The role of preemptive antimicrobial therapy in kidney recipients of urine‐only positive donor cultures

Abstract

Background The use of preemptive antimicrobial therapy for recipients of donors with microbial growth on pre‐transplant urine cultures remains poorly studied. Methods Single‐center retrospective study of kidney transplant recipients of allografts from deceased donors with urine‐only (ie, in absence of donor bacteremia) positive cultures (September 2011 to August 2015). Transplant outcomes, including donor‐derived infections (DDI) within the first three months post transplant, were analyzed. Results Of the 970 kidney transplants performed during the study period, urine cultures were obtained from all donors, and of these, 27 (2.8%) yielded growth. Twenty‐nine (73%) recipients were treated preemptively after transplantation. All of the recipients of donors with urine cultures positive for Enterococcus, Pseudomonas, or Candida spp. received therapy whereas only one of seven recipients with urine cultures positive for Escherichia coli was treated (P < .0001). All E coli isolates were susceptible to trimethoprim‐sulfamethoxazole (TMP‐SMX), which was given to all patients for Pneumocystis pneumonia (PCP) prophylaxis. Infection within 3 months was evident in 16 (40%) patients: 10 out of 29 (35%) in the preemptive group and 6 out of 11 (55%) in the not‐treatment group (P = .29). Evidence of DDI occurred in two recipients, one in each group. There were no differences in one‐year graft and patient survival between groups. Conclusion Preemptive antibiotic therapy did not seem to impact transmission events and transplant outcomes in this small cohort. Low transmission rates might have been influenced by administration of PCP prophylaxis and universal preemptive therapy for positive donor urine cultures with virulent organisms. Larger studies are needed.

Utility of deceased donor cultures in solid organ transplantation in preventing donor‐derived bacterial and fungal infectious diseases transmission

“…3,4 Reported urine culture positivity rate among donors has ranged from 2.8 to 16%, but the risk of transmission could vary between asymptomatic bacteriuria, cystitis, or pyelonephritis. 9,15,23,24 When donor bacteriuria is associated with other positive culture sites at the time of procurement, suggesting a high bacterial load, transmission could also be more likely. 25 The risk of DDI associated with isolated donor bacteriuria is more debatable.…”

“…In a retrospective study evaluating cadaveric donors with isolated bacteria, no difference in infection, allograft dysfunction, or survival was seen between recipients with or without preemptive therapy. 24 It is possible that reported cases of vasculitis and anastomotic rupture among kidney recipients were derived from a donor with undiagnosed bacteremia at the time of procurement. Donor CRE bacteria or UTIs are even more challenging and remain a relative contraindication for kidney procurement currently.…”

“…The risk of DDI associated with isolated donor bacteriuria is more debatable. In a retrospective study evaluating cadaveric donors with isolated bacteria, no difference in infection, allograft dysfunction, or survival was seen between recipients with or without preemptive therapy 24 …”

“…Urine donor cultures have been systematically recommended for cadaveric kidney donors as UTIs prior to procurement are common due to bacteria ascending along the urethral catheter 3,4 . Reported urine culture positivity rate among donors has ranged from 2.8 to 16%, but the risk of transmission could vary between asymptomatic bacteriuria, cystitis, or pyelonephritis 9,15,23,24 . When donor bacteriuria is associated with other positive culture sites at the time of procurement, suggesting a high bacterial load, transmission could also be more likely 25 .…”

Prevention, diagnosis, and management of donor derived infections in pediatric kidney transplant recipients

“…More studies are needed to understand the risk of positive urine cultures for kidney transplant recipients. Regardless, at this time it is still recommended to treat positive urine culture, especially of virulent or more resistant organisms (34).…”