Epidemiology and Management of Extended Spectrum Beta Lactamase (ESBL) Enterobacteriaceae Bacteriuria in Renal Transplant Recipients in a UK Centre
Papakonstantinou D., Borrows R., David M.D.
Department of Clinical Microbiology, Department of Nephrology
Queen Elizabeth Hospital, Birmingham
Urinary tract infections are common in renal transplant recipients (RTR) and the incidence of antibiotic resistance is high in this population. The optimal management of bacteriuria especially when caused by multidrug resistant organisms such as ESBL producers is yet to be determined. The aim of this study is to review the epidemiology and management of ESBL bacteriuria in RTR in a large UK centre.
Queen Elizabeth Hospital is a large tertiary centre where more than 170 renal transplants occur per year.
All the RTR with ESBL bacteriuria during the period 1 April 2010 to 31 March 2014 were included in this study. Data was collected from the hospital electronic records on the demographic characteristics, aetiology of end stage renal failure, type of immunosuppression and transplant received, presence of ureteric stent, impact on renal function and antibiotics used.
During the study period, 35 RTR (21 female, 14 male) had bacteriuria with an ESBL-producing organism (E. coli: 31, Klebsiella pneumoniae: 4). The median age of the patients was 46 years (range: 17-81).
With regards to the ethnic origin, 16 were Asian, 15 white and 4 belonged to another group. (Figure 1).
Previous study (Shabir et al, 2014) in our hospital has shown that male RTR predominate (61.8%) than female and the proportion of Asian RTR was 16.8% versus 75.8% white RTR. There were no differences in age between the two studies.
Twenty-two patients received a cadaveric renal transplant and 13 a live donation.
Aetiology of renal failure in these 35 patients was:
glomerulonephritis (20%), adult polycystic kidney disease (APKD:14.5%), reflux nephropathy (14.5%), SLE (11%), diabetic nephropathy (6%) and other/unknown cause (34%). 17% of patients had a ureteric stent in situ.As part of their immunosuppressive protocol, all patients were receiving steroids, 80% tacrolimus, 54% mycophenolate mofetil, 14% azathioprine and 6% cyclosporine.
A total of 94 episodes of ESBL bacteriuria were identified. Each patient had 1-14 episodes (median: 2). Patients with APKD had more recurrences.
The time from the renal transplantation to the first ESBL bacteriuria episode ranged between 1 month and 17 years (median: 2 years). In 37 % patients, the isolation of an ESBL producing organism was preceded by more sensitive urinary isolates.
In 32 episodes no treatment was given. When treatment was deemed necessary, the antibiotic course duration varied from 5 days to 5 weeks and the carbapenems (meropenem, ertapenem) were the most commonly used antibiotics (33 episodes). In 18 episodes, narrower spectrum antibiotics were used (e.g. trimethoprim) in some cases despite in vitro resistance. No information was available regarding treatment in 11 episodes. Deterioration in renal function was noted after 39% of ESBL bacteriuria episodes, including all patients receiving co-amoxiclav or amoxicillin (Figure 2).
ESBL related bacteriuria was more common in RTR of Asian origin.
Renal function seemed to be worsened by both the ESBL bacteriuria episodes and the ineffective antibiotic therapy. Therefore the relevant antibiogram should guide the antibiotic choice.
Shabir S et al. Predicting 5-Year Risk of Kidney Transplant Failure: A Prediction Instrument using data available at 1 Year Posttransplantation Am J Kidney Dis. 2014, 63(4):643-651.
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