BACKGROUND: Despite the burden of pyelonephritis after kidney transplantation, there is no consensus on initial empirical antibiotic management. METHODS: We surveyed clinicians throughout the world on their practice and opinions about the initial empirical therapy of post-transplant pyelonephritis, using clinical vignettes. A panel of experts from 19 countries on six continents designed this survey, and invited 2145 clinicians to participate. RESULTS: A total of 721 clinicians completed the survey (response rate: 34%). In the hypothetical case of a kidney transplant recipient admitted with pyelonephritis but not requiring intensive care, most respondents reported initiating either a 3rd-generation cephalosporin (37%) or piperacillin-tazobactam (21%) monotherapy. Several patient-level factors dictated the selection of broader-spectrum antibiotics, including having a recent urine culture showing growth of a resistant organism (85% for extended-spectrum ß-lactamase-producing organisms, 90% for carbapenemase-producing organisms, and 94% for Pseudomonas aeruginosa). Respondents attributed high importance to the appropriateness of empirical therapy, which 87% judged important to prevent mortality. Significant practice and opinion variations were observed between and within countries. CONCLUSION: High-quality studies are needed to guide the empirical management of post-transplant pyelonephritis. In particular, whether prior urine culture results should systematically be reviewed and considered remains to be determined. Studies are also needed to clarify the relationship between the appropriateness of initial empirical therapy and outcomes of post-transplant pyelonephritis.

Department of Infectious Diseases Austin Health Heidelberg Australia

Department of Infectious Diseases Guadeloupe University Hospital Les Abymes France

Department of Kidney Transplant Hospital Evangelico de Minas Gerais Belo Horizonte Brazil

Department of Kidney Transplantation Hôpital Necker Enfants Malades Assistance Publique Hôpitaux de Paris Paris France

Department of Laboratory Medicine Transplant Program Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brazil

Department of Medicine and Surgery Kidney Pancreas Transplant Unit University of Parma Parma Italy

Department of Medicine Harvard Medical School Boston Massachusetts USA

Department of Medicine Unit of Infectious Diseases Hospital Universitario 12 de Octubre Instituto de Investigación Sanitaria Hospital 12 de Octubre School of Medicine Universidad Complutense Madrid Spain

Department of Nephrology Aalborg University Hospital Aalborg Denmark

Department of Nephrology and Organ Transplantation Toulouse Rangueil University Hospital Toulouse Institute for Infectious and Inflammatory Diseases University Paul Sabatier Toulouse France

Department of Nephrology BRB Hospitals Ltd Dhaka Bangladesh

Department of Nephrology Dialysis and Kidney Transplantation CUB Hôpital Erasme Brussels Belgium

Department of Nephrology Institute for Clinical and Experimental Medicine Prague Czech Republic

Department of Nephrology Medanta Medicity Gurgaon India

Department of Nephrology Radboud University Medical Center Nijmegen The Netherlands

Department of Nephrology Transplantation Dialysis and Apheresis Pellegrin University Hospital Bordeaux France

Department of Renal Medicine Singapore General Hospital Singapore Singapore

Division of Nephrology Department of Internal Medicine 3 Medical University of Vienna Vienna Austria

Infectious Diseases Division Hospital das Clínicas University of São Paulo Medical School Sao Paulo Brazil

Infectious Diseases Unit Sheba Medical Center Tel Hashomer Israel

Infectious Diseases Unit St Louis Hospital Assistance Publique Hôpitaux de Paris Paris France

Internal Medicine Department Infectious Diseases Section Hospital Italiano de Buenos Aires Buenos Aires Argentina

Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Australia

Transplant Infectious Disease and Compromised Host Program Division of Infectious Diseases Massachusetts General Hospital Boston Massachusetts USA

Transplant Unit Groote Schuur Hospital and University of Cape Town Cape Town South Africa

Transplantation Centre and Service of Infectious Diseases University Hospital of Lausanne Lausanne Switzerland

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