Does lymphoproliferative disease (LPD) increase the risk of urinary tract infections (UTIs)?

Does Lymphoproliferative Disease Increase Risk of UTIs?

Yes, patients with lymphoproliferative disorders (LPD) have a significantly increased risk of urinary tract infections, with severe infection rates reaching 23% and bacterial infections being the most common etiology. 1, 2

Evidence for Increased UTI Risk in LPD

The most compelling evidence comes from a multicenter real-world study of 458 LPD patients treated with targeted therapies, which demonstrated:

• Overall severe infection incidence of 23% during a median 17-month follow-up 2
• Bacterial infections comprised 54% of all severe infections, making them the predominant pathogen type 2
• Highest infection risk occurred in the first 3-6 months of targeted drug treatment, then decreased 2
• Infection-related mortality was 6%, indicating these are clinically significant complications 2

The 2022 European Conference on Infections in Leukaemia (ECIL 9) guidelines specifically identify lymphoproliferative disorders—particularly non-Hodgkin's lymphoma (NHL), chronic lymphocytic leukemia (CLL), and multiple myeloma—as being particularly associated with higher risk of SARS-CoV-2 and other infections due to acquired immunodeficiency and immunosuppressive treatments. 1

Specific Risk Factors That Amplify UTI Risk in LPD

Patient-Specific Factors:

• Severe lymphopenia (OR 4.7, p=0.009) is the strongest independent risk factor 2
• Combined targeted treatment versus single agent (OR 2.2, p=0.014) 2
• Previous rituximab exposure (OR 1.8, p=0.03) 2

Disease-Specific Considerations:

• Chronic lymphocytic leukemia patients treated with ibrutinib showed the highest rates of invasive fungal infections (6% of severe infections) 2
• Patients with chronic kidney disease and LPD face compounded immunocompromise, requiring adjusted antibiotic dosing and heightened surveillance 3

Clinical Management Approach

Diagnostic Evaluation:

• Obtain urinalysis and urine culture during each symptomatic episode to guide antimicrobial therapy 4
• Perform upper tract imaging (ultrasound or CT) if febrile UTI occurs or if patient doesn't respond to antibiotics 4
• Do NOT obtain surveillance/screening urine cultures in asymptomatic patients, as this promotes unnecessary antibiotic use and resistance 4

Treatment Strategy:

• Treat symptomatic UTIs with culture-directed antibiotics based on local resistance patterns 4
• Adjust antibiotic dosing based on renal function, particularly important given the overlap between LPD and chronic kidney disease 4, 3
• Do NOT treat asymptomatic bacteriuria, as this increases antimicrobial resistance without clinical benefit 4

Prophylaxis Considerations:

• Do NOT use daily antibiotic prophylaxis routinely in LPD patients, as this increases bacterial resistance without significantly reducing symptomatic infections 4
• In selected high-risk cases (severe lymphopenia, combined targeted therapy), antimicrobial prophylaxis should be considered on an individual basis 2
• Low-dose trimethoprim-sulfamethoxazole or fluoroquinolones have shown efficacy in other immunocompromised populations (transplant patients), though specific LPD data are limited 5

Critical Pitfalls to Avoid

Common Errors:

• Treating asymptomatic bacteriuria: This is the most common mistake and directly contributes to multidrug-resistant organisms without improving outcomes 4
• Obtaining urine cultures from collection bags or tubing: Always change catheters and allow fresh urine accumulation 4
• Delaying imaging in febrile UTI: Upper tract complications (stones, hydronephrosis) are more common in immunocompromised hosts 4, 3

Special Considerations:

• 22% of patients with severe infections required definitive discontinuation of their targeted LPD therapy, highlighting the clinical impact of infections on cancer treatment continuity 2
• JC virus reactivation has been reported in the urinary tract after long-term rituximab, causing severe ureteral strictures and nephropathy—consider this in patients with unexplained urinary tract deterioration 6

Follow-Up Recommendations

• Instruct patients to seek prompt evaluation (within 48 hours) for febrile episodes 4
• Monitor for infection risk particularly in the first 3-6 months of new targeted therapy initiation 2
• Consider urodynamic evaluation if recurrent UTIs persist despite unremarkable upper and lower tract imaging 4

The infection risk in LPD patients is substantial but manageable with appropriate surveillance, prompt treatment of symptomatic infections, and avoidance of unnecessary antibiotics for asymptomatic bacteriuria. 1, 4, 2