Perioperative genitourinary infection associated with sodium-glucose co-transporter 2 inhibitor use

Abstract

LEARNING OBJECTIVE #1: Describe the association between genitourinary tract infections and SGLT-2 inhibitors CASE: A 47 year old male with history of diabetes mellitus type 2 presented with acute onset progressive scrotal swelling and pain and fever 3 weeks after penile implant surgery. His current medications included canagliflozinmetformin, added just before surgery to improve his perioperative glucose control. On physical examination, the patient was febrile with scrotal swelling and tenderness to palpation. The patient laboratory evaluation was unremarkable includingWBC count of 7.5/mul and serumlactate of 1.0meq/L. Urinalysis was positive for glucose and trace ketones but negative for bacteria and white cells. A CT pelvis showed scrotal fluid consistent with abscess, and he was brought to the OR for penile prosthesis explant. Cultures grew MRSA and gram-negative rods. Blood cultures found MRSA bacteremia on second day of hospitalization. The patient was eventually discharged on IV vancomycin and amoxicillin-clavulanic acid for 14 days. In addition, the patients sodium glucose co-transporter 2 (SGLT-2) inhibitor, canagliflozin, was discontinued. The incident was reported to the FDA's post-marketing surveillance system. IMPACT: This case emphasizes the importance of shared decision making prior to surgery. As the SGLT-2 inhibitors are gaining in popularity the provider must be aware of the potential adverse outcomes and may even considering holding or discontinuing this medication in the setting of impending GU surgery as the risks of this medication class include increased risks of genitourinary infections DISCUSSION: SGLT-2 inhibitors are a novel treatment option for type 2 diabetes mellitus which have been shown to lower hyperglycemia, systolic blood pressure, and promote weight loss with reported adverse events including infections involving the genitourinary(GU) tract due to the medication mechanism of action. Canagliflozin is a selective SGLT-2 inhibitor which increases urinary excretion of glucose but is associated with an increased the rate of GU infections. The incidence of GU infections on an SGLT-2 inhibitor in the setting of GU surgery has not been described, but caution should be taken in perioperative use of this class in light of this risk.