Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The following is a summary of the recommendations for urinary tract infections in renal insufficiency, transplant recipients, diabetes mellitus, and immunosuppression. Refer to the original guideline for more detailed recommendations and discussion.
Levels of evidence (Ia-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Acute Effects of Urinary Tract Infection (UTI) on the Kidney
In acute pyelonephritis very dramatic changes can occur with focal reduction in perfusion on imaging and corresponding renal tubular dysfunction. However, if in the adult, the kidney is normal beforehand, chronic renal damage is most unlikely. There is no evidence that more prolonged or intensive antibiotic treatment of acute pyelonephritis will shorten the episode or prevent complications.
In diabetes mellitus, overwhelming infection can predispose to pyogenic infection with intrarenal perinephric abscess formation, emphysematous pyelonephritis, and, very rarely, a specific form of infective interstitial nephropathy. Papillary necrosis is a common consequence of pyelonephritis in diabetics. Females are more prone to asymptomatic bacteriuria than diabetic men, but in both sexes progression to clinical pyelonephritis is more likely than in normal individuals. The risk factors for developing asymptomatic bacteriuria differ between type I and type II diabetes.
It is arguable that diabetic patients are susceptible to rapid progression of parenchymal infection. However, the clearance of asymptomatic bacteriuria should not be attempted if the intention is to prevent complications, notably acute pyelonephritis (A).
Chronic Renal Disease and UTI
There are several factors of general potential importance predisposing to infection in uraemia, including the loss of several urinary defence mechanisms and a degree of immunosuppression. Typically, adult polycystic kidney disease (APCKD), gross vesicoureteric reflux (VUR) and endstage obstructive uropathy will harbour infective foci or promote ascending infection, but not invariably so. Clearly, severe UTI with accompanying bacteraemia can hasten progression of renal failure, but there is little evidence that vigorous treatment of lesser degrees of infection or prophylaxis will slow renal functional impairment once it is established (C).
In patients with VUR and UTI in endstage chronic renal failure bilateral nephroureterectomy should only be undertaken as a last resort (B).
Adult Polycystic Kidney Disease (APCKD)
In patients with acute pyelonephritis and infected cysts (presenting as recurrent bacteraemia or 'local sepsis') treatment requires a long course of high-dose systemic fluoroquinolones, followed by prophylaxis. Bilateral nephrectomy should be utilized as a last resort (B).
Calculi and UTI
Management is similar to that for patients without renal impairment (i.e., to clear the stones if possible and to minimize antibiotic treatment if the calculus cannot be removed). Nephrectomy should be performed as a last resort, but even residual renal function may be of vital importance (B).
Obstruction and UTI
As in all other situations, the combination of obstruction and infection is dangerous and should be treated vigorously. Obstruction may be covert and require specific diagnostic tests (e.g., video-urodynamics, upper tract pressure flow studies).
UTI in Renal Transplantation and Immunosuppression
The need to correct uropathy or to remove a potential focus of infection in a diseased endstage kidney is more pressing in a patient enlisted for renal transplantation. Even so, the results of nephrectomy for a scarred or hydronephrotic kidney may be disappointing.
Immunosuppression is of secondary importance, although if this is extreme, immunosuppression will promote, at least, persistent bacteriuria, which may become symptomatic. In the context of renal transplantation, UTI is very common, but immunosuppression is only one of many factors which are mainly classified as 'surgical'.
HIV infection is associated with acute and chronic renal disease, possibly through the mechanisms of thrombotic microangiopathy and immune mediated glomerulonephritis. Steroids, angiotensin-converting enzyme (ACE) inhibitors and highly active retroviral therapy appear to have reduced progression to endstage renal disease.
Antibiotic Treatment for UTI in Renal Insufficiency and After Renal Transplantation
The principles of antibiotic treatment for UTI in the presence of renal impairment, during dialysis treatment and after renal transplantation, is discussed in the text (see original guideline document) and summarized in the tables below.
Table: Use of Antibiotics for UTI with Renal Impairment
- Most antibiotics have a wide therapeutic index. No adjustment of dose is necessary until glomerular filtration rate (GFR) <20 mL/min, except antibiotics with nephrotoxic potential (e.g., aminoglycosides).
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- Drugs removed by dialysis should be administered after a dialysis treatment.
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- Combination of loop diuretics, (e.g., furosemide and a cephalosporin) is nephrotoxic.
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- Nitrofurantoin and tetracycline are contraindicated, but not doxycycline.
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Table: Clearance of Antibiotics at Haemodialysis
| Dialyzed |
Slightly Dialyzed |
Not Dialyzed |
| Amoxycillin/ampicillin |
Fluoroquinolones* |
Amphotericin |
| Carbenicillin |
Co-trimoxazole |
Methicillin |
| Cephalosporins* |
Erythromycin |
Teicoplanin |
| Aminoglycosides* |
Vancomycin |
|
| Trimethoprim |
|
|
| Metronidazole |
|
|
| Aztreonam* |
|
|
| Fluconazole* |
|
|
| *Drugs cleared by peritoneal dialysis |
Table: Treatment of Tuberculosis in Renal Failure
| Rifampicin and isoniazid not cleared by dialysis. Give pyridoxine. |
| Ethambutol not dialyzed. Reduce dose if glomerular filtration rate (GFR)<30 mL/min. |
| Avoid rifampicin with cyclosporine. |
Table: Recommendations for Prevention and Treatment of UTI in Renal Transplantation
- Treat infection in recipient before transplantation
|
- Culture donor tissue sample and perfusate
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- Perioperative antibiotic prophylaxis
|
- 6-month low-dose TMP-SMX (co-trimoxazole) (IbA)
|
- Empirical treatment of overt infection (quinolone, TMP-SMX for 10-14 days)
|
|
TMP-SMX = trimethoprim-sulphamethoxazole
|
Table: Drug Interactions with Cyclosporin and Tacrolimus
| Rifampicin |
| Erythromycin |
| Aminoglycosides |
| TMP-SMX |
| Amphotericin B |
TMP-SMX = trimethoprim-sulphamethoxazole.
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomized trials
Ib Evidence obtained from at least one randomized trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
IV Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
