Epidemiology and outcomes of carbapenem-resistant Klebsiella pneumoniae bacteriuria in kidney transplant recipients

Different profiles of acute graft pyelonephritis among kidney recipients from standard or elderly donors

Background

Acute graft pyelonephritis (AGPN) is a relatively common complication in kidney transplants (KTs); however, the effects on allograft function, diagnostic criteria, and risk factors are not well established.

Methods

Retrospective analysis of all consecutive adult KTs was performed between 01 January 2011 and 31 December 2018 (follow-up ended on 31 December 2019) to examine the association between the diagnosis of AGPN (confirmed with magnetic resonance imaging [MRI]) during the first post-transplantation year and graft outcomes.

Results

Among the 939 consecutive KTs (≈50% with donors ≥60 years), we identified 130 MRI-confirmed AGPN episodes, with a documented association with recurrent and multidrug-resistant bacterial urinary tract infections (UTIs) (p < 0.005). Ureteral stenosis was the only risk factor associated with AGPN (OR 2.9 [95% CI, 1.6 to 5.2]). KTs with AGPN had a decreased allograft function at the first year (ΔeGFR 6 mL/min/1.73 m2 [-2-15] in non-AGPN vs. -0.2 [-6.5-8.5] in AGPN, p < 0.001), with similar and negative profiles in KTs from standard or elderly donors. However, only KTs with AGPN and a donor <60 years showed reduced death-censored graft survival (p = 0.015); most of this subgroup received anti-thymocyte globulin (ATG) induction (40.4% vs. 17.7%), and their MRI presented either a multifocal AGPN pattern (73.9% vs. 56.7%) or abscedation (28.3% vs. 11.7%). No difference was noted in death-censored graft survival between early (<3 months post-KT) or late (3-12 months) AGPN, solitary/recurrent forms, or types of multidrug-resistant pathogens. Linear regression confirmed the independent role of multifocal pattern, abscedation, ATG induction, and donor age on the eGFR at the first year.

Conclusion

AGPN, influenced by multifocal presentation, ATG induction, donor age, and abscedation, affects kidney function and significantly impacts allograft survival in KTs with donors <60 years.

The Burden and Impact of Early Post-transplant Multidrug-Resistant Organism Detection Among Renal Transplant Recipients, 2005-2021

Background

Reducing the burden of multidrug-resistant organism (MDRO) colonization and infection among renal transplant recipients (RTRs) may improve patient outcomes. We aimed to assess whether the detection of an MDRO or a comparable antibiotic-susceptible organism (CSO) during the early post-transplant (EPT) period was associated with graft loss and mortality among RTRs.

Methods

We conducted a retrospective cohort study of RTRs transplanted between 2005 and 2021. EPT positivity was defined as a positive bacterial culture within 30 days of transplant. The incidence and prevalence of EPT MDRO detection were calculated. The primary outcome was a composite of 1-year allograft loss or mortality following transplant. Multivariable Cox hazard regression, competing risk, propensity score-weighted sensitivity, and subgroup analyses were performed.

Results

Among 3507 RTRs, the prevalence of EPT MDRO detection was 1.3% (95% CI, 0.91%-1.69%) with an incidence rate per 1000 EPT-days at risk of 0.42 (95% CI, 0.31-0.57). Among RTRs who met survival analysis inclusion criteria (n = 3432), 91% (3138/3432) had no positive EPT cultures and were designated as negative controls, 8% (263/3432) had a CSO detected, and 1% (31/3432) had an MDRO detected in the EPT period. EPT MDRO detection was associated with the composite outcome (adjusted hazard ratio [aHR], 3.29; 95% CI, 1.21-8.92) and death-censored allograft loss (cause-specific aHR, 7.15; 95% CI, 0.92-55.5; subdistribution aHR, 7.15; 95% CI, 0.95-53.7). A similar trend was seen in the subgroup and sensitivity analyses.

Conclusions

MDRO detection during the EPT period was associated with allograft loss, suggesting the need for increased strategies to optimize prevention of MDRO colonization and infection.

The Global and Regional Prevalence of Hospital-Acquired Carbapenem-Resistant Klebsiella pneumoniae Infection: A Systematic Review and Meta-analysis

Background

Due to scarce therapeutic options, hospital-acquired infections caused by Klebsiella pneumoniae (KP), particularly carbapenem-resistant KP (CRKP), pose enormous threat to patients' health worldwide. This study aimed to characterize the epidemiology and risk factors of CRKP among nosocomial KP infections.

Method

MEDLINE, Embase, PubMed, and Google Scholar were searched for studies reporting CRKP prevalence from inception to 30 March 2023. Data from eligible publications were extracted and subjected to meta-analysis to obtain global, regional, and country-specific estimates. To determine the cause of heterogeneity among the selected studies, prespecified subgroup analyses and meta-regression were also performed. Odds ratios of CRKP-associated risk factors were pooled by a DerSimonian and Laird random-effects method.

Results

We retained 61 articles across 14 countries and territories. The global prevalence of CRKP among patients with KP infections was 28.69% (95% CI, 26.53%-30.86%). South Asia had the highest CRKP prevalence at 66.04% (95% CI, 54.22%-77.85%), while high-income North America had the lowest prevalence at 14.29% (95% CI, 6.50%-22.0%). In the country/territory level, Greece had the highest prevalence at 70.61% (95% CI, 56.77%-84.45%), followed by India at 67.62% (95% CI, 53.74%-81.79%) and Taiwan at 67.54% (95% CI, 58.65%-76.14%). Hospital-acquired CRKP infections were associated with the following factors: hematologic malignancies, corticosteroid therapies, intensive care unit stays, mechanical ventilations, central venous catheter implantations, previous hospitalization, and antibiotic-related exposures (antifungals, carbapenems, quinolones, and cephalosporins).

Conclusions

Study findings highlight the importance of routine surveillance to control carbapenem resistance and suggest that patients with nosocomial KP infection have a very high prevalence of CRKP.

An Emerging Issue: Carbapenem-Resistant Enterobacteriaceae in Solid-Organ Transplantation

OBJECTIVES

Bloodstream infections caused by carbapenem-resistant bacteria have increased globally. Solid-organ transplant recipients are more prone to these infections. This study aimed to compare the clinical courses of carbapenem-susceptible and carbapenem-resistant Enterobacteriaceae bloodstream infections and to identify risk factors for carbapenem resistance in solid-organ transplant recipients.

MATERIALS AND METHODS

For this retrospective descriptive study, data for solid-organ transplant recipients (age ≥18) treated from 2015 to 2022 were obtained from medical records. Enterobacteriaceaepositive blood culture was screened from laboratory data.

RESULTS

Among 72 patients, there were 100 bacteremia episodes. Patients included 40 kidney (55.6%), 21 liver (29.2%), 7 heart (9.7%), and 4 combined liver and kidney (5.6%) transplant recipients. Fifty-seven bacteremia episodes were recorded between 2015 and 2020, and 43 bacteremia episodes were recorded between 2020 and 2022. Carbapenem resistance was reported in 15.8% of patients before 2020, whereas this rate increased to 39.5% after 2020 (P = .007). Pitt bacteremia score ≥4 (P < .001), Charlson comorbidity index ≥4 (P = .021), chronic liver disease (P = .015), septic shock at admission (P = .001), hypotension at admission (P = .006), bacteremia episodes 48 hours after hospitalization (P = .004), hospitalization in the past 3 months (P = .004), and prior invasive procedure (P = .043) were significant factors for carbapenem resistance. Logistic regression analysis showed that bacteremia 48 hours after hospitalization (P = .002) and hospitalization in the past 3 months (P = .006) were independent risk factors.

CONCLUSIONS

Carbapenem resistance increased significantly over the years. Bacteremia 48 hours after hospitalization and hospitalization within the past 3 months were determined to be risk factors for carbapenem resistance. Carbapenem-resistant infections are still nosocomial infections. Patients should be hospitalized for as a short time as possible, and both patients and their physicians should follow infection control and prevention methods.

Molecular Epidemiology of Carbapenem Resistant Klebsiella Pneumoniae in Northern China: Clinical Characteristics, Antimicrobial Resistance, Virulence and Geographic Distribution

Purpose

In this article, we studied in detail 74 Carbapenem Resistant Klebsiella pneumoniae (CRKP) in Shanxi to provide essential insight into development of effective strategies for control of CRKP.

Patients and Methods

From 2018 to 2021, we collected 74 clinical CRKP from 11 hospitals in Shanxi Province. Clinical data were obtained from medical records, and all isolates were subjected to antimicrobial susceptibility testing, multi locus sequence typing, capsular serotypes, resistant gene profiles and virulence gene profiles. The synergistic activity was performed by microdilution checkerboard method.

Results

Our study found differences in the clinical characteristics of CRKP between regions in Shanxi. Sequence type (ST) 11 was the dominant ST in Shanxi; however, the ST types in Shanxi had become more diverse over time and the proportion of STs showed a more balanced distribution with a significant decrease in ST11. NDM was the most common carbapenemase in Shanxi. In addition, the STs, carbapenemases, serotypes and virulence gene distribution varied by region in Shanxi. Moreover, tigecycline in combination with carbapenems and aztreonam had an excellent synergistic effect on CRKP in vitro.

Conclusion

The results of this study provide essential insight into development of effective strategies for control of CRKP in Shanxi.

Safety and effectiveness of tigecycline combination therapy in renal transplant patients with infection due to carbapenem-resistant gram-negative bacteria

Background

Carbapenem-resistant gram-negative bacterial (CRGNB) infections are increasing among kidney transplant recipients, and effective therapeutic options are limited. This study aimed to investigate the efficacy and adverse events associated with combination therapy tigecycline in renal transplant patients with CRGNB infections.

Methods

This study retrospectively analyzed 40 Chinese patients with confirmed or suspected CRGNB infections who received tigecycline therapy. The patients' case features and clinical and microbiological data were analyzed.

Results

A total of 40 renal transplant recipients received tigecycline therapy for a median duration of 9 (range, 3-25) days. CRGNB isolates were obtained from the organ preservation solution of the donor kidney in 28 patients, with confirmed transmission in 4 patients. Infections were detected in the bloodstream, urinary tract, sputum, and wound. The most prevalent isolates were Klebsiella pneumoniae (75%, 30/40), Acinetobacter baumannii (15%, 6/40), and Escherichia coli (10%, 4/40). A clinical response was observed in 32 (80%) patients. The 28-day all-cause mortality rate was 7.5% (3/40), while the one-year all-cause mortality rate was 2.5% (1/40). While one patient died owing to severe pancreatitis, no serious adverse events related to tigecycline therapy were reported. However, multiple indices of liver function and pancreatitis precursors increased after treatment with tigecycline compared to before treatment.

Conclusion

Tigecycline therapy appears to be well tolerated in renal transplant recipients with multidrug-resistant bacterial infections. Nevertheless, attention should be paid to adverse reactions related to tigecycline therapy, especially gastrointestinal reactions, and the related laboratory tests should be closely monitored.

Analysis of risk factors associated with healthcare-associated carbapenem-resistant Klebsiella pneumoniae infection in a large general hospital: a case-case-control study

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection is a major public health threat in the world. To inform the prevention and control of CRKP infection in hospitals, this study analyzed the factors associated with CRKP infection and resistance to carbapenems in K. pneumoniae. This case-case-control study was carried out in a large general hospital in China from January 2016 to December 2018, comprising 494 hospitalized patients infected with CRKP (case group 1) and 2429 hospitalized patients infected with carbapenem-susceptible K. pneumoniae (CSKP, case group 2). We selected control groups from hospitalized patients without K. pneumoniae infections for the two case groups separately, with a 1:3 case-control ratio, to analyze the risk factors of the two case groups using the conditional logistic regression. Multivariate analysis showed that the risk factors of CRKP infection were intensive care unit (ICU) admission (odds ratio [OR], 6.85; 95% confidence interval [CI], 4.90-9.58; P < 0.001), respiratory failure (OR, 1.93; 95% CI, 1.34-2.77; P < 0.001), age-adjusted Charlson comorbidity index (aCCI; OR, 1.08; 95% CI, 1.02-1.15; P = 0.007), admission from the Emergency (OR, 1.37; 95% CI, 1.02-1.85; P = 0.036), and imipenem use (OR, 1.80; 95% CI, 1.30-2.49; P < 0.001). Among the aforementioned five risk factors, aCCI (OR, 1.09; 95% CI, 1.06-1.13; P < 0.001) was also identified as a risk factor of CSKP infections in multivariate analysis. The risk factors for resistance to carbapenems in K. pneumoniae were ICU admission, respiratory failure, admission from the Emergency, and imipenem use.

Quaternary Ammonium Salts: Insights into Synthesis and New Directions in Antibacterial Applications

The overuse of antibiotics has led to the emergence of a large number of antibiotic-resistant genes in bacteria, and increasing evidence indicates that a fungicide with an antibacterial mechanism different from that of antibiotics is needed. Quaternary ammonium salts (QASs) are a biparental substance with good antibacterial properties that kills bacteria through simple electrostatic adsorption and insertion into cell membranes/altering of cell membrane permeability. Therefore, the probability of bacteria developing drug resistance is greatly reduced. In this review, we focus on the synthesis and application of single-chain QASs, double-chain QASs, heterocyclic QASs, and gemini QASs (GQASs). Some possible structure-function relationships of QASs are also summarized. As such, we hope this review will provide insight for researchers to explore more applications of QASs in the field of antimicrobials with the aim of developing systems for clinical applications.

Clinical Outcomes and Risk Factors for Death following Carbapenem-Resistant Klebsiella pneumoniae Infection in Solid Organ Transplant Recipients

Infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) are associated with significant morbidity and mortality. Among solid organ transplant recipients (SOTRs), clinical outcomes and risk factors for death following such infections remain not well documented. A single-center retrospective study was performed. All SOTRs with a CRKP infection at the First Affiliated Hospital of Zhengzhou University between 1 January 2018 and 31 December 2021 were included. Multivariable Cox regression was performed to determine risk factors for death following CRKP infection. We identified 94 SOTRs with CRKP infection, with a median age of 50 years old. CRKP infections resulted in 38.3% of overall 30-day mortality. On multivariable analysis, independent risk factors for death following CRKP infection included older age (hazard ratio [HR], 1.044; 95% confidence interval [CI], 1.007 to 1.083; P = 0.02), allograft failure (HR, 3.962; 95% CI, 1.628 to 9.644; P = 0.002), and septic shock (HR, 8.512; 95% CI, 3.294 to 21.998; P < 0.001). Receiving appropriate targeted therapy was associated with a reduced hazard of death (HR, 0.245; 95% CI, 0.111 to 0.543; P = 0.001). Our study characterized the clinical features and mortality in SOTRs with CRKP infection. The protective effects of appropriate targeted therapy highlight the importance of assessing how antibiotic choices affect the clinical outcomes among SOTRs. IMPORTANCE Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are increasingly identified in solid organ transplant recipients (SOTRs), but data on the clinical outcomes and risk factors for death following such infections remain limited. Here, we reported CRKP infection was associated with 38.3% of overall 30-day mortality in SOTRs. Independent risk factors for death after CRKP infection included older age, allograft failure, and septic shock. Appropriate targeted therapy was important for alleviating the impact of CRKP infections on these SOTRs.

Clinical Outcomes and Risk Factors for Carbapenem-resistant Enterobacterales Bloodstream Infection in Solid Organ Transplant Recipients

BACKGROUND

The clinical outcomes associated with, and risk factors for, carbapenem-resistant Enterobacterales (CRE) bloodstream infections (BSIs) in solid organ transplant (SOT) recipients remain ill-defined.

METHODS

A multicenter retrospective cohort study was performed, including SOT recipients with an Enterobacterales BSI between 2005 and 2018. Exposed subjects were those with a CRE BSI. Unexposed subjects were those with a non-CRE BSI. A multivariable survival analysis was performed to determine the association between CRE BSI and risk of all-cause mortality within 60 d. Multivariable logistic regression analysis was performed to determine independent risk factors for CRE BSI.

RESULTS

Of 897 cases of Enterobacterales BSI in SOT recipients, 70 (8%) were due to CRE. On multivariable analysis, CRE BSI was associated with a significantly increased hazard of all-cause mortality (adjusted hazard ratio, 2.85; 95% confidence interval [CI], 1.68-4.84; P < 0.001). Independent risk factors for CRE BSI included prior CRE colonization or infection (adjusted odds ratio [aOR] 9.86; 95% CI, 4.88-19.93; P < 0.001)' liver transplantation (aOR, 2.64; 95% CI, 1.23-5.65; P = 0.012)' lung transplantation (aOR, 3.76; 95% CI, 1.40-10.09; P = 0.009)' and exposure to a third-generation cephalosporin (aOR, 2.21; 95% CI, 1.17-4.17; P = 0.015) or carbapenem (aOR, 2.80; 95% CI, 1.54-5.10; P = 0.001) in the prior 6 months.

CONCLUSIONS

CRE BSI is associated with significantly worse outcomes than more antibiotic-susceptible Enterobacterales BSI in SOT recipients.

Effect of Carbapenem-Resistant Klebsiella pneumoniae Infection on the Clinical Outcomes of Kidney Transplant Recipients

Background

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection has proven to be difficult to control and typically presents with devastating effects.

Methods

This retrospective study was conducted on the renal recipients at our institution between January 2021 to January 2022. Clinical data was collected to identify factors associated with CRKP infection and clinical outcomes.

Results

There were 104 cases out of 186 total renal recipients who presented with at least one infection within 3 months after KT, and 14 cases developed unfavorable clinical outcomes. We identified 16 confirmed CRKP infected cases with the incidence of 8.60%. Possible donor derived infection (DDI) (OR = 6.743; 95% CI: 1.477–30.786; P = 0.014) were independent risk factors for the occurrence of CRKP infection of renal recipients in our analysis, CRKP infection (OR = 20.723; 95% CI: 3.448–124.547; P = 0.001) and pneumonia (OR = 28.458; 95% CI: 1.956–413.984 P = 0.014) were independent risk factors for the occurrence of unfavorable clinical outcomes following KT, and the occurrence of unfavorable clinical outcomes following KT were significantly associated with CRKP infection (r = 0.535; P < 0.001) and antibiotic regimen containing ceftazidime/avibactam (CZA) (r = −0.655; P = 0.006). The use of CZA was significantly different in the comparison of antibiotic regimens between the CRKP infected renal recipients with unfavorable outcomes and CRKP infected patients with favorable outcomes.

Conclusion

It is possible that DDI can lead to CRKP infection, and CRKP infection and pneumonia were closely correlated with poor prognosis. The use of CZA may play a role in avoiding the unfavorable outcomes of CRKP infected recipients.

Extended-spectrum β-lactamase-producing and carbapenem-resistant Enterobacterales bloodstream infection after solid organ transplantation: Recent trends in epidemiology and therapeutic approaches

Background

Infections caused by multidrug‐resistant gram‐negative bacilli (MDR GNB), in particular extended‐spectrum β‐lactamase‐producing (ESBL‐E) and carbapenem‐resistant Enterobacterales (CRE), pose a major threat in solid organ transplantation (SOT). Outcome prediction and therapy are challenging due to the scarcity of randomized clinical trials (RCTs) or well‐designed observational studies focused on this population.

Methods

Narrative review with a focus on the contributions provided by the ongoing multinational INCREMENT‐SOT consortium (ClinicalTrials identifier NCT02852902) in the fields of epidemiology and clinical management.

Results

The Spanish Society of Transplantation (SET), the Group for Study of Infection in Transplantation of the Spanish Society of Infectious Diseases and Clinical Microbiology (GESITRA‐SEIMC), and the Spanish Network for Research in Infectious Diseases (REIPI) recently published their recommendations for the management of MDR GNB infections in SOT recipients. We revisit the SET/GESITRA‐SEIMC/REIPI document taking into consideration new evidence that emerged on the molecular epidemiology, prognostic stratification, and treatment of post‐transplant ESBL‐E and CRE infections. Results derived from the INCREMENT‐SOT consortium may support the therapeutic approach to post‐transplant bloodstream infection (BSI). The initiatives devoted to sparing the use of carbapenems in low‐risk ESBL‐E BSI or to repurposing existing non‐β‐lactam antibiotics for CRE in both non‐transplant and transplant patients are reviewed, as well as the eventual positioning in the specific SOT setting of recently approved antibiotics.

Conclusion

Due to the clinical complexity and relative rarity of ESBL‐E and CRE infections in SOT recipients, multinational cooperative efforts such as the INCREMENT‐SOT Project should be encouraged. In addition, RCTs focused on post‐transplant serious infection remain urgently needed.

Higher Incidence of Neurotoxicity and Skin Hyperpigmentation in Renal Transplant Patients Treated With Polymyxin B

BACKGROUND

Toxicity is a major concern related to the clinical use of polymyxin B, and available safety data for renal transplant patients are limited.

AIMS

We investigated the safety of polymyxin B and toxicity risk factors in renal transplant patients.

METHODS

A prospective study was performed on a group of renal transplant patients who received intravenous polymyxin B between January 2018 and August 2021. Polymyxin B treatment was monitored to evaluate toxicity and risk factors.

RESULTS

A total of 235 courses of polymyxin B were administered to 213 patients. Of these, 121 (51.5%) developed SH, 149 (63.4%) developed neurotoxicity, and 10 (5.5%) developed acute kidney injury of which 80% was reversible. Risk factors for developing SH included a high total dose by weight (OR=1.31, 95%CI: 1.08-1.60, p=0.008) and the presence of neurotoxicity (OR=2.86, 95%CI: 1.56-5.26, p=0.001). Neurotoxicity manifested during the first two days of treatment. Neurotoxicity occurred most commonly in women (OR=3.84, 95%CI: 1.82-8.10, p<0.0001), and the presence of SH (OR=1.98, 95%CI: 1.13-3.46, p=0.016) was also an independent risk factor.

CONCLUSIONS

Neurotoxicity and SH are the two major adverse effects of polymyxin B in renal transplant patients, which may limit its clinical use.

Prevalence of carbapenemase-producing organisms among hospitalized solid organ transplant recipients, five U.S. hospitals, 2019-2020

BACKGROUND

Passive reporting to the Centers for Disease Control and Prevention has identified carbapenemase-producing organisms (CPOs) among solid organ transplant (SOT) recipients, potentially representing an emerging source of spread. We analyzed CPO prevalence in wards where SOT recipients receive inpatient care to inform public health action to prevent transmission.

METHODS

From September 2019 to June 2020, five U.S. hospitals conducted consecutive point prevalence surveys (PPS) of all consenting patients admitted to transplant units, regardless of transplant status. We used the Cepheid Xpert® Carba-R assay to identify carbapenemase genes (bla_KPC , bla_NDM , bla_VIM , bla_IMP , bla_OXA-48 ) from rectal swabs. Laboratory-developed molecular tests were used to retrospectively test for a wider range of bla_IMP and bla_OXA variants.

RESULTS

In total, 154 patients were screened and 92 (60%) were SOT recipients. CPOs were detected among 7 (8%) SOT recipients, from two of five screened hospitals: 4 bla_KPC , 1 bla_NDM , 2 blaOXA_-23 . CPOs were detected in 2 (3%) of 62 non-transplant patients. In three of five participating hospitals, CPOs were not identified among any patients admitted to transplant units.

CONCLUSIONS

Longitudinal surveillance in transplant units, as well as PPS in areas with diverse CPO epidemiology, may inform the utility of routine screening in SOT units to prevent the spread of CPOs. This article is protected by copyright. All rights reserved.

Systematic Review of Literature Examining Bacterial Urinary Tract Infections in Diabetes

This systematic review addresses the central research question, "what is known from the published, peer-reviewed literature about the impact of diabetes on the risk of bacterial urinary tract infections (UTI)?" We examine the results from laboratory studies where researchers have successfully adapted mouse models of diabetes to study the pathophysiology of ascending UTI. These studies have identified molecular and cellular effectors shaping immune defenses against infection of the diabetic urinary tract. In addition, we present evidence from clinical studies that in addition to diabetes, female gender, increased age, and diabetes-associated hyperglycemia, glycosuria, and immune impairment are important risk factors which further increase the risk of UTI in diabetic individuals. Clinical studies also show that the uropathogenic genera causing UTI are largely similar between diabetic and nondiabetic individuals, although diabetes significantly increases risk of UTI by drug-resistant uropathogenic bacteria.

Efficacy of Ceftazidime-Avibactam in the Treatment of Carbapenem-Resistant Klebsiella pneumoniae Infection After Kidney Transplantation

Purpose

The clinical efficacy of ceftazidime-avibactam (CAZ-AVI) in treating carbapenem-resistant Klebsiella pneumoniae (CRKP)-infected recipients after kidney transplantation (KT) has not been well evaluated. We aimed to assess its efficacy in a single-center cohort of KT recipients infected with CRKP.

Materials and Methods

We retrospectively observed KT recipients diagnosed with CRKP infection from June 2019 to July 2021. The primary outcome was 30-day mortality and secondary outcomes were 14-day clinical cure and 14-day microbiological cure. Logistic regression analysis was used to evaluate the relationship between CAZ-AVI treatment and prognosis.

Results

A total of 54 CRKP-infected KT recipients were recorded in this study. Twenty-two recipients received CAZ-AVI and 32 received other antibiotic regimens. Recipients in both groups had similar baseline characteristics, with the most common site of infection being surgical site infections (n=27; 50.0%) and bloodstream infections (n=23; 42.6%). Recipients treated with CAZ-AVI had significantly lower 30-day mortality (3/22 vs 14/32, P=0.019), significantly higher 14-day clinical cure (18/22 vs 17/32, P=0.030) and 14-day microbiological cure (19/22 vs 15/32, P=0.003) compared with recipients receiving other treatment regimens. Kaplan–Meier survival curves for 30-day mortality confirmed the findings (log-rank=0.014). In a multivariate logistic regression model, receiving CAZ-AVI was found to be an independent protective factor for 30-day mortality (odds ratio=0.148, 95% confidence interval, 0.027–0.800; P=0.026). No significant side effects were recorded.

Conclusion

CAZ-AVI may be more valuable than other antibiotic regimens for the treatment of CRKP infection after kidney transplantation, and further large randomized controlled trials are needed to assess its efficacy.

Impact of carbapenem resistance on mortality in patients infected with Enterobacteriaceae: a systematic review and meta-analysis

OBJECTIVES

To provide a comprehensive assessment of the impact of carbapenem resistance on mortality among patients infected with Enterobacteriaceae and to explore the source of heterogeneity across studies.

DESIGN

This systematic review was conducted following the guidelines of Cochrane Guidance and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

We conducted a systematic literature search of the PubMed, Embase, Web of Science and Cochrane Library databases to identify relevant studies published between 1 January 1994 and 30 August 2020.

ELIGIBILITY CRITERIA

We included primary observational studies published in English that reported the mortality outcomes for hospitalised patients with confirmed infections due to carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-susceptible Enterobacteriaceae (CSE). Studies with no comparison group or with a comparison group of patients infected with unconfirmed CSE were excluded.

DATA EXTRACTION AND SYNTHESIS

Data extraction and assessment of risk bias were conducted independently by two reviewers. The pooled relative risk and risk difference were calculated as effect measures with 95% CIs using a random effects model. The heterogeneity across studies was assessed by Q-statistic and I² measures.

RESULTS

Of 10 304 studies initially identified, 50 studies were included in the meta-analyses. The results of the meta-analyses showed that carbapenem resistance has a significant positive effect on the probability of death for patients infected with Enterobacteriaceae for any type of mortality outcome. The results of the stratified analysis and meta-regression suggested that the effect of carbapenem resistance on the risk of death varied by infection type, sample size and year of publication.

CONCLUSIONS

Our results suggested that patients with CRE infection still face a greater risk of death than patients with CSE infection do, and an urgent need to develop new antibiotics and appropriate treatments to reduce the risk of death.

PROSPERO REGISTRATION NUMBER

CRD42020176808.

Carbapenemase-Producing Klebsiella pneumoniae Colonization and Infection in Solid Organ Transplant Recipients: A Single-Center, Retrospective Study

Carbapenemase-KPC producing Klebsiella pneumoniae (CP-Kp) infection represents a serious threat to solid organ transplant (SOT). All patients admitted between 1 May 2011 and 31 August 2014 undergoing SOT were included in the retrospective study. The primary outcomes included a description of the association of enteric colonization and invasive infections by CP-Kp with one-year mortality. Secondary outcomes were the study of risk factors for colonization and invasive infections by CP-Kp. Results: A total of 5.4% (45/828) of SOT recipients had at least one positive rectal swab for CP-Kp, with most (88.9%) occurring after transplantation. 4.5% (35/828) of patients developed a CP-Kp-related invasive infection, with 68.6% (24/35) being previously colonized. The 1-year mortality was 31.1% in patients with enteric colonization with CP-Kp and, it was 51.4% among patients with CP-Kp-related invasive infections. At univariate analysis, colonization, invasive infections, sepsis, severe sepsis, and septic shock were significantly associated with 1-year mortality. At multivariate analysis, only invasive infections and the combination of sepsis, severe sepsis, or septic shock were significantly associated with 1-year mortality, whereas gastrointestinal colonization was significantly associated with survival. In this population, the 1-year mortality was significantly associated with invasive infections; otherwise, gastrointestinal colonization was not associated with increased 1-year mortality.

Analysis of Risk Factors for Carbapenem-Resistant Klebsiella pneumoniae Infection and Its Effect on the Outcome of Early Infection After Kidney Transplantation

Background

Infections remain a major cause of morbidity and mortality in kidney transplant (KT) recipients. This study was performed to identify the overall prevalence of early infections, prevalence of carbapenem-resistant Klebsiella pneumoniae (CRKP) infection after KT, one-year postoperative mortality in patients with early infections and risk factors for CRKP infections.

Methods

We conducted a retrospective study of all patients who received KT in our hospital between January 2017 and December 2019. We evaluated the demographic, clinical, infection characteristics and the one-year postoperative outcomes.

Results

Among the 419 patients who received KT between January 2017 and December 2019, 150 patients had at least one infection within 90 days after KT. The total prevalence of early infections was 36.1% (150/415), the prevalence of early CRKP infections was 10.4% (43/415), and the one-year postoperative mortality was 15.3% (23/150) in patients with early infections. The risk factors independently related to one-year postoperative mortality were mechanical ventilation (MV) > 48 h (Odds ratio (OR)= 13.879, 95%Confidence interval (CI): 2.265~85.035; P=0.004) and CRKP infection (OR=6.751, 95% CI: 1.051~43.369; P =0.044). MV> 48 h was independently related to CRKP infection (OR=3.719, 95% CI: 1.024~13.504; P=0.046). Kaplan-Meier survival curves showed that the one-year survival rate of patients infected with CRKP in the early postoperative stage was significantly lower than that of uninfected patients.

Conclusions

In general, the prevalence of early infections after KT is high, and CRKP infection is closely correlated with poor prognosis. The effective prevention and treatment of CRKP infection is an important way to improve the one-year survival rate after KT.

Carbapenemase-producing Enterobacteriaceae in transplant patients

Carbapenemase-producing Enterobacteriaceae (CPE) are a serious public health concern and represent a major threat to immunocompromised hosts, including solid organ (SOT) and stem cell transplant (HSCT) recipients. Transplant patients are at particular risk of developing CPE colonization and/or infection due to their frequent exposure to prolonged courses of broad-spectrum antibiotics, altered immunocompetence and exposure to invasive procedures and immunosuppressive drugs. Gut colonization with CPE, in particular carbapenem-resistant Klebsiella pneumoniae, may occur before or after SOT in 2%-27% of patients and among 2%-9% of HSCT and has been associated with increased risk of developing CPE infections. In endemic areas, CPE infections occur in up to 18% of SOT, and HSCT patients can account for 5%-18% of all patients with CPE bacteraemia. Mortality rates up to 70% have been associated with CPE infections in both patient populations. The rapid initiation of an active therapy against CPE is advocated in these infections. Therapeutic options, however, are limited by the paucity of novel compounds that are currently available and by potential antibiotic-associated toxicities. Therefore, a multidisciplinary approach involving infection control and antimicrobial stewardship programmes still represents the mainstay for the management of CPE infections among transplant patients. The evidence for the use of prevention strategies such as CPE-targeted perioperative prophylaxis or gut decolonization is still scarce. Large, multicentre trials are required to better define prevention strategies and to guide the management of CPE infections in the transplant setting.

Impact of pre-transplant carbapenem-resistant Enterobacterales colonization and/or infection on solid organ transplant outcomes

The impact of pre-transplant (SOT) carbapenem-resistant Enterobacterales (CRE) colonization or infection on post-SOT outcomes is unclear. We conducted a multi-center, international, cohort study of SOT recipients, with microbiologically diagnosed CRE colonization and/or infection pre-SOT. Sixty adult SOT recipients were included (liver n = 30, hearts n = 17). Klebsiella pneumoniae (n = 47, 78%) was the most common pre-SOT CRE species. Median time from CRE detection to SOT was 2.32 months (IQR 0.33-10.13). Post-SOT CRE infection occurred in 40% (n = 24/60), at a median of 9 days (IQR 7-17), and most commonly due to K pneumoniae (n = 20/24, 83%). Of those infected, 62% had a surgical site infection, and 46% had bloodstream infection. Patients with post-SOT CRE infection more commonly had a liver transplant (16, 67% vs. 14, 39%; p =.0350) or pre-SOT CRE BSI (11, 46% vs. 7, 19%; p =.03). One-year post-SOT survival was 77%, and those with post-SOT CRE infection had a 50% less chance of survival vs. uninfected (0.86, 95% CI, 0.76-0.97 vs. 0.34, 95% CI 0.08-1.0, p =.0204). Pre-SOT CRE infection or colonization is not an absolute contraindication to SOT and is more common among abdominal SOT recipients, those with pre-SOT CRE BSI, and those with early post-SOT medical and surgical complications.

Does Antimicrobial Therapy Affect Mortality of Patients with Carbapenem-Resistant Klebsiella pneumoniae Bacteriuria? A Nationwide Multicenter Study in Taiwan

Few clinical studies have previously discussed patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria. This study aimed to assess the effect of antimicrobial therapy on the mortality of patients with CRKP bacteriuria. Hospitalized adults with CRKP bacteriuria were enrolled retrospectively from 16 hospitals in Taiwan during 2013 and 2014. Critically ill patients were defined as those with an Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥ 20. Multivariate Cox regression analysis was used to determine independent risk factors for 14- and 28-day mortality. Of 107 patients with CRKP bacteriuria, the 14-day and 28-day mortality was 14.0% and 25.2%, respectively. Thirty-three patients received appropriate antimicrobial therapy. In the multivariate Cox regression analysis, the APACHE II score ≥ 20 was the only independent risk factor for 14-day mortality (hazard ratio [HR]: 6.15, p = 0.024). APACHE II score ≥ 20 (HR: 3.05, p = 0.018) and male sex (HR: 2.57, p = 0.037) were associated with 28-day mortality. Among critically ill patients with CRKP bacteriuria, appropriate antimicrobial therapy was not associated with 14-day or 28-day survival. In conclusion, in patients with CRKP bacteriuria, the use of appropriate antimicrobial therapy was not an independent factor associated with reduced mortality. Our findings may inform future antibiotic stewardship interventions for bacteriuria caused by multidrug resistant pathogens.

Carbapenem-resistant Enterobacterales bacteriuria and subsequent bacteremia: A population-based study

OBJECTIVE

To describe the epidemiology of carbapenem-resistant Enterobacterales (CRE) bacteriuria and to determine whether urinary catheters increase the risk of subsequent CRE bacteremia.

DESIGN

Using active population- and laboratory-based surveillance we described a cohort of patients with incident CRE bacteriuria and identified risk factors for developing CRE bacteremia within 1 year.

SETTING

The study was conducted among the 8 counties of Georgia Health District 3 (HD3) in Atlanta, Georgia.

PATIENTS

Residents of HD3 with CRE first identified in urine between 2012 and 2017.

RESULTS

We identified 464 patients with CRE bacteriuria (mean yearly incidence, 1.96 cases per 100,000 population). Of 425 with chart review, most had a urinary catheter (56%), and many resided in long-term care facilities (48%), had a Charlson comorbidity index >3 (38%) or a decubitus ulcer (37%). 21 patients (5%) developed CRE bacteremia with the same organism within 1 year. Risk factors for subsequent bacteremia included presence of a urinary catheter (odds ratio [OR], 8.0; 95% confidence interval [CI], 1.8-34.9), central venous catheter (OR, 4.3; 95% CI, 1.7-10.6) or another indwelling device (OR, 4.3; 95% CI, 1.6-11.4), urine culture obtained as an inpatient (OR, 5.7; 95% CI, 1.3-25.9), and being in the ICU in the week prior to urine culture (OR, 2.9; 95% CI, 1.1-7.8). In a multivariable analysis, urinary catheter increased the risk of CRE bacteremia (OR, 5.3; 95% CI, 1.2-23.6).

CONCLUSIONS

In patients with CRE bacteriuria, urinary catheters increase the risk of CRE bacteremia. Future interventions should aim to reduce inappropriate insertion and early removal of urinary catheters.

Burden of carbapenem non-susceptible infections in high-risk patients: systematic literature review and meta-analysis

Background

Owing to their resistance to an important class of antibiotics, the prevention and treatment of carbapenem-resistant (CR)/non-susceptible Gram-negative (GN) infections has become an important public health objective. We conducted a systematic review and meta-analysis of published literature to evaluate the burden of CR GN infections, focusing on high-risk patients such as transplant recipients, or patients with cancer, renal impairment, or sepsis.

Methods

MEDLINE®, Cochrane Central, and Embase® were searched between 2010 and March 2019. Abstracts and full-text articles were screened in duplicate. Random effects meta-analysis was conducted when reported outcomes were sufficiently similar.

Results

Twenty-six publications were eligible. Meta-analyses found increased mortality associated with CR infections among high-risk patients in both unadjusted analysis (8 studies; summary unadjusted odds ratio [OR]: 5.85; 95% confidence interval [CI]: 3.69, 9.26; I² = 19.8%) and adjusted analysis (5 studies; summary hazard ratio [HR]: 4.67; 95% CI: 2.18, 9.99; I² = 77.7%), compared to patients with carbapenem-susceptible (CS) infections or no infection. Increased mortality was also seen in subgroup analyses by length of follow-up (either short-term or long-term) or causative pathogen. A limited number of studies found that CR GN infections increased the risk for mechanical ventilation, adverse events such as graft failure or acute rejection in solid organ transplant recipients, increased renal failure or nephrotoxicity, and an increase in readmissions and costs, though the findings reported in the literature were not consistent.

Conclusion

This systematic literature review and meta-analysis indicates that CR GN infections in high-risk patients are associated with increased mortality, emphasizing the need for antimicrobial stewardship and infection control in hospitals which treat high-risk patients and for the development of effective antimicrobials with favorable efficacy and safety profiles for the treatment of CR GN infections.

Epidemiology, Risk Factors, and Outcome of Bloodstream Infection Within the First Year After Kidney Transplantation

BACKGROUND

Multi-drug resistant organisms have been emerging among kidney transplant (KT) recipients with bloodstream infections (BSI). The investigation for epidemiology, risk factors and outcome of these infections following KT was initiated.

MATERIALS AND METHODS

A retrospective study of all adult KT recipients who developed a BSI within the first year after KT in 2016 at a single transplant center was conducted. The cumulative incidence of BSI was estimated with Kaplan-Meier methodology. Clinical characteristics and outcome were extracted. Risk factors were analyzed with Cox proportional hazards models.

RESULTS

Among 171 KT recipients, there were 26 (15.2%) episodes of BSI. Fifty-nine percent were men and the mean ± SD age was 43 ± 12 years. The cumulative incidence of BSIs was 10.1% at 1 month, 13.5% at 6 months, and 15.2% at 12 months. Gram-negative bacteria were responsible for 92% of BSIs, Escherichia coli was the most common pathogen (65%) followed by Klebsiella pneumoniae (11%). Among those, 71% were resistant to extended-spectrum cephalosporins. The genitourinary tracts were the predominant source of BSIs (85%). The second kidney transplantation (HR, 4.55; 95% CI, 1.24-16.79 [P = 0.02]) and receiving induction therapy (HR, 3.05; 95% CI, 1.15-8.10 [P < 0.03]) were associated with BSI in a multivariate analysis. One patient (4%) developed allograft rejection, allograft failure and death from septic shock.

CONCLUSIONS

One out of six KT recipients could develop BSI from gram-negative bacteria within the first year after transplant, particularly in those that received the second transplantation or induction therapy.

Treatment of multidrug-resistant gram-negative bacilli after solid organ transplant: Outcomes and complications

BACKGROUND

Infections caused by multidrug-resistant gram-negative bacilli (GNB) cause significant morbidity and mortality in solid organ transplant (SOT) recipients.

METHODS

We retrospectively collected data from all SOT recipients at a single center from 1 January 2007 to 15 April 2017 treated for infections caused by multi-drug-resistant GNB. This study examined the effects of specific antibiotics on nephrotoxicity, neurotoxicity, 30-day mortality, and length of stay in the hospital and intensive care unit.

RESULTS

A total of 225 infections were identified among 143 patients. Carbapenem-sensitive organisms were present in 112 (49.8%) infections and were associated with decreased 30-day mortality (OR 0.35, 95% CI 0.16-0.75). Neurotoxicity was associated with polymyxin use with an 8% increase in odds of neurotoxicity per day of exposure (P=.03). There was no relationship between nephrotoxicity and any individual antibiotic class. Increased hospital length-of-stay occurred among patients exposed to aminoglycosides (β-statistic = 0.48 (0.23); P = .04), while there was no relationship between antibiotic class and intensive care unit (ICU) length-of-stay. Mortality at 30 days occurred in 37 infections (16%). Carbapenem exposure was associated with decreased 30-day mortality (OR 0.93; 95% CI 0.90-0.98; P = .02). No other antibiotic class had a significant impact on 30-day mortality.

CONCLUSIONS

Carbapenems appear to be a safe and effective treatment for solid-organ transplant recipients with infections caused by carbapenem-sensitive multidrug-resistant GNB; treatment of carbapenem-resistant gram-negatives remains challenging.

Risk Factors for Acquisition of Carbapenem-Resistant Klebsiella pneumoniae and Mortality Among Abdominal Solid Organ Transplant Recipients with K. pneumoniae Infections

Background

For abdominal solid organ transplant (ASOT) recipients, infection with Klebsiella pneumoniae, particularly carbapenem-resistant K. pneumoniae (CRKP), can be life-threatening. The aims of this study were to characterize the risk factors associated with acquisition of CRKP and 90-day crude mortality among patients.

Material/Methods

In our cohort study, we retrospectively reviewed 68 K. pneumoniae-infected transplant recipients, studied their demographics, clinical manifestations, microbiology, and outcomes, and determined the risk factors associated with the occurrence of CRKP and crude mortality due to K. pneumoniae infections.

Results

Sixty-eight ASOT recipients (5.4%) experienced 78 episodes of K. pneumoniae infection. Among these, 20 patients (29.4%) died. The independent risk factors associated with mortality were multiple infected organs or sites (odds ratio=22.034, 95% confidence intervals=4.348–111.653, P=0.001) and septic shock (odds ratio=27.090, 95% confidence intervals=1.841–398.512, P=0.016). Risk factors associated with acquisition of CRKP were multiple infected organs or sites (odds ratio=3.056, 95% confidence intervals=1.091–8.556, P=0.033).

Conclusions

K. pneumoniae infections, especially CRKP, frequently occurred among ASOT recipients, with a high mortality rate. Multiple infected organs or sites and septic shock were predictors of crude mortality caused by K. pneumoniae infections, while CRKP infections were associated with multiple infected organs or sites. Greater efforts are needed towards improved antibiotic administration, early diagnosis and precise treatment, recognition of septic shock, and reduced length of hospitalization.

Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients

BACKGROUND

Solid organ transplant recipients are at high risk for infections due to the complexity of surgical procedures combined with the impact of immunosuppression. No consensus exists on the role of antibiotics for surgical site infections in solid organ transplant recipients.

OBJECTIVES

To assess the benefits and harms of prophylactic antimicrobial agents for preventing surgical site infections in solid organ transplant recipients.

SEARCH METHODS

The Cochrane Kidney and Transplant Register of Studies was searched up to 21 April 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs in any language assessing prophylactic antibiotics in preventing surgical site infections in solid organ transplant recipients at any time point after transplantation.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, assessed quality, and extracted data. Primary outcomes were surgical site infections and antimicrobial resistance. Other outcomes included urinary tract infections, pneumonias and septicaemia, death (any cause), graft loss, graft rejection, graft function, adverse reactions to antimicrobial agents, and outcomes identified by the Standardised Outcomes of Nephrology Group (SONG), specifically graft health, cardiovascular disease, cancer and life participation. Summary effect estimates were obtained using a random-effects model and results were expressed as risk ratios (RR) and 95% confidence intervals (CI). The quality of the evidence was assessed using the risk of bias and the GRADE approach.

MAIN RESULTS

We identified eight eligible studies (718 randomised participants). Overall, five studies (248 randomised participants) compared antibiotics versus no antibiotics, and three studies (470 randomised participants) compared extended duration versus short duration antibiotics. Risk of bias was assessed as high for performance bias (eight studies), detection bias (eight studies) and attrition bias (two studies). It is uncertain whether antibiotics reduce the incidence of surgical site infections as the certainty of the evidence has been assessed as very low (RR 0.42, 95% CI 0.21 to 0.85; 5 studies, 226 participants; I² = 25%). The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). It is uncertain whether extended duration antibiotics reduces the incidence of surgical site infections in either solid organ transplant recipients (RR 1.19, 95% CI 0.58 to 2.48; 2 studies, 302 participants; I² = 0%) or kidney-only transplant recipients (RR 0.50, 95% CI 0.05 to 5.48; 1 study, 205 participants) as the certainty of the evidence has been assessed as very low. The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). None of the eight included studies evaluated antimicrobial agent adverse reactions, graft health, cardiovascular disease, cancer, life participation, biochemical and haematological parameters, intervention cost, hospitalisation length, or overall hospitalisation costs.

AUTHORS' CONCLUSIONS

Due to methodological limitations, risk of bias and significant heterogeneity, the current evidence for the use of prophylactic perioperative antibiotics in transplantation is of very low quality. Further high quality, adequately powered RCTs would help better inform clinical practice.

Analysis of Susceptibility to Selected Antibiotics in Klebsiella pneumoniae, Escherichia coli, Enterococcus faecalis and Enterococcus faecium Causing Urinary Tract Infections in Kidney Transplant Recipients over 8 Years: Single-Center Study

Background: Urinary tract infections (UTIs) are the most common bacterial infections among kidney transplant (KTX) recipients. The purpose of this study was to analyze antimicrobial resistance (AMR) in four most common pathogens responsible for UTIs in KTX recipients and determine risk factors (RF) for resistance in the same group. Methods: Analyzed antibiograms were based on urine samples positive for bacterial growth of 10⁵ colony-forming units (CFU)/mL obtained from hospitalized adult KTX recipients presenting with UTI symptoms upon admission to the center in years 2011–2018. Results: In total, 783 antibiograms were analyzed for Klebsiella pneumoniae (258 samples, 33.0%), Escherichia coli (212, 27.0%), Enterococcus faecalis (128, 24.0%), and Enterococcus faecium (125, 16.0%). The decrease in susceptibility of E. coli to amoxicillin/clavulanic acid (62.9% vs. 40.0%) and ciprofloxacin (100% to 40.0%) was observed. Susceptibility to gentamicin increased from 33.3% to 92.9% in E. faecium. Susceptibility to tigecycline remained 100% through all years in case of E. faecalis and E. faecium. Male gender was a RF for resistance to amoxicillin/clavulanic acid (p = 0.008), ciprofloxacin (p = 0.0003), trimethoprim/sulfamethoxazole (p = 0.00009), ceftriaxone (p = 0.0001), and cefuroxime axetil (p = 0.00038) in K. pneumoniae and against gentamicin in E. faecalis (p = 0.015). Higher resistance to ampicillin in E. faecalis (p = 0.012) and to ciprofloxacin (p = 0.0003), trimethoprim/sulfamethoxazole (p = 0.007), piperacillin/tazobactam (p = 0.003), ceftriaxone (p = 0.001), and cefuroxime axetil (p = 0.013) in K. pneumoniae was observed in higher age groups of patients. Diabetes as a cause of kidney insufficiency (p = 0.026) and kidney-pancreas transplantation (p = 0.014) was RF for resistance to ceftriaxone in K. pneumoniae. Conclusions: AMR in uropathogens from KTX recipients fluctuated. There were identifiable RFs for resistance in the examined bacteria–antibiotic combinations. We recommend continuous mapping of site-specific microorganisms as etiology and susceptibility may vary between institutions and over time.

Positively Charged Polymers as Promising Devices against Multidrug Resistant Gram-Negative Bacteria: A Review

Antibiotic resistance has increased markedly in Gram-negative bacteria, causing severe infections intractable with traditional drugs and amplifying mortality and healthcare costs. Consequently, to find novel antimicrobial compounds, active on multidrug resistant bacteria, is mandatory. In this regard, cationic antimicrobial peptides (CAMPs)—able to kill pathogens on contact—could represent an appealing solution. However, low selectivity, hemolytic toxicity and cost of manufacturing, hamper their massive clinical application. In the recent years—starting from CAMPs as template molecules—less toxic and lower-cost synthetic mimics of CAMPs, including cationic peptides, polymers and dendrimers, have been developed. Although the pending issue of hemolytic toxicity and biodegradability is still left not completely solved, cationic antimicrobial polymers (CAPs), compared to small drug molecules, thanks to their high molecular weight, own appreciable selectivity, reduced toxicity toward eukaryotic cells, more long-term activity, stability and non-volatility. With this background, an updated overview concerning the main manufactured types of CAPs, active on Gram-negative bacteria, is herein reported, including synthetic procedure and action’s mechanism. Information about their structures, antibacterial activity, advantages and drawbacks, was reported in the form of tables, which allow faster consultation and quicker learning concerning current CAPs state of the art, in order not to retrace reviews already available.

Carbapenemase-producing organisms in solid organ transplantation

PURPOSE OF REVIEW

Carbapenem-resistant enterobacteriaceae (CRE) are a critical healthcare threat. Infections caused by CRE disproportionately affect transplant patients. Retrospective case studies suggest that up to 10% of transplant recipients develop a CRE infection. The current literature is reviewed with a particular focus on transplant-specific implications.

RECENT FINDINGS

There are specific risks inherent to transplant recipients that result in an elevated risk for CRE carriage and subsequent infection. Additionally, the manifestations of these infections are dependent on the specific transplant type. The optimal treatment of CRE infections in transplant recipients has not been defined.

SUMMARY

A reduction in the regional community CRE burden can lead to a secondary reduction in their occurrence within vulnerable transplant populations. Therefore, core principles of antibiotic stewardship and infection control within all levels of the healthcare system remains the most effective strategy for addressing the current health crisis. Simultaneously, an integrated approach to risk stratification and an approach to treatment is postulated for management of CRE infection within the solid-organ transplant population.

Allograft hemorrhage as a manifestation of carbapenem-resistant Klebsiella pneumonia infection in kidney transplant recipients: Case series

RATIONALE

Carbapenem-resistant Klebsiella pneumonia (CRKP) infections have been a concerning threat, especially in organ transplant patients with very high mortality. Allograft hemorrhage associated with CRKP infection has never been described.

PATIENT CONCERNS

A total of 6 recipients tested positive for CRKP were identified in 297 adult kidney transplant recipients who received kidney from donors according to Chinese type donation after cardiac death (DCD) at our center between January 2006 and December 2017.

DIAGNOSES

CRKP identification was performed via Vitek 2 system, and the susceptibility was tested by broth microdilution and disk diffusion. Based on the signs of infection and the positive culture, the diagnosis of CRKP infection was established.

INTERVENTIONS

Therapy with antibiotic such as including ceftazidime-avibactam or tigecycline and surgical control of primary infection source including allograft nephrectomy and/or thorough debridement was administrated.

OUTCOMES

The most striking aspect was that spontaneous recurrent hemorrhage occurred in all the 6 patients. The mortality of CRKP infection in our study was 50%.

LESSONS

CRKP infection possibly due to donor-to-recipient transmission in DCD kidney transplants was essentially a necrotic hemorrhagic inflammation and characterized by recurrent hemorrhage and high mortality. The pre-donation screening for CRKP colonization should be mandatory and, if positive, donation should be contraindicated. And, the effective infection source control such as allograft nephrectomy and/or thorough debridement was important to improve outcomes. Further investigation will be required to further characterize the clinical efficacy of new pharmacotherapeutic schemes including ceftazidime-avibactam.

Mortality, clinical and microbiological response following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae infections (a meta-analysis dataset)

This meta-analysis was conducted to assess mortality, clinical and microbiological response following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) infections. Fifty-four observational studies involving 3195 CRKP-infected patients who received antibiotic treatment were included. We found combination therapy to be associated with lower mortality than monotherapy, but no differences in clinical and microbiological response. Among the various combination therapies, no significant differences in mortality, clinical and microbiological response were found. Moreover, clinical outcomes did not differ significantly among various monotherapies. This report describes the data related to the article entitled: "A systematic review and meta-analysis of treatment outcomes following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae infections".

Clinical Manifestation, Distribution, and Drug Resistance of Pathogens Among Abdominal Solid Organ Transplant Recipients With Klebsiella pneumoniae Infections

BACKGROUND

A Klebsiella pneumoniae infection is a life-threatening disease among abdominal solid organ transplant (ASOT) recipients. The objectives of our present work are to investigate the distribution and drug resistance of pathogens, and clinical manifestation among ASOT recipients suffering from K pneumoniae infections.

METHODS

The medical records of 53 ASOT recipients with 63 episodes of K pneumoniae infections from October 1, 2013 to June 1, 2019 were reviewed according to the Declaration of Helsinki and the Declaration of Istanbul. There were no grafts from prisoners used in these 53 patients and the donors were not coerced or paid. The distribution and drug resistance of each pathogen and clinical manifestation among ASOT recipients with K pneumoniae infections were retrospectively reviewed and summarized.

RESULTS

Prevalence and mortality of K pneumoniae infections among ASOT recipients were 4.5% and 32.1%, respectively. The origins of K pneumoniae infections were the blood (n = 21), deep wound and skin (n = 10), urinary tract (n = 9), abdomen (n = 6), and lung (n = 7). The numbers of organs from donors after cardiac death and living-related donors were 52 and 1, respectively. Twenty-nine patients had a serum creatinine level >1.5 mg/dL at the onset of K pneumoniae infections. Fifty-eight percent of K pneumoniae strains were carbapenem resistant. The resistance rate of K pneumoniae to 5 of 12 antibiotics investigated was more than 60%. The strains were relatively susceptible to meropenem, tigecycline, sulfamethoxazole, and amikacin; while there were distinctly increasing trends of resistance to meropenem and amikacin as time went on.

CONCLUSIONS

The clinical manifestation of K pneumoniae infections included elevated serum creatinine level, high carbapenem-resistant rate, and mortality. The drug-resistance rates of K pneumoniae to the most commonly used antibiotics were high with an increasing trend of resistance in recent years. Tigecycline, meropenem, sulfamethoxazole, and amikacin are recommended to treat K pneumoniae infections among ASOT recipients.

Association between carbapenem-resistant Enterobacteriaceae and death: A systematic review and meta-analysis

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) has emerged in health care facilities around the world. Several studies demonstrated data regarding clinical outcomes for CRE infections including death. This systematic review and meta-analysis summarized literature discussing association between CRE and mortality.

METHODS

A systematic literature review was performed by searching EMBASE, International Pharmaceutical Abstract databases, PubMed, and Scopus and to identify studies that assessed the association between CRE and death published from April 2012 to October 2017. A meta-analysis was performed using a random effect model. Heterogeneity was assessed using the I²-statistic.

RESULTS

Twenty-one studies were included in this meta-analysis. The underlying populations were moderately heterogeneous (I² = 60%; P = .01). Pooled risk estimates from 9 studies revealed a significant association between CRE and death (pooled-adjusted odds ratio: 2.85; 95% confidence interval: 1.88, 4.30). The unadjusted variable pooled from 18 studies demonstrated a significant association between CRE and death (pooled-unadjusted odds ratio: 3.73; 95% confidence interval: 2.02, 6.88).

DISCUSSION

The finding that CRE infection was positively associated with death agreed with the previous meta-analysis of studies published before April 2012.

CONCLUSIONS

This meta-analysis found that CRE was associated with increased risk of death. Our analysis implies a need for strict infection control measures.

Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe

Background

Asymptomatic bacteriuria is frequent in kidney transplant recipients (KTRs). However, there is no consensus on diagnosis or management. We conducted a European survey to explore current practice related to the diagnosis and management of asymptomatic bacteriuria in adult KTRs.

Methods

A panel of experts from the European Renal Association-European Dialysis Transplant Association/Developing Education Science and Care for Renal Transplantation in European States working group and the European Study Group for Infections in Compromised Hosts of the European Society of Clinical Microbiology and Infectious Diseases designed this cross-sectional, questionnaire-based, self-administered survey. Invitations to participate were e-mailed to European physicians involved in the care of KTRs.

Results

Two hundred and forty-four participants from 138 institutions in 25 countries answered the survey (response rate 30%). Most participants [72% (176/244)] said they always screen for asymptomatic bacteriuria in KTRs. Six per cent (15/240) reported never treating asymptomatic bacteriuria with antibiotics. When antimicrobial treatment was used, 24% of the participants (53/224) said they would start with empirical antibiotics. For an episode of asymptomatic bacteriuria caused by a fully susceptible microorganism and despite no contraindications, a majority of participants (121/223) said they would use a fluoroquinolone (n = 56), amoxicillin/clavulanic acid (n = 38) or oral cephalosporins (n = 27).

Conclusions

Screening for and treating asymptomatic bacteriuria are common in KTRs despite uncertainties around the benefits and harms. In an era of antimicrobial resistance, further studies are needed to address the diagnosis and management of asymptomatic bacteriuria in these patients.

Multidrug-resistant Gram-negative bacterial infections in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of infections due to multidrug-resistant (MDR) Gram-negative bacilli in the pre- and post-transplant period. MDR Gram-negative bacilli, including carbapenem-resistant Enterobacteriaceae, MDR Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii, remain a threat to successful organ transplantation. Clinicians now have access to at least five novel agents with activity against some of these organisms, with others in the advanced stages of clinical development. No agent, however, provides universal and predictable activity against any of these pathogens, and very little is available to treat infections with MDR nonfermenting Gram-negative bacilli including A baumannii. Despite advances, empiric antibiotics should be tailored to local microbiology and targeted regimens should be tailored to susceptibilities. Source control remains an important part of the therapeutic armamentarium. Morbidity and mortality associated with infections due to MDR Gram-negative organisms remain unacceptably high. Heightened infection control and antimicrobial stewardship initiatives are needed to prevent these infections, curtail their transmission, and limit the evolution of MDR Gram-negative pathogens, especially in the setting of organ transplantation.

Infectious disease risks in pediatric renal transplantation

Renal transplantation is a vital treatment option in children with ESRD with more than 10,000 pediatric kidney transplants and survival rates of greater than 80% at 10 years post-transplant in the USA alone. Despite these advances, infection remains a significant cause of morbidity in pediatric recipients. Screening potential organ donors and recipients is imperative to identify and mitigate infectious risks in the transplant patient. Despite the unique risks of each patient, the timing of many infections post-transplant is predictable. In early post-transplant infections (within 30 days), bacterial and fungal pathogens predominate with donor-derived events and nosocomial infections. In the intermediate period (31-180 days after transplant), latent infections from donor organs, such as EBV and CMV, develop. Late infections occurring > 180 days after the transplant can be due to latent pathogens or community-acquired organisms. Approaching an infectious evaluation in a pediatric kidney recipient requires finesse to diagnose and treat this vulnerable population in a timely manner. The following article highlights the most relevant and common infections including clinical manifestations, risk factors, diagnostic techniques, and treatment options.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

Epidemiology and Mechanisms of Resistance of Extensively Drug Resistant Gram-Negative Bacteria

Antibiotic resistance has increased markedly in gram-negative bacteria over the last two decades, and in many cases has been associated with increased mortality and healthcare costs. The adoption of genotyping and next generation whole genome sequencing of large sets of clinical bacterial isolates has greatly expanded our understanding of how antibiotic resistance develops and transmits among bacteria and between patients. Diverse mechanisms of resistance, including antibiotic degradation, antibiotic target modification, and modulation of permeability through the bacterial membrane have been demonstrated. These fundamental insights into the mechanisms of gram-negative antibiotic resistance have influenced the development of novel antibiotics and treatment practices in highly resistant infections. Here, we review the mechanisms and global epidemiology of antibiotic resistance in some of the most clinically important resistance phenotypes, including carbapenem resistant Enterobacteriaceae, extensively drug resistant (XDR) Pseudomonas aeruginosa, and XDR Acinetobacter baumannii. Understanding the resistance mechanisms and epidemiology of these pathogens is critical for the development of novel antibacterials and for individual treatment decisions, which often involve alternatives to β-lactam antibiotics.

The use of predictive scores in the management of patients with carbapenem-resistant Klebsiella pneumoniae infection

INTRODUCTION

Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections are associated with high morbidity and mortality rates. A therapeutic approach based on the patient risk stratification could improve outcome and avoid antibiotic misuse. Areas covered: English literature search, from 2008 to 2018, was done using PubMed database. Risk factors for developing CR-KP infection in several settings were reviewed. Since, rectal carriage was a main risk factor for developing infection, we revised in deep clinical score to predict infection among colonized patients. Furthermore, we investigated overall and treatment-related risk factors for poor outcome in patients with CR-KP infection, in particular the carbapenem producing Enterobacteriacieae (CPE)-INCREMENT score. Finally, an algorithm, based on such scores, for the therapeutic management of patients with CR-KP colonization was commented. Expert opinion: The therapeutic approach analyzed in this review could help physicians to avoid antibiotic overuse as well as to start promptly with the most appropriate antibiotic regimen. However, it has to be validated in further studies, mainly among special population such as immunocompromised patients. The availability of new drugs, fast microbiology, and analysis of gut microbiome could significantly improve the management of CR-KP colonized and/or infected patients.

Acquisition of Carbapenemase-Producing Enterobacteriaceae in Solid Organ Transplantation Recipients

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) can lead to life-threatening outcomes with rapid spread of the carbapenemase gene in solid organ transplantation (SOT) recipients because of limitations of available antibiotics. We examined the characteristics and importance of CPE acquisition in SOT recipients with large numbers of CPE isolates.

METHODS

Between November 2015 and October 2016, 584 CPE isolates were found in 37 recipients and verified by carbapenemase gene multiplex polymerase chain reaction (PCR). One hundred recipients with at least 2 negative results in carbapenemase PCR for stool surveillance and no CPE isolates in clinical samples were retrospectively included.

RESULTS

Most CPE isolates were Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (546, 93.5%). The most frequent transplantation organ was lung (43.3%), and the most common sample with CPE isolates other than stool was respiratory tract (22.6%). The median time between SOT and first CPE acquisition was 7 days. All-cause mortality was significantly higher in recipients with CPE than in those without CPE (24.3% vs 10.0%; P = .03). In multivariate regression analysis, stool colonization of vancomycin-resistant Enterococci and/or Clostridium difficile during 30 days before SOT (odds ratio [OR], 3.28; 95% CI, 1.24-8.68; P = .02), lung transplantation (OR, 4.50; 95% CI, 1.19-17.03; P = .03), and intensive care unit stay ≥2 weeks (OR, 6.21; 95% CI, 1.72-22.45; P = .005) were associated with acquisition of CPE.

CONCLUSIONS

Early posttransplantation CPE acquisition may affect the clinical outcome of SOT recipients. Careful screening for CPE during the early posttransplantation period would be meaningful in recipients with risk factors.

The Role of Trimethoprim/Sulfamethoxazole in the Treatment of Infections Caused by Carbapenem-Resistant Enterobacteriaceae

In the Consortium on Resistance Against Carbapenems in Klebsiella and other Enterobacteriaceae (CRACKLE), trimethoprim-sulfamethoxazole (TMP-SMX) had a limited role in the treatment of less severe carbapenem-resistant Enterobacteriaceae (CRE) infections, especially urinary tract infections. Of tested CRE, only 29% were susceptible to TMP-SMX. Development of resistance further limits the use of TMP-SMX in CRE infections.

Managing recurrent urinary tract infections in kidney transplant patients

INTRODUCTION

Recurrent urinary tract infections (UTI) are a common clinical problem in kidney transplant recipients. Due to the complex urological anatomy derived from the implantation of the kidney graft, the spectrum of the disease and the broad underlying pathophysiological mechanisms. Recurrent UTI worsen the quality of life, decrease the graft survival and increase the costs of kidney transplantation. Areas covered: In this review, we describe the definitions, clinical characteristics, pathophysiological mechanisms and microbiology of recurrent urinary tract infections in kidney transplantations. The actual published literature on the management of recurrent urinary tract infections is based on case series, observational cohorts and very few clinical trials. In this review, the available evidence is compiled to propose evidence-based strategies to manage these complex cases. Expert commentary: The management of recurrent urinary tract infections in kidney transplant patients requires a proper diagnosis of the underlying mechanism. Early identification of structural or functional urological abnormalities, potentially amenable for surgical correction, is crucial for a successful management. The use of antibiotics to prevent recurrent infections should be carefully evaluated to avoid side effects and emergence of antibiotic-resistant microorganisms.

Does the urinary tract infection caused by carbapenem-resistant Gram-negative bacilli impact the outcome of kidney transplant recipients?

The incidence of urinary tract infection (UTI) after kidney transplantation (KT) caused by multidrug-resistant (MDR) bacteria is growing. The aim of this study was to analyze the impact of UTI caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) in the survival of graft and recipients following KT. This was a retrospective cohort study involving patients who underwent KT between 2013 and 2016. Patients were followed since the day of the KT until loss of graft, death or end of the follow-up period (31th December 2016). The outcomes measured were UTI by MDR following KT and graft and patient survival. Analyses were performed using Cox regression; for the graft and patient survival analysis, we used a propensity score for UTI by CR-GNB to matching a control group. UTI was diagnosed in 178 (23.9%) of 781 patients, who developed 352 UTI episodes. 44.6% of the UTI cases were caused by MDR bacteria. Identified risk factors for UTI by MDR bacteria were DM, urologic disease as the cause of end-stage renal failure, insertion of ureteral stent, carbapenem use, and delayed graft function (DGF). Risk factors for death during the follow-up period were female gender, patients over 60 years old at the time of KT, DM, body mass index over 31.8, UTI caused by CR-GNB. In conclusion, UTIs caused by CR-GNB have great impact on patients' survival after KT.

Estimating the burden of antimicrobial resistance: a systematic literature review

Background

Accurate estimates of the burden of antimicrobial resistance (AMR) are needed to establish the magnitude of this global threat in terms of both health and cost, and to paramaterise cost-effectiveness evaluations of interventions aiming to tackle the problem. This review aimed to establish the alternative methodologies used in estimating AMR burden in order to appraise the current evidence base.

Methods

MEDLINE, EMBASE, Scopus, EconLit, PubMed and grey literature were searched. English language studies evaluating the impact of AMR (from any microbe) on patient, payer/provider and economic burden published between January 2013 and December 2015 were included. Independent screening of title/abstracts followed by full texts was performed using pre-specified criteria. A study quality score (from zero to one) was derived using Newcastle-Ottawa and Philips checklists. Extracted study data were used to compare study method and resulting burden estimate, according to perspective. Monetary costs were converted into 2013 USD.

Results

Out of 5187 unique retrievals, 214 studies were included. One hundred eighty-seven studies estimated patient health, 75 studies estimated payer/provider and 11 studies estimated economic burden. 64% of included studies were single centre. The majority of studies estimating patient or provider/payer burden used regression techniques. 48% of studies estimating mortality burden found a significant impact from resistance, excess healthcare system costs ranged from non-significance to $1 billion per year, whilst economic burden ranged from $21,832 per case to over $3 trillion in GDP loss. Median quality scores (interquartile range) for patient, payer/provider and economic burden studies were 0.67 (0.56-0.67), 0.56 (0.46-0.67) and 0.53 (0.44-0.60) respectively.

Conclusions

This study highlights what methodological assumptions and biases can occur dependent on chosen outcome and perspective. Currently, there is considerable variability in burden estimates, which can lead in-turn to inaccurate intervention evaluations and poor policy/investment decisions. Future research should utilise the recommendations presented in this review.

Trial registration

This systematic review is registered with PROSPERO (PROSPERO CRD42016037510).

Clinical Significance of Gastrointestinal Carriage of Klebsiella Pneumoniae-Producing Extended-Spectrum Beta-Lactamases in Kidney Graft Recipients

The burden of Klebsiella pneumoniae (KP) producing extended-spectrum beta-lactamases (ESBL+) urinary tract infections (UTIs) is a growing problem after kidney transplantation (KTX). The study was aimed at evaluating the incidence of KP ESBL+ gut colonization in KTX recipients and its correlation with clinical outcomes with special regard to UTIs. The study included all KTX patients hospitalized in our department between January 2014 and December 2016. During this period 2018 KTX patients were admitted: 605 in 2014, 750 in 2015, and 663 in 2016, respectively. Screening for drug-multiresistant Enterobacteriaceae gut carriage was performed in 104 patients (2014), 122 (2015), and 166 (2016). In 2014, 2015, and 2016, 18 (17.3%), 26 (21.3%), and 30 (18.1%) patients had positive test results, and 44 (42.3%), 36 (29.5%), and 45 (27.4%) KTX patients were diagnosed with KP ESBL+ UTI. In 2014, KP ESBL+ UTI was diagnosed in 30 (34.9%) cases with negative anal swab and in 14 patients (77.8%) with positive test result (P = .0008). In 2015, KP ESBL+ UTI was diagnosed in 21 patients (21.9%) with negative anal swab and in 15 (57.7%) with positive test result (P = .0004). In 2016, KP ESBL+ UTI was diagnosed in 24 patients (17.8%) with negative anal swab and in 21 (72.4%) with positive test result (P = .000001). In conclusion, we have revealed a strong association between gut K. pneumoniae colonization, female sex, and MPA intake and KP ESBL+ urinary tract infections in kidney transplant recipients. Our results indicate the very important role of KP ESBL+ screening, while strategies of identified carriers require further research.

The challenge of urinary tract infections in renal transplant recipients

Urinary tract infections (UTI) are an important cause of morbidity and mortality in renal transplant patients. These infections are quite common, and the goal of care is to identify and reduce risk factors while providing effective prophylaxis and treatment. Better understanding of long-term outcomes from these infections has led to the distinctions among UTI, recurrent UTI, and asymptomatic bacteriuria (ASB), and that each requires a different therapeutic approach. Specifically, new research has supported the perspective that asymptomatic bacteriuria should not be treated. Symptomatic UTI, on the other hand, requires intervention and remains an ongoing challenge for infectious disease clinicians. Many bacteria species are responsible for UTI in renal transplant patients, and in recent years there has been a global rise in infection caused by bacteria with newly acquired antibacterial resistance genes. Many renal transplant patients who experience UTI will also have multiple recurring episodes, which likely has a distinct pathophysiological mechanism leading to chronic colonization of the urinary tract. In these cases, long-term management includes bacterial suppression, which aims to reduce rather than eliminate bacteria to levels below the threshold for symptomatic infection. This review will address the current understanding of UTI epidemiology, pathogenesis, and risk factors in the renal transplant community, and also focus on current prevention and treatment strategies for patients who face an environment of increasingly antibiotic-resistant bacteria.