What is the recommended treatment for a urinary tract infection (UTI) in a patient post-transplant and on Adaport (mycophenolate mofetil)?

Treatment of UTI in Post-Transplant Patients on Adaport (Mycophenolate Mofetil)

For urinary tract infections in post-transplant patients on mycophenolate mofetil (Adaport), initial treatment should include intravenous antibiotics for pyelonephritis or oral antibiotics for lower UTIs, with trimethoprim-sulfamethoxazole as first-line therapy if the patient is not already on prophylaxis.

Diagnosis and Assessment

• Distinguish between asymptomatic bacteriuria (which should not be treated beyond 1 month post-transplant) and symptomatic UTI
• Obtain urine culture before initiating antibiotics to guide targeted therapy
• Assess for signs of upper UTI (pyelonephritis): fever, flank pain, costovertebral angle tenderness
• Evaluate for potential urological abnormalities that may predispose to infection

Treatment Algorithm

For Allograft Pyelonephritis (Upper UTI)

1. Initial approach: Hospitalization and intravenous antibiotics 1

   • Recommended empiric regimens:
     • Amoxicillin plus an aminoglycoside
     • Second-generation cephalosporin plus an aminoglycoside
     • Intravenous third-generation cephalosporin 1

2. Duration: 14 days (especially for men when prostatitis cannot be excluded) 1, 2

3. Step-down therapy: Consider oral antibiotics when patient is afebrile for at least 48 hours and clinically improving

For Lower UTI (Cystitis)

1. First-line options (if not already on prophylaxis):

   • Trimethoprim-sulfamethoxazole 160/800mg twice daily 2
   • Ciprofloxacin 500mg twice daily (only if local resistance <10%) 1, 2

2. Duration: 7 days for uncomplicated lower UTI 1, 2

Important Considerations

• Drug interactions: Monitor mycophenolate mofetil (Adaport) levels when using certain antibiotics, particularly fluoroquinolones, as they may affect drug metabolism 2

• Antibiotic resistance: Avoid ciprofloxacin if:

  • Local resistance rates exceed 10%
  • Patient has used fluoroquinolones in the last 6 months
  • Patient is from a urology department 1

• Prophylaxis: All kidney transplant recipients should receive UTI prophylaxis with daily trimethoprim-sulfamethoxazole for at least 6 months after transplantation 1, 2

• Asymptomatic bacteriuria: Do not treat asymptomatic bacteriuria after 1 month post-transplant as it does not prevent symptomatic UTI or improve graft outcomes and may increase antibiotic resistance 2

Special Situations

• Recurrent UTIs: Consider urological evaluation for anatomical abnormalities that may require correction 3

• Antibiotic dosing: Adjust based on renal function to avoid toxicity 2

• Early post-transplant period: UTIs are most common in the first month post-transplant when patients are at highest risk due to intensive immunosuppression, urological devices, and interventions 2

Common Pathogens

Most common organisms in post-transplant UTIs include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1

Monitoring

• Follow-up urine cultures to confirm eradication
• Monitor renal function and immunosuppression levels
• Assess for clinical improvement within 48-72 hours of initiating therapy

Early and appropriate treatment of UTIs in transplant patients is crucial to prevent complications that could affect graft function and patient survival.