ORIGINAL RESEARCH

Prevalence of urinary tract infection in the first month after kidney transplant at a university hospital

Natasha Cristina Cunha Muniz^I; Felipe Kaezer dos Santos ^II; Frances Valéria Costa e Silva^III; Joyce Martins Arimatea Branco Tavares^IV; Ricardo de Mattos Russo Rafael^V; Ingrid Fernanda Oliveira Vieira^VI

^I Nurse. Specialist in Nephrology Nursing, and Intensive Therapy, Rio de Janeiro State University. Brazil. E-mail: natasha.cunha84@yahoo.com
^II Nurse. PhD in Nursing. Assistant Professor, Faculty of Nursing, Rio de Janeiro State University. Brazil. E-mail: felipe.santos@uerj.br
^III Nurse. PhD in Health Sciences. Adjunct Professor, Faculty of Nursing, Rio de Janeiro State University. Brazil. E-mail: francesvcs@gmail.com
^IV Nurse. PhD in Nursing. Assistant Professor, Faculty of Nursing, Rio de Janeiro State University. Brazil. E-mail: joyarimatea@yahoo.com
^V Nurse. PhD in Sciences. Adjunct Professor, Faculty of Nursing, Rio de Janeiro State University. Brazil. E-mail: prof.ricardomattos@gmail.com
^VI Nurse. Specialist in Nephrology Nursing, Rio de Janeiro State University, Brazil. E-mail: ingridfoliveira@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.26479

ABSTRACT

Objective: to ascertain the prevalence of cases of urinary tract infection (UTI) in patients during the first month after receiving a kidney transplant, and identify possible explanatory factors. Method: this quantitative, retrospective, cohort study examined the records and laboratory database of a university hospital in Rio de Janeiro. Data on 73 patients were collected from March to July 2016 into a database, and analyzed descriptively using STATA software. The study was approved by the research ethics committee (Opinion 1.517.614). Results: a higher incidence of UTI was found in female patients and in those with longer hospital stays. Conclusion: UTI rates were high in the first month after kidney transplants. At the end of the study, it was possible to highlight factors possibly related to that rate, such as the use of immunosuppressive induction.

Keywords: Kidney transplantation, infection, nursing in nephrology, complications.

INTRODUCTION

Chronic kidney disease (CKD) is currently considered a public health problem and can be defined as the gradual and irreversible loss of renal function. Although it is considered a silent disease¹, CKD has six stages classified according to the glomerular filtration rate, comprising the stages 1, 2, 3a, 3b, 4 and 5, the latter being the most severe, also called end-stage renal failure characterized by a glomerular filtration rate below 15ml/min/1.73m².

Renal replacement therapy may be performed through hemodialysis, peritoneal dialysis or renal transplantation and should be implemented when the patient reaches end-stage renal failure, when the kidneys are unable to maintain metabolic and electrolyte balance^3,4.

The worldwide prevalence of end-stage CKD has increased considerably in recent years and as a result, the number of patients requiring some type of renal replacement therapy has significantly increased^4-6.

Renal transplantation is the replacement therapy considered the treatment of choice for patients in the end-stage CKD, since it improves the quality of life of the recipient and presents lower financial costs for the health system in relation to the other^5,7,8 choices. However, it is important to note that approximately 80% of renal graft recipients present some type of infectious complication during the first year after transplantation. In many cases, patients are affected by the infectious complication even during hospitalization⁹.

Urinary tract infection (UTI) represents the most common nosocomial infection, one of the main sites of infection according to topography, and is also the most common infection after renal transplantation¹⁰.

Infectious processes may be associated with multiple risk factors such as sanitary conditions, immunity, non-adherence to hand sanitization by health professionals, among others. In this context, nursing plays an essential role in the prevention and control of infectious complications, not only in patients after renal transplantation, but also in all cases of hospital infections^9,11.

Furthermore, although other professionals also frequently get in contact with the patients, the nursing team is the segment of the multidisciplinary team that performs most of the direct contact actions, besides routinely manipulating equipment and medications¹¹.

UTIs represent one of the main threats in the first weeks after kidney transplantation, directly influencing the morbidity and mortality rates of the population submitted to this procedure. In view of the relevance of the presented theme, the objectives of this study were: to identify the prevalence of UTI cases in patients submitted to renal transplantation during the first month after the procedure; and analyze the possible explanatory factors for such occurrences.

LITERATURE REVIEW

The science and technology involved in transplantations have evolved over the years, causing a significant increase in the number of procedures that benefit patients who need solid organs⁴. Only in the year 2014, 5,639 kidney transplants were registered in Brazil¹⁰.

Evidence has shown that some transplanted patients successfully and rapidly recover, but others present postoperative complications, the main ones being of immunological and infectious nature⁷.

The large number of patients who develop infectious diseases in the first year after renal transplantation represents a major challenge because these complications significantly interfere in the increase of morbidity and mortality among this population^9,12.

Studies have shown that infections account for about 51% of readmissions occurring within six months after transplantation in kidney transplant patients, behind only to surgical complications¹².

According to recent research, the most frequent infections after renal transplantation are mostly those related to the urinary tract (28.5%), followed by surgical wound and venous catheter in second and third place, respectively. It should be noted that the main cause of death in this population has infectious origin^7,10,13.

UTI consists in an inflammatory response of the urethium characterized by the invasion and multiplication of potentially pathogenic germs in any segment of the urinary tract, which is normally sterile^14,15.

In transplanted patients, specifically, the main factors that interact to modify the risk of infections are the profile of immunosuppression employed, exposure to infecto-contagious diseases, grafts provided by deceased donors, quality of the surgical procedure and postoperative care ^9,10.

In the first three months after kidney transplantation, hospital infections are predominant, especially in the urinary tract, surgical wound, and caused by cytomegalovirus⁹.

As a serious public health problem and among the main causes of morbidity and mortality, the prevention, treatment and control of hospital infections represent serious challenges for government authorities, institutions and health professionals¹¹.

In this sense, the interdisciplinary team and especially the nurses play an important role to patients and their families. Nursing monitoring, detection and intervention of injuries are essential to minimize and prevent complications and improve the quality of life of these patients ^16,17.

It is worth noting that nurses have legal support from the Federal Nursing Council (COFEN), through the Professional Exercise Law 7,498 of June 25, 1986, to carry out interventions to reduce the risk of hospital infections and must intervene specifically bearing in mind the customers' needs ^11,18.

METHODOLOGY

This is a quantitative, retrospective, cross-sectional, cohort study, where an group exposed from a certain moment of the past until recent past or present is followed-up in order to identify the morbidity or mortality that occurred among the participants^19,20.

In order to identify the occurrence of UTI within 1 month after renal transplantation, a documentary analysis technique was used in a university hospital in the State of Rio de Janeiro, a research modality that examines materials from primary sources, i.e. that have not received no scientific treatment and neither the contributions of other authors²¹.

The primary sources analyzed were the medical charts of the sample patients, and the database of the bacteriology laboratory of the unit. We analyzed the original records of the nephrology multidisciplinary team in medical charts and the results of urine culture from the database of the laboratory in question.

Initially, 156 patients were submitted to renal transplantation between January 2011 and December 2015. The medical charts of patients of both sexes (female and male) of different age groups with negative and positive serology for Hepatitis B and C and submitted to one or more renal transplants in the described period were considered for inclusion.

We did not include in the study the charts of patients with grafts from donors with positive culture (when perfusion fluid culture was not performed, or when perfusion fluid culture was also positive for being a possible infectious focus), with positive serology for HIV, charts that were unavailable for some reason. We found 73 charts of patients that met the inclusion criteria. We excluded 49 patients from the study because of positive culture of donor, positive perfusion fluid culture or nephrectomy in the first month. Another 11 subjects were excluded because their medical records were not found, and 23 because their records belonged to the deceased patient file section, where an accident had occurred, making it impossible to access these documents.

After collection, the data were organized in a spreadsheet to begin the descriptive analysis based on absolute and relative frequencies for the categorical variables, and means and standard deviation for the continuous variables. For this, the software STATA was used.

It was determined the percentage of patients who developed UTI during the observation period, the characteristics of this group, the associated germs, and the characteristics of the group that did not develop this complication.

This type of analysis had as purpose to understand how the events develop so as to generate new knowledge and new ways to understand the phenomena ²¹.

It should be noted that all aspects of Resolution nº 466/2012 of the National Health Council ²² were respected, and the project was approved by the Research Ethics Committee under the Opinion nº 1,517,614.

RESULTS AND DISCUSSION

Among the 73 patients who had the charts analyzed, 34 (46.58%) had a positive urine culture in the first month after renal transplantation. In the group that had positive urine culture, 22 (64.71%) patients were females; 15 (44.12%) were between 46 and 60 years of age; and 29 (85.30%) had received the renal graft from a deceased donor.

Regarding immunosuppressive therapy, 27 (79.41%) had undergone induction with the use of thymoglobulin and 31 (91.18%) had made use of the initial immunosuppressive scheme protocol.

The presence of indwelling bladder catheters (IBC) for more than 5 days occurred in 18 (52.94%) patients and 5 (14.70%) changed the IBC or had their catheter reinserted within one month after transplantation. Only 2 (5.88%) patients underwent bladder catheterization during this period.

Of the 34 patients who had a positive urine culture, 26 (76.47%) had remained hospitalized for more than 15 days in the first month after transplantation, and 20 (58.80%) showed a positive result for urine culture before completing 15 days after the procedure.

Research has shown that one out of six patients in hospitals is victim of some kind of incident related to patient safety, which is most often preventable. Such incidents may cause temporary or permanent damage and prolongation of hospitalization, as evidenced in the results of the study, and can cause even death^23,24.

As demonstrated in the results of this study, likewise reported in the literature, UTI deserves special attention for it represents the most common hospital infection (responsible for 35 to 45% of all hospital-acquired infections) and one of the main sites of infection according to topography. UTIs have a great potential to trigger other complications besides renal parenchymal lesions, which may prolong hospitalization time, increase treatment costs and the risk associated with the newly implanted graft^10,15.

Among the most relevant characteristics found in the profile of patients who developed UTIs within one month post-transplant, we observed a predominance of females and the adult age group. These data are in agreement with information in the literature in general, where the high prevalence of female and adulthood among UTI patients is widely reported, despite the fact that the population studied here was predominantly male ^14,25.

Permanent use of immunosuppressants may be directly related to the incidence and severity of infectious complications, especially in the early post-transplant period. This finding is corroborated by the high prevalence of thymoglobulin induction and the initial immunosuppressive regimen used in the unit (predinisone, mycophenolate mofetila and tacrolimus) in the established profile^7,13.

Endorsing this information, some authors emphasize that the individual's immune system plays an active role in the prevention and resolution of UTIs. Therefore, the fact that transplanted patients require continuous immunosuppression in the postoperative period makes them more susceptible to developing the infectious process^7,13,14.

Another factor described in the literature that has a significant association with the incidence and severity of infectious complications in renal transplant patients, and which was also found in the profile of patients who developed UTI during the period studied, is the graft originating from a deceased donor⁹.

A 2010 study showed that transplants using organs from deceased donors were 5.4 times more likely to develop infectious complications when compared to transplants performed with live donors and siblings. Such finding may be associated with a longer time of cold ischemia, a typical characteristic of transplants with organs from deceased donors⁹.

Reinforcing this data, the same study admits that every 30 further minutes of cold ischemia to the graft obtained from deceased donor imply a significant and independent association with the risk of developing infectious complications⁹.

Regarding the use and maintenance of IBC in the postoperative period, although the findings in the patients' profile did not show to have been a highly relevant factor, they are in accordance with the literature, which has described the use of IBC as a factor frequently present among patients who develop UTIs^7,13.

The use of IBC is a routine procedure in renal transplant recipients during the postoperative recovery, for strict control of urinary output and water balance. However, the literature recommends the use of IBC for the shortest possible time as a strategy to reduce the risk of infections^7,13 .

IBCs represent an important resource in health care. However, although published and updated protocols on the installation and maintenance of IBCs are available, an often excessive use and the permanence of the device for longer periods of time than necessary are still observed^10,26.

The continuing education of the nursing team, with an increase in hand hygiene measures and adequate manipulation of the catheter, early diagnosis and continuous follow-up of the incidence of UTI associated with IBC are fundamental elements for the control of UTIs^{10, 27}.

There is also a clear association between UTI and prolonged hospital stay, either because of the increased risk of developing an infectious complication with the long hospitalization period, or in the opposite direction, when we associate the infectious complication as a cause of prolonged hospitalization.

Recent investigations have emphatically associated the occurrence of infectious complications with longer hospital stay. In addition, the statistical association between infectious conditions and renal graft rejection has also been widely reported in current publications ^7,13.

Some authors attribute to nephrology nurses the responsibility to promote greater adherence to the treatment of the recipient, in addition to preventing and acting adequately before possible diseases, especially infectious ones^13,17.

In this sense, such professionals play an important role in the prevention of infectious complications, since they must be able to carry out safe practices, emphasizing the observation of the human being in a holistic way, with the objective of helping the individual and the family to face and understand the experience of pain, and suffering^7,11.

Another finding of great relevance in the research was the long interval between the results of contaminated urine cultures and subsequent cultures. A portion of the sample presented contamination in the first month after kidney transplantation 12 (16.44%), with an average interval of 10 days between the result of contamination and the next culture, reaching up to 27 days in certain cases.

Identification of two or more strains of different bacteria in a single sample should be considered as contamination. To this fact, it follows the recommendation to immediately collect a new sample¹⁵. However, in the hospital studied, results are considered contaminated only when more than three different strains appear, being considered positive results with up to 3 distinct strains, what minimizes the prevalence of UTIs in these patients.

Of the 12 (16.44%) results considered cases of contamination, 5 (41.67%) presented a positive culture result in the subsequent collection. However, most of these were not considered in the research because they were already outside the one-month post-transplant period. Thus, it should be considered that this fact may have minimized the UTI rates determined in the study.

Early diagnosis and treatment of UTI is a way of avoiding renal parenchymal lesions, since there is a greater risk of renal damage when initiating the therapy is delayed²⁸. In this context, nurses have relevant attributions; they must guide the patients and their relatives, clarifying doubts about possible complications inherent to the treatment, seeking strategies to avoid complications, mainly infectious, or formulating strategies to combat them when already installed, among others¹⁷ .

In recent years the concern with providing the patient a safe health care has been frequent, and the correlation between the direct care provided to patients and the occurrence of care-related incidents has been minimized as the appreciation for safety in individual and group values ​​has increased ²⁹.

Thus, the characteristics of all organizational levels are taken into consideration, from the managerial to the professionals who work with the direct care to the patients, stimulating the recognition of risk circumstances throughout the organizational process^29-31.

Finally, the high UTI rate found, as well as the delineation of the profile of the patients affected in the first month, leads to the reflection about the consequences of patient safety flaws related to infection control at various organizational levels, which may incur in increased expenses for patients, as well as length of hospitalization and even death. This would reduce the patients' confidence in the system and in the health professionals²⁴.

CONCLUSION

As conclusion of the study, it was possible to identify the high prevalence of UTI within one month after renal transplantation in a university hospital in Rio de Janeiro, as well as recognize and discuss the main factors of greater influence for this occurrence, thus achieving the proposed objectives.

The factors that demonstrated the most significant association with the occurrence of UTI were gender, type of donor, use of immunosuppressive induction and length of hospital stay. All factors have been described in the scientific literature.

However, considering that most of the patients are male and that there is still a significant incidence of cases of UTI among female patients, it is necessary to reflect on the common causes of infection in non-transplanted persons, such as the issue of hygiene and related self-care.

Another factor of great relevance was the length of hospital stay, a fact that correlates directly with infectious complications. This association has been widely discussed and already established as one patient safety goals.

The research presented as a limitation the impossibility of gathering information from all patients during the intended period, which prevented the inclusion of more than 30 medical charts.

Finally, it is important to emphasize that the UTIs in this unit represent a major challenge not only for nurses, but also for the other areas related to the care of patients undergoing kidney transplantation. It is necessary to invest in continuing education, and to improve communication within the multidisciplinary team so as to optimize the quality of care offered.

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