Challenges and controversies of urinary tract infection treatment in kidney transplant recipients.

Introduction: Urinary tract infection (UTI) is the most common infectious complication in kidney transplant recipients (KTRs). Beyond attributable morbidity and related costs, post-transplant UTI appears to exert a deleterious effect on graft outcomes. Uncertainties on the significance of asymptomatic bacteriuria (ASB) and the increasing role as uropathogens of multidrug-resistant organisms (MDROs) further complicate the therapeutic approach.

Areas covered: Following a contextualizing introduction on the epidemiology, risk factors and consequences of post-transplant UTI, we reviewed the rationale underlying the 'screen-and-treat' strategy for ASB and the recently generated evidence. Most appropriate regimens for the empirical treatment of cystitis and pyelonephritis are discussed in light of recent microbiological trends. The role of novel antibiotics against MDROs is considered, as well as the management of recurrent UTI and the feasibility of dedicated antibiotic stewardship programs (ASPs). Finally, future directions and unmet needs are addressed in the present narrative review.

Expert opinion: Despite advances to clarify the management of ASB and recent additions to the antibiotic armamentarium, research is needed to optimize the empirical and definitive therapy for post-transplant UTI. This should include the validation of predictive scores for MDRO infection, the effectiveness and safety of novel antibiotics, and the implementation of ASPs in KTRs.