Infecções bacterianas do trato urinário em pacientes submetidos ao transplante renal no Hospital das Clínicas de Botucatu entre 2012 e 2014
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2017-12-14
Autores
Galvão, Tassiana Rodrigues dos Santos
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Universidade Estadual Paulista (Unesp)
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Introdução: Nos dias atuais, o transplante renal (TxR) é a melhor alternativa terapêutica para os pacientes no estágio final da doença renal. Apesar dos relevantes progressos do TxR, os transplantados permanecem sujeitos a complicações importantes. A infecção bacteriana do trato urinário (ITUB) é a complicação infecciosa mais frequente, cuja incidência pode chegar a valores maiores que 70%, ocorrendo principalmente no primeiro ano após o TxR. Alguns estudos indicam que as ITUB podem interferir no prognóstico do transplantado renal, elevando a morbidade, o número de internações, a disfunção do enxerto e a mortalidade. Objetivo: Verificar a incidência de ITUB no primeiro ano após o TxR e identificar, ainda, o período de ocorrência pós-TxR, os agentes etiológicos e padrões de resistência, assim como tratamentos e principais desfechos relacionados à primeira ITUB. Métodos: Estudo de coorte não concorrente, cuja população estudada foram todos os pacientes submetidos ao TxR no HC-Botucatu, entre julho de 2012 e junho de 2014. Foram incluídos indivíduos com pelo menos 15 anos de idade e acompanhamento regular durante o primeiro ano após o TxR ou até o óbito. Os critérios de exclusão foram transplantes não exclusivamente renais e retransplantes dentro do período estudado. Foram coletados dados sobre demografia; epidemiologia hospitalar, apresentação clínica, antecedentes pessoais e risco imunológico do receptor; características do doador; transplante renal e suas complicações; imunossupressão utilizada; periodicidade, perfil microbiológico e de resistência antimicrobiana, sintomatologia, alterações laboratoriais, terapias antimicrobianas e desfechos específicos relacionados à primeira ITUB; além dos desfechos gerais mortalidade, perda do enxerto e função renal após um ano. Resultados: Foram incluídos 221 pacientes. As características gerais dos pacientes foram semelhantes às de outros centros nacionais. A incidência de ITUB no primeiro ano foi de 37,8%, ocorrendo na mediana de 18 dias após o TxR. A maioria das ITUB aconteceram dentro dos primeiros dois meses (88,2%). Destas, 54 (71,1%) foram assintomáticas e 13 sintomáticas (17,1%). As espécies mais frequentemente isoladas das ITUB foram a Escherichia coli (40,5%) e a Klebsiella spp. (29,1%). Vinte e cinco (32,9%) ITUB foram devidas a bactérias multirresistentes (MR), dentre elas, 92,0% por bactérias produtoras de ESBL, 4,0% EPC e 4,0% causadas por Acinetobacter baumanii multidrogarresistente. Apenas 55,3% dos pacientes diagnosticados com ITUB foram tratados com esquema antimicrobiano. O esquema inicial mais empregado foi o ciprofloxacino (33,3%). Os esquemas iniciais contendo pelo menos um carbapenêmico foram utilizados em 40,5% das vezes. Apenas 9,5% dos pacientes precisaram realizar readequação dos esquemas inicialmente prescritos. Dentre os 22 pacientes sintomáticos tratados, 95,5% evoluíram com cura clínica. Houve cura microbiológica constada em 81% dos casos. Não houve diferença estatística significante com relação à ocorrência de óbito ou perda do enxerto entre os pacientes com ITUB e sem ITUB no primeiro ano após o TxR. Porém, o clearance de creatinina 12 meses após o TxR foi estatisticamente menor nos pacientes com ITUB. Não houve diferença estatística entre os desfechos acima citados, com relação ao tratamento antimicrobiano, ou não, da primeira ITUB assintomática. Discussão/Conclusão: A porcentagem de pacientes que apresentaram ITUB durante o primeiro ano após o TxR mostrou-se elevada. As ITUB foram mais frequentes nos dois primeiros meses, essencialmente durante o primeiro mês após o TxR. A ocorrência de ITUB MR foi relevante, destacando-se as bactérias produtoras de ESBL. Os desfechos clínicos e microbiológicos das primeiras ITUB foram favoráveis, apesar da incapacidade de negativação da cultura de urina em parcela considerável dos pacientes tratados. Não houve diferença estatisticamente significante quanto à sobrevida dos pacientes e do enxerto entre pacientes que apresentaram, ou não, ITUB no primeiro ano após o TxR. Porém, a função renal dos transplantados renais com ITUB mostrou-se inferior. Os desfechos acima também não diferiram estatisticamente com relação ao tratamento, ou não, de ITUB assintomáticas, diagnosticadas dentro de 60 dias após o TxR. Os fatores de risco associados à ocorrência de ITUB, ITUBMR e, mais especificamente, por bactérias produtoras de ESBL encontram-se em análise. Espera-se que os resultados finais do presente permitam auxiliar na elaboração de protocolos de prevenção e tratamento de ITUB na população estudada.
Introduction: Kidney transplantation (KTx) is the most cost-effective renal replacement therapy for patients with end-stage renal disease. Despite the relevant progress of KTx, transplanted patients are permanently subject to major complications. Bacterial Urinary Tract Infection (BUTI) is the most frequent infectious complication, which can reach values higher than 70%, occurring mainly during the first year after KTx. Some studies indicate that the BUTI may interfere with the prognosis of the KTx, increasing morbidity, number of hospitalizations, graft dysfunction, and mortality. Objective: To verify the incidence of BUTI in the first year after KTx and to identify the period of occurrence, etiological agents and resistance patterns, as well as treatments and main outcomes related to the first BUTI. Methods: A non-concurrent cohort study was conducted on all patients submitted to KTx at Botucatu Clinics Hospital between July 2012 and June 2014. Subjects at least 15 years old with regular follow-up during the first year after the KTx or until death were included. Exclusion criteria were non-exclusively kidney transplantation and retransplantation within the study period. Data collected were on recipient demography, hospital epidemiology, clinical presentation, medical history and immunological risk; characteristics of the donor; KTx and its complications; immunosuppression; periodicity, microbiological profile, antimicrobial resistance, symptomatology, laboratory evaluation, antimicrobial therapies and specific outcomes related to the first BUTI; besides the general outcomes after one year of KTx: mortality, graft loss and renal function. Results: A total of 221 patients were included. The general characteristics of the patients were similar to those of other national centers. The incidence of BUTI in the first year was 37.8%, occurring at a median time of 18 days after KTx. Most BUTI occurred within the first two months (88.2%). Of these, 54 (71.1%) were asymptomatic and 13 were symptomatic (17.1%). The most frequently isolated species were Escherichia coli (40.5%) and Klebsiella spp. (29.1%). Twenty-five (32.9%) BUTI were due to multiresistant (MR) bacteria, among them, 92.0% by ESBL-producing bacteria, 4.0% carbapenem- producing enterobacteriaceae (CPE) and 4.0% caused by multidrug-resistant Acinetobacter baumanii. Only 55.3% of patients diagnosed with BUTI were treated with an antimicrobial regimen. The most used initial scheme was ciprofloxacin (33.3%). Initial schemes containing at least one carbapenem were used 40.5% of the time. Only 9.5% of the patients needed re-adjustment of the initially prescribed regimens. Among the 22 symptomatic patients treated, 95.5% developed clinical cure. There was a microbiological cure in 81% of cases. There was no statistically difference regarding the occurrence of death or graft loss between patients with BUTI and without BUTI in the first year after KTx. However, creatinine clearance 12 months after KTx was statistically lower in patients with BUTI. There was no statistical difference between the abovementioned outcomes, regarding the antimicrobial treatment or not of the first asymptomatic BUTI. Discussion/Conclusion: The percentage of patients who presented BUTI during the first year after KTx was high. The BUTI were more frequent in the first two months, essentially during the first month after KTx. The occurrence MR BUTI was relevant, highlighting the ESBL-producing bacteria. The clinical and microbiological outcomes of the first BUTI were favorable, despite the inability of the urine culture to be negatived in a considerable number of patients treated. There was no statistically difference in patient and graft survival between patients who presented or not BUTI in the first year after KTx. However, renal function of KTx patients with BUTI was inferior. Patient and graft survival also did not differ statistically with respect to the treatment or not of asymptomatic BUTI diagnosed within 60 days after KTx. The risk factors associated with the occurrence of BUTI, MR BUTI and, more specifically, ESBL-producing bacteria are being analyzed. It is hoped that the final results of this study are useful for the elaboration of protocols of prevention and treatment of BUTI for the kidney transplant population studied.
Introduction: Kidney transplantation (KTx) is the most cost-effective renal replacement therapy for patients with end-stage renal disease. Despite the relevant progress of KTx, transplanted patients are permanently subject to major complications. Bacterial Urinary Tract Infection (BUTI) is the most frequent infectious complication, which can reach values higher than 70%, occurring mainly during the first year after KTx. Some studies indicate that the BUTI may interfere with the prognosis of the KTx, increasing morbidity, number of hospitalizations, graft dysfunction, and mortality. Objective: To verify the incidence of BUTI in the first year after KTx and to identify the period of occurrence, etiological agents and resistance patterns, as well as treatments and main outcomes related to the first BUTI. Methods: A non-concurrent cohort study was conducted on all patients submitted to KTx at Botucatu Clinics Hospital between July 2012 and June 2014. Subjects at least 15 years old with regular follow-up during the first year after the KTx or until death were included. Exclusion criteria were non-exclusively kidney transplantation and retransplantation within the study period. Data collected were on recipient demography, hospital epidemiology, clinical presentation, medical history and immunological risk; characteristics of the donor; KTx and its complications; immunosuppression; periodicity, microbiological profile, antimicrobial resistance, symptomatology, laboratory evaluation, antimicrobial therapies and specific outcomes related to the first BUTI; besides the general outcomes after one year of KTx: mortality, graft loss and renal function. Results: A total of 221 patients were included. The general characteristics of the patients were similar to those of other national centers. The incidence of BUTI in the first year was 37.8%, occurring at a median time of 18 days after KTx. Most BUTI occurred within the first two months (88.2%). Of these, 54 (71.1%) were asymptomatic and 13 were symptomatic (17.1%). The most frequently isolated species were Escherichia coli (40.5%) and Klebsiella spp. (29.1%). Twenty-five (32.9%) BUTI were due to multiresistant (MR) bacteria, among them, 92.0% by ESBL-producing bacteria, 4.0% carbapenem- producing enterobacteriaceae (CPE) and 4.0% caused by multidrug-resistant Acinetobacter baumanii. Only 55.3% of patients diagnosed with BUTI were treated with an antimicrobial regimen. The most used initial scheme was ciprofloxacin (33.3%). Initial schemes containing at least one carbapenem were used 40.5% of the time. Only 9.5% of the patients needed re-adjustment of the initially prescribed regimens. Among the 22 symptomatic patients treated, 95.5% developed clinical cure. There was a microbiological cure in 81% of cases. There was no statistically difference regarding the occurrence of death or graft loss between patients with BUTI and without BUTI in the first year after KTx. However, creatinine clearance 12 months after KTx was statistically lower in patients with BUTI. There was no statistical difference between the abovementioned outcomes, regarding the antimicrobial treatment or not of the first asymptomatic BUTI. Discussion/Conclusion: The percentage of patients who presented BUTI during the first year after KTx was high. The BUTI were more frequent in the first two months, essentially during the first month after KTx. The occurrence MR BUTI was relevant, highlighting the ESBL-producing bacteria. The clinical and microbiological outcomes of the first BUTI were favorable, despite the inability of the urine culture to be negatived in a considerable number of patients treated. There was no statistically difference in patient and graft survival between patients who presented or not BUTI in the first year after KTx. However, renal function of KTx patients with BUTI was inferior. Patient and graft survival also did not differ statistically with respect to the treatment or not of asymptomatic BUTI diagnosed within 60 days after KTx. The risk factors associated with the occurrence of BUTI, MR BUTI and, more specifically, ESBL-producing bacteria are being analyzed. It is hoped that the final results of this study are useful for the elaboration of protocols of prevention and treatment of BUTI for the kidney transplant population studied.
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Palavras-chave
Transplante renal, Infecção do trato urinário bacteriana, Bacteriúria assintomática