Renal Transplantation and the Risk of Antibiotic Resistance: Need for New Guidelines Reference: Orlando G, Di Cocco P, Angelo MD, et al. Surgical antibiotic prophylaxis after renal transplantation: Time to reconsider. Transplant Proc.2010;42:1118– 1119.

A chief public health problem in both developed and developing countries all over the world according to the World Health Organisation was the increase in antibiotic resistance. As the antimicrobial agents have been losing their effectiveness, the incidence of this phenomenon has increased shockingly in the recent years and is expected to rise at a higher rate in the future. The onset of resistance to antimicrobial agents not only causes a signifi cant economic problem, but also poses a serious threat to human health.

Accordingly, the World Health Organization strongly recommends global programs to reduce the usage of antibiotic agents in humans. Antibiotic prophylaxis before surgery is one fi eld in which antibiotic agents leave much to be desired. Although there are many evidences, which have shown the uselessness of multiple doses of antibiotic agents in most surgeries, physicians and surgeons involved in postoperative care still prescribe antibiotic agents in numerous doses for more than a day and is attributed to four factors, – Personal preference – Bad habit – Ignorance – Medicolegal concerns that force healthcare providers to adopt self- defensive strategies to prevent legal accusations

The effi cient administration of a single dose of antibiotic therapy at the induction of anesthesia has been demonstrated in urology, but the optimal regimen is yet to be determined after renal transplantation. According to a survey published by a Scandinavian consortium, it was found that in renal transplantation centers worldwide, 11% of the responding centers did not administer antibiotics for perioperative prophylaxis indicating a decreased trend in the usage of antibiotic prophylaxis (commonly administered for not more than 48 h after surgery). This observation infers that the aim of perioperative prophylaxis should be to prevent infections of the surgical wound and not the urinary tract. Urinary tract infections (UTIs) cannot be prevented by the usage of systemic antibiotic prophylaxis.

In renal transplantation procedure, the bladder is opened to facilitate the ureterovesical anastomosis, this could lead to contamination due to superinfection of the stagnant residual urine. Renal transplant patients are supposed to show a high-risk for postoperative wounds as a reason of chronicity of renal failure, anemia, malnutrition secondary to protein depletion and concomitant impairment of the immune system. Predisposing conditions like diabetes mellitus, coagulopathy, uremia and colonization of the bladder mucosa may be present in some patients and such conditions have a minimum effect on the risk of surgeryrelated infections because of the introduction of effi cient dialysis therapy and improvized management of the patient. Besides, surgeries have been modernized and prevention of surgical site infections being very important can be attained through a careful surgical technique, complete hemostasis and obliteration of dead space.

In many cases, infections are the main cause of mortality, morbidity and hospitalization after renal transplantation. During such situations, optimal usage of the antibiotic therapy can be considered to prevent the emergence of infection by resistant strains. Recently, a demonstration was conducted to show high incidence rates of antibiotic resistance in renal transplant recipients. In a retrospective study, the incidence of UTIs caused by germs resistant to cefotaxime and trimethoprim-sulfamethoxazole was evaluated and were routinely administered for perioperative antibiotic prophylaxis and anti- Pneumocystis carinii prophylaxis. The presence of more than 100,000 colonyforming units defi ned the UTI even if the patient did or did not show signs of infection. An observation showed resistance to cefotaxime in 49.0% of patients, and to trimethoprim-sulfamethoxazole in 70.8% in UTI patients.

After administration of minimum doses of these molecules, resistance to antibiotic therapy developed. On the whole there was a need for more effective and safer use of this class of compounds. There should be a reformulation of guidelines for perioperative antibiotic prophylaxis. For defi ning an optimal treatment, a multicenter prospective randomized trial comparing 1-shot vs. multiple dose regimens should be performed. In the intervening time, there should be an optimum usage of antibiotic agents to lower the emergence of resistant strains. The guidelines for nosocomial hygiene should be strictly followed, sterility in the operating room and on the ward should be stringently emphasized, external tools like urinary catheters, central lines and surgical drains should be removed as soon as possible. It is necessary for high-risk patients such as those with diabetes, abnormalities of the urinary tract, morbid obesity or severe malnutrition to adopt a more aggressive prophylactic regimen.