Epidemiology and outcomes of carbapenem‐resistant Klebsiella pneumoniae bacteriuria in kidney transplant recipients

Abstract

Background Little is known about the epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria following kidney transplantation. We determined the incidence of post-transplant CRKP bacteriuria in adults who underwent kidney transplant from 2007 to 2010 at two New York City centers. Methods We conducted a case-control study to identify factors associated with CRKP bacteriuria compared to of carbapenem-susceptible K. pneumoniae (CSKP) bacteriuria, assessed whether CRKP bacteriuria was associated with mortality or graft failure, and compared outcomes of treated episodes of CRKP and CSKP bacteriuria. Results Of 1852 transplants, 20 (1.1%) patients developed CRKP bacteriuria. Factors associated with CRKP bacteriuria included receipt of multiple organs (odds ratio [OR] 4.7, 95% confidence interval [CI] = 1.1–20.4), deceased donor allograft (OR 5.9, 95% CI 1.3–26.8), transplant admission length of stay (OR 1.1 per day, 95% CI 1.0–1.1), pre-transplant CRKP infection or colonization (OR 18.3, 95% CI 2.0–170.5), diabetes mellitus (OR 2.8, 95% CI 1.0–7.8), and receipt of antimicrobials other than trimethoprim-sulfamethoxazole (OR 4.3, 95% CI 1.6–11.2). Conclusion Compared to CSKP bacteriuria, CRKP bacteriuria was associated with increased mortality (30% vs. 10%, P = 0.03) but not graft failure. Treated episodes of CRKP bacteriuria were less likely to achieve microbiologic clearance (83% vs. 97%; P = 0.05) and more likely to recur within 3 months (50% vs. 22%, P = 0.02) than CSKP episodes. CRKP bacteriuria after kidney transplant is associated with mortality and antimicrobial failure after treatment.

Carbapenem-resistant Enterobacteriaceae in special populations: Solid organ transplant recipients, stem cell transplant recipients, and patients with hematologic malignancies

“…On the other hand, aminoglycoside monotherapy may be efficacious in the treatment of CRE UTIs; however, rates of associated nephrotoxicity and clinical success have varied. 27,33,76,78 While available as a parenteral agent in Europe, fosfomycin is only available in an oral powder formulation in the United States, and this formulation has only been evaluated for the treatment of UTIs. CRE are often susceptible to fosfomycin, 79 and thus fosfomycin is an attractive option as an oral therapy for CRE UTIs, particularly in kidney transplant recipients where it would be preferable to avoid aminoglycosides.…”

“…Reported mortality rates among SOT recipients with CRE infection generally range from 30-50%, and post-transplant CRKP infections have been associated with as much as a 10-fold risk of death. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] However, a more recent cohort of 164 SOT recipients across 15 international sites confirmed that while CRE infection typically occurs in the early post-transplant period, the one-year survival rate of patients who developed CRE infection within the first year of transplant was 72%. 34 While CRKP infections remain the most common type of CRE infection in SOT recipients, infections due to carbapenem-resistant Enterobacter spp., as well as NDM-and OXA-48-producing K. pneumoniae have also been reported.…”

“…Most of these infections are CRKP urinary tract infections (UTIs), with secondary bacteremia present in up to 32% of patients. 20,[26][27][28]30,33 CRKP UTIs are associated with high rates of microbiological failure compared to carbapenem-susceptible K. pneumoniae UTIs, and the presence of post-transplant CRKP bacteriuria has been independently associated with a 3-fold risk of death in kidney transplant recipients. 27,33 To date, 7 cases of CRKP donor-derived infection have been reported.…”

“…19 The incidence of post-SOT CRKP infection varies considerably by center and type of transplant (Table 1). [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] In general, CRKP infections occur early after transplant, with most studies reporting a median time of <50 days from transplant to infection. Reported mortality rates among SOT recipients with CRE infection generally range from 30-50%, and post-transplant CRKP infections have been associated with as much as a 10-fold risk of death.…”

Successful Treatment of Extended-Spectrum β-Lactamase-Producing Klebsiella pneumoniae Recurrent Urinary Tract Infection with High Doses of Amoxicillin with Clavulanic Acid in a Kidney Transplant Recipients: A Case Report

“…Several reports confirm observations that high doses of beta-lactam antibiotics could overcome bacterial resistance in vivo. In the literature, there are cases describing the use of high doses of amoxicillin to effectively treat drug-resistant strains of pneumococcal carriage (5), community-acquired pneumonia (6), inflammation of the middle ear (5), and even in combined therapy with a high dose of esomeprazole to eradicate Helicobacter pylori. This report describes a case of a 44-year-old kidney transplant recipient, who, despite several prolonged, intravenous, targeted antibiotic therapies, developed recurrent urinary tract infection (UTI) caused by ESBL-producing K. pneumoniae.…”