New England Surgical Society

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Higher Risk of Urinary Tract Infections in Renal Transplant Recipients Receiving Pentamidine Versus Trimethoprim-Sulfamethoxazole (TMP-SMX) for Pneumocystis Pneumonia Prophylaxis
*Whitney Fu1, *Maria Barahona1, *Taylor Harkness1, *Elizabeth Cohen1, *David Reardon2, Peter Yoo1
1Yale School of Medicine, New Haven, CT;2Vizient, Inc., Irving, TX

Objective: For renal transplant patients who are intolerant of trimethoprim-sulfamethoxazole (TMP-SMX), aerosolized pentamidine may be used for Pneumocystis pneumonia (PCP) prophylaxis; however, this regimen does not provide the same coverage against urinary tract infections (UTI), one of the most common infectious complications. This study aimed to evaluate the risk of UTI in the first six months post-transplant among patients receiving PCP prophylaxis with TMP-SMX or pentamidine.

Design: Single tertiary referral transplant center
Patients: Renal transplant patients between the dates of 1/1/15 and 12/31/15 receiving TMP-SMX or pentamidine who completed at least six months follow-up post-transplant to completion of prophylaxis course. 81 patients included in the analysis.
Interventions: PCP prophylaxis with TMP-SMX (400/80 mg oral daily) or pentamidine (300 mg monthly)
Main Outcome Measures: Cumulative incidence of UTI; independent risk factors for UTI
Results: There were no breakthrough cases of PCP. Nineteen patients (23.5%) experienced at least one UTI. The rates of UTI in the TMP-SMX and pentamidine groups were 12% (9/58) and 43% (10/23), respectively. Kaplan-Meier analysis showed significantly higher cumulative incidence of UTI in the pentamidine group than in the TMP-SMX group (Log-rank test p<0.001) (Figure 1). On multivariate analysis, female sex (HR 3.773; 95% CI 1.654-8.603; p=0.002) and pentamidine prophylaxis (HR 3.464; 95% CI 1.615-7.432; P=0.001) were independently associated with increased UTI incidence.
Conclusions: Patients receiving pentamidine for PCP prophylaxis are at higher risk of developing UTI than patients receiving TMP-SMX. UTI prophylaxis with a second antibiotic agent for patients with other risk factors for UTI warrants further study.

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