How should Group B Streptococcus (GBS) bacteriuria be managed in a potential living kidney donor?

Management of Group B Streptococcus (GBS) Bacteriuria in a Potential Living Kidney Donor

In a potential living kidney donor with Group B Streptococcus bacteriuria, treatment is not recommended unless the donor is symptomatic, as asymptomatic bacteriuria does not impact donation eligibility or outcomes.

Evaluation of GBS Bacteriuria in Living Kidney Donors

Assessment Framework

• GBS bacteriuria in potential kidney donors should be categorized as either:
  • Asymptomatic bacteriuria (ASB): No urinary symptoms present
  • Symptomatic urinary tract infection (UTI): Presence of dysuria, frequency, urgency, or suprapubic pain

Key Considerations

• The Infectious Diseases Society of America (IDSA) guidelines specifically recommend against screening for or treating asymptomatic bacteriuria in most adult populations 1
• No evidence suggests that asymptomatic GBS bacteriuria impacts donor eligibility or recipient outcomes
• Treatment of asymptomatic bacteriuria in transplant candidates may lead to antimicrobial resistance 1

Management Algorithm

For Asymptomatic GBS Bacteriuria:

1. Do not treat with antibiotics

   • IDSA guidelines strongly recommend against treatment of ASB in most adults 1
   • Treatment does not prevent progression to symptomatic infection and may increase antimicrobial resistance 1
   • Multiple studies show no benefit of treating ASB in transplant recipients 1

2. Proceed with donor evaluation

   • GBS bacteriuria alone is not a contraindication to donation
   • KDIGO guidelines for living kidney donors do not list asymptomatic bacteriuria as an exclusion criterion 1

For Symptomatic GBS UTI:

1. Treat according to standard UTI protocols

   • Appropriate antibiotics based on susceptibility testing
   • Complete treatment course before donation procedure

2. Reassess after treatment

   • Confirm resolution of infection with follow-up culture
   • Proceed with donation evaluation once infection has resolved

Special Considerations

Important Exceptions

• Pregnant donors: GBS bacteriuria in pregnancy requires treatment regardless of symptoms 2
  • Indicates heavy genital tract colonization
  • Associated with maternal and neonatal complications

Donation-Specific Concerns

• Screening for bacteriuria should be performed close to donation time (within 28 days) 1
• If GBS bacteriuria is detected immediately prior to surgery, consider perioperative prophylaxis to prevent surgical site infection 1
• No evidence suggests that treated or untreated GBS bacteriuria affects donor outcomes post-nephrectomy

Evidence Quality and Limitations

• Most evidence comes from studies on kidney transplant recipients rather than donors 1
• Studies consistently show no benefit to treating ASB in transplant recipients beyond the first month post-transplant 1, 3, 4
• Retrospective studies suggest untreated ASB has similar or better outcomes than treated ASB, with 70% showing spontaneous bacterial clearance 3
• Treatment of ASB may select for resistant organisms, potentially complicating management of future symptomatic infections 1

Conclusion for Clinical Practice

The presence of asymptomatic GBS bacteriuria in a potential living kidney donor should not delay or prevent donation, nor does it require specific antimicrobial treatment. Symptomatic infections should be treated according to standard protocols before proceeding with donation.