Effectiveness and safety of antibiotics in kidney transplant recipients with asymptomatic bacteriuria: a systematic review and meta-analysis of randomized controlled trials

Abstract Background Asymptomatic bacteriuria (ASB) is generally systematically screened and treated with antibiotics in kidney transplant recipients (KTRs). We aimed to explore the role of antibiotic therapy in management of ASB in KTRs. Methods Randomized controlled trials (RCTs) conducted up to May 10, 2023 were searched on Ovid MEDLINE, Web of Science, PubMed, and Cochrane CENTRAL. We used inverse variance random effects models for all meta-analyses; in the case of rare outcomes, we used the Mantel-Haenszel method. ROB-2 criteria were used for assessment of risk of bias. Results We identified four RCTs (478 participants). Antibiotic therapy non-significantly increased acute pyelonephritis risk by 19% (relative risk [RR] 1.19, 95% CI 0.72-1.94; I2=0%) and symptomatic UTI risk by 18% (RR 1.18, 95% CI 0.78-1.78; I2=28%) vs. no therapy. Risks of all-cause mortality (RR 1.56, 95% CI 0.54-4.52); graft loss (RR 0.80, 95% CI 0.20-3.19); graft rejection (RR 0.89, 95% CI 0.46-1.70); change in serum creatinine level from baseline to end of study (mean difference [MD] 0.40 mg/dL, 95% CI -0.05 to 0.85); hospital admission due to symptomatic UTI (RR 0.92, 95% CI 0.48-1.76); symptomatic UTI caused by a multidrug-resistant organism (RR 1.31, 95% CI 0.63-2.74); Clostridioides difficile diarrhoea (RR 0.75, 95% CI 0.23-2.42); and serious adverse events (RR 1.20, 95% CI 0.75-1.91) did not significantly differ between groups. No significant difference in any outcomes between antibiotic therapy and no therapy arms was demonstrated across subgroup and sensitivity analyses. Conclusions Current evidence does not support routine screening and treatment of post-transplant ASB in KTRs.