Prevention and management of urinary tract infections in kidney transplantation recipients

Risk factors associated with an increased risk of UTI include female sex, anatomical abnormalities of the urinary tract or neurogenic bladder, immunosuppression, impaired graft function, the presence of urinary catheters, and urinary tract obstruction. Furthermore, kidney graft pyelonephritis may be associated with bacteraemia, sepsis, and impaired graft function.

Therefore, several important considerations should be addressed to prevent and optimise the management of UTIs in kidney transplant recipients.

Asymptomatic bacteriuria should not be treated beyond the second month after kidney transplantation. Several randomised controlled trials have demonstrated that antibiotic treatment of asymptomatic bacteriuria is not associated with a reduced risk of acute pyelonephritis, hospital admission, or graft loss.

In cases of symptomatic UTI, empirical antibiotic therapy should be guided by local antimicrobial susceptibility patterns and the patient’s prior urine culture results. Escherichia coli is the most frequently isolated pathogen. However, other Gram-negative uropathogens are also commonly identified, and Enterococcus species account for up to 25-30% of cases. Additional pathogens, including Corynebacterium urealyticum and certain viruses, may also cause UTIs in this population.

Short-course therapy or single-dose antibiotic regimens are not recommended in kidney transplant recipients. Moreover, fluoroquinolones should not be used as empirical therapy. Fosfomycin and trimethoprim–sulfamethoxazole (TMP–SMX) are considered first-line agents for localised UTIs. In patients presenting with systemic infection, intravenous antibiotic therapy is recommended, with agents such as piperacillin–tazobactam, meropenem, vancomycin, or cefepime, depending on clinical severity and microbiological data.

In kidney transplant recipients with recurrent UTIs, management principles are generally similar to those applied in the general population. However, the evidence supporting non-antibiotic preventive strategies is limited, as immunosuppression and kidney transplantation are frequently exclusion criteria in published studies. Nevertheless, several investigations have been conducted specifically in kidney transplant populations.

Pagonas et al. evaluated the effects of cranberry juice and L-methionine in 82 kidney transplant recipients and reported that cranberry juice reduced the number of UTI episodes by 63.9%, while L-methionine reduced the annual incidence by 48.7%. Regarding immunoactive prophylaxis, Zgoura et al. conducted a study including 28 patients, 14 of whom received three subcutaneous injections of inactivated bacteria and 14 controls. The treated group demonstrated a reduced incidence of UTIs, whereas the control group had a higher proportion of non–E. coli isolates. Furthermore, a study evaluating six months of sublingual vaccination with the MV-140 formulation in 43 kidney transplant recipients reported a reduction in the annual incidence of UTIs from 4.2 to 2.7 episodes per year.

Particular attention should be given to the prompt removal of urinary catheters. Urethral catheters are recommended to be removed within the first week after kidney transplantation, unless specific patient factors necessitate prolonged bladder drainage. The routine use of ureteral stents may reduce urological complications, such as urinary fistula; however, stents should also be removed as early as clinically feasible.

Department of Urology, Hospital Universitario 12 de Octubre, Madrid, Spain
EAU Section of Transplantation Urology (ESTU)

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