A single dose of meropenem is superior to ciprofloxacin in preventing infections after transrectal ultrasound-guided prostate biopsies in the era of quinolone resistance

Occurrence and significance of fluoroquinolone-resistant and ESBL-producing Escherichia coli and Klebsiella pneumoniae complex of the rectal flora in Ghanaian patients undergoing prostate biopsy

Background

Reports suggest that fluoroquinolone (FQ)-resistant and ESBL-producing rectal flora are associated with infectious complications in men undergoing transrectal ultrasound-guided prostate needle biopsy (TRUS-B)

Objectives

We investigated the relationship between carriage of FQ-resistant and ESBL-producing Escherichia coli and Klebsiella pneumoniae complex of the rectal flora, and the 30 day incidence rate of post-TRUS-B infectious complications.

Methods

From 1 January 2018 to 30 April 2019, rectal swabs of 361 patients were cultured pre-TRUS-B for FQ-resistant and ESBL-producing flora. Patients were followed up for 30 days for infectious complications post-biopsy. Multivariable logistic regression analyses were used to identify risk factors.

Results

Overall, 86.4% (n = 312/361) and 62.6% (n = 226/361) of patients carried FQ-resistant and ESBL-producing E. coli and K. pneumoniae complex, respectively. Approximately 60% (n = 289/483) of the FQ-resistant and 66.0% (n = 202/306) of the ESBL-positive isolates exhibited in vitro resistance to the pre-biopsy prophylactic antibiotic regimen of levofloxacin and gentamicin. Amikacin and meropenem were the most effective antibiotics against the MDR rectal E. coli and K. pneumoniae complex (78.7% and 84.3%, respectively). The 30 day incidence rate for post-biopsy infections was 3.1% (n = 11/361), with an overall high probability (96.9%) of staying free of infections within the 30 day period post-TRUS-B. Antibiotic use in the previous 3 months was a risk factor for rectal carriage of FQ-resistant and ESBL-positive isolates. Rectal colonization by ESBL-positive E. coli and K. pneumoniae complex comprised an independent risk factor for post-biopsy infectious complications.

Conclusions

The findings suggest that a change in prophylactic antibiotics to a more targeted regimen may be warranted in our institution.

Recent Trends in Prostate Biopsy Complication Rates and the Role of Aztreonam in Periprocedural Antimicrobial Prophylaxis—A Nationwide Population-Based Study from Korea

An increase in the rate of complications after prostate biopsy (PB) due to increased antibiotic-resistant bacteria is a global issue. We report the safety of aztreonam as a prophylactic antibiotic in patients undergoing PB. We investigated the complication rates according to several antibiotic regimens, including aztreonam. We hypothesized that PB complications increased following a rise in antibiotic-resistant bacteria. We examined the annual rates of complications among patients in our hospital (clinical cohort) and the Korea Health Insurance Review and Assessment Service (HIRA) cohort. Data regarding complications, hospitalization, emergency room (ER) visits, and febrile urinary tract infections occurring within 2 weeks after PB were recorded. The rate of complications was significantly lower in patients who received oral quinolone and intravenous aztreonam than in those who received oral quinolone. The complication rates did not increase throughout the study period. Additionally, 1754 patients from the HIRA cohort were included. The rates of complications, hospitalizations, and ER visits did not increase among these patients. Oral quinolone combined with intravenous aztreonam reduced the rate of febrile complications compared to quinolone alone and was safe to use after PB. Therefore, we recommend intravenous aztreonam with oral quinolone as a prophylactic antibiotic regimen before PB.

Current routines for antibiotic prophylaxis prior to transrectal prostate biopsy: a national survey to all urology clinics in Sweden

Background: The risk of infection after transrectal ultrasound (TRUS)-guided prostate biopsies is increasing. The aim of the study was to assess the use of antibiotic prophylaxis for prostate biopsy in Sweden. Methods: All public and private urology clinics reporting to the National Prostate Cancer Register of Sweden received a survey on TRUS-biopsy prophylaxis. Results: Of the 84 clinics surveyed, 76 replied (90%). If no risk factors for infection were present, a single dose of ciprofloxacin 750 mg was used by 50 clinics (66%). Multiple doses of ciprofloxacin 500 or 750 mg (n=14; 18%) or a single dose of trimethoprim-sulfamethoxazole 160/800 mg (n=7; 9%) were other common prophylaxes. Most clinics gave the prophylaxes immediately before the biopsy (n=41; 54%). Urine dipstick was used by 30 clinics (39%) and rectal enema by six (8%). In patients with high risk of infection, the survey mirrors a large variety of regiments used. Conclusions: The preference to use a single dose of ciprofloxacin 750 mg is in accordance with the Swedish national guidelines for patients with a low risk of infection. Better compliance to the guideline recommendation to use a urine dipstick would probably increase the number of patients classified as having an increased risk of infection. Being classified as a high-risk patient should lead to an extended duration of antibiotic prophylaxis, however, the variety of regimens used in the high-risk group reflects an inability to treat these patients in a standardized fashion and also highlights a need for more clear-cut guidelines. Pre-biopsy identification of high-risk patients is an important issue to tackle for the urologic clinics in order to reduce the number of infections.

Considerations and Caveats in Combating ESKAPE Pathogens against Nosocomial Infections

ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are among the most common opportunistic pathogens in nosocomial infections. ESKAPE pathogens distinguish themselves from normal ones by developing a high level of antibiotic resistance that involves multiple mechanisms. Contemporary therapeutic strategies which are potential options in combating ESKAPE bacteria need further investigation. Herein, a broad overview of the antimicrobial research on ESKAPE pathogens over the past five years is provided with prospective clinical applications.

A significant percentage of patients with transrectal biopsy-related infections have positive blood cultures but negative urine cultures. A literature review and meta-analysis

BACKGROUND

Infectious complications after transrectal prostate biopsy are rare. Nevertheless, since these are frequent procedures, the burden of infectious complications is high. Considering the increasing antimicrobial resistance, microbiological confirmation is important to guide antimicrobial therapy.

METHODS

We reviewed PubMed for original studies providing concurrent urine and blood culture data in symptomatic patients with transrectal biopsy-related infectious complications. We performed a proportions meta-analysis (with MedCalc) and calculated the pooled yield of urine and blood cultures and the pooled discordance rate between urine and blood cultures.

RESULTS

Our review identified 41 studies, involving 852 patients with infectious complications after transrectal prostate biopsy and sufficient data to calculate discordance. The pooled yield of urine cultures was 64.6% (95% CI: 56.2-72.3%, I² 83%), the pooled yield of blood cultures was 43% (95% CI: 36.5-49.7%, I² 74%) and the pooled discordance rate was 14% (95% CI: 10.6-17.8%, I² 53%). In subgroup analyses the pooled discordance was; 19.6% (95% CI: 11.8-28.9%, I² 31%) in 113 patients presenting within 2 calendar days after the biopsy and 11.2% (95% CI: 4.5-20%, I² 47%) in 143 patients presenting with fever and symptoms of lower urinary tract symptoms. The statistical and methodological heterogeneity of included studies was high.

CONCLUSION

Obtaining blood cultures is reasonable in all patients presenting with systemic symptoms suggestive of infection after a transrectal prostate biopsy. Blood cultures can provide additional microbiological data in about 1 of 7 patients with post-biopsy infectious complications. Prospective studies are needed to validate these results.

Antibiotic Prophylaxis in Prostate Biopsies: Contemporary Practice Patterns in Germany

Purpose

Prostate biopsy (pbx) is the most common outpatient procedure in urology. Complications are urinary tract infections, including hospitalization and sepsis. Recommendations on antibiotic prophylaxis (apx) are scarce, and healthcare data are not available. The study addressed the following endpoints: the duration and spectrum of antimicrobial prophylaxis in transrectal and transperineal pbx in the hospital and the practice setting.

Methods

A questionnaire compiled data about age, gender, board certification, and place of work. Information about the frequency of pbx, duration and type of apx, usage of disinfecting lubricant, and urine or rectal swab cultures was collected. The study refers to German urologists.

Results

Overall 478 urologists answered the questionnaire. 15.5% (74) of respondents were residents. 50.8% (243) of urologists work in a practice; the rest in a hospital. Only 4.8% do not perform pbx. Transrectal pbx are performed a median of two times a week. The majority (446, 98%) prescribe an apx, mostly fluoroquinolones (407, 89.5%). In total, 10.1% (46) of the participants use a single-shot-apx. apx has a median duration of 4 days. One-third uses a disinfecting lubricant. Urine and rectal swab cultures are analyzed by 45.5% (207) and 24.4% (111), respectively.

Conclusion

Most urologists prescribe an extended apx for both transrectal and transperineal pbx. Perineal pbx is still a deviation from everyday practice and not an established alternative to transrectal pbx. Urologists are aware of the increasing fluoroquinolone-resistance and are adapting with rectal swab and urine cultures. Further studies need to evaluate alternatives to 5-day apx and results should be addressed in our guidelines. This is of importance in light of the increasing resistance rates and fluoroquinolone side effects.

Transrectal ultrasound guided prostate biopsy in the era of increasing fluoroquinolone resistance: prophylaxis with single-dose ertapenem

PURPOSE

The aim of the study was to compare single-dose ertapenem (ERT) with the 3-day regime of ciprofloxacin (CIP) for prophylaxis of possible infections following transrectal prostate biopsy.

METHODS

Data from a consecutive group of 542 patients from January 2012 to January 2017 were retrospectively analysed. As preinterventional prophylaxis patient group A (179) received 500 mg CIP twice a day for three days, beginning on the day before the biopsy (until June 2013); group B (363) received a single dose of ERT 60 min prior to intervention. The first follow-up examination for all patients was between post-intervention days 2 and 3. The second follow-up examination was between day 15 and 30 following biopsy. Urine was cultured in all cases and any adverse drug reactions (ADRs) related to the antibiotic treatment were noted. We also recorded all clinically relevant morbidities requiring intervention (ischuria, macrohaematuria, symptomatic urinary tract infections and urosepsis), as well as those not requiring active intervention (macrohaematuria, decreased urinary stream, pain, haemospermia). The main study criterion was the symptomatic urinary tract infection rate and ADRs.

RESULTS

All 542 biopsied patients could be included in the study and the drop-out rate was zero. There were no significant differences between groups A and B with regards to complications not requiring intervention. There was, however, a significant reduction from 14.5% (group A) to 0.8% (group B) in infectious complications. This showed a significant correlation in favour of ERT (p < 0.001). Furthermore, in the ERT group there was also a distinct and significant reduction (p > 0.001) in the number of patients with bacteriuria (>10e4 cfu per ml urine) without fever (0.5%) compared to the CIP group (12.3%).

CONCLUSION

A single-dose of 1 g of intravenous ERT applied 1 h before a scheduled transrectal prostate biopsy is a safe option and provides effective protection against infection-related complications arising from surgery.