Transplant Int (1990) 3:12-14 TRANSPLANT- International 9 Springer-Verlag 1990 The effect of intravesically applied antibiotic solution in the prophylaxis of infectious complications of renal transplantation K. Salmela, B. Eklund, L. Kylliinen, H. Isoniemi, C. Korsbiick, K. Hiickerstedt, and J. Ahonen The Fourth Department of Surgery, Helsinki University Central Hospital, Kasarmikatn 11-13, SF-00130 Helsinki, Finland Received August 2, 1989/Received after revision December 28, 1989/Accepted January 23, 1990 Abstract.The effect of intravesically applied antibiotic solution in the prevention of infectious complications of renal transplantation was evaluated in a prospective, ran- domized study. The bladder was filled preoperatively with saline solution containing cephalotin in the test group, and with saline solution only in the controls. Both groups of patients received IV doses of cephamandole during, and once after, surgery. Two hundred consecutive patients were randomly allocated to the study groups. The overall incidence of urinary tract infection was 10.4% during the first 4 postoperative weeks; that of wound infections was 1.6% and of septicemia 3.3%. The addition of cephalotin to the bladder irrigation fluid did not have any effect on the overall incidence of infectious complications. Key words: Urinary tract infection, prophylaxis - Bladder irrigation, antibiotics - Antibiotics, bladder, prophylaxis Urinary tract infection (UTI) can lead to major morbidity in renal transplant patients. UTI has been reported to be associated with deep wound infections, septicemia, and impaired graft survival in kidney transplant recipients [1, 2, 3, 6, 7]. It has been shown that patients with chronic renal failure harbor organisms in their bladder [6]. Al- though it has been postulated that irrigation of the bladder with antibiotic solution may reduce the incidence of post- operative infectious complications of renal transplanta- tion [9], no randomized study has been published. We, therefore, conducted a prospective, randomized study to analyze the incidence of early infectious complications in renal transplant recipients when the bladder was irrigated with saline solution with or without cephalotin. Patients and methods This prospective, randomized study on 200 consecutive kidney trans- plant recipients was conducted at our center during the period from September 1987 to February 1989. Retransplantations comprised 17% of the cases (12% second,3% third, and 2% fourth). The patients were randomly allocated to two groups by the closed envelope Offprint requests' to: K. Salmela method. Prior to surgery the bladder was filled either with 200 ml or to capacity in those few cases with bladder volume less than 200 ml. In one group (cephalotin group; n = 100), the bladder was filled with saline solution (NaC1 0.9% in water) containing 1 g cephalotin sodium (Keflin, Eli Lilly, Indianapolis, Ind). In the other group (saline group; n = 100), it was filled with saline solution only. During the transplant operation and 12 h postoperatively, 1 g cephamandol (Mandokef, Eli Lilly, Indianapolis, Ind) was given to the patients. Eighteen patients were excluded because of additional antibiotic use for different reasons within 3 weeks after transplantation (Table 1). The remaining 182 patients with no additional antibiotic therapy were included in the study. The cephalotin and saline groups were comparable with regard to age, sex, source of kidney graft, primary disease, pretransplant oliguriaJanuria, onset of graft function, and number of rejection episodes (Tables 2, 3). There were no significant differences between the groups. The infectious complications occur- ring within 4 weeks post-transplantation were analyzed in this study. The surgical technique used for the transplant operation was the same for all of the patients. The kidney graft was placed extraperito- neally in the iliac fossa, the allograft artery was anastomosed to the internal or external iliac artery and the allograft vein to the external iliac vein. The ureter was anastomosed to the recipient bladder as an open intravesical ureteroneocystostomy. In one patient with a pyeloureteral stenosis in the graft, the ureteral continuity was pri- marily restored using a pyeloureterostomy. No drains were left in the operation area. The indwelling bladder catheter was left in place for 5 days. A bacterial culture of the urine was taken preoperatively, during the transplant operation, and postoperatively every 5th day. Immunosuppressive treatment included azathioprine (2 mg/kg per day tapered to I mg/kg per day at 2 weeks), methylprednisolone (1 mg/kg per day tapered to 0.25 mg/kg per day by 2 weeks), and cyclosporin (initially 10 mg/kg per day, dose-adjusted according to the trough level). For recipients of kidneys from living related Table 1. Causes for antibiotic use in excluded patients Upper respiratory tract infections 4 Prophylactic antibiotics Skin infections 5 Tuberculosis in history 1 Osteitis in history 1 Postsplenectomy ] Extended operation time 1 Colon dilatation 1 Positive legionella antibody 1 Positive culture Urine preoperatively 1 Peritoneal catheter exit site 1 Transplant preservation fluid 1 Total 18