Urinary Tract Infections In Solid Organ Transplant Recipients

Publication Date: March 1, 2019

Recommendations

DIAGNOSIS OF UTI

Urine culture collection technique is important. After use of antiseptic wipes to clean the perineum/glans, a midstream urine sample is collected in a sterile container. In patients unable to perform these steps, straight catheterization to obtain a urine specimen can be considered. For patients with indwelling catheters (especially those in place >2 weeks) and a suspected UTI, the catheter should be removed and a specimen collected either via a midstream urine or newly placed urinary catheter. (Low, Strong)
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Because asymptomatic bacteriuria (AB) is not necessarily a disease state, it should not be uniformly classified as a UTI. (Moderate, Strong)
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Lack of pyuria should prompt consideration of an alternative diagnosis; yet, depending on the performance characteristics of the urinalysis or presence of neutropenia, even if < 10 WBC/mL in the urine, an otherwise consistent clinical context may still be indicative of UTI in a KT recipient. (Low, Strong)
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TREATMENT OF UTI

We recommend against routinely collecting urine cultures or treating bacteriuria in asymptomatic KT recipients more than 2 months after KT. (Moderate, Strong)
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If screening asymptomatic KT recipients any time in the posttransplant period and AB is found, a second urine culture (minimizing risk of contamination) should be collected and reviewed prior to decision about whether or not to treat AB. We strongly recommend observation without treatment of asymptomatic KT recipients who show clearance of the initial bacteriuria or development of different organism in the urine. (Moderate, Strong)
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Because of the uncommon occurrence of asymptomatic pyelonephritis, treatment of persistent AB can be considered in patientswith an associated unexplained rise in creatinine. (Low, Weak)
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Multi‐drug resistant AB should not be treated. The risks of inducing further antibiotic resistance outweigh any potential theoretical benefit of treating AB. (Moderate, Strong)
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For simple cystitis in KT recipients, it is reasonable to limit treatment to 5‐10 days. Single‐ dose or 3‐day treatment courses are not recommended. (Low, Strong)
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For pyelonephritis/complicated UTI in KT recipients, narrow-spectrum antibiotic should be used to complete 14‐21 days of therapy based on susceptibility data;. Treatment should be extended until adequate drainage of abscesses has been achieved. (Low, Strong)
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PREVENTION OF UTI

To prevent donor‐derived infections, treatments should be directed against pathogenic organisms cultured in donor cultures of urine and blood. If preservations fluid cultures are obtained, treatment can be administered for pathogenic organisms. (Low, Strong)
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Trimethoprim‐sulfamethoxazole (TMP‐SMX, co‐trimoxazole) prophylaxis for 6 months is recommended for Pneumocystis jirovecii pneumonia (PJP) prophylaxis, and it decreases UTI and bacteremia in KT recipients. (High, Strong)
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If TMP‐SMX cannot be used for primary prophylaxis of UTI after KT, alternative agents with limited data include nitrofurantoin (avoid if GFR <60 mL/min), cephalexin or fluoroquinolones. Fluoroquinolones are not recommended because of safety concerns and risk for selecting for fluoroquinolone‐resistant pathogens. It is recommended that primary prophylaxis for UTI with agents other than TMP‐SMX be limited to the first post‐transplant month. (Low, Weak)
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For secondary prophylaxis of UTI in KT recipients with recurrent UTI, non‐antimicrobial prevention strategies are preferred. Antimicrobial prophylaxis may be appropriate for selected patients who have severe episodes of recurrent UTIs such as pyelonephritis. (Low, Weak)
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In KT recipients, limiting the duration of catheters and stents to within 4 weeks of renal transplantation is suggested. If severe UTI occurs in the period from 2‐4 weeks after transplant, consider early stent removal while balancing risk of urologic complications. (Moderate, Strong)
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Recommendation Grading

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Overview

Title

Urinary Tract Infections In Solid Organ Transplant Recipients

Authoring Organization

Publication Month/Year

March 1, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of urinary tract infections (UTI) in solid organ transplantation, focusing on kidney transplant (KT) recipients.

Target Patient Population

Patient underwent kidney transplant

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management

Diseases/Conditions (MeSH)

D016030 - Kidney Transplantation, D019737 - Transplants, D014552 - Urinary Tract Infections

Keywords

urinary tract infection (UTI), solid organ transplant, kidney, urinary tract infection