Renal transplant sonrası iki yıllık izlemde gelişen üriner sistem enfeksiyonlarının değerlendirilmesi: tek merkez deneyimi

Yıl 2023, Cilt: 16 Sayı: 1, 51 - 57, 31.01.2023

Tugba Sarı , Belda Dursun , Mevlüt Çeri , İlknur Kaleli , Hüseyin Turgut , Murat Özban

https://doi.org/10.31362/patd.1162235

Öz

Giriş: Renal transplantasyon sonrası, %23-75 oranında üriner sistem enfeksiyonu (ÜSE) görülmektedir. Bu çalışmada böbrek nakli sonrası ÜSE sıklığı, neden olan patojenler ve riski artıran predispozan faktörlerin araştırılması amaçlanmıştır.
Hastalar ve metod: 2016-2017 yılları arasında hastanemizde renal transplant yapılan hastalar çalışmaya dahil edildi. Postoperatif immunsupresif tedavileri; basiliksimab, mikofenolat mofetil, takrolimus ve prednizolon kombinasyonundan oluştu. Perioperatif antibiyotik profilaksisinde bir hastada klindamisin, diğerlerinde sefuroksim aksetil kullanıldı. Tüm hastalara üriner kateterizasyon ve anastomoz esnasında double- J stend kullanıldı. Hastalara postoperatif dönemde 6 ay boyunca Pneumocystis jirovecii profilaksisi için trimetoprim sulfametaksazol (TMP-SXT) verildi.
Bulgular: Böbrek transplantasyonu yapılan 25 hasta çalışmaya dahil edildi. On iki hastada (%48) ÜSE saptandı. Bir hastada nörojenik mesane, üçünde nefrolitiyazis ve birinde vezikoüreteral reflü mevcuttu. Hastaların 8’inde en az iki ÜSE atağı mevcuttu. Toplam 38 ÜSE atağında; 7 (%18,4) nitrit pozitifliği saptandı. 15’inde (%39,5) transplantasyon sonrası ilk 3 ay içerisinde ÜSE saptandı. İdrar kültürlerinin 7’sinde (%18,4) gram pozitif, 27’sinde (%71,1) gram negatif bakteri üremesi olurken, 4’ü (%10,5) kontaminasyon olarak bulundu. Üreyen etkenler arasında Escherichia coli (%34,2) ilk sırada yer alırken, bunu sırasıyla Klebsiella pneumoniae (%21,1), Enterococcus faecium (%18,4), Pseudomonas aeruginosa (%5,3) ve diğer gram negatif (%10,5) üropatojenlerin izlediği bulundu. ÜSE öncesi bazal ve ÜSE sırasındaki GFR (glomerüler filtrasyon hızı) düzeyleri karşılaştırıldığında ÜSE sırasında saptanan GFR değerlerinin öncesine göre anlamlı derecede azaldığı saptandı (p=0.00) ÜSE tedavisinde en sık tercih edilen antibiyotikler ertapenem %42,1, levofloksasin %10,5, seftriakson %10,5 ve fosfomisin %10,5 idi.
Sonuç: Transplant alıcılarında profilaksi ve tedavi amaçlı antibiyotiklerin kullanımına bağlı üropatojenlerin direnç oranları artmaktadır. Uygunsuz tedavi edilen ÜSE, transplantasyonun sonucunu olumsuz etkilemekte ve mortaliteyi arttırmaktadır. Bu yüzden hastaların risk faktörleri, antibiyotik dirençleri, ampirik tedaviler gözden geçirilmeli ve tedavi başarısının arttırılması sağlanmalıdır.

Anahtar Kelimeler

transplant, ÜSE, Renal transplant, transplant, ÜSE, Renal transplant, transplant, ÜSE

Evaluation of urinary tract infections in a two-year follow-up after renal transplantation: a single center experience

Öz

Introduction: After renal transplantation, urinary tract infection (UTI) is observed in 23-75% of cases. In this study, we aimed to investigate the incidence of UTIs after renal transplantation, the causative pathogens and the predisposing factors that increase the risk.
Methodology: Patients who underwent renal transplantation in our hospital between 2016-2017 were included in the study.
Results: Twenty-five patients who underwent kidney transplantation were included in the study. UTI was detected in 12 patients (48%). One patient had neurogenic bladder, three had nephrolithiasis and one had vesicoureteral reflux. 8 of the patients had at least two UTI attacks. In total 38 UTI attacks; There were 7 (18.4%) nitrite positivity. UTI was detected in 15 (39.5%) patients during the first 3 months after transplantation. While 7 (18.4%) of the urine cultures were gram positive and 27 (71.1%) were gram negative bacteria, 4 (10.5%) were found as contamination. Escherichia coli (34.2%) was the most common causative agent, followed by Klebsiella pneumoniae (21.1%), Enterococcus faecium (18.4%), Pseudomonas aeruginosa (5.3%) and other gram negative (%). 10.5 uropathogens were found to be followed. When compared with basal and UTI GFR (glomerular filtration rate) levels, the GFR values detected during UTI were decreased significantly (p=0.00). The most frequently preferred antibiotics in UTI treatment were ertapenem 42.1%, levofloxacin 10.5%, seftriaxon 10.5% and fosfomycin 10.5%.
Conclusion: Improperly treated UTI negatively affects the outcome of transplantation and increases mortality. Therefore, risk factors, antibiotic resistance and empirical treatments should be reviewed and treatment success should be increased.

Anahtar Kelimeler

Renal transplantation, transplantation, UTI

Kaynakça

• 1. Satish R, Gokulnath null. Intractable urinary tract infection in a renal transplant recipient. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant Saudi Arab. 2009;20(3):458–61.
• 2. Sorto R, Irizar SS, Delgadillo G, Alberú J, Correa-Rotter R, Morales-Buenrostro LE. Risk factors for urinary tract infections during the first year after kidney transplantation. Transplant Proc. 2010;42(1):280–1.
• 3. Sqalli TH, Laboudi A, Arrayhani M, Benamar L, Amar Y, Ouzeddoun N, et al. Urinary tract infections in renal allograft recipients from living related donors. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant Saudi Arab. 2008;19(4):551–3.
• 4. Hussain Z, Rizvi SAH, Naqvi A, Zafar N, Ahmed E, Sultan. Risk factors and adverse effects of urinary tract infections in live related allograft recipients (Abstract 1385 poster board session). Am J Transpl. 2003;507:141.
• 5. Hussain A, Ewers C, Nandanwar N, Guenther S, Jadhav S, Wieler LH, et al. Multiresistant uropathogenic Escherichia coli from a region in India where urinary tract infections are endemic: genotypic and phenotypic characteristics of sequence type 131 isolates of the CTX-M-15 extended-spectrum-β-lactamase-producing lineage. Antimicrob Agents Chemother. 2012;56(12):6358–65.
• 6. Brayman KL, Stephanian E, Matas AJ, Schmidt W, Payne WD, Sutherland DE, et al. Analysis of infectious complications occurring after solid-organ transplantation. Arch Surg Chic Ill 1960. 1992;127(1):38–47; discussion 47-48.
• 7. Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev. 2004;(3):CD001209.
• 8. Parasuraman R, Julian K, AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2013;13 Suppl 4:327–36. 9. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 8.1, valid from 2018-0515Erişim:www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Breakpoint_tables/v_8.1_Breakpoint_Tables.pdf.
• 10. Vidal E, Torre-Cisneros J, Blanes M, Montejo M, Cervera C, Aguado JM, et al. Bacterial urinary tract infection after solid organ transplantation in the RESITRA cohort. Transpl Infect Dis Off J Transplant Soc. 2012;14(6):595–603.
• 11. Parasuraman R, Julian K; AST Infectious Diseases Community of Practice. Urinary tract infections in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:327-36. doi: 10.1111/ajt.12124.
• 12. Trzeciak S, Sharer R, Piper D, Chan T, Kessler C, Dellinger RP, Pursell KJ. Infections and severe sepsis in solid-organ transplant patients admitted from a university-based ED. Am J Emerg Med. 2004 Nov;22(7):530-3. doi: 10.1016/j.ajem.2004.09.010.
• 13. Bodro M, Sanclemente G, Lipperheide I, Allali M, Marco F, Bosch J, et al. Impact of urinary tract infections on short-term kidney graft outcome. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2015;21(12):1104.e1-8.
• 14. Gondos AS, Al-Moyed KA, Al-Robasi ABA, Al-Shamahy HA, Alyousefi NA. Urinary Tract Infection among Renal Transplant Recipients in Yemen. PloS One. 2015;10(12):e0144266.
• 15. Abbott KC, Swanson SJ, Richter ER, Bohen EM, Agodoa LY, Peters TG, et al. Late urinary tract infection after renal transplantation in the United States. Am J Kidney Dis Off J Natl Kidney Found. 2004;44(2):353–62.
• 16. Rice JC, Peng T, Kuo Y-F, Pendyala S, Simmons L, Boughton J, et al. Renal allograft injury is associated with urinary tract infection caused by Escherichia coli bearing adherence factors. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2006;6(10):2375–83.
• 17. Barbouch S, Cherif M, Ounissi M, Karoui C, Mzoughi S, Hamida FB, et al. Urinary tract infections following renal transplantation: a single-center experience. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant Saudi Arab. 2012 ;23(6):1311–4.
• 18. Bodro M, Sanclemente G, Lipperheide I, Allali M, Marco F, Bosch J, et al. Impact of antibiotic resistance on the development of recurrent and relapsing symptomatic urinary tract infection in kidney recipients. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2015;15(4):1021–7.
• 19. Silva C, Afonso N, Macário F, Alves R, Mota A. Recurrent urinary tract infections in kidney transplant recipients. Transplant Proc. 2013;45(3):1092–5.
• 20. Green H, Rahamimov R, Gafter U, Leibovitci L, Paul M. Antibiotic prophylaxis for urinary tract infections in renal transplant recipients: a systematic review and meta-analysis. Transpl Infect Dis. 2011 Oct;13(5):441-7. doi: 10.1111/j.1399-3062.2011.00644.x.
• 21. Senger, SS, Arslan, H, Azap, OK, et al. Urinary tract infections in renal transplant recipients. Transpl Proc. 2007;39:1016–7.
• 22. Kawecki D, Kwiatkowski A, Sawicka-Grzelak A, Durlik M, Paczek L, Chmura A, et al. Urinary tract infections in the early posttransplant period after kidney transplantation: etiologic agents and their susceptibility. Transplant Proc. 2011 ;43(8):2991–3.
• 23. Ak O, Yildirim M, Kucuk HF, Gencer S, Demir T. Infections in renal transplant patients: risk factors and infectious agents. Transplant Proc. 2013;45(3):944–8.
• 24. Kamath NS, John GT, Neelakantan N, Kirubakaran MG, Jacob CK. Acute graft pyelonephritis following renal transplantation. Transpl Infect Dis Off J Transplant Soc. 2006;8(3):140–7.
• 25. Memikoğlu KO, Keven K, Sengül S, Soypaçaci Z, Ertürk S, Erbay B. Urinary tract infections following renal transplantation: a single-center experience. Transplant Proc. 2007 Dec;39(10):3131-4. doi: 10.1016/j.transproceed.2007.10.005.
• 26. Dupont PJ, Psimenou E, Lord R, Buscombe JR, Hilson AJ, Sweny P. Late recurrent urinary tract infections may produce renal allograft scarring even in the absence of symptoms or vesicoureteric reflux. Transplantation. 2007 15;84(3):351–5.
• 27. Tavakoli A, Surange RS, Pearson RC, Parrott NR, Augustine T, Riad HN. Impact of stents on urological complications and health care expenditure in renal transplant recipients: results of a prospective, randomized clinical trial. J Urol. 2007;177(6):2260–4; discussion 2264.
• 28. Säemann M, Hörl WH. Urinary tract infection in renal transplant recipients. Eur J Clin Invest. 2008;38(2):58–65. 29. Muñoz P. Management of urinary tract infections and lymphocele in renal transplant recipients. Clin Infect Dis Off Publ Infect Dis Soc Am. 2001. 1;33:53-57.
• 30. Vidal E, Cervera C, Cordero E, Armiñanzas C, Carratalá J, Cisneros JM, et al. Management of urinary tract infection in solid organ transplant recipients: Consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI). Enferm Infecc Microbiol Clin. 2015 Dec;33(10):679.e1-679.e21.
• 31. Pinheiro HS, Mituiassu AM, Carminatti M, Braga AM, Bastos MG. Urinary tract infection caused by extended-spectrum beta-lactamase-producing bacteria in kidney transplant patients. Transplant Proc. 2010 Mar;42(2):486-7. doi: 10.1016/j.transproceed.2010.02.002.