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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 204-207

Bedside strategy to prevent postrenal transplant urinary tract infection-non randomised, case control pilot study


Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Date of Submission05-Nov-2019
Date of Acceptance28-Mar-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Mital Parikh
A/5 Vrundavan Park Society, VIP Road, Karelibaug, Vadodara - 390 018, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_62_19

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  Abstract 


Background: Post renal transplant UTI is very common, increasing the morbidity and mortality with high chances of graft failure. Majority of centres use prophylactic antibioitcs like TMP-SMX after renal transplantation within first 6 months. Aims and Objectives: To understand the incidence of UTI and it's risk factors, to compare the effectiveness of using individual commode in decreasing incidence of post transplant UTI with historical cohort of renal transplant recipients. Materials and Methods: 25 patients were recruited from April 01, 2017, to June 01, 2017. They were encouraged to bring along a portable commode to use it during their stay as well as at home after discharge and followed for 1 month for presence of urinary tract infection. Results: 6 patients had culture proven UTI(24%) in historical cohort while no patient had UTI in study group using commode(0%). Conclusion: Individualizing personal waste disposal techniques using disposable bedside commode is an effective and economical strategy.

Keywords: Bedside strategy, portable commode, renal transplant, urinary tract infection


How to cite this article:
Parikh M, Patel N, Konnur A, Gang S, Mohan R, Hegde U. Bedside strategy to prevent postrenal transplant urinary tract infection-non randomised, case control pilot study. Indian J Transplant 2020;14:204-7

How to cite this URL:
Parikh M, Patel N, Konnur A, Gang S, Mohan R, Hegde U. Bedside strategy to prevent postrenal transplant urinary tract infection-non randomised, case control pilot study. Indian J Transplant [serial online] 2020 [cited 2020 Nov 1];14:204-7. Available from: https://www.ijtonline.in/text.asp?2020/14/3/204/296898




  Introduction Top


Posttransplantation urinary tract infection (UTI) is common, increases the morbidity, and increases the risk of graft failure. The importance of this issue is further underscored by the fact that UTI is the most common infection in renal-transplant recipients[1],[2],[3] ranging from 6% to 86%[4],[5],[6],[7] and accounting for approximately 40%–50% of all infectious complications. Renal-transplant recipients develop UTIs more frequently than the general population.[8],[9],[10] The majority of centers routinely use antimicrobial prophylaxis after renal transplantation within the first 6 months, although the individual antibiotic strategies vary. Trimethoprim-sulfamethoxazole (TMP-SMX) is the most commonly used antibiotic for prophylaxis in renal-transplant patients for the initial 6 months. In the first 3 months after transplantation, infection often presents as overt pyelonephritis and is associated with relatively high rates of bacteremia[11],[12] causing graft dysfunction. One of the largest retrospective series suggests that the overall impact on graft survival is not significant, but subgroup analysis of those with infections occurring in the first 3 months after transplantation suggests a long-term adverse effect.[13] Renal-transplant recipients with UTIs are more likely to be clinically asymptomatic compared to nonimmunocompromised patients as they do not mount the typical inflammatory response to infection primarily as a consequence of immunosuppression. The emergence of multidrug-resistant organisms, including extended-spectrum beta-lactamases-producing organisms or carbapenemase-producing organisms, have been observed in transplant units worldwide and may be associated with a poorer prognosis.[14],[15]

The frequency of developing UTIs depends on many factors such as age and female gender of renal-transplant recipients, kidney function and comorbidities, immunosuppressive protocol, or the follow-up period (short term and long term). Transplant recipients who need prolonged Foleys catheterization and prolong posttransplant hospitalization were found to have an increased risk of developing UTI. The prevention of both asymptomatic bacteriuria and UTI after kidney transplantation has improved with the introduction of routine perioperative antibiotic prophylaxis, minimization of the use of indwelling urethral catheters and ureteral stents, and long-term use of antimicrobial prophylaxis with TMP-SMX to prevent pneumocystis pneumonia.[16],[17]

Despite these and optimizing primary prevention strategies such as handwashing and washing toilet seats adequately, there was no decrease in incidence in our center. It was hypothesized that UTI was promoted by the use of common toilet and urinary catheter touching the seat.

The aim of this study is to implement a bedside strategy to prevent immediate postoperative renal-transplant UTI.


  Methodology Top


This was a nonrandomized case–control study where 25 patients who underwent renal transplant from April 01, 2017, to June 01, 2017, were recruited inclusion and exclusion. They were encouraged to bring along a portable commode. It was washed with 4% bleach after each use. During the inpatient postoperative stay of approximately 10 days, they were asked to use only this for urination and defecation. They were also advised to continue using this commode at their home after discharge. This group was similarly matched to historical controls (February 01, 2017–April 01, 2017) at the same center before this study period for the factors implicated in posttransplant UTI and outcomes were studied. All patients were followed for 1-month posttransplant, and similarly, data of 1-month posttransplant of historical controls were analyzed. All recipients who had a suspicion of UTI either on the basis of symptoms (fever/burning micturition/dysuria/frequency) or laboratory reports (pyuria) were subjected to urine culture (clean-catched midstream urine sample was sent in sterile container). Using calibrated loop, about 0.01 ml of urine sample was transferred onto chrome agar and spread – the inoculums were spread by a routine streaking method, and the plate was incubated at 37°C overnight. The culture report was read and the number of colonies counted if positive. Antibiotic-sensitivity test was also performed for the positive reports by the microbiologist. Similarly, urine cultures were also sent at the time of the rise in creatinine along with fever. Clinical UTI was defined on the basis of the presence of symptoms-fever/burning micturition/dyuria/frequency. All patients were given antibiotic prophylaxis for UTI in the form of TMP-SMX (800/160 mg) at bedtime as per our institution's transplant policy.

  • Inclusion criteria: All those who underwent live renal transplant and were postrenal transplant <2 days
  • Exclusion criteria: Postrenal transplant >2 days and not consenting for individualized commode.


Primary outcome

The incidence of culture-positive UTI among postrenal transplant recipients.

Secondary outcomes

The incidence of graft dysfunction due to UTI, risk factors for UTI posttransplant, and cost-effectiveness of using commode as a preventive measure to decrease the incidence of posttransplant UTI.

Patient consent

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

As this study involved change in hospital's existing method of using single/common washroom for all transplant patients in the transplant ward for urination and defecation and since no active direct intervention (neither medical nor surgical intervention) to patients was involved, the institute's ethics committee approval was deemed not necessary. The study was carried out as per the Declaration of Helsinki.


  Results Top


There were 25 patients in each group. The baseline characteristics of both groups were similar [Table 1]. The incidence of culture-proven UTI was significantly less (n = 0) in group using the portable commode than the historical controls (n = 6), P < 0.05 [Table 2]. Graft function was not significantly different in both groups. The duration of indwelling catheter length was significantly more in the commode using a group but is influenced by outliers. There were ten patients who were treated for clinical UTI in the historical control, of which 6 had urine culture positive for the organism.
Table 1: Baseline Characteristics of both groups

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Table 2: Outcome analysis of both the groups

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Pseudomonas was the predominant causative organism in four patients but tressing the nosocomial nature of infection [Table 3], and it was multidrug resistant with sensitivity only to colistin. Vancomycin-resistant enterococcal infection and multidrug-resistant Klebsiella infection were detected in 1 patient each. In the commode using group, 4 were treated for clinical UTI, of which none had urine culture positive. All ten patients in the historical cohort were similarly treated for UTI with injectable antibiotics as per the sensitivity pattern.
Table 3: Patients buttressing the nosocomial nature of infection

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A total of 29 patients received antithymocyte globulin as the induction agent (15 patients in the study group and 14 in the historical cohort [P-NS]). Rituximab was used in five recipients in the study group as part of desensitization protocol for ABO-incompatible transplant while 1 in the historical group (P < 0.05). Basiliximab was used as induction in 4 and 5 recipients in the study and historical group, respectively (P-NS). A total of five recipients did not receive any induction agent in the historical group. Despite these observed differences in the induction agent with overall more immunosuppression in the study group, there was a less occurrence of UTI in the study group. The average patient in hospital stay in both the groups was 14 days and not significant, and acute rejection episodes were not significantly different in both the groups. The cumulative cost of treatment of UTI in the historical control group was twice that in the commode using the group. The cumulative cost was calculated taking into consideration the cost of commode and the cost of any antibiotics if used for the treatment of UTI. Similarly, the cumulative cost in the historical cohort was calculated taking into consideration the total cost of all antibiotics used for the treatment of UTI.


  Discussion Top


In our study, both groups were matching in terms of demographic data such as age, sex, diabetes mellitus, and use of induction agents. In our study, a total of six recipients had culture-proven UTI (24%) while no patient had UTI in the study group using commode (0%). Even asymptomatic bacteriuria was seen in only two recipients in the study group as compared to four patients in the historical cohort. UTI incidence rate in our study was average as compared to the various previous study having a wide range of UTI ranging from 17% to 45%.[3],[4],[5],[14] We also studied the effect of various risk factors for UTI such as age, gender, diabetes, ureteric stent, per urethral catheter (PUC)/ suprapubic catheter (SPC) duration, and induction agent. A study done by Dantas et al. demonstrated that the duration of urinary bladder catheterization as main risk factors for UTIs in posttransplant patients.[15] Diabetes mellitus (type 1 and type 2) has also been shown to increase the risk of bacterial UTI in some studies, but the data on these are conflicting. In our study, we also did not see a significant increase in UTI episodes in diabetic patients nor any association with the duration of catheterization. This may be due to a short follow-up and small sample size to study the difference. There was a significant difference in the cost of therapy between both the groups (control group having double the cost as compared to study group) which make the practice of using individual commode as a cost-effective strategy for the prevention of postrenal transplant UTI in busy transplant units with no individual toilet facilities for individual patients. Furthermore, the cost of the study group had increased mainly due to the use of antibiotics for suspicious UTI (study being done in the immediate postoperative period and UTI being major risk factor for graft dysfunction – the practicing transplant physician decided to treat empirically while awaiting the results of urine culture which increased the total cost of therapy).

Limitations

  1. Due to small sample size, this was a pilot study, it was decided to confine the enrolment for the duration of 2 months only and later on based on the results, it was decided to continue the study for 1 year of enrollment and 1 year of follow-up
  2. Comparison with historical cohort-considering the logical benefit of using individual commode in decreasing the spread and incidence of UTI among recipients, it was decided not to randomize, but to include all recipients and compare with previous recipients as the demographics and the center including the transplant ward were in general similar.



  Conclusion Top


In the present scenario of increased incidences of postoperative multidrug-resistant UTI, individualizing personal waste disposal techniques using disposable bedside commode is an effective and economical strategy. However, it needs to be validated using a larger sample population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shaheen FA, Basri N, Mohammed Z, Abdullah K, Haider R, Awad A, et al. Experience of renal transplantation at the king Fahd hospital, Jeddah, Saudi Arabia. Saudi J Kidney Dis Transpl 2005;16:562-72.  Back to cited text no. 1
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2.
de Souza RM, Olsburgh J. Urinary tract infection in the renal transplant patient. Nat Clin Pract Nephrol 2008;4:252-64.  Back to cited text no. 2
    
3.
Alangaden GJ, Thyagarajan R, Gruber SA, Morawski K, Garnick J, El-Amm JM, et al. Infectious complications after kidney transplantation: Current epidemiology and associated risk factors. Clin Transplant 2006;20:401-9.  Back to cited text no. 3
    
4.
Alangaden G. Urinary tract infections in renal transplant recipients. Curr Infect Dis Rep 2007;9:475-9.  Back to cited text no. 4
    
5.
Veroux M, Giuffrida G, Corona D, Gagliano M, Scriffignano V, Vizcarra D, et al. Infective complications in renal allograft recipients: Epidemiology and outcome. Transplant Proc 2008;40:1873-6.  Back to cited text no. 5
    
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Pellé G, Vimont S, Levy PP, Hertig A, Ouali N, Chassin C, et al. Acute pyelonephritis represents a risk factor impairing long-term kidney graft function. Am J Transplant 2007;7:899-907.  Back to cited text no. 6
    
7.
Abbott KC, Oliver JD 3rd, Hypolite I, Lepler LL, Kirk AD, Ko CW, et al. Hospitalizations for bacterial septicemia after renal transplantation in the united states. Am J Nephrol 2001;21:120-7.  Back to cited text no. 7
    
8.
Satish R, Gokul N. Intractable urinary tract infection in a renal transplant recipient. Saudi J Kidney Dis Transpl 2009;20:458-61.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Dupont PJ, Manuel O, Pascual M. Infection and chronic allograft dysfunction. Kidney Int Suppl. 2010:S47-S=53.  Back to cited text no. 9
    
10.
Sandegren L, Lindqvist A, Kahlmeter G, Andersson DI. Nitrofurantoin resistance mechanism and fitness cost in Escherichia coli. J Antimicrob Chemother 2008;62:495-503.  Back to cited text no. 10
    
11.
Rubin NE, Rubin RH. Urinary tract infection in the immunocompromised host. Lessons from kidney transplantation and the AIDS epidemic. Infect Dis Clin North Am 1997;11:707-17.  Back to cited text no. 11
    
12.
Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993;44:221-36.  Back to cited text no. 12
    
13.
Giral M, Pascuariello G, Karam G, Hourmant M, Cantarovich D, Dantal J, et al. Acute graft pyelonephritis and long-term kidney allograft outcome. Kidney Int 2002;61:1880-6.  Back to cited text no. 13
    
14.
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 2004;44:353-62.  Back to cited text no. 14
    
15.
Dantas SR, Kuboyama RH, Mazzali M, Moretti ML. Nosocomial infections in renal transplant patients: Risk factors and treatment implications associated with urinary tract and surgical site infections. J Hosp Infect 2006;63:117-23.  Back to cited text no. 15
    
16.
Linares L, Cervera C, Cofán F, Ricart MJ, Esforzado N, Torregrosa V, et al. Epidemiology and outcomes of multiple antibiotic-resistant bacterial infection in renal transplantation. Transplant Proc 2007;39:2222-4.  Back to cited text no. 16
    
17.
Hoy WE, Kissel SM, Freeman RB, Sterling WA Jr. Altered patterns of posttransplant urinary tract infections associated with perioperative antibiotics and curtailed catheterization. Am J Kidney Dis 1985;6:212-6.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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