -Oral beta-lactams (given for 7 to 10 days) are less effective for acute complicated UTI but are appropriate alternatives if susceptibility is documented and the other agents are not feasible.
ILEAL CONDUITS Ileal conduits were the gold standard for urinary reconstruction before the advent of continent diversions . Due to the relative ease of their formation and the shorter operative time ileal conduits are often used in patients with significant medical comorbidities to minimize postoperative complications and the risk of reoperation.
Ileal conduits remain the procedures of choice for many patients, especially those with a shorter life expectancy and those who cannot complete the necessary rehabilitation process to learn how to manage a continent diversion
Infectious complications urinary diversion
Intestinal segments that are used to fashion the reservoir/conduit are normally colonized with bacteria ●Incomplete voluntary voiding may leave residual urine, a nidus for infection. ●Intermittent catheterization may introduce bacteria into the reservoir in a retrograde manner, especially if it is done carelessly.
After urinary diversion, patients do not require chronic suppressive antibiotic therapy unless there is a history of recurrent infections. Although the presence of small bowel intestinal mucosa appears to promote asymptomatic bacterial colonization, urosepsis rarely occurs unless the patient has recurrent urinary tract infections. .Asymptomatic bacteriuria – In the transplant population, this is defined by the presence of >100000 (CFU/mL) on urine culture with no local or systemic symptoms of UTI.
The detection of asymptomatic bacteriuria should prompt a second urine culture to confirm persistent bacteriuria with the same pathogen before treatment decisions are made.
If the patient has two consecutive cultures that yield >100000 colony-forming units (CFU)/mL of the same pathogen,
antibiotic treatment for five days may be reasonable, with antibiotic selection based upon the susceptibility pattern of the microorganism.
If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
Monitoring for asymptomatic bacteriuria after two months should not be performed since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration
No indication for native nephrectomy, except in selected cases. Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level
How would you manage this patient?
Ileal conduit in the renal transplant patients as in the above case is usually done in patients with abnormal urinary tracts. Such patients are prone to have recurrent UTIs either asymptomatic or symptomatic .Thorough history,examination and investigations to assess the severity of disease must like CBC,RFTs, CRP ,DIC profile and proper collection of urine sample for culture. Symptomatic UTI needs treatment and choice of antibiotic depends on whether complicated or uncomplicated UTI. Uncomplicated UTI- fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin or amoxicillin-clavulanate while for complicated UTI- broad spectrum antibiotics like piperacillin-tazobactam, meropenem, etc. Asymptomatic UTI did not need treatment except in the first 1 month post transplant but that also varies center-center. Above case has asymptomatic UTI so just need monitoring and no antibiotic therapy .The patient should give advice for behavioral therapy, including increasing oral fluid intake, frequent voiding,and post coital voiding, Long-term graft and patient survival is almost similar to normal transplant population REFERENCES:
1-Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
2-A lecture of Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105CFU/ml. Urinary tract infections (UTI) are the most common infection in the early postoperative phase after kidney transplantation. Urinary tract infections (UTI) are defined as the growth of 105 colony forming units on a proper urine sample) in the presence of symptoms such as dysuria, urinary frequency or localized pain (the incidence of a UTI ranges from 4–80%. Risk factors of UTIs after kidney transplantation include:
Female gender
Advanced age
Pre-transplant UTIs
Prolonged period of hemodialysis before transplantation
Immunosuppression
Ileal conduit
Patients with Ileal Conduit:
Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients ESRD due to abnormal lower urinary tracts. Long-term graft and patient survival is comparable to that in the normal transplant population despite pre-existing co-morbidity and the increased complication rate The presence of constant bacteriuria did not adversely affect survival
Prophylactic antibiotic treatment is not warranted
No indication for native nephrectomy, except in selected cases
Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level. Classification of UTI includes. Asymptomatic bacteriuria
Simple cystitis which presents with local symptoms such as dysuria, frequency, and urgency without systemic symptoms such as allograft pain and fever, and there is no indwelling device such as chronic urinary catheter, ureteral stent or nephrostomy tube.
Complicated UTI which presents by systemic symptoms including allograft pain, fever, chills, malaise, or bacteremia with the same organism in urine, or a biopsy with findings consistent with pyelonephritis or if there is an indwelling device.
Recurrent UTI which is defined as ≥ 2 episodes of symptomatic UTI within 6 months or ≥ 3 episodes within 1 year.
Recurrent UTI is associated with an increased risk of graft and patient loss.
Screening and monitoring
Screening of UTI by either urine culture or urine analysis (and culture taken if urine analysis is suspicious for UTI) every week is recommended only in the first month after transplantation, if culture is positive, another culture should be taken, and if the same pathogen is isolated asymptomatic bacteriuria is documented.
Monitoring of renal function is recommended in patients with symptomatic recurrent UTI since it may have a bad impact on graft survival. How would you manage this patient?
According to the guidelines of the European Association of Urology (EAU), UTI after KTX might present either as: A-Asymptomatic bacteriuria = (>105 colony-forming units/mL in two urine samples > 24 h apart) is common in renal transplant recipients.
B-Symptomatic infection Any symptoms of dysuria, urgency, frequency, fever, and flank/graft pain If the recipient develops signs and symptoms of UTI, leucocytes, and CRP, exclude BK/CMV infection, and do ultrasonography for any structural abnormalities.
If no fever or other symptoms and with normal kidney function, this transplant recipient has asymptomatic bacteriuria (>105c colony-forming units/mL in two urine samples >24h apart).
Patients with Ileal Conduit
Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients with end stage renal disease due to abnormal lower urinary tracts.
Despite pre-existing co-morbidity and the increased complication rate long-term graft and patient survival is comparable to that in the normal transplant population.
The presence of constant bacteriuria did not adversely affect survival.
Prophylactic antibiotic treatment seems not to be warranted.
There appears to be no indication for native nephrectomy, except in selected cases. Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level.
Post renal transplant recipients who have had renal transplant surgery >1 month prior, we recommend against screening for or treating ASB (strong recommendation, high-quality evidence).
Treatment asymptomatic bacteria is recommended by some experts in early post-transplant period (first month after transplantation), although there is no strong evidence, due to the higher incidence of progression to septicemia, immunosuppression may mask the symptoms, after that period no need for treatment unless the patient develop symptoms. So, I will not treat asymptomatic bacteriuria in the current case. On the other hand, all patients with symptomatic UTI should be treated.
The recommended antibiotic for simple cystitis includes fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin or amoxicillin-clavulanate) or nitrofurantoin provided that GFR> 30 ml /min, on the other hand Fosfomycin, and SMX-TMP are not recommended empiric treatment. The recommended antibiotics for complicated UTI are piperacillin-tazobactam, meropenem, or vancomycin plus cefepime. IV broad spectrum antibiotic are given till culture result then step-down therapy should be according to the culture result.
Duration of treatment is 5 -7 days in simple cystitis occurring after 6 months of transplantation, and 2-3 weeks in complicated UTI and in simple cystitis before 6 months of transplantation, but if recurrence is causes by the same organism or in case of an indwelling source such as the ileal conduit in the current case, I may recommend longer treatment duration for four to six weeks of therapy.
After successful treatment of symptomatic UTI, if the patient had recurrent attacks of symptomatic UTI, prevention of recurrence is indicated using the following strategies:
Use of prolonged prophylactic antibioticsis recommended, the most important regimen is the use of SMX-TMP for 6 months -1 year, which was associated with reduction of UTI episodes and severity.
some experts continue TMP-SMX prophylaxis indefinitely and if SMX-TMP is contraindicated, some recommends the use of nitrofurantoin 100 mg twice daily provided GFR > 30 ml/min or cephalexin 500 mg twice daily.
Behavioral therapy including increasing oral fluid intake, frequent voiding, post coital voiding, wiping from front to back in females.
For post-menopausal females like the current case, topical oestrogen may decrease her frequency of recurrent UTI.
Methenamine Hippurate (1000 mg twice daily) can be used for prevention of recurrent UTI, which was found that it is associated with 45 % reduction in the frequency of UTI, 42 % reduction in the duration of antibiotic use for the treatment of UTI, and 59 % reduction in hospitalization due to UTI (4). Patients with eGFR <30 mL/min are less likely to benefit from this intervention.
Probiotics are not recommended to be used in transplant recipients, as they are immunocompromised and data regarding its benefit is not clear. Cranberry juice although the evidence is limited but because of the high safety, we can use it.
Screening and Monitoring of ASB post kidney transplant. Not recommended, Post renal transplant recipients who have had renal transplant surgery >1 month prior, we recommend against screening for or treating ASB (strong recommendation, high-quality evidence).
No recommendation to change immunosuppressive drugs. Overall, the need for treating ASB in kidney graft recipients remains unclear. Screening of UTI by either urine culture or urine analysis (and culture taken if urine analysis is suspicious for UTI) every week is recommended only in the first month after transplantation, if culture is positive, another culture should be taken, and if the same pathogen is isolated asymptomatic bacteriuria is documented.
For Candiduria, most often caused by C. glabrata and C. albicans, treatment is always recommended to prevent local fungal complications. Monitoring of renal function is recommended in patients with symptomatic recurrent UTI since it may have a bad impact on graft survival. References
A lecture of Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America
Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
Horwedel TA, Bowman LJ, Saab G, Brennan DC. Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant. Transpl Infect Dis 2014; 16:261.
Hollyer I, Varias F, Ho B, Ison MG. Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study. Transpl Infect Dis 2019; 21:e13063.
Female kidney transplant recipient with an ileal conduit, on triple IS for 6 months having persistent leukocyturia without signs & symptoms of UTI She has good graft function. She is having asymptomatic bacteriuria (ASB), and treatment of ABU after kidney transplantation is a topic of various opinions [1, 2]. ASB can be associated with an increased risk of
1. Symptomatic UTI that can negatively impact graft function. However, A meta-analysis recommended not to treat ASB after the first-month post kidney transplant and 8 studies from this meta-analysis, they failed to find any benefit of treating ASB in regards to the risk of symptomatic UTI or change in renal function [2].
2. ASB was not associated with an increased risk of acute graft rejection, treatment with ABx should be questioned as might associate with MDR and high cost. Therefore NO agreement on the use of antibiotics for ASB in kidney transplantation [2].
3. American Society of Transplantation Infectious Diseases Community of Practice suggested not treating asymptomatic bacteriuria that occurs beyond three months after kidney transplantation unless in case of an accompanied by rise in serum creatinine [3].
Reference
1. Coussement J, Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2018;2(2):CD011357. Published 2018 Feb 1. doi:10.1002/14651858.CD011357.pub2
2. 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. 2020;22(1):e13221. doi:10.1111/tid.13221
3. Parasuraman R, Julian K; AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant. 2013;13 Suppl 4:327-336. doi:10.1111/ajt.12124
Need to confirm whether this is symptomatic or asymptomatic UTI. Given scenario look like of asymptomatic bacteriuria.
Diagnosis can be made by Two consecutive cultures that yield >105 colony-forming units (CFU)/mL of the same pathogen 24 hr apart
In absence of history of pain in graft site, malaise, fever without obvious cause, high TLC counts, crp >80.
In case of asymptomatic bacteriuria after transplantation there is insufficient evidence to support routinely treating kidney transplant recipients with antibiotics
Need to monitor fever, malaise, leukocytosis, or a nonspecific sepsis syndrome.
Reference Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients . Curr Opin Infect Dis. 2020 Dec;33(6):419-425.
Post renal transplant UTI Lecture, Prof Mohamed Salah Eldin Zaki
The urine culture in this case is not valuable. There would be always pyuria and microorganisms from the gastrointestinal system. In case of symptoms or pyelonephritis, revision should be considered
I will ask or symptoms of upper UTI, pain check blood sample for systemic infection and give antibiotics accordingly
The threshold for asymptomatic bacteriuria from a clean-catch voided urine specimen is isolation of a single organism in quantitative counts ≥105 colony-forming units (CFU)/mL
For females, a second specimen should be obtained (preferably within two weeks) to confirm growth of the same organism over the same quantitative threshold.
For males, a single urine specimen meeting the criteria is sufficient for making the diagnosis.
Monitoring for asymptomatic bacteriuria
Whether monitoring and treating asymptomatic bacteriuria in the early post-transplant period improves clinical outcomes is uncertain.
If monitoring is performed (with routine urine cultures), it should be limited to the first one to two months posttransplant.
The detection of asymptomatic bacteriuria should prompt a second urine culture to confirm persistent bacteriuria with the same pathogen before treatment decisions are made. If the patient has two consecutive cultures that yield >105 colony-forming units (CFU)/mL of the same pathogen, antibiotic treatment for five days may be reasonable, with antibiotic selection based upon the susceptibility pattern of the microorganism. If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
Monitoring for asymptomatic bacteriuria after two months should not be performed since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration (up to date)
– Ileal conduit urinary diversion is a safe technique that can be used in patients with urodynamic problems or with a non functioning lower urinary system without increasing the risk of early graft loss.
Risks of antimicrobial resistance must be considered in KT recipients when strategies of UTI prevention and management are applied .
This patient has asymptomatic bacteriuria ,but it is important to recognize that some renal transplant recipients with UTI may primarily present with fever, malaise, leukocytosis, or a nonspecific sepsis syndrome without symptoms localized to the urinary tract so proper history clinical examination and laboratory test is mandatory before deciding that it is asymptomatic bacteriuria .
Currently, in case of asymptomatic bacteriuria after transplantation there is insufficient evidence to support routinely treating kidney transplant recipients with antibiotics
Reference :
Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature .DOI: 10.31487/j.TCR.2020.02.02
Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients . Curr Opin Infect Dis. 2020 Dec;33(6):419-425. doi: 10.1097/QCO.0000000000000678
⭐Ileal conduit is a common procedure done to create neobladder (we must ask about the cause or indication) …, In such old patient may be after radical cystectomy for bladder carcinoma, or may be for non neurogenic neurogenic bladder.
⭐In addition, there are various types either continent or incontinent.
⭐incontinent one has higher risk for bacterial colonization with either skin flora as staph epidermidis or strept or colonic bacteria as E coli or Proteus.
_mostly asymptomatic bacteriuria is not treated and most of the studies suggest that no need for antibiotics treatment and that cases with Ileal conduit have good long term prognosis.
_so follow up for development of any symptoms to start treatment.
a female recipient with an ileal conduit, on tripleIS including tacrolimus, 6 months after transplantation and persistent leukocyturia > 100000 without clinical signs or symptoms of UTI, and she is having excellent graft function this fits the definition of asymptomatic bacteriuria (ASB), and treatment of ABU after kidney transplantation is a topic of argument, and need more studies.
ASB can be associated with an increased risk of symptomatic UTI that can negatively impact graft function. However, A meta-analysis from Spain (15 studies) recommended not to treat ASB after the first-month post-KT (1), and in 8 studies from this meta-analysis, they failed to find any benefit of treating ASB in regards to the risk of symptomatic UTI or change in renal function (1).
ASB with increased incidence reported in the first month up to 22% and even more up to 30% after the first year of transplantation and some reports it varies between 17-51% of kidney transplant recipients, however, ASB was not associated with an increased risk of acute graft rejection and they ended with the conclusion that ASB is a frequent finding in the first months after transplantation and starting treatment with AB should be questioned as might associate with MDR and high cost. So there is no agreement about the use of antibiotics for ASB in kidney transplantation (1,3).
the American Society of Transplantation Infectious Diseases Community of Practice suggested not treating asymptomatic bacteriuria that occurs beyond three months after kidney transplantation unless in case of an accompanying rise in serum creatinine (SCr) level (4), however, the general practice is to treat ASB taken in consideration this is a denervated organ and with the use of IS may mask the clinical symptoms of UTI and may develop complicated pyelonephritis, especially in a patient with anatomical abnormalities like this case may it worth screening her frequently and avoid use AB unless it’s indicated as she will be at risk of MDR infection in addition to the cost.
decision making here should be individualized case by case as we have no consensuses regarding ASB treatment.
References
1. 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. 2020 Feb;22(1):e13221. doi: 10.1111/tid.13221. Epub 2019 Dec 12. PMID: 31782870.
2.Gołębiewska JE, Krawczyk B, Wysocka M, Dudziak A, Dębska-Ślizień A. Asymptomatic Bacteriuria in Kidney Transplant Recipients-A Narrative Review. Medicina (Kaunas). 2023 Jan 19;59(2):198.
3. Coussement J, Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2018 Feb 1;2(2): CD011357.
4. Parasuraman R, Julian K; AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:327-36. doi: 10.1111/ajt.12124. PMID: 23465025.
Ileal conduit urinary diversion (ICUD) is the operation that is both most popular & least likely to cause complications after radical cystectomy.
Several complications are recognized including UTI, upper tract stones, & calculi within the diversion segment. Other potential complications include ureteroileal stricture, stomal stenosis, shortening of the upper urinary tract to the conduit & hydronephrosis.
So, I will evaluate this post kidney transplant woman bearing all these possible complications in my mind:
I will first review the initial problem that led to the need for this procedure, including history of malignancy. I will ask about the primary disease that caused her kidney failure, the time spent on dialysis before transplantation, history of diabetes mellitus, & previous history of urinary tract infections.
Review the history of the primary urological disease & use of chemotherapy is also necessary.
History of peri-operative prophylactic antibiotic treatment.
I will look for any evidence of systemic inflammatory response syndrome criteria (Temp > 38°C or < 36°C, HR > 90, RR > 20, WBC > 12000/mm3 , < 4000/mm3 , or > 10% bands) to determine clinical suspicion or evidence of UTI.
I will communicate with the surgeon to know the method used in the creation of the conduit (incontinent urinary conduit versus continent urinary diversion). N.B: The incontinent urinary conduit is linked to renal scarring compared with continent urinary diversion.
I will talk to the radiologist to order the appropriate imaging to exclude the above-mentioned complications in this patient.
I will do CRP & blood cultures to exclude septicemia.
In view of asymptomatic bacteriuria, & in the absence of any systemic symptoms, as well as the presence of excellent graft function, I will not use prophylactic antibiotics.
The use of antibiotics prophylaxis to reduce infection complications is not currently supported by any acknowledged guidelines or recommendations in the literature. The frequency of intestinal infections caused by Clostridium difficile has also been associated to prolonged antibiotic use following major urologic surgery.
References
Liu YL, Luo HL, Chiang PH, Chang YC, Chiang PH. Long-term urinary tract effect of ileal conduit after radical cystectomy compared with bladder preservation: a nationwide, population-based cohort study with propensity score-matching analysis. BMJ Open. 2018 Dec 9;8(12):e023136. doi: 10.1136/bmjopen-2018-023136. PMID: 30530582; PMCID: PMC6292418.
Carson Kirkpatrick, Allan Haynes, Pranav Sharma, Antibiotic prophylaxis is not associated with reduced urinary tract infection-related complications after cystectomy and ileal conduit, Bladder | 2018 | Vol. 5(3)| e35 DOI: 10.14440/bladder. 2018.722
Management of asymptomatic bacteriuria in the post-transplant period 1. The index case caries high risk for UTI(ileal conduit and immunosuppression). KT recipients have unique risk factors for UTI, including indwelling stents and surgical manipulation of the genitourinary tract. 2. Asymptomatic bacteriuria:
· According to European Society of Clinical Microbiology and Infectious Diseases(ESCMID)defined as the presence of a uropathogen bacteria (≥105 CFU/mL) in the urine without signs or symptoms of UTI, regardless of the presence of pyuria, occurs frequently in KT recipients(1).
· According to American Society of Transplantation Infectious Diseases Community of Practice:Asymptomatic bacteriuria, defined as bacteriuria without signs or symptoms of urinary tract infection (UTI), occurs in 17% to 51% of kidney transplant recipients and is thought to increase the risk for a subsequent UTI. No consensus exists on the role of antibiotics for asymptomatic bacteriuria in kidney transplantation(2). 3. The 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:
a) 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.
b) Asymptomatic bacteriuria (AB) must be distinguished from UTI because AB is not necessarily a disease state. 4. Accumulating data indicate that there are no benefits of antibiotics for treatment of AB in KT recipients more than 2 months after post-transplant(3,4,5). 5. Minimization of ASB treatment in kidney transplant recipients remains an important antimicrobial stewardship target(6). 6. 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(7). 7.
References 1. VOLUME 27, ISSUE 3, P319-321, MARCH 2021 Asymptomatic bacteriuria in kidney transplant recipients: to treat or not to treat-that is the question Josep M. Cruzado Jordi Carratal Open Archive Published:November 30, 2020DOI:https://doi.org/10.1016/j.cmi.2020.11.016 2. Coussement J, Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2018 Feb 1;2(2):CD011357. doi: 10.1002/14651858.CD011357.pub2. PMID: 29390169; PMCID: PMC6491324. 3. 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 Sep;33(9):e13507. doi: 10.1111/ctr.13507. Epub 2019 Mar 28. PMID: 30793386. 4. 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. 2020 Feb;22(1):e13221. doi: 10.1111/tid.13221. Epub 2019 Dec 12. PMID: 31782870. 5. Coussement J, Maggiore U, Manuel O, Scemla A, López-Medrano F, Nagler EV, Aguado JM, Abramowicz D; European Renal Association-European Dialysis Transplant Association (ERA-EDTA) Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) working group and the European Study Group for Infections in Compromised Hosts (E; COLLABORATORS (IN ALPHABETICAL ORDER); European Renal Association-European Dialysis Transplant Association (ERA-EDTA) Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) working group and the European Study Group for Infections in Compromised Hosts (ESGICH) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe. Nephrol Dial Transplant. 2018 Sep 1;33(9):1661-1668. doi: 10.1093/ndt/gfy078. PMID: 29635410. 6. Bohn BC, Athans V, Kovacs CS, Stephany BR, Spinner ML. Impact of asymptomatic bacteriuria incidence and management post-kidney transplantation. Clin Transplant. 2019 Jun;33(6):e13583. doi: 10.1111/ctr.13583. Epub 2019 May 23. PMID: 31038773. 7. Coussement J, Kaminski H, Scemla A, Manuel O. Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients. Curr Opin Infect Dis. 2020 Dec;33(6):419-425. doi: 10.1097/QCO.0000000000000678. PMID: 33148983.
Thank you. Can you please summarize your opinion of the management of this patient? Would you recommend or not to have antibiotics?
Do you think long term antibiotic here would be of any value?
I wouldn’t recommend antibiotics in this case scenario as it represents an asymptomatic bacteruria.
Long term antibiotic will not be of value provided that multiple pathogens are commonly encountered in the setting of urinary diversion, in addition to development of resistance to agents being used for prophylaxis
-How would you manage this patient? A. Introduction
Further history e.g what type of urinary diversion she had i.e, noncontinent, continent, or orthotopic
According to the data from university of Toronto ,conduit mucus was heavily colonized with microcolonies of gram +ve and gram -ve bacteria. Mixed flora were found in ileal loops, whereas culture from colonic conduit often grew a single bacterial species. The reason for this is not clear
I wound be interested as well to know the indication of urinary diversion
Ask for symptoms of pyelonephritis/sepsis e.g., fever,nausea, vomiting,localized pain, and dysuria although these may not be apparent in transplant patient due to immune suppression and denervation of the transplanted kidney
B.Asymptomatic bacteria (ASB) in pt with urinary diversion; depends on the type of diversion 1.Noncontinent:
Thank you for such comprehensive answer. Excellent and well done.
How important to know the reason of urinary diversion in a 57 year lady?
Please complete the reference for anyone wants to get more information from this article to include the year as 2005 and the source as Am J Kidney disease.
Yes, prof there are many indications for this procedure e.g., mainly Ca bladder, but it can be done due to neurological disorders and severe inflammatory disease of the bladder. It would be important to know this as part of evaluating a patient with history urinary diversion.
Absolutely prof here it is the reference: Urinary tract infections in patients with urinary diversion by Mathhew E. Falagas et al. Originally published online as doi: 10.1053/j.ajkd.2005.09.008 on November 2, 2005.
Our patient has many risk factors as female, with ileal conduit and immunosuppressed and the main complication of this type of kidney transplant is urinary tract infection, although it has not been seen to have a significant medium-term impact on kidney grafts
How would you manage this patient?
Adequate prophylaxis and strict follow-up of the patient can avoid most of the complications resulting from the infections.
Our patient has asymptomatic bacteriuria which need close follow up and no need for active treatment.
Our case may need treatment if become symptomatic or complicated. References:
1- J.E. Robles García,A. García Cortés,B. Miñana López,C. Gutiérrez Castañé,D. Rosell Costa,F. Ramón de Fata Chillón,F. Villacampa Aubá,F.J. Ancizu Marckert,F.J. Diez-Caballero Alonso,G. Andrés Boville,G. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature Transplantation Case Reports 2020 2733-2527 http://dx.doi.org/10.31487/j.TCR.2020.02.02.
2-Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Thank you. Do you think with urinary diversion, would be much of a difference between male and female for urinary tract infection risk?
What are the drawbacks of antibiotic prophylaxis in these cases?
6. A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
How would you manage this patient?
According to the guidelines of the European Association of Urology (EAU) , UTI after KTX might present either as;
– Asymptomatic bacteriuria (ABU) – Or as Symptomatic infection.
According to EAU Guidelines Asymptomatic bacteriuria ,No urologic symptoms 10 WBC/mm3 >105 cfu/mL in two urine samples > 24 h apart.
Patients with Ileal Conduit
Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients with end stage renal disease due to abnormal lower urinary tracts.
Despite preexisting co-morbidity and the increased complication rate long-term graft and patient survival is comparable to that in the normal transplant population.
The presence of constant bacteriuria did not adversely affect survival.
Prophylactic antibiotic treatment seems not to be warranted.
There appears to be no indication for native nephrectomy, except in selected cases.
Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level.
Should patients who have received a kidney transplant be screened or treated for ASB? Recommendation
In renal transplant recipients who have had renal transplant surgery >1 month prior, we recommend against screening for or treating ASB (strong recommendation, high-quality evidence).
Remarks: There is insufficient evidence to inform a recommendation for or against screening or treatment of ASB within the first month following renal transplantation.
Therapy of Asymptomatic Bacteriuria
ABU (>105 colony-forming units/mL in two urine samples > 24 h apart) is common in renal transplant recipients.
Although treatment is often used, it remains unclear whether each ABU must be treated.
Studies promoting treatment have found reduced transplant function due to ABU and a higher virulence of E. coli .
Other studies question the benefit of antibiotic treatment of ABU, as the effect was found to be insufficient , the risk of selection of resistance was higher than the expected benefit, and the virulence of E. coli was not found to be higher in transplant recipients.
Only one prospective study has been published on treating ABU in transplant recipients.
Overall, the need for treating ABU in kidney graft recipients remains unclear.
For candiduria, most often caused by C. glabrata and C. albicans, treatment is always recommended to prevent local fungal complications.
Thank you for your input. Would you please provide the reference for your statement ‘Despite preexisting co-morbidity and the increased complication rate long-term graft and patient survival is comparable to that in the normal transplant population.
What is the reference type here ‘Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah Eldin Zaki Dean of National Institute of Urology and Nephrology’????
What is the reference type here ‘Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah Eldin Zaki Dean of National Institute of
Urology and Nephrology’????
How would you manage this patient?There is chronic bacteriuria in this case . if asymptomatic , then will not require any treatment.
If symptomatic , then will require treatment.
Asymptomatic bacteriuria post transplant requires monitoring only for two months. Beyond two months monitoring is not required as it has not shown in preventing the symptomatic UTIs and pyelonephritis.
In symptomatic cases further assessment is needed. This will include review of urine culture, Blood CP , CRP , renal functions, ultrasound to see any obstruction, stones, kinks etc
Duration of treatment is around 7 days. In recurrent cases, antibiotic prophylaxis is recommended.
Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, Augustine T. Kidney transplantation into an ileal conduit: a single center experience of 59 cases. J Urol. 2003 Nov;170(5):1727-30.
KTR with ileal conduit:
– Urinary diversion is an effective option for individuals with lower urinary tract anomalies.
– KTR with urinary diversion have the same graft survival as other KTR without diversion.
– Rejection are consistently found to be the most frequent cause of allograft loss.
– They are at risk of certain complications including; reflux nephropathy, nephrolithiasis, metabolic acidosis, electrolyte disturbances and UTI.
– Chronic bacteriuria was almost universally encountered in diverted patients, and no effect on graft survival.
– The reason for bacteriuria as the intestinal epithelium lacks the inhibitory actions against bacterial adherence allows the bacteria to proliferate in urinary reservoirs with integrated intestinal segments.
– Obtaining a urine culture in patients with urinary diversion or augmentation should be done cautiously because the interpretation is challenging.
– Most of these patients will have a positive urine culture even in the absence of symptoms, the distinction from true UTI is of utmost importance, to avoid unnecessary antibiotic use.
– In KTR immunosuppression increases the complexity of decision making regarding treatment of positive cultures.
– Previously patients were given antibiotics on grounds of bacteriuria, at present, antibiotic treatment is not prescribed unless the patient has additional symptoms such as tenderness in the graft, fever, or an elevated CRP.
Asymptomatic bacteriuria
– Monitoring is not recommended beyond 2 months post transplantation, as it has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration. – The detection of asymptomatic bacteriuria should prompt a second urine culture to confirm persistent bacteriuria with the same pathogen before treatment decisions are made. If the patient has two consecutive cultures of the same pathogen, antibiotic treatment for five days may be reasonable.
Conclusion:
The index case and have chronic bacteriuria of mixed organism, which is expected in individuals with ileal conduit. If patient is asymptomatic no need to treat.
This patient need to be evaluated for the following before considering treatment:
– Proper sample collection.
– The presence of any symptoms; fever, urinary symptoms, graft tenderness.
References: Robles Garcia J E et al. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature. Science Repository 2020. Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Symeonidis EN, Falagas ME, Dimitriadis F. Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis. Transl Androl Urol. 2019;8(4):286-289. doi:10.21037/tau.2019.07.12
UTI is defined as the presence of > 105 CFU in a proper urine sample (early morning sample, or from a sterile catheter) associated with upper or lower urinary tract symptoms, on the other hand if the patient is asymptomatic the condition is termed ASB.
Categories of UTI includes
Asymptomatic bacteriuria
Simple cystitis which presents with local symptoms such as dysuria, frequency and urgency without systemic symptoms such as allograft pain and fever, and there is no indwelling device such as chronic urinary catheter, ureteral stent or nephrostomy tube
Complicated UTI which presents by systemic symptoms including allograft pain, fever, chills, malaise, or bacteremia with the same organism in urine, or a biopsy with findings consistent with pyelonephritis or if there is an indwelling device.
Recurrent UTI which is defined as ≥ 2 episodes of symptomatic UTI within 6 months or ≥ 3 episodes within 1 year
Screening and monitoring
Screening of UTI by either urine culture or urine analysis (and culture taken if urine analysis is suspicious for UTI) every week is recommended only in the first month after transplantation, if culture is positive, another culture should be taken, and if the same pathogen is isolated asymptomatic bacteriuria is documented.
Monitoring of renal function is recommended in patients with symptomatic recurrent UTI since it may have a bad impact on graft survival
Treatment (which patient I will treat?)
Treatment asymptomatic bacteria is recommended by some experts in early post-transplant period (first month after transplantation), although there is no strong evidence, due to the higher incidence of progression to septicemia, immunosuppression may mask the symptoms, after that period no need for treatment unless the patient develop symptoms. So I will not treat asymptomatic bacteriuria in the current case.
On the other hand, all patients with symptomatic UTI should be treated
The recommended antibiotics for simple cystitis includes fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin (eg, cefpodoxime or cefdinir), or amoxicillin-clavulanate ) or nitrofurantoin provided that GFR> 30 ml /min, on the other hand fosfomycin, and SMX-TMP are not recommended empiric treatment.
The recommended antibiotics for complicated UTI are piperacillin-tazobactam, meropenem, or vancomycin plus cefepime. IV broad spectrum antibiotic are given till culture result then step down therapy should be according to the culture result.
Duration of treatment is 5 -7 days in simple cystitis occurring after 6 months of transplantation, and 2-3 weeks in complicated UTI and in simple cystitis before 6 months of transplantation, but if recurrence is causes by the same organism or in case of an indwelling source such as the ileal conduit in the current case I may recommend longer treatment duration for four to six weeks of therapy.
After successful treatment of symptomatic UTI, if the patient had recurrent attacks of symptomatic UTI, prevention of recurrence is indicated using the following stratigies:
Use of prolonged prophylactic antibiotics is recommended, the most important regimen is the use of SMX-TMP for 6 months -1 year, which was associated with reduction of UTI episodes and severity. (1, 2), some experts continue TMP-SMX prophylaxis indefinitely (3), and if SMX-TMP is contraindicated, some recommends the use of nitrofurantoin 100 mg twice daily provided GFR > 30 ml/min or cephalexin 500 mg twice daily.
Behavioral therapy including increasing oral fluid intake, frequent voiding, post coital voiding, wiping from front to back in females
For post-menopausal females like the current case, topical eostrogen may decrease he frequency of recurrent UTI
Methenamine hippurate (1000 mg twice daily) can be used for prevention of recurrent UTI, which was found that it is associated with 45 % reduction in the frequency of UTI, 42 % reduction in the duration of antibiotic use for the treatment of UTI, and 59 % reduction in hospitalization due to UTI (4). Patients with eGFR <30 mL/min are less likely to benefit from this intervention.
Probiortics are not recommended to be used in transplant recipients, as theey are immunocompromised and data regarding its benefit is not clear
Cranberry juice although the evidence is limited but because of the high safety, the patient can use it if he/she wants
References
1. Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
2. Singh R, Bemelman FJ, Hodiamont CJ, et al. The impact of trimethoprim-sulfamethoxazole as Pneumocystis jiroveci pneumonia prophylaxis on the occurrence of asymptomatic bacteriuria and urinary tract infections among renal allograft recipients: a retrospective before-after study. BMC Infect Dis 2016; 16:90.
3. Horwedel TA, Bowman LJ, Saab G, Brennan DC. Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant. Transpl Infect Dis 2014; 16:261.
4. Hollyer I, Varias F, Ho B, Ison MG. Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study. Transpl Infect Dis 2019; 21:e13063.
1- keep regular clean intermittent self catheterization CISC
2- no antibiotic needed except if symptomatic
3-regular follow up for any appearance of symptoms like fever or tender graft
-Detailed history , examination and lab tests including CBC with differential, inflammatory markers,KFT,electrolytes as well as imaging as Renal US and CT if needed
-Persistent bacteriuria doesnot affect survival nor graft survival in transplant recipients with conduits
-Prophylactic antibiotic therapy is not warranted , native nephrectomy is not needed except in certain cases
-Antibiotics are given in case there is an additional symptom as fever, graft tenderness and high CRP
-Urinary diversion by ileal conduit lead to rapid deterioration of renal function due to the increased risk of UTI meanwhile in transplanted patients it did not lead to a greater loss of the renal graft nor has it been seen to be an independent factor for renal function worsening
– Bacteria are abundant in urine samples from conduits . Contaminated samples are avoided by proper collecting method of urine from the conduit.
– Recurrent urinary tract infections may also predispose to formation of calculi in the conduit
-Adequate prophylaxis and strict follow-up of the patient can avoid most of the complications resulting from the infections
Reference
-Robles Garcia J E et al. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature. Science Repository 2020.
-Carl Warholm, Jonas Berglund, Jan Andersson, Gunnar Tydén, Renal transplantation in patients with urinary diversion: a case-control study, Nephrology Dialysis Transplantation, Volume 14, Issue 12, December 1999, Pages 2937–2940
How would you manage this patient?
The management of this index patient will include identifying the potential risk factors and preventing them or any other one.
Present risk factors are:
Ilea conduit divertion
Tacrolimus based immunosuppression
The clinical history of UTI signs and symptoms like graft tenderness, flank pain, dysuria, and fever.
Investigations like FBC+differential, CRP, and urinary bladder ultrasound should be done
Unfortunately, a urine culture may be of great help because of the possibility of mixed infections
According to a single-center study by Surange et al involving 59 cases of ilea conduit diversion.
The actuarial graft survival was 90% at 1 year, 63% at 5 years, 52% at 10 years, and 52% at 15 years. Graft and patient survival were statistically similar to the outcome of the 2,579 other transplants done at the centre within the same study period of time, thus making it an effective method of treatment.
Furthermore, prophylactic antibiotics are not indicated except there are clinical findings like graft tenderness, fever, and elevated CRP
This patients is having recurrent urinary tract infections post kidney transplantation with a urinary diversion
The most common complication of urinary diversion is urinary tract infection
She is having a mixed growth of micro-organisms from the urine.
Management:
History of the ideal conduit – reason for the ileal conduit – primary diagnosis, when it was done
Whether she has any symptoms like fevers, flank pain and tenderness
History of antimicrobial prophylaxis post-transplant – with septrin as it would suggest resistance to septrin
Collection of the urine specimen in an aseptic technique as there could be contamination since her urine is growing multiple micro-organisms
Imaging: This is very important to rule out any structural abnormalities, obstruction, renal calculi
The treatment will depend on whether it is a true infection or a contaminant
If it is a true infection she will require antimicrobial therapy based on the culture and sensitivity
Whilst waiting for the culture results, she can be started on empiric therapy with either a fluoroquinolone, third generation cephalosporin or amoxicillin/clavulunate
If she has had exposure to a fluoroquinolone in the past thirty days, then she is at high risk of having ESBL – then the empiric therapy should consist of either a carbapenem or tazobactum/piperacillin
If the patient has been exposed to multiple broad spectrum antibiotics, there is a high risk of candida UTI
As conduit urine is bacteriuric in most cases, antibiotic coverage poses a dilemma and treatment should only be instituted if the symptoms indicate upper or lower urinary tract infection
Prophylactic treatment should be reserved for patients with a history of recurrent pyelonephritis
Symeonidis E et al. Transl Androl and Urol 2019;8(4):286-289
Bacteria are frequently found in urine samples from conduits. Contaminated samples can be avoided by using a proper technique. One consideration that should be taken into account is that patients with urinary diversions frequently become colonized.
Tzardis PJ (1990) recommended to treat all bacteriuria in transplant recipients with conduits, since they are on standard triple immunosuppression with cyclosporin, prednisolone, and azathioprine that can mask symptoms of urinary tract infection, and that recurrent urinary tract infections may also predispose to formation of calculi in the conduit.
However, the patients with conduits or reservoirs were given antibiotics on grounds of bacteriuria alone less frequently in recent years. This is due to the experience that many patients do well, despite chronic bacteriuria, and to a general trend to restrict the use of antibiotics to avoid superimposed infections, such as Pseudomonas. Thus, patients with urinary diversions have no benefit in asymptomatic bacteriuria treatment. Screening and treatment of asymptomatic bacteriuria in these patient groups are therefore, not recommended.
At present, antibiotic treatment is not prescribed unless the patient has additional symptoms such as tenderness in the graft, fever, or an elevated C-reactive protein level. Carl Warholm et al, found that chronic bacteriuria did not predispose to urosepticaemia, as septicaemia was only found in one patient and in one control. There appears to be a low risk of ascending infections, which is in accordance with findings by other investigators. Moreover, they found that patients with ileal conduits or continent reservoirs have similar graft and patient survival rates as the general kidney transplant population. The presence of constant bacteriuria did not adversely affect survival. Prophylactic antibiotic treatment seems not to be warranted.
References:
1- Symeonidis EN, Falagas ME, Dimitriadis F. Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis. Transl Androl Urol. 2019 Aug;8(4):286-289. doi: 10.21037/tau.2019.07.12. PMID: 31555550; PMCID: PMC6732096. 2- Carl Warholm, Jonas Berglund, Jan Andersson, Gunnar Tydén, Renal transplantation in patients with urinary diversion: a case-control study, Nephrology Dialysis Transplantation, Volume 14, Issue 12, December 1999, Pages 2937–2940, https://doi.org/10.1093/ndt/14.12.2937 3- Tzardis PJ, Matas AJ, Dunn DL, Payne WD, Sutherland DE, Najarian JS. Ileal and colon conduits in renal transplantation. Clinical transplantation. 1990;4(3):125-8.
Thank you. Prophylactic antibiotic treatment seems not to be warranted in these cases. WHY?
Recurrent urinary tract infections may also predispose to formation of calculi in the conduit. Do you think this risk is equal amongst different organisms?
Intestinal segments in the urine tract promote bacteriuria. The intestinal epithelium lacks bacterial adherence inhibitors like the urothelium, which may explain why.
Urinary diversion or augmentation patients should be careful while getting a urine culture since interpretation is difficult. Most of these individuals have positive urine cultures even without symptoms (asymptomatic bacteriuria). Identifying asymptomatic bacteriuria from actual urine infection is crucial.
Rigamonti and colleagues used prophylactic antibiotics in 24 renal transplant patients after urine diversion and augmentation. Surange and colleagues stressed the significance of thorough infection control during conduit formation in 59 patients with staged renal transplantation with ileal conduit urine diversion.
In urinary diversion patients, turning the kidney upside-down reduces the transplanted ureter’s travel and prevents ureteral kinking. Ureteral peristalsis, not gravity, drives antegrade urine flow.
Oral hydration, pouch irrigation, prophylactic antibiotics, and metabolic derangements may reduce the risk of infection and stone development, which can be extremely difficult to control in rebuilt systems.
Antibiotics are not recommended for asymptomatic positive urine cultures. Immunosuppression complicates positive culture therapy in renal transplant patients with urine diversion.
Eltemamy, Mohamed, Alice Crane, and David A. Goldfarb. “Urinary diversion in renal transplantation.” Urologic Clinics 45.1 (2018): 113-121.
A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml. How would you manage this patient? Patient with an ileal coduitare at increased risk of asymptomatic bacteriuria, this due to lack of inhibitory bacterial adherence factors, and incomplete emptying renders bacterial overgrowth, but long term outcome is comparable to normal bladder kidney transplant.
Asymptomatic bacteriuria defined bypersistent pyuria (WBC 10) and at least twice presence of positive bacterial culture with 10*5 cfu/ml > 24 hours apart, without any patient symptoms.
No prophylactic antibiotics recommended.
Some expert suggests early post-transplant screen for bacteriuria and give treatment for 6 months
The treatment is recommended if patient developed symptoms, such as fever and chills, graft pain and vomiting, with raised CRP, and a positive blood culture indicating bacteremia.
No reduction of immunosuppressive is needed unless severe urosepsis/septic shock occur. Native kidneys nephrectomy may be needed in some cases References:
(1) Suriano F, Gallucci M, Flammia GP, Musco S, Alcini A, Imbalzano G, Dicuonzo G. Bacteriuria in patients with an orthotopic ileal neobladder: urinary tract infection or asymptomatic bacteriuria? BJU Int. 2008 Jun;101(12):1576-9. doi: 10.1111/j.1464-410X.2007.07366.x. Epub 2007 Dec 5. PMID: 18070190.
(2) Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Ask for symptoms: dysuria, urgency, frequency, fever and flank/graft pain
If the recipient develops signs and symptoms of UTI, leucocytes, and CRP, exclude BK/CMV infection, and do ultrasonography for any structural abnormalities
If no fever or other symptoms and with normal kidney function, this transplant recipient has asymptomatic bacteruira (>105c olony-forming units/mL in two urine samples >24h apart)
Patients with Ileal Conduit:
o Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients ESRD due to abnormal lower urinary tracts
o Long-term graft and patient survival is comparable to that in the normal transplant population despite preexisting co-morbidity and the increased complication rate
o The presence of constant bacteriuria did not adversely affect survival
o Prophylactic antibiotic treatment is not warranted
o No indication for native nephrectomy, except in selected cases
o Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level
Screening and treatment of ASB:
o Not recommended
o Experts suggest to screen and start treatment for bacteriuria in the early postoperative period and up to 6 months post transplant
o No recommendation to change immunosuppressive drugs
References
1. A lecture of Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
2. Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Notes
○excellent kidney function.○Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
==> First of all we should ask about the symptoms.
If this patient is symptomatic or asymptomatic.
==> Therefore, the type of bacteria (Ecoli or non Ecoli ) bacteria
□patient with kidney transplant drainage into an ileal conduit for urinary diversion has a long-term graft and patient survival comparable to that in the normal transplant population.
□The presence of constant bacteriuria did not adversely affect survival.
●Prophylactic antibiotic treatment seems not to be warranted.
●There appears to be no indication for native nephrectomy, except in selected cases.
●Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level.
Monitoring for asymptomatic bacteriuria —
Does it improves clinical outcomes ? ==> it is uncertain in fact.
In the past, monitoring with routine urine cultures was frequently performed. However, many transplant centers have moved away from routine monitoring for asymptomatic bacteriuria.
●If monitoring is performed (with routine urine cultures), it should be limited to the first one to two months posttransplant
■■If the patient has
2 consecutive cultures
that yield >105 colony-forming units (CFU)/mL
of the same pathogen
==> antibiotic treatment for five days may be reasonable
■■If the second urine culture shows
clearance of the initial bacteriuria
or if a different organism is identified,
==>
antibiotic treatment should not be initiated.
●Monitoring for asymptomatic bacteriuria after two months should not be performed since
treatment beyond this time has not been shown to be effective in preventing
symptomatic UTI,
pyelonephritis,
bloodstream infection,
or allograft rejection
and can lead to unnecessary antibiotic administration
We should keep on mind that mixed populations of Gram-negative and Gram-positive pathogens can be isolated in ileal conduit (IC) reconstructions
REFERENCES
1- Asymptomatic Bacteriuria in Kidney Transplant Recipients—A Narrative Review Justyna E. Goł˛ebiewska Medicina 2023, 59, 198. https://doi.org/10.3390/medicina59020198
2 Urinary tract infection in kidney transplantation recipients (UpToDate)
3- Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis . Evangelos N. Symeonidis, Transl Androl Urol. 2019 Aug; 8(4): 286–289.
4- Post Renal Transplantation Urinary TractInfection By Prof. Mohamed Salah EldinZaki
I appreciate your observation that mixed populations of Gram-negative and Gram-positive pathogens can be isolated in ileal conduit (IC). Hence it may not be sensible to treat asymptomatic bacteriuria.
Asymptomatic bacteruria (whether treatment is necessary or not) treatment in post transplant is controversial.
From my personal opinion, asymptomatic bacteruria is common in ileal conduit & antibiotic treatment is necessary only if patient becomes symptomatic, has graft dysfunction or lab abnormality ( leucocytosis, high CRP).
Patient has no urinary symptoms ,has also ideal conduit in which asymptomatic bacteriuria is common and no need to be treated but in kidney transplant ,Pt is on immunosuppression so better to treat asymptomatic bacteriuria to avoid progression to UTI
How would you manage this patient?
This patient with urinary diversion, expected to have bacturia (mixed with intestinal flora) – growth of multiple organism points towards contamination.
In general population post-urinary diversion, we don’t screen for it, unless the patient has symptomatic febrile UTI / pyelonephritis. In such cases also, anatomical abnormalities (ureter stricture, stone etc) are important and its correction eliminates further risk of UTI.
In transplant recipients ASB may aggravate to pyelonephritis, as the denervated kidney in ileal conduit may not produce classical symptoms of UTI, and IS may mask the inflammatory reactions.
But majority of the guidelines don’t recommend treatment of ASB, to aboid antibiotic resistance; unless patient becomes symptomatic / raised CRP / Leucocytosis /graft dysfunction.
Routine screening by urinalysis and culture is also not recommended beyond 3months post-transplant.
1) References:
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 Sep;33(9):e13507. doi: 10.1111/ctr.13507. Epub 2019 Mar 28. PMID: 30793386.
2) 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. 2020 Feb;22(1): e13221. doi: 10.1111/tid.13221. Epub 2019 Dec 12. PMID: 31782870.
3) Coussement J, Maggiore U, Manuel O, et al. Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe. Nephrol Dial Transplant. 2018 Sep 1;33(9):1661-1668. doi: 10.1093/ndt/gfy078. PMID: 29635410.
4) Bohn BC, Athans V, Kovacs CS, Stephany BR, Spinner ML. Impact of asymptomatic bacteriuria incidence and management post-kidney transplantation. Clin Transplant. 2019 Jun;33(6):e13583. doi: 10.1111/ctr.13583. Epub 2019 May 23. PMID: 31038773.
5) Coussement J, Kaminski H, Scemla A, Manuel O. Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients. Curr Opin Infect Dis. 2020 Dec;33(6):419-425. doi: 10.1097/QCO.0000000000000678. PMID: 33148983.
If the patient has no urinary or systemic symptoms, this is an asymptomatic bacteriuria due to ileal conduit and there is no need for treatment unless the patient become symptomatic and shows laboratory abnormalities such as elevated CRP.
· How would you manage this patient?
This patient with urine diversion, expected to have bacteruria as the urine is mixed with intestinal normal flora. Specially the growth of multiple organism will point to contamination.
So in such case, only treatment is offered if there is significant symptoms of UTI.
So no need for treatment in this scenario.
-Management of this case starts by proper history taking and assessment of the reasons that have led to ileal conduit
-Asymptomatic bacteriuria management post transplantation is a point of debate .
-assessment of fever , CBC ,CRP with titer, associated vaginal infections , drug levels of FK and MMF are the keys for proper management.
workup for complications related to ileal conduits. interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients’ renal function and maintain their quality of life.
https://pubs.rsna.org/doi/10.1148/rg.2021200067
How would you manage this patient?
Ileal conduit urinary diversion (ICUD) is the least complication-prone and most common procedure after radical cystectomy.
It is associated with number of complication including UTI, upper tract stones as well as calculi within the diversion segment, and progressive decrease of renal function are noted in most patients during long-term follow-up after radical cystectomy.
Patients who had undergone ICUD had a higher incidence of UTI and UTI with septicaemia during long-term follow-up. The major concern following ICUD is the potential for bacterial colonisation of the intestinal conduit. However, asymptomatic bacterial tolerance is common in patients who have undergone ICUD
The ICUD increases the risk of UTI with septicaemia about fivefold, and the mortality rate of septicaemia increases with age.
– In the index case no data available about the cause of this procedure, other risk factors as DM ,level of IS, and presence of symptomatic or complicated UTI.
– Full history about symptoms of UTI (urgency , frequency , dysuria …).
– CBC, CRP ,urine culture.
– Kidney function.
– Blood culture in case of suspected urosepsis.
–Perioperative prophylactic antibiotic treatment has been proven to be effective
-asymptomatic UTI antibiotic treatment is unnecessary as this is a chronic complication ,only needs to be monitored.
Symptomatic UTI treated according to severity
References
Liu YL, Luo HL, Chiang PH, Chang YC, Chiang PH. Long-term urinary tract effect of ileal conduit after radical cystectomy compared with bladder preservation: a nationwide, population-based cohort study with propensity score-matching analysis. BMJ Open. 2018 Dec 9;8(12):e023136.
How would you manage this patient?This a case of asymptomatic bactiuria .
No need for treatment after tow months of transplantation.
In this case, the diagnosis is asymptomatic bacteriuria, which is also expected due to the fact that the ureter was implanted in the ileal conduit.
After 2 months of transplantation, there is no longer any indication for monitoring urine culture, as there is no longer any impact on the graft.
REFERENCE:
– Robles Garcia et al; Kidney Transplant and ileal conduit diversion on same surgical procedure ;clinical case and review of literature.2020
– 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. 2020;22(1):e13221
How would you manage this patient?
Physical examination and Lab Tests for CBC, DIC profile, CRP, RFTs, and microbiological analysis of urine culture are done.
Antibiotic treatment with fluoroquinolone and specific antibiotics against the identified causative agent.
the index patient is a 57 year old female patient who received kidney from her sister 6 months ago… The recipient has abnormal bladder and is on an ileal conduit created for urinary diversion…. she has neocystoureterostomy on the ileal conduit…. This is 6 months post transplant and she has excellent graft function with no features of pyelonephritis…. Urine culture shows bacterial count >105 CFU/ml….
this patient has asymptomatic bacteriuria after renal transplant….
The time period of 6months does not warrant treatment with antibiotics for prophylaxis
There is data to show that antibiotic prophylaxis’s is indicated in the first 3 months post renal transplant as there is high incidence of acute pyelonephritis… AST recommend treatment of asymptomatic bacteriuria in the first 3 months of transplant…they do not recommend routine screening or treatment of asymptomatic bacteriuria after 3 months…
There is no evidence to say that asymptomatic bacteriuria is associated with increased graft loss… there is no correlation with long term graft function deterioration also….
A recent meta analysis showed that there is no need to treat Asymptomatic bacteriuria across 8 studies after 1 month of renal transplantation….
This patient, I would like to confirm whether she has symptomatic UTI…with fever, elevated total count and graft tenderness…if none is there I would diagnose her to have asymptomatic bacteriuria…..I would monitor her regularly for symptomatic UTI on her follow up visit
I will not reduce the immunosuppression or give antibiotic prophylaxis’s.
References:
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. 2020;22(1):e13221
Asymptomatic bacteriuria – In the transplant population, can be defined by the presence of >10*5 bacteria (CFU/mL) on urine culture with no symptoms of UTI.
· Recurrent UTI – can be defined as Two or more episodes of UTI in six months, or three or more episodes of UTI in one year.
Monitoring for asymptomatic bacteriuria should be limited to the first one to two months post transplant. Most patients who are observed without antibiotic treatment will clear bacteriuria spontaneously .
If two consecutive cultures yield >105 (CFU)/mL of the same pathogen, antibiotic treatment for five days .
· If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
· No Monitoring for asymptomatic bacteriuria after two months since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, allograft rejection and can lead to unnecessary antibiotic administration.
Long term graft & patient survival in illeual conduits is comparable to that in normal transplant population.
Screening and treatment of asymptomatic bacteriuria is not recommended.
As in the foregoing example, patients with anomalous urinary tracts are typically recipients of an ileal conduit. These individuals are prone to recurring asymptomatic or symptomatic UTIs. To determine the severity of the disease, a comprehensive medical history, physical examination, and investigations, including a CBC, RFTs, CRP, DIC profile, and urine culture, are necessary. Whether an antibiotic is prescribed for a symptomatic UTI depends on the infection’s complexity.
Simple urinary tract infections are treated with fluoroquinolones, a third-generation cephalosporin, or amoxicillin-clavulanate, while complicated infections are treated with broad-spectrum antibiotics such as piperacillin-tazobactam, meropenem, etc. Although center-specific, asymptomatic UTIs did not necessitate treatment until the first month after a transplant, A patient with an asymptomatic UTI only needs to be monitored; antibiotic treatment is unnecessary.
Patient recommendations for behavioral therapy should include increasing oral fluid intake, frequent urination, and urination after coitus. The graft and patient survival rates over the long term are comparable to those of the typical transplant population.
How would you manage this patient?
REF;
How would you manage this patient?This patient has ill conduit this means hat she has voiding problems .
Such conduit is another way of urine voiding in case of bladder dysfucntions .
In case of ileal condiut we may have ASB and UTIS but not affect Grfat fucntion .
screen for ASB: if positive (i.e., 2 consecutive urine cultures yielding >10⁵ CFU/ml of the same pathogen), treat with antibiotics for 5days as guided by the sensitivity pattern; however, if the 2nd culture is negative or grows another organism do not give antibiotics
· use pathogen-specific antibiotics as guided by the culture and sensitivity patterns
· antibiotics prophylaxis should be carefully evaluated to avoid adverse effects and emergence of antibiotic-resistant microorganisms
· management of symptomatic infections: obtain urine sample for m/c/s, then start with empiric therapy awaiting definitive therapy as guided by the sensitivity patterns
6. A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
Issues/ concerns
– 57yo female, LDKTx 6months ago, donor sister
– ureter implanted into the ileal conduit created for urine diversion
– medication: tacrolimus-based triple immunosuppression
– excellent kidney function
– urine keeps growing many organisms, bacterial count ≥ 105 CFU/ml
How would you manage this patient? (1-4)
– the recipient most probably had an incompetent bladder or a voiding problem which could have directly affected the function of the graft kidney hence the need to have an ileal conduit urinary diversion
– the main complication of ileal conduit urinary diversion in kidney transplantation is ASB and UTIs which do not lead to graft loss
– fortunately, the long-term outcome is comparable to transplantation in healthy native bladders
– multidisciplinary approach: urologists, infectious disease specialist
– further history and physical examination: indication for the ileal conduit, any urological malformations, VUR, history of recurrent UTIs prior to transplant, local and systemic symptoms of infection (frequency, urgency, dysuria, fevers, nausea, flank pain, graft tenderness), antibiotic prophylaxis, ureteric stent
– baseline investigations: CBC, ESR, CRP, procalcitonin, urine m/c/s, blood cultures, UECs, LFTs, blood sugar, tacrolimus trough levels
– imaging:
· ultrasound to assess the graft kidney, native kidneys, postvoid residual volume
· non-contrast CT scan of the urinary tract for patients with recurrent UTIs and a normal ultrasound – to assess for strictures, stones, complex cysts
· if CT scan is unrevealing, rule out bladder dysfunction and outflow tract obstruction by measuring urine flow rate and performing urodynamic studies
· flexible cystoscopy to detect abnormalities in the urethra or bladder
– treatment:
· patients with ileal conduits are at increased risk of asymptomatic bacteriuria (ASB)
· screen for ASB: if positive (i.e., 2 consecutive urine cultures yielding >10⁵ CFU/ml of the same pathogen), treat with antibiotics for 5days as guided by the sensitivity pattern; however, if the 2nd culture is negative or grows another organism do not give antibiotics
· use pathogen-specific antibiotics as guided by the culture and sensitivity patterns
· antibiotics prophylaxis should be carefully evaluated to avoid adverse effects and emergence of antibiotic-resistant microorganisms
· management of symptomatic infections: obtain urine sample for m/c/s, then start with empiric therapy awaiting definitive therapy as guided by the sensitivity patterns
– simple cystitis: empiric therapy with a fluoroquinolone or a 3rd generation cephalosporin or amoxicillin-clavulanate or nitrofurantoin (if eGFR >30); duration of therapy 10-14days if the simple cystitis occurs earlier than 6 months posttransplant and 5-7days if it occurs 6 months posttransplant
– complicated UTI: empiric therapy with piperacillin-tazobactam or meropenem or a combination of vancomycin plus cefepime; treat for 14-21days, can switch to oral medications once the patient is symptom free and the antibiotic sensitivity patterns are known
· optimal duration of antimicrobial therapy for recurrent UTIs in kidney transplant recipients remains unknown
References
1. Doménech P, Garcia J, Cortés A, Miñana B, Castañé C, Costa D, et al. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature. Transplantation Case Reports. 2020 05/30:1-3.
2. Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, et al. Kidney transplantation into an ileal conduit: a single center experience of 59 cases. The Journal of urology. 2003 Nov;170(5):1727-30. PubMed PMID: 14532763. Epub 2003/10/09. eng.
3. Mitra S, Alangaden GJ. Recurrent urinary tract infections in kidney transplant recipients. Current infectious disease reports. 2011 Dec;13(6):579-87. PubMed PMID: 21870039. Epub 2011/08/27. eng.
4. Bodro M, Linares L, Chiang D, Moreno A, Cervera C. Managing recurrent urinary tract infections in kidney transplant patients. Expert Review of Anti-infective Therapy. 2018 2018/09/02;16(9):723-32.
· transplantation in patients with an abnormal lower urinary tract (LUT), associated with an increased risk of pyelonephritis and thus graft loss
· Thus, in patients with an abnormal LUT, anatomical, and functional evaluations are recommended to detect and treat abnormalities that may impact kidney allograft survival.
· The first case of kidney transplantation into a urinary tract deviation with an intestinal conduit was described in 1966 by Kelly et al.
· In Kidney transplant with drainage into an ileal conduit, long-term graft and patient survival is comparable to that in the normal transplant population.
· Urinary tract infection (UTI) is the most common infection after kidney transplantation.
· UTI is associated with the development of bacteremia, acute T cell-mediated rejection, impaired allograft function, and allograft loss, with increased risk of hospitalization and death.
· Asymptomatic bacteriuria – In the transplant population, this is defined by the presence of >105 bacterial (CFU/mL) on urine culture with no local or systemic symptoms of UTI.
· Recurrent UTI – Two or more episodes of UTI in six months, or three or more episodes of UTI in one year.
Risk factors for UTI in kidney transplant recipients
· Female sex
· Advanced age
· Recurrent UTI prior to transplant
· Vesicoureteral reflux
· Urethral catheterization
· Ureteral stent placement
· Deceased-donor kidney transplant
· History of autosomal dominant polycystic kidney disease (ADPKD)
· Delayed graft function
The widespread use of antibiotic prophylaxis among kidney transplant recipients has led to an increased rate of resistance to ciprofloxacin and trimethoprim-sulfamethoxazole
UTIs are associated with significant morbidity among transplant recipients, especially if they occur early after transplantation.
Prophylaxis with TMP-SMX can be administered as one double-strength tablet daily or three times per week or one single-strength tablet daily and continued for six months to one year posttransplant;
Early ureteral stent removal within four weeks of transplant may help to prevent UTI after kidney transplantation.
Monitoring for asymptomatic bacteriuria
· it should be limited to the first one to two months posttransplant
· Most patients who are observed without antibiotic treatment will spontaneously clear bacteriuria
· If the patient has two consecutive cultures that yield >105 (CFU)/mL of the same pathogen, antibiotic treatment for five days may be reasonable (according to culture result).
· If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
· Monitoring for asymptomatic bacteriuria after two months should not be performed since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration
Approach to prevention
· Behavioral changes: increased fluid intake, frequent voiding, postcoital voiding, contraception modification (in sexually active patients), and wiping from front to back
· Some experts administer prophylactic antibiotics to selected patients with recurrent UTI.
· For postmenopausal females, topical estrogen may prevent recurrence of UTIs
· Some transplant programs use methenamine hippurate (1000 mg twice daily) with or without ascorbic acid (1000 mg twice daily) for prevention of recurrent UTI.
MANAGEMENT OF SYMPTOMATIC INFECTIONS
Simple cystitis
· An oral fluoroquinolone (ciprofloxacin 250 mg twice daily or levofloxacin 500 mg once daily, or
· A third-generation cephalosporin (eg, cefpodoxime 100 mg twice daily or cefdinir 300 mg twice daily), or
· Amoxicillin-clavulanate (500 mg twice daily).
· Nitrofurantoin (100 mg twice daily) is another option for patients with an eGFR >30 mL/min/1.73 m2.
· Duration of therapy:
1) For that occurs earlier than six months posttransplant, treat for 10 to 14 days.
2) For that occurs more than six months posttransplant, treat for five to seven days.
Complicated UTI
· Piperacillin-tazobactam 4.5 g IV every six hours, or
· Meropenem 1 g IV every eight hours, or
· Combination therapy with vancomycin plus cefepime 1 g IV every eight hours.
· Duration of therapy: 14 to 21 days of antibiotic therapy
1)https://www.uptodate.com/contents/urinary-tract-infection-in-kidney-transplant-recipients?search=asymptomatic%20bacteriuria&source=search_result&selectedTitle=8~74&usage_type=default&display_rank=8#:~:text=Urinary%20tract%20infection%20in%20kidney%20transplant%20recipients
2)https://pubmed.ncbi.nlm.nih.gov/21521435/#:~:text=Antibiotic%20prophylaxis%20for%20urinary%20tract%20infections%20in%20renal%20transplant%20recipients%3A%20a%20systematic%20review%20and%20meta%2Danalysis
A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
How would you manage this patient?
REF;
asymptomatic bacteruria(>105c CFU/ML in 2 urine samples >24h in between) in the settings of urinary diversion espicially with normal graft function & isolation of different organisms, should be monitored only for symptoms& graft function, it dosent necessiate AB therapy or reduction of immunosupression
asymptomatic UTI and stable graft function do not warrant any intervention
incontinent stoma is the reason for culture growth
long term graft function is not hampered
Six months post-transplant (donor is the patient sister)
Ureter was implanted into the ileal conduit
On triple therapy as maintenance
Significance urine culture (recurrent)
Management
Reference
Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, Augustine T. Kidney transplantation into an ileal conduit: a single center experience of 59 cases. J Urol. 2003 Nov;170(5):1727-30. doi: 10.1097/01.ju.0000092023.39043.67. PMID: 14532763.
there is 3 types of operation for urinary divergent includes
–ileal conduit (mostly non continent operation needs ostoma and patient not on CIC)
-indiana pouch reservior (patient on CIC)
-neobladder with uretheral connection (Patient on CIC)
and another classification according continent( needs CIC and non continent on ostoma)
So, more details are needed about kind of operation and patiient is maintained on what??
and what is the cause for this urinary conversion is needed???
Multiple organism in urine culture in patients post urine divergent is consider normal and usually no need to be treated unless symptomatic
post kidney transplant patient usually symptoms will not be that typical because of immunosuppression medications.
So,clincal examination ,lab investiagtions (dearranged kidney functions ,CBC and CRP) and radiological assessment maybe needed for further evaluation in such specfic group of patients.
In this case i will go for conservative managment unless there is symptoms or signs of sepsis
References
1. Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
2. Singh R, Bemelman FJ, Hodiamont CJ, et al. The impact of trimethoprim-sulfamethoxazole as Pneumocystis jiroveci pneumonia prophylaxis on the occurrence of asymptomatic bacteriuria and urinary tract infections among renal allograft recipients: a retrospective before-after study. BMC Infect Dis 2016; 16:90.
3. Horwedel TA, Bowman LJ, Saab G, Brennan DC. Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant. Transpl Infect Dis 2014; 16:261.
4. Hollyer I, Varias F, Ho B, Ison MG. Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study. Transpl Infect Dis 2019; 21:e13063.
References:
ileal conduit
How would you manage this patient?
Ileal condiu in kidney transplant recipient is indicated for patients with abnormal urinary tract and commonly complicated with recurrent UTI either symptomatic or not as the intestinal segments used to form the conduit are normally colonized with bacteria . Management of this recurrent UTI depends on presence of symptoms as fever , tachycardia.– Investigations needed include : CBC , CRP ,procalcitonin , KFT, LFT– Antibiotic treatment is largely based on presence of symptomatic classification :1- Asymptomatic bacteriuria : defined as the presence of >100000 CFU/mL on urine culture without assiociated local or systemic symptoms of UTI and should be confirmed with another urine culture growing the same organism before starting treatment.2- Complicated UTI including upper UTI (pelonephritis) or Lower UTI (cystitis) :any symptomatic UTI in kidney transplant recipient is considered complicated . -The presence of >100000 CFU/mL on urine culture associated with with local urinary symptoms as frequency, urgency or dysuria ( acute cystitis ) or with tender graft (pyelonephritis) or with systemic inflammatory symptoms as fever.Symptoms of complicated UTI may be atypical due to denervated graft and immunesuppressive status.Investigations 1- CBC, LFT,KFT2- Inflammatory markers: ESR, CRP, procalcitonon 3- Urine culture and sensitivityManagement :According to presense of symptoms , complicated or not a- For persistent asymptomatic pyuria : 5 days antibiotic course should be considered b- For mild cases : outpatient empiric treatment with oral fluoroquinolone.– For severe and complicated cases: -hospitalization , maintain good hydration , correct any electrolytes disturbance .– Antibiotic treatment bases on culture and sensitivity and start empirical treatment with either fluroquinolone oral or IV or if suspected MDR gram negative organism consider antipseudomonal carbapenem, piperacillin-tazobactam or cefepime
How would you manage this patient?Ileal condiu in kidney transplant recipient is indicated for patients with abnormal urinary tract and commonly complicated with recurrent UTI either symptomatic or not as the intestinal segments used to form the conduit are normally colonized with bacteria . Management of this recurrent UTI depends on presence of symptoms as fever , tachycardia.– Investigations needed include : CBC , CRP ,procalcitonin , KFT, LFT– Antibiotic treatment is largely based on presence of symptomatic classification :1- Asymptomatic bacteriuria : defined as the presence of >100000 CFU/mL on urine culture without assiociated local or systemic symptoms of UTI and should be confirmed with another urine culture growing the same organism before starting treatment.2- Complicated UTI including upper UTI (pelonephritis) or Lower UTI (cystitis) :any symptomatic UTI in kidney transplant recipient is considered complicated . -The presence of >100000 CFU/mL on urine culture associated with with local urinary symptoms as frequency, urgency or dysuria ( acute cystitis ) or with tender graft (pyelonephritis) or with systemic inflammatory symptoms as fever.Symptoms of complicated UTI may be atypical due to denervated graft and immunesuppressive status.Investigations 1- CBC, LFT,KFT2- Inflammatory markers: ESR, CRP, procalcitonon 3- Urine culture and sensitivityManagement :According to presense of symptoms , complicated or not a- For persistent asymptomatic pyuria : 5 days antibiotic course should be considered b- For mild cases : outpatient empiric treatment with oral fluoroquinolone.– For severe and complicated cases: -hospitalization , maintain good hydration , correct any electrolytes disturbance .– Antibiotic treatment bases on culture and sensitivity and start empirical treatment with either fluroquinolone oral or IV or if suspected MDR gram negative organism consider antipseudomonal carbapenem, piperacillin-tazobactam or cefepime
How would you manage this patient?This patient first would be a detailed history- History on indication of the urinary diversion, ileal conduit are usually done to due lower urinary tract abnormalitiesHistory of UTI clinical symptoms.
In this patient absence of any clinical symptoms makes it a diagnosis of asymptomatic bacteriuria which is defined as CFU>105 in 2 urine samples 24 hours apart.
This patient has history of multiple organisms grown hence it would be prudent to know whether the urine sample was collected in a sterile procedure.
Presence of ASB doesn’t affect the overall graft function and survival hence prophylactic antibiotics is not warranted.
Patients with ileal conduit had similar longterm graft function and survival in comparison to patients with no urinary diversion.
Thus antibiotics should be started when there is additional symptoms of tender graft, fever or high inflammatory markers.
Thus in this patient one should look for markers of inflammation like CRP, Procalcitonin and ESR.
There is also no indication of native kidney nephrectomy.
References
Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology lecturer on post-renal transplantation urinary tract infection.
According to the guidelines of the European Association of Urology (EAU), UTI after TX might present as:
If the recipient develops signs and symptoms of UTI, leucocytes, and CRP, exclude BK/CMV infection, and do ultrasonography for any structural abnormalities
If no fever or other symptoms and with normal kidney function, this transplant recipient has asymptomatic bacteriuria (>105 colony-forming units/mL in two urine samples >24h apart)
Patients with Ileal Conduit:
Screening and treatment of ASB:
References
lecture on Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
How would you manage this patient?
Introduction;
–Urinary diversion is required following cystectomy for benign or malignant conditions.
-Ileal conduit, continent cutaneous diversion, and orthotopic neobladder are the three most commonly used techniques of urinary diversion.
-Ileal conduits are the archetypical procedure of incontinent urinary diversions.
-Urine is directed from the ureters through a segment of isolated bowel to the surface of the abdominal wall via a cutaneous stoma.
-There, urine drains continuously and is collected by an external appliance adhered to the skin surface.
Asymptomatic bacteriuria;
-In the transplant population, this is defined by the presence of >105 bacterial colony-forming units per milliliter (CFU/mL) on urine culture with no local or systemic symptoms of UTI.
Simple cystitis;
-The presence of >105 CFU/mL on urine culture with local urinary symptoms, such as dysuria, frequency, or urgency, but no systemic symptoms, such as fever or allograft pain, and no indwelling device (eg, ureteral stent, nephrostomy tube, or chronic urinary catheter).
Complicated UTI;
-The presence of >105 CFU/mL on urine culture with fever, allograft pain, chills, malaise, or bacteremia with the same organism in urine, or a biopsy with findings consistent with pyelonephritis.
Recurrent UTI;
Two or more episodes of UTI in six months, or three or more episodes of UTI in one year.
Risk factors;
-Female sex
-Advanced age
-Recurrent UTI prior to transplant
-Vesicoureteral reflux
-Urethral catheterization
-Ureteral stent placement
-Deceased-donor kidney transplant
-History of autosomal dominant polycystic kidney disease (ADPKD)
-Delayed graft function
Evaluation;
-For patients with suspected acute complicated UTI, send urine for both urinalysis (either by microscopy or by dipstick) and culture with susceptibility testing.
-Imaging is generally reserved for those who are severely ill, have suspected urinary tract obstruction, have persistent symptoms despite 48 to 72 hours of appropriate antimicrobial therapy, or have recurrent symptoms.
Diagnosis;
-The diagnosis of acute complicated UTI is made in patients who have consistent clinical findings as well as pyuria and bacteriuria.
-UTI is unlikely if pyuria is absent.
Indications for hospitalization;
-Outpatient management is acceptable for patients with acute complicated UTI of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in an outpatient facility or the emergency department and discharged on oral antimicrobials with close follow-up.
Empiric therapy;
-The approach to empiric therapy of acute complicated UTI depends on the severity of illness, the risk factors for resistant pathogens, and specific host factors.
Critical illness/urinary tract obstruction;
-For patients who are critically ill or have urinary tract obstruction, suggest an antipseudomonal carbapenem plus vancomycin.
Other hospitalized patients;
-For hospitalized patients without critical illness or urinary tract obstruction who have no risk factors for a multidrug-resistant (MDR) gram-negative infection, suggest ceftriaxone or piperacillin-tazobactam .
-Oral or parenteral fluoroquinolones are also reasonable options.
-For patients who have risk factors for an MDR gram-negative infection, suggest piperacillin-tazobactam, cefepime , or an antipseudomonal carbapenem.
-For those with a recent history of an ESBL-producing urinary isolate specifically, use a carbapenem.
Outpatients without risk for resistance;
-For outpatients without risk factors for an MDR gram-negative infection , suggest an oral fluoroquinolone, such as levofloxacin or ciprofloxacin.
-If the community prevalence of E. coli fluoroquinolone resistance is known to be higher than 10%, suggest also a single dose of a long-acting parenteral agent such as ceftriaxone or ertapenem prior to administering the fluoroquinolone.
Outpatients with risk for resistance;
-For outpatients with risk factors for an MDR gram-negative infection , suggest an initial dose of ertapenem .
-Subsequently, an oral fluoroquinolone or daily ertapenem can be used.
Directed therapy and duration;
-Results of urine culture and susceptibility testing should be used to confirm that the chosen empiric regimen is active and to tailor the regimen, including switching a parenteral regimen to an oral agent once symptoms have improved.
-Appropriate oral agents to treat acute complicated UTI include fluoroquinolones (eg, levofloxacin or ciprofloxacin) ciprofloxacin , given for 5 to 7 days) or TMP/SMX (given for 7 to 10 days).
-Oral beta-lactams (given for 7 to 10 days) are less effective for acute complicated UTI but are appropriate alternatives if susceptibility is documented and the other agents are not feasible.
ILEAL CONDUITS
Ileal conduits were the gold standard for urinary reconstruction before the advent of continent diversions . Due to the relative ease of their formation and the shorter operative time
ileal conduits are often used in patients with significant medical comorbidities to minimize postoperative complications and the risk of reoperation.
Ileal conduits remain the procedures of choice for many patients, especially those with a shorter life expectancy and those who cannot complete the necessary rehabilitation process to learn how to manage a continent diversion
Infectious complications urinary diversion
Intestinal segments that are used to fashion the reservoir/conduit are normally colonized with bacteria
●Incomplete voluntary voiding may leave residual urine, a nidus for infection.
●Intermittent catheterization may introduce bacteria into the reservoir in a retrograde manner, especially if it is done carelessly.
After urinary diversion, patients do not require chronic suppressive antibiotic therapy unless there is a history of recurrent infections. Although the presence of small bowel intestinal mucosa appears to promote asymptomatic bacterial colonization, urosepsis rarely occurs unless the patient has recurrent urinary tract infections.
.Asymptomatic bacteriuria – In the transplant population, this is defined by the presence of >100000 (CFU/mL) on urine culture with no local or systemic symptoms of UTI.
The detection of asymptomatic bacteriuria should prompt a second urine culture to confirm persistent bacteriuria with the same pathogen before treatment decisions are made.
If the patient has two consecutive cultures that yield >100000 colony-forming units (CFU)/mL of the same pathogen,
antibiotic treatment for five days may be reasonable, with antibiotic selection based upon the susceptibility pattern of the microorganism.
If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
Monitoring for asymptomatic bacteriuria after two months should not be performed since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration
No indication for native nephrectomy, except in selected cases. Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level
How would you manage this patient?
Ileal conduit in the renal transplant patients as in the above case is usually done in patients with abnormal urinary tracts. Such patients are prone to have recurrent UTIs either asymptomatic or symptomatic .Thorough history,examination and investigations to assess the severity of disease must like CBC,RFTs, CRP ,DIC profile and proper collection of urine sample for culture. Symptomatic UTI needs treatment and choice of antibiotic depends on whether complicated or uncomplicated UTI. Uncomplicated UTI- fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin or amoxicillin-clavulanate while for complicated UTI- broad spectrum antibiotics like piperacillin-tazobactam, meropenem, etc. Asymptomatic UTI did not need treatment except in the first 1 month post transplant but that also varies center-center. Above case has asymptomatic UTI so just need monitoring and no antibiotic therapy .The patient should give advice for behavioral therapy, including increasing oral fluid intake, frequent voiding,and post coital voiding, Long-term graft and patient survival is almost similar to normal transplant population
REFERENCES:
1-Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
2-A lecture of Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
Urinary tract infections (UTI) are the most common infection in the early postoperative phase after kidney transplantation.
Urinary tract infections (UTI) are defined as the growth of 105 colony forming units on a proper urine sample) in the presence of symptoms such as dysuria, urinary frequency or localized pain (the incidence of a UTI ranges from 4–80%.
Risk factors of UTIs after kidney transplantation include:
Female gender
Advanced age
Pre-transplant UTIs
Prolonged period of hemodialysis before transplantation
Immunosuppression
Ileal conduit
Patients with Ileal Conduit:
Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients ESRD due to abnormal lower urinary tracts.
Long-term graft and patient survival is comparable to that in the normal transplant population despite pre-existing co-morbidity and the increased complication rate
The presence of constant bacteriuria did not adversely affect survival
Prophylactic antibiotic treatment is not warranted
No indication for native nephrectomy, except in selected cases
Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level.
Classification of UTI includes.
Asymptomatic bacteriuria
Simple cystitis which presents with local symptoms such as dysuria, frequency, and urgency without systemic symptoms such as allograft pain and fever, and there is no indwelling device such as chronic urinary catheter, ureteral stent or nephrostomy tube.
Complicated UTI which presents by systemic symptoms including allograft pain, fever, chills, malaise, or bacteremia with the same organism in urine, or a biopsy with findings consistent with pyelonephritis or if there is an indwelling device.
Recurrent UTI which is defined as ≥ 2 episodes of symptomatic UTI within 6 months or ≥ 3 episodes within 1 year.
Recurrent UTI is associated with an increased risk of graft and patient loss.
Screening and monitoring
Screening of UTI by either urine culture or urine analysis (and culture taken if urine analysis is suspicious for UTI) every week is recommended only in the first month after transplantation, if culture is positive, another culture should be taken, and if the same pathogen is isolated asymptomatic bacteriuria is documented.
Monitoring of renal function is recommended in patients with symptomatic recurrent UTI since it may have a bad impact on graft survival.
How would you manage this patient?
According to the guidelines of the European Association of Urology (EAU), UTI after KTX might present either as:
A-Asymptomatic bacteriuria = (>105 colony-forming units/mL in two urine samples > 24 h apart) is common in renal transplant recipients.
B-Symptomatic infection
Any symptoms of dysuria, urgency, frequency, fever, and flank/graft pain
If the recipient develops signs and symptoms of UTI, leucocytes, and CRP, exclude BK/CMV infection, and do ultrasonography for any structural abnormalities.
If no fever or other symptoms and with normal kidney function, this transplant recipient has asymptomatic bacteriuria (>105c colony-forming units/mL in two urine samples >24h apart).
Patients with Ileal Conduit
Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients with end stage renal disease due to abnormal lower urinary tracts.
Despite pre-existing co-morbidity and the increased complication rate long-term graft and patient survival is comparable to that in the normal transplant population.
The presence of constant bacteriuria did not adversely affect survival.
Prophylactic antibiotic treatment seems not to be warranted.
There appears to be no indication for native nephrectomy, except in selected cases.
Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level.
Post renal transplant recipients who have had renal transplant surgery >1 month prior, we recommend against screening for or treating ASB (strong recommendation, high-quality evidence).
Treatment asymptomatic bacteria is recommended by some experts in early post-transplant period (first month after transplantation), although there is no strong evidence, due to the higher incidence of progression to septicemia, immunosuppression may mask the symptoms, after that period no need for treatment unless the patient develop symptoms. So, I will not treat asymptomatic bacteriuria in the current case.
On the other hand, all patients with symptomatic UTI should be treated.
The recommended antibiotic for simple cystitis includes fluoroquinolone (ciprofloxacin or levofloxacin), a third-generation cephalosporin or amoxicillin-clavulanate) or nitrofurantoin provided that GFR> 30 ml /min, on the other hand Fosfomycin, and SMX-TMP are not recommended empiric treatment.
The recommended antibiotics for complicated UTI are piperacillin-tazobactam, meropenem, or vancomycin plus cefepime. IV broad spectrum antibiotic are given till culture result then step-down therapy should be according to the culture result.
Duration of treatment is 5 -7 days in simple cystitis occurring after 6 months of transplantation, and 2-3 weeks in complicated UTI and in simple cystitis before 6 months of transplantation, but if recurrence is causes by the same organism or in case of an indwelling source such as the ileal conduit in the current case, I may recommend longer treatment duration for four to six weeks of therapy.
After successful treatment of symptomatic UTI, if the patient had recurrent attacks of symptomatic UTI, prevention of recurrence is indicated using the following strategies:
Use of prolonged prophylactic antibiotics is recommended, the most important regimen is the use of SMX-TMP for 6 months -1 year, which was associated with reduction of UTI episodes and severity.
some experts continue TMP-SMX prophylaxis indefinitely and if SMX-TMP is contraindicated, some recommends the use of nitrofurantoin 100 mg twice daily provided GFR > 30 ml/min or cephalexin 500 mg twice daily.
Behavioral therapy including increasing oral fluid intake, frequent voiding, post coital voiding, wiping from front to back in females.
For post-menopausal females like the current case, topical oestrogen may decrease her frequency of recurrent UTI.
Methenamine Hippurate (1000 mg twice daily) can be used for prevention of recurrent UTI, which was found that it is associated with 45 % reduction in the frequency of UTI, 42 % reduction in the duration of antibiotic use for the treatment of UTI, and 59 % reduction in hospitalization due to UTI (4). Patients with eGFR <30 mL/min are less likely to benefit from this intervention.
Probiotics are not recommended to be used in transplant recipients, as they are immunocompromised and data regarding its benefit is not clear.
Cranberry juice although the evidence is limited but because of the high safety, we can use it.
Screening and Monitoring of ASB post kidney transplant.
Not recommended,
Post renal transplant recipients who have had renal transplant surgery >1 month prior, we recommend against screening for or treating ASB (strong recommendation, high-quality evidence).
No recommendation to change immunosuppressive drugs.
Overall, the need for treating ASB in kidney graft recipients remains unclear.
Screening of UTI by either urine culture or urine analysis (and culture taken if urine analysis is suspicious for UTI) every week is recommended only in the first month after transplantation, if culture is positive, another culture should be taken, and if the same pathogen is isolated asymptomatic bacteriuria is documented.
For Candiduria, most often caused by C. glabrata and C. albicans, treatment is always recommended to prevent local fungal complications.
Monitoring of renal function is recommended in patients with symptomatic recurrent UTI since it may have a bad impact on graft survival.
References
A lecture of Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America
Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
Horwedel TA, Bowman LJ, Saab G, Brennan DC. Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant. Transpl Infect Dis 2014; 16:261.
Hollyer I, Varias F, Ho B, Ison MG. Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study. Transpl Infect Dis 2019; 21:e13063.
Female kidney transplant recipient with an ileal conduit, on triple IS for 6 months having persistent leukocyturia without signs & symptoms of UTI She has good graft function.
She is having asymptomatic bacteriuria (ASB), and treatment of ABU after kidney transplantation is a topic of various opinions [1, 2].
ASB can be associated with an increased risk of
1. Symptomatic UTI that can negatively impact graft function. However, A meta-analysis recommended not to treat ASB after the first-month post kidney transplant and 8 studies from this meta-analysis, they failed to find any benefit of treating ASB in regards to the risk of symptomatic UTI or change in renal function [2].
2. ASB was not associated with an increased risk of acute graft rejection, treatment with ABx should be questioned as might associate with MDR and high cost. Therefore NO agreement on the use of antibiotics for ASB in kidney transplantation [2].
3. American Society of Transplantation Infectious Diseases Community of Practice suggested not treating asymptomatic bacteriuria that occurs beyond three months after kidney transplantation unless in case of an accompanied by rise in serum creatinine [3].
Reference
1. Coussement J, Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2018;2(2):CD011357. Published 2018 Feb 1. doi:10.1002/14651858.CD011357.pub2
2. 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. 2020;22(1):e13221. doi:10.1111/tid.13221
3. Parasuraman R, Julian K; AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant. 2013;13 Suppl 4:327-336. doi:10.1111/ajt.12124
How would you manage this patient?
Need to confirm whether this is symptomatic or asymptomatic UTI. Given scenario look like of asymptomatic bacteriuria.
Diagnosis can be made by
Two consecutive cultures that yield >105 colony-forming units (CFU)/mL of the same pathogen 24 hr apart
In absence of history of pain in graft site, malaise, fever without obvious cause, high TLC counts, crp >80.
In case of asymptomatic bacteriuria after transplantation there is insufficient evidence to support routinely treating kidney transplant recipients with antibiotics
Need to monitor fever, malaise, leukocytosis, or a nonspecific sepsis syndrome.
Reference
Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients . Curr Opin Infect Dis. 2020 Dec;33(6):419-425.
Post renal transplant UTI Lecture, Prof Mohamed Salah Eldin Zaki
The urine culture in this case is not valuable. There would be always pyuria and microorganisms from the gastrointestinal system. In case of symptoms or pyelonephritis, revision should be considered
I will ask or symptoms of upper UTI, pain check blood sample for systemic infection and give antibiotics accordingly
The threshold for asymptomatic bacteriuria from a clean-catch voided urine specimen is isolation of a single organism in quantitative counts ≥105 colony-forming units (CFU)/mL
For females, a second specimen should be obtained (preferably within two weeks) to confirm growth of the same organism over the same quantitative threshold.
For males, a single urine specimen meeting the criteria is sufficient for making the diagnosis.
Monitoring for asymptomatic bacteriuria
Whether monitoring and treating asymptomatic bacteriuria in the early post-transplant period improves clinical outcomes is uncertain.
If monitoring is performed (with routine urine cultures), it should be limited to the first one to two months posttransplant.
The detection of asymptomatic bacteriuria should prompt a second urine culture to confirm persistent bacteriuria with the same pathogen before treatment decisions are made. If the patient has two consecutive cultures that yield >105 colony-forming units (CFU)/mL of the same pathogen, antibiotic treatment for five days may be reasonable, with antibiotic selection based upon the susceptibility pattern of the microorganism. If the second urine culture shows clearance of the initial bacteriuria or if a different organism is identified, antibiotic treatment should not be initiated.
Monitoring for asymptomatic bacteriuria after two months should not be performed since treatment beyond this time has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration (up to date)
How would you manage this patient?
– Ileal conduit urinary diversion is a safe technique that can be used in patients with urodynamic problems or with a non functioning lower urinary system without increasing the risk of early graft loss.
Reference :
⭐Ileal conduit is a common procedure done to create neobladder (we must ask about the cause or indication) …, In such old patient may be after radical cystectomy for bladder carcinoma, or may be for non neurogenic neurogenic bladder.
⭐In addition, there are various types either continent or incontinent.
⭐incontinent one has higher risk for bacterial colonization with either skin flora as staph epidermidis or strept or colonic bacteria as E coli or Proteus.
_mostly asymptomatic bacteriuria is not treated and most of the studies suggest that no need for antibiotics treatment and that cases with Ileal conduit have good long term prognosis.
_so follow up for development of any symptoms to start treatment.
a female recipient with an ileal conduit, on tripleIS including tacrolimus, 6 months after transplantation and persistent leukocyturia > 100000 without clinical signs or symptoms of UTI, and she is having excellent graft function this fits the definition of asymptomatic bacteriuria (ASB), and treatment of ABU after kidney transplantation is a topic of argument, and need more studies.
ASB can be associated with an increased risk of symptomatic UTI that can negatively impact graft function. However, A meta-analysis from Spain (15 studies) recommended not to treat ASB after the first-month post-KT (1), and in 8 studies from this meta-analysis, they failed to find any benefit of treating ASB in regards to the risk of symptomatic UTI or change in renal function (1).
ASB with increased incidence reported in the first month up to 22% and even more up to 30% after the first year of transplantation and some reports it varies between 17-51% of kidney transplant recipients, however, ASB was not associated with an increased risk of acute graft rejection and they ended with the conclusion that ASB is a frequent finding in the first months after transplantation and starting treatment with AB should be questioned as might associate with MDR and high cost. So there is no agreement about the use of antibiotics for ASB in kidney transplantation (1,3).
the American Society of Transplantation Infectious Diseases Community of Practice suggested not treating asymptomatic bacteriuria that occurs beyond three months after kidney transplantation unless in case of an accompanying rise in serum creatinine (SCr) level (4), however, the general practice is to treat ASB taken in consideration this is a denervated organ and with the use of IS may mask the clinical symptoms of UTI and may develop complicated pyelonephritis, especially in a patient with anatomical abnormalities like this case may it worth screening her frequently and avoid use AB unless it’s indicated as she will be at risk of MDR infection in addition to the cost.
decision making here should be individualized case by case as we have no consensuses regarding ASB treatment.
References
1. 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. 2020 Feb;22(1):e13221. doi: 10.1111/tid.13221. Epub 2019 Dec 12. PMID: 31782870.
2.Gołębiewska JE, Krawczyk B, Wysocka M, Dudziak A, Dębska-Ślizień A. Asymptomatic Bacteriuria in Kidney Transplant Recipients-A Narrative Review. Medicina (Kaunas). 2023 Jan 19;59(2):198.
3. Coussement J, Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2018 Feb 1;2(2): CD011357.
4. Parasuraman R, Julian K; AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:327-36. doi: 10.1111/ajt.12124. PMID: 23465025.
I appreciate your well-referenced reply.
Please use headings and sub-headings to make easier to read your write-up. Please use bold or underline to highlight headings and sub-headings.
How would you manage this patient?
References
I appreciate your well-referenced reply.
Ileal conduit ( a urinary diversion with cystectomy of non continent type)
Presentation
Pathogen isolated
Treatment
Refernces
I appreciate your well-referenced reply.
Management of asymptomatic bacteriuria in the post-transplant period
1. The index case caries high risk for UTI(ileal conduit and immunosuppression). KT recipients have unique risk factors for UTI, including indwelling stents and surgical manipulation of the genitourinary tract.
2. Asymptomatic bacteriuria:
· According to European Society of Clinical Microbiology and Infectious Diseases(ESCMID)defined as the presence of a uropathogen bacteria (≥105 CFU/mL) in the urine without signs or symptoms of UTI, regardless of the presence of pyuria, occurs frequently in KT recipients(1).
· According to American Society of Transplantation Infectious Diseases Community of Practice:Asymptomatic bacteriuria, defined as bacteriuria without signs or symptoms of urinary tract infection (UTI), occurs in 17% to 51% of kidney transplant recipients and is thought to increase the risk for a subsequent UTI. No consensus exists on the role of antibiotics for asymptomatic bacteriuria in kidney transplantation(2).
3. The 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:
a) 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.
b) Asymptomatic bacteriuria (AB) must be distinguished from UTI because AB is not necessarily a disease state.
4. Accumulating data indicate that there are no benefits of antibiotics for treatment of AB in KT recipients more than 2 months after post-transplant(3,4,5).
5. Minimization of ASB treatment in kidney transplant recipients remains an important antimicrobial stewardship target(6).
6. 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(7).
7.
References
1. VOLUME 27, ISSUE 3, P319-321, MARCH 2021 Asymptomatic bacteriuria in kidney transplant recipients: to treat or not to treat-that is the question Josep M. Cruzado Jordi Carratal Open Archive Published:November 30, 2020DOI:https://doi.org/10.1016/j.cmi.2020.11.016
2. Coussement J, Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev. 2018 Feb 1;2(2):CD011357. doi: 10.1002/14651858.CD011357.pub2. PMID: 29390169; PMCID: PMC6491324.
3. 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 Sep;33(9):e13507. doi: 10.1111/ctr.13507. Epub 2019 Mar 28. PMID: 30793386.
4. 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. 2020 Feb;22(1):e13221. doi: 10.1111/tid.13221. Epub 2019 Dec 12. PMID: 31782870.
5. Coussement J, Maggiore U, Manuel O, Scemla A, López-Medrano F, Nagler EV, Aguado JM, Abramowicz D; European Renal Association-European Dialysis Transplant Association (ERA-EDTA) Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) working group and the European Study Group for Infections in Compromised Hosts (E; COLLABORATORS (IN ALPHABETICAL ORDER); European Renal Association-European Dialysis Transplant Association (ERA-EDTA) Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) working group and the European Study Group for Infections in Compromised Hosts (ESGICH) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe. Nephrol Dial Transplant. 2018 Sep 1;33(9):1661-1668. doi: 10.1093/ndt/gfy078. PMID: 29635410.
6. Bohn BC, Athans V, Kovacs CS, Stephany BR, Spinner ML. Impact of asymptomatic bacteriuria incidence and management post-kidney transplantation. Clin Transplant. 2019 Jun;33(6):e13583. doi: 10.1111/ctr.13583. Epub 2019 May 23. PMID: 31038773.
7. Coussement J, Kaminski H, Scemla A, Manuel O. Asymptomatic bacteriuria and urinary tract infections in kidney transplant recipients. Curr Opin Infect Dis. 2020 Dec;33(6):419-425. doi: 10.1097/QCO.0000000000000678. PMID: 33148983.
Thank you. Can you please summarize your opinion of the management of this patient? Would you recommend or not to have antibiotics?
Do you think long term antibiotic here would be of any value?
I wouldn’t recommend antibiotics in this case scenario as it represents an asymptomatic bacteruria.
Long term antibiotic will not be of value provided that multiple pathogens are commonly encountered in the setting of urinary diversion, in addition to development of resistance to agents being used for prophylaxis
I like your response to Prof Kossi. Yes, unthoughful use of antibiotics leads to resistant bugs.
-How would you manage this patient?
A. Introduction
B.Asymptomatic bacteria (ASB) in pt with urinary diversion; depends on the type of diversion
1.Noncontinent:
2. Continent nonorthotopic:
3.Orthotopic:
Conclusion; More work in terms of research is needed in this area
Source;
Urinary tract infections in patients with urinary diversion by Mathhew E. Falagas et al.
Thank you for such comprehensive answer. Excellent and well done.
How important to know the reason of urinary diversion in a 57 year lady?
Please complete the reference for anyone wants to get more information from this article to include the year as 2005 and the source as Am J Kidney disease.
Thank you, Prof, for your input.
I like your response to Prof Kossi.
Thank you, prof, for your input.
Our patient has many risk factors as female, with ileal conduit and immunosuppressed and the main complication of this type of kidney transplant is urinary tract infection, although it has not been seen to have a significant medium-term impact on kidney grafts
How would you manage this patient?
Adequate prophylaxis and strict follow-up of the patient can avoid most of the complications resulting from the infections.
Our patient has asymptomatic bacteriuria which need close follow up and no need for active treatment.
Our case may need treatment if become symptomatic or complicated.
References:
1- J.E. Robles García,A. García Cortés,B. Miñana López,C. Gutiérrez Castañé,D. Rosell Costa,F. Ramón de Fata Chillón,F. Villacampa Aubá,F.J. Ancizu Marckert,F.J. Diez-Caballero Alonso,G. Andrés Boville,G. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature Transplantation Case Reports 2020 2733-2527 http://dx.doi.org/10.31487/j.TCR.2020.02.02.
2-Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Thank you. Do you think with urinary diversion, would be much of a difference between male and female for urinary tract infection risk?
What are the drawbacks of antibiotic prophylaxis in these cases?
6. A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
How would you manage this patient?
– Asymptomatic bacteriuria (ABU)
– Or as Symptomatic infection.
Patients with Ileal Conduit
Should patients who have received a kidney transplant be screened or treated for ASB?
Recommendation
Therapy of Asymptomatic Bacteriuria
====================================================================
Reference
Thanks you prof.Mohsen El Kossi
What is the reference type here ‘Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah Eldin Zaki Dean of National Institute of
Urology and Nephrology’????
What is the reference type here (A lecture)
How would you manage this patient?There is chronic bacteriuria in this case . if asymptomatic , then will not require any treatment.
If symptomatic , then will require treatment.
Asymptomatic bacteriuria post transplant requires monitoring only for two months. Beyond two months monitoring is not required as it has not shown in preventing the symptomatic UTIs and pyelonephritis.
In symptomatic cases further assessment is needed. This will include review of urine culture, Blood CP , CRP , renal functions, ultrasound to see any obstruction, stones, kinks etc
Duration of treatment is around 7 days. In recurrent cases, antibiotic prophylaxis is recommended.
Surange RS, Johnson RW, Tavakoli A, Parrott NR, Riad HN, Campbell BA, Augustine T. Kidney transplantation into an ileal conduit: a single center experience of 59 cases. J Urol. 2003 Nov;170(5):1727-30.
How would you manage this patient?
and close monitoring especially if recurred (need proper evaluation)
KTR with ileal conduit:
– Urinary diversion is an effective option for individuals with lower urinary tract anomalies.
– KTR with urinary diversion have the same graft survival as other KTR without diversion.
– Rejection are consistently found to be the most frequent cause of allograft loss.
– They are at risk of certain complications including; reflux nephropathy, nephrolithiasis, metabolic acidosis, electrolyte disturbances and UTI.
– Chronic bacteriuria was almost universally encountered in diverted patients, and no effect on graft survival.
– The reason for bacteriuria as the intestinal epithelium lacks the inhibitory actions against bacterial adherence allows the bacteria to proliferate in urinary reservoirs with integrated intestinal segments.
– Obtaining a urine culture in patients with urinary diversion or augmentation should be done cautiously because the interpretation is challenging.
– Most of these patients will have a positive urine culture even in the absence of symptoms, the distinction from true UTI is of utmost importance, to avoid unnecessary antibiotic use.
– In KTR immunosuppression increases the complexity of decision making regarding treatment of positive cultures.
– Previously patients were given antibiotics on grounds of bacteriuria, at present, antibiotic treatment is not prescribed unless the patient has additional symptoms such as tenderness in the graft, fever, or an elevated CRP.
Asymptomatic bacteriuria
– Monitoring is not recommended beyond 2 months post transplantation, as it has not been shown to be effective in preventing symptomatic UTI, pyelonephritis, bloodstream infection, or allograft rejection and can lead to unnecessary antibiotic administration.
– The detection of asymptomatic bacteriuria should prompt a second urine culture to confirm persistent bacteriuria with the same pathogen before treatment decisions are made. If the patient has two consecutive cultures of the same pathogen, antibiotic treatment for five days may be reasonable.
Conclusion:
The index case and have chronic bacteriuria of mixed organism, which is expected in individuals with ileal conduit. If patient is asymptomatic no need to treat.
This patient need to be evaluated for the following before considering treatment:
– Proper sample collection.
– The presence of any symptoms; fever, urinary symptoms, graft tenderness.
References:
Robles Garcia J E et al. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature. Science Repository 2020.
Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Symeonidis EN, Falagas ME, Dimitriadis F. Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis. Transl Androl Urol. 2019;8(4):286-289. doi:10.21037/tau.2019.07.12
UTI is defined as the presence of > 105 CFU in a proper urine sample (early morning sample, or from a sterile catheter) associated with upper or lower urinary tract symptoms, on the other hand if the patient is asymptomatic the condition is termed ASB.
Categories of UTI includes
Screening and monitoring
Treatment (which patient I will treat?)
After successful treatment of symptomatic UTI, if the patient had recurrent attacks of symptomatic UTI, prevention of recurrence is indicated using the following stratigies:
References
1. Green H, Rahamimov R, Gafter U, et al. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis 2011; 13:441.
2. Singh R, Bemelman FJ, Hodiamont CJ, et al. The impact of trimethoprim-sulfamethoxazole as Pneumocystis jiroveci pneumonia prophylaxis on the occurrence of asymptomatic bacteriuria and urinary tract infections among renal allograft recipients: a retrospective before-after study. BMC Infect Dis 2016; 16:90.
3. Horwedel TA, Bowman LJ, Saab G, Brennan DC. Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant. Transpl Infect Dis 2014; 16:261.
4. Hollyer I, Varias F, Ho B, Ison MG. Safety and efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections in adult renal transplant recipients: A single center, retrospective study. Transpl Infect Dis 2019; 21:e13063.
management:
1- keep regular clean intermittent self catheterization CISC
2- no antibiotic needed except if symptomatic
3-regular follow up for any appearance of symptoms like fever or tender graft
Dr. Mohamed Salah lecture
Do you need ISC for all cases of urinary diversion?
-Detailed history , examination and lab tests including CBC with differential, inflammatory markers,KFT,electrolytes as well as imaging as Renal US and CT if needed
-Persistent bacteriuria doesnot affect survival nor graft survival in transplant recipients with conduits
-Prophylactic antibiotic therapy is not warranted , native nephrectomy is not needed except in certain cases
-Antibiotics are given in case there is an additional symptom as fever, graft tenderness and high CRP
-Urinary diversion by ileal conduit lead to rapid deterioration of renal function due to the increased risk of UTI meanwhile in transplanted patients it did not lead to a greater loss of the renal graft nor has it been seen to be an independent factor for renal function worsening
– Bacteria are abundant in urine samples from conduits . Contaminated samples are avoided by proper collecting method of urine from the conduit.
– Recurrent urinary tract infections may also predispose to formation of calculi in the conduit
-Adequate prophylaxis and strict follow-up of the patient can avoid most of the complications resulting from the infections
Reference
-Robles Garcia J E et al. Kidney Transplant and Ileal Conduit Diversion on the Same Surgical Procedure: Clinical Case and Review of the Literature. Science Repository 2020.
-Carl Warholm, Jonas Berglund, Jan Andersson, Gunnar Tydén, Renal transplantation in patients with urinary diversion: a case-control study, Nephrology Dialysis Transplantation, Volume 14, Issue 12, December 1999, Pages 2937–2940
How would you manage this patient?
The management of this index patient will include identifying the potential risk factors and preventing them or any other one.
Present risk factors are:
The clinical history of UTI signs and symptoms like graft tenderness, flank pain, dysuria, and fever.
Investigations like FBC+differential, CRP, and urinary bladder ultrasound should be done
Unfortunately, a urine culture may be of great help because of the possibility of mixed infections
According to a single-center study by Surange et al involving 59 cases of ilea conduit diversion.
The actuarial graft survival was 90% at 1 year, 63% at 5 years, 52% at 10 years, and 52% at 15 years. Graft and patient survival were statistically similar to the outcome of the 2,579 other transplants done at the centre within the same study period of time, thus making it an effective method of treatment.
Furthermore, prophylactic antibiotics are not indicated except there are clinical findings like graft tenderness, fever, and elevated CRP
References
This patients is having recurrent urinary tract infections post kidney transplantation with a urinary diversion
The most common complication of urinary diversion is urinary tract infection
She is having a mixed growth of micro-organisms from the urine.
Management:
As conduit urine is bacteriuric in most cases, antibiotic coverage poses a dilemma and treatment should only be instituted if the symptoms indicate upper or lower urinary tract infection
Prophylactic treatment should be reserved for patients with a history of recurrent pyelonephritis
Symeonidis E et al. Transl Androl and Urol 2019;8(4):286-289
Bacteria are frequently found in urine samples from conduits. Contaminated samples can be avoided by using a proper technique.
One consideration that should be taken into account is that patients with urinary diversions frequently become colonized.
Tzardis PJ (1990) recommended to treat all bacteriuria in transplant recipients with conduits, since they are on standard triple immunosuppression with cyclosporin, prednisolone, and azathioprine that can mask symptoms of urinary tract infection, and that recurrent urinary tract infections may also predispose to formation of calculi in the conduit.
However, the patients with conduits or reservoirs were given antibiotics on grounds of bacteriuria alone less frequently in recent years. This is due to the experience that many patients do well, despite chronic bacteriuria, and to a general trend to restrict the use of antibiotics to avoid superimposed infections, such as Pseudomonas. Thus, patients with urinary diversions have no benefit in asymptomatic bacteriuria treatment. Screening and treatment of asymptomatic bacteriuria in these patient groups are therefore, not recommended.
At present, antibiotic treatment is not prescribed unless the patient has additional symptoms such as tenderness in the graft, fever, or an elevated C-reactive protein level.
Carl Warholm et al, found that chronic bacteriuria did not predispose to urosepticaemia, as septicaemia was only found in one patient and in one control. There appears to be a low risk of ascending infections, which is in accordance with findings by other investigators. Moreover, they found that patients with ileal conduits or continent reservoirs have similar graft and patient survival rates as the general kidney transplant population. The presence of constant bacteriuria did not adversely affect survival. Prophylactic antibiotic treatment seems not to be warranted.
References:
1- Symeonidis EN, Falagas ME, Dimitriadis F. Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis. Transl Androl Urol. 2019 Aug;8(4):286-289. doi: 10.21037/tau.2019.07.12. PMID: 31555550; PMCID: PMC6732096.
2- Carl Warholm, Jonas Berglund, Jan Andersson, Gunnar Tydén, Renal transplantation in patients with urinary diversion: a case-control study, Nephrology Dialysis Transplantation, Volume 14, Issue 12, December 1999, Pages 2937–2940, https://doi.org/10.1093/ndt/14.12.2937
3- Tzardis PJ, Matas AJ, Dunn DL, Payne WD, Sutherland DE, Najarian JS. Ileal and colon conduits in renal transplantation. Clinical transplantation. 1990;4(3):125-8.
Thank you. Prophylactic antibiotic treatment seems not to be warranted in these cases. WHY?
Recurrent urinary tract infections may also predispose to formation of calculi in the conduit. Do you think this risk is equal amongst different organisms?
Intestinal segments in the urine tract promote bacteriuria. The intestinal epithelium lacks bacterial adherence inhibitors like the urothelium, which may explain why.
Urinary diversion or augmentation patients should be careful while getting a urine culture since interpretation is difficult. Most of these individuals have positive urine cultures even without symptoms (asymptomatic bacteriuria). Identifying asymptomatic bacteriuria from actual urine infection is crucial.
Rigamonti and colleagues used prophylactic antibiotics in 24 renal transplant patients after urine diversion and augmentation. Surange and colleagues stressed the significance of thorough infection control during conduit formation in 59 patients with staged renal transplantation with ileal conduit urine diversion.
In urinary diversion patients, turning the kidney upside-down reduces the transplanted ureter’s travel and prevents ureteral kinking. Ureteral peristalsis, not gravity, drives antegrade urine flow.
Oral hydration, pouch irrigation, prophylactic antibiotics, and metabolic derangements may reduce the risk of infection and stone development, which can be extremely difficult to control in rebuilt systems.
Antibiotics are not recommended for asymptomatic positive urine cultures. Immunosuppression complicates positive culture therapy in renal transplant patients with urine diversion.
Eltemamy, Mohamed, Alice Crane, and David A. Goldfarb. “Urinary diversion in renal transplantation.” Urologic Clinics 45.1 (2018): 113-121.
A 57-year-old female patient received a kidney from her sister 6 months ago. The ureter was implanted into the ileal conduit created for urine diversion. Currently, she is on Tacrolimus-based triple immunosuppression with excellent kidney function. Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
How would you manage this patient?
Patient with an ileal coduit are at increased risk of asymptomatic bacteriuria, this due to lack of inhibitory bacterial adherence factors, and incomplete emptying renders bacterial overgrowth, but long term outcome is comparable to normal bladder kidney transplant.
Asymptomatic bacteriuria defined by persistent pyuria (WBC 10) and at least twice presence of positive bacterial culture with 10*5 cfu/ml > 24 hours apart, without any patient symptoms.
No prophylactic antibiotics recommended.
Some expert suggests early post-transplant screen for bacteriuria and give treatment for 6 months
The treatment is recommended if patient developed symptoms, such as fever and chills, graft pain and vomiting, with raised CRP, and a positive blood culture indicating bacteremia.
No reduction of immunosuppressive is needed unless severe urosepsis/septic shock occur.
Native kidneys nephrectomy may be needed in some cases
References:
(1) Suriano F, Gallucci M, Flammia GP, Musco S, Alcini A, Imbalzano G, Dicuonzo G. Bacteriuria in patients with an orthotopic ileal neobladder: urinary tract infection or asymptomatic bacteriuria? BJU Int. 2008 Jun;101(12):1576-9. doi: 10.1111/j.1464-410X.2007.07366.x. Epub 2007 Dec 5. PMID: 18070190.
(2) Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
How would you manage this patient?According to the guidelines of the European Association of Urology (EAU), UTI after KTX might present either as:
1. Asymptomatic bacteriuria (ABU)
2. Symptomatic infection
Ask for symptoms: dysuria, urgency, frequency, fever and flank/graft pain
If the recipient develops signs and symptoms of UTI, leucocytes, and CRP, exclude BK/CMV infection, and do ultrasonography for any structural abnormalities
If no fever or other symptoms and with normal kidney function, this transplant recipient has asymptomatic bacteruira (>105c olony-forming units/mL in two urine samples >24h apart)
Risk factors include:
1. Female gender
2. Ileal conduit
3. Immunosuppressive regimen
Patients with Ileal Conduit:
o Kidney transplant drainage into an ileal conduit for urinary diversion is an effective treatment for patients ESRD due to abnormal lower urinary tracts
o Long-term graft and patient survival is comparable to that in the normal transplant population despite preexisting co-morbidity and the increased complication rate
o The presence of constant bacteriuria did not adversely affect survival
o Prophylactic antibiotic treatment is not warranted
o No indication for native nephrectomy, except in selected cases
o Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level
Screening and treatment of ASB:
o Not recommended
o Experts suggest to screen and start treatment for bacteriuria in the early postoperative period and up to 6 months post transplant
o No recommendation to change immunosuppressive drugs
References
1. A lecture of Post Renal Transplantation Urinary Tract Infection By Prof. Mohamed Salah EldinZaki, Dean of National Institute of Urology and Nephrology
2. Eltemamy M, Crane A, Goldfarb DA. Urinary Diversion in Renal Transplantation. Urol Clin North Am. 2018 Feb;45(1):113-121. doi: 10.1016/j.ucl.2017.09.012. PMID: 29169444.
Thanks, Mohamed
I agree with you.
Risk factors○female patient ○ileal conduit ( urine diversion). ○TAC MMF PRED
Notes
○excellent kidney function.○Urine kept growing many organisms with bacterial count ≥ 105 CFU/ml.
==> First of all we should ask about the symptoms.
If this patient is symptomatic or asymptomatic.
==> Therefore, the type of bacteria (Ecoli or non Ecoli ) bacteria
□patient with kidney transplant drainage into an ileal conduit for urinary diversion has a long-term graft and patient survival comparable to that in the normal transplant population.
□The presence of constant bacteriuria did not adversely affect survival.
●Prophylactic antibiotic treatment seems not to be warranted.
●There appears to be no indication for native nephrectomy, except in selected cases.
●Antibiotic is not prescribed unless the patient has additional symptoms as tender graft, fever, or elevated CRP level.
Monitoring for asymptomatic bacteriuria —
Does it improves clinical outcomes ? ==> it is uncertain in fact.
In the past, monitoring with routine urine cultures was frequently performed. However, many transplant centers have moved away from routine monitoring for asymptomatic bacteriuria.
●If monitoring is performed (with routine urine cultures), it should be limited to the first one to two months posttransplant
■■If the patient has
2 consecutive cultures
that yield >105 colony-forming units (CFU)/mL
of the same pathogen
==> antibiotic treatment for five days may be reasonable
■■If the second urine culture shows
clearance of the initial bacteriuria
or if a different organism is identified,
==>
antibiotic treatment should not be initiated.
●Monitoring for asymptomatic bacteriuria after two months should not be performed since
treatment beyond this time has not been shown to be effective in preventing
symptomatic UTI,
pyelonephritis,
bloodstream infection,
or allograft rejection
and can lead to unnecessary antibiotic administration
We should keep on mind that mixed populations of Gram-negative and Gram-positive pathogens can be isolated in ileal conduit (IC) reconstructions
REFERENCES
1- Asymptomatic Bacteriuria in Kidney Transplant Recipients—A Narrative Review Justyna E. Goł˛ebiewska Medicina 2023, 59, 198. https://doi.org/10.3390/medicina59020198
2 Urinary tract infection in kidney transplantation recipients (UpToDate)
3- Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis . Evangelos N. Symeonidis, Transl Androl Urol. 2019 Aug; 8(4): 286–289.
4- Post Renal Transplantation Urinary TractInfection By Prof. Mohamed Salah EldinZaki
I appreciate your observation that mixed populations of Gram-negative and Gram-positive pathogens can be isolated in ileal conduit (IC). Hence it may not be sensible to treat asymptomatic bacteriuria.