Increasing proportion of extensively drug-resistant gram-negative uropathogens among renal transplant recipients in Northern India
Sameer Bhuwania1, Rajesh Goel2, Ravi Bansal3, Sanjiv Saxena4
1 Senior Resident, Department of Nephrology, PSRI Hospital, New Delhi, India
2 Consultant, Department of Nephrology, PSRI Hospital, New Delhi, India
3 Senior Consultant, Department of Nephrology, PSRI Hospital, New Delhi, India
4 Head and Chairman, Department of Nephrology, PSRI Hospital, New Delhi, India
|Date of Submission||14-Apr-2020|
|Date of Acceptance||23-Jul-2020|
|Date of Web Publication||10-Apr-2021|
Pushpawati Singhania Research Institute (PSRI) Hospital, Sheikh Sarai Phase 2, New Delhi - 110 017
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Bhuwania S, Goel R, Bansal R, Saxena S. Increasing proportion of extensively drug-resistant gram-negative uropathogens among renal transplant recipients in Northern India. Indian J Nephrol [Epub ahead of print] [cited 2021 Jun 18]. Available from: https://www.indianjnephrol.org/preprintarticle.asp?id=313403
Kidney transplantation is now the preferred treatment for end-stage kidney disease. Urinary tract infections (UTIs) are the most common infectious complications with 79% prevalence after renal transplant as a result of chronic immunosuppressive therapy. The incidence of extensively drug-resistant (XDR) organisms causing UTI has been increasing over the past few years and they pose a threat to transplant population.
Here we report a Retrospective medical data record analysis of 211 renal transplant recipients followed up over a median period of 22 months from a tertiary care facility in New Delhi during the period January 2015–July 2018. The median age of recipients was 43 yrs, 74% were males. All of them received induction therapy followed by triple drug maintenance immunosuppression (antithymocyte globulin followed by tacrolimus, mycophenolate and prednisolone). Foleys catheter was removed on the fifth postoperative day (4–7 days) and DJ ureteral stent removed 4 weeks postoperatively. All patients received third-generation cephalosporin perioperatively for five days and then oral Cotrimoxazole on discharge for one year. Cases were defined as those with symptomatic urinary infection in midstream clean catch urine sample culture showing significant monomicrobial growth using the Vitek2 compact system (Biomerieux Ltd). XDR-UTI was defined as resistance to-all classes of Betalactams (including 1, 2, 3, 4th generation cephalosporins and in combination with beta-lactamase inhibitors), fluoroquinolones, aminoglycosides, and carbapenems.
A total of 91 culture-positive UTIs were reported in 84 cases, 87% due to gram-negative bacteria (GNB), out of which 24 isolates (26% overall) of XDR-GNB were detected. Sixty percent of infections (UTIs or XDR-UTIs) occurred within 1 month of transplant (99% being first episode of infection) followed by 20% in the next 2 months. Cumulative Incidence of UTI over the first month of transplant (11.1% overall) has also increased over the years. It was 6% in 2015, 7.41% in 2016, 15.09% in 2017 and 27.63% in 2018. Cumulative incidence rate of XDR-GNB (cases of XDR-GNB/total transplant) in 2015 was 6%, reduced to 5% in 2016 but then increased to 11% in 2017 and then 15% in 2018, proving the point that the incidence has increased over the years, although the outcome was not statistically significant. Most common culprit in these patients was Escherichia coli. (10 cases), followed by Klebsiella (9) and Pseudomonas (3) [Table 1]. All these cases were sensitive to colistin only (except 2 with colisitin-resistant isolates who succumbed to the disease). Among all GNB urine culture isolates, the proportion of XDR cases was 13% in 2015, 17.6% in 2016, 28.5% in 2017, and later increased to 40% in 2018 [Graph 1]. The incidence of UTI as calculated from this study was 0.149 per person-year whereas XDR-UTI was 0.047 per person year. Limitations of the data include the absence of a bacterial antimicrobial resistance genetic analysis and the noninclusion of an audit of change in the surgical techniques and catheter care practices.
Indian data are still lacking in this field, data from China showed 86.4% of MDR and 13.2% of XDR cases in their transplant patients with Pseudomonas being the prime culprit while Australia has shown 3.9% prevalence of ESBL organisms. The data from different studies may also vary according to the definition of XDR, since none of these studies have included all the antibiotics in inclusion criteria as we have.
Through this study, we bring to your notice the rapidly increasing proportion of XDR-GNB isolates and challenges that it poses for health care providers since antibiotic inventions are not at pace with the developing rate of resistance. A proper infection control practice and antibiotic policy needs to be made at local level to control the situation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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