Effectiveness of fosfomycin tromethamine prophylaxis in preventing infection following transrectal ultrasound-guided prostate needle biopsy: Results from a large Canadian cohort

Preventing Infections After Prostate Biopsy: Prophylactic Antibiotics, Prebiopsy Rectal Culture, and Biopsy Approach

Prostate biopsies are commonly performed for the early detection of prostate cancer and yet are associated with risks of life-threatening infections. Drug-resistant strains of Escherichia coli are the most common etiologic agents. Multiple maneuvers can reduce the risk of postbiopsy infections and sepsis during transrectal prostate biopsy including periprocedural empiric or targeted prophylactic antibiotics (based on previous rectal culture) and prebiopsy rectal cleansing with a povidone-iodine solution. The transperineal approach is associated with a very low risk of infection without requiring antibiotic prophylaxis.

Efficacy of fosfomycin compared to second generation cephalosporin flumarin as antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy: a single center retrospective study

BACKGROUND

Fluoroquinolone has been the historic choice of antimicrobial prophylaxis for transrectal ultrasound (TRUS) guided prostate biopsy. However, increased fluoroquinolone resistance and recent restrictions of its use for antimicrobial prophylaxis has led to the emergence of alternative agents for antimicrobial prophylaxis for TRUS guided prostate biopsy including fosfomycin and cephalosporins. This study aimed to compare the efficacy of fosfomycin and a second-generation cephalosporin flumarin as alternative antimicrobials for TRUS-guided prostate biopsy in terms of the incidence of infectious complications after TRUS-guided prostate biopsy.

METHODS

A retrospective chart review of all patients who underwent TRUS-guided prostate biopsy between November 2009 to January 2023 was undertaken. Comparison of baseline characteristics and the incidence of infectious complications was done between those who received fosfomycin as antimicrobial prophylaxis for TRUS-guided prostate biopsy and those who received flumarin. Multivariate logistic regression analysis was conducted to identify risk factors for infectious complications after TRUS-guided prostate biopsy.

RESULTS

Of 2,900 patients identified as eligible candidates for analysis, 333 (11.5%) received fosfomycin and 2,567 (88.5%) received flumarin. The overall rate of infectious complications was approximately 3% lower in patients who received fosfomycin, although such difference did not reach statistical significance (5.7% vs. 8.6%, p = 0.074). Multivariate logistic regression analysis showed that history of operation done under general anaesthesia within six months of the biopsy (odds ratio [OR]: 2.216; 95% confidence interval [CI]: 1.042-4.713; p = 0.039) and history of prior antimicrobial use within six months (OR: 1.457; 95% CI: 1.049-2.024; p = 0.025) were significant risk factors for infectious complications after TRUS-guided prostate biopsy.

CONCLUSION

Fosfomycin was comparable to second-generation cephalosporin flumarin in preventing infectious complications after TRUS-guided prostate biopsy. Coupled with its properties such as ease of administration, low adverse effects, low resistance rate, and low collateral damage, fosfomycin might be an attractive alternative antimicrobial prophylaxis for TRUS-guided prostate biopsy.

[Prostate biopsy-infection prophylaxis and patient preparation]

Prostate biopsy has been at the center of controversy in recent years due to high infection complications associated with the transrectal route and the withdrawal of authorization for fluoroquinolones and fosfomycin trometemol as prophylaxis. The Urological Infections Guideline Group of the European Association of Urology (EAU) recently published a meta-analysis in two parts based on randomized controlled trials (RCTs) and annually updates the data for the EAU guidelines. The meta-analyses show that transperineal prostate biopsy is associated with significantly fewer infectious complications than transrectal biopsy and should therefore be preferred. If transrectal biopsy is still used, then intrarectal cleansing with povidone-iodine and antibiotic prophylaxis should be used. Antibiotic prophylaxis strategies include targeted prophylaxis after sensitivity testing of the rectal flora, augmented prophylaxis with several antibiotics and empirical monoprophylaxis. Data from RCTs are available for aminoglycosides and third-generation cephalosporins.

Cost-Effectiveness Analysis of Stockholm 3 Testing Compared to PSA as the Primary Blood Test in the Prostate Cancer Diagnostic Pathway: A Decision Tree Approach

OBJECTIVE

This study evaluated the cost effectiveness of using Stockholm 3 (STHLM3) testing compared to the prostate-specific antigen (PSA) test in the diagnostic pathway for prostate cancer.

METHODS

We created a decision tree model for PSA (current standard) and STHLM3 (new alternative). Cost effectiveness was evaluated in a hypothetical cohort of male individuals aged 50-69 years. The study applied a Danish hospital perspective with a time frame restricted to the prostate cancer diagnostic pathway, beginning with the initial PSA/STHLM3 test, and ending with biopsy and histopathological diagnosis. Estimated values from the decision-analytical model were used to calculate the incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses were conducted to test the robustness of the base-case analysis.

RESULTS

The model-based analysis revealed that STHLM3 testing was more effective than the PSA, but also more costly, with an incremental cost-effectiveness ratio of €511.7 (95% credible interval, 359.9-674.3) for each additional correctly classified individual. In the deterministic sensitivity analysis, variations in the cost of STHLM3 had the greatest influence on the incremental cost-effectiveness ratio. In the probabilistic sensitivity analysis, all iterations were positioned in the north-east quadrant of the incremental cost-effectiveness scatterplot. At a willingness to pay of €700 for an additional correctly classified individual, STHLM3 had a 100% probability of being cost effective.

CONCLUSIONS

Compared to the PSA test as the initial testing modality in the prostate cancer diagnostic workup, STHLM3 testing showed improved incremental effectiveness, however, at additional costs. The results were sensitive to the cost of the STHLM3 test; therefore, a lower cost of the STHLM3 test would improve its cost effectiveness compared with PSA tests.

Fosfomycin Trometamol for the Prevention of Infectious Complications After Prostate Biopsy: A Consensus Statement by an International Multidisciplinary Group

CONTEXT

Transrectal ultrasound-guided prostate biopsy (TRPB) has been a standard of care for diagnosing prostate cancer but is associated with a high incidence of infectious complications.

OBJECTIVE

To achieve an expert consensus on whether fosfomycin trometamol provides adequate prophylaxis in TRPB and discuss its role as prophylaxis in transperineal prostate biopsy (TPPB).

EVIDENCE ACQUISITION

An international multidisciplinary group of experts convened remotely to discuss how to best use fosfomycin in various clinical settings and patient situations. Six statements related to prostate biopsy and the role of fosfomycin were developed, based on literature searches and relevant clinical experience.

EVIDENCE SYNTHESIS

Consensus was reached for all six statements. The group of experts was unanimous regarding fosfomycin as a preferred candidate for antimicrobial prophylaxis in TRPB. Fosfomycin potentially also meets the requirements for empiric prophylaxis in TPPB, although further clinical studies are needed to confirm or refute its utility in this setting. There is a risk of bias due to sponsorship by a pharmaceutical company.

CONCLUSIONS

Antimicrobial prophylaxis is mandatory in TRPB, and fosfomycin trometamol is an appropriate candidate due to low rates of resistance, a good safety profile, sufficient prostate concentrations, and demonstrated efficacy in reducing the risk of infectious complications following TRPB.

PATIENT SUMMARY

Patients undergoing transrectal ultrasound-guided prostate biopsy (TRPB) have a high risk of infectious complications, and antimicrobial prophylaxis is mandatory. However, increasing antimicrobial resistance, as well as safety concerns with fluoroquinolones, has restricted the number of antimicrobial options. Fosfomycin trometamol meets the requirements for a preferred antimicrobial in the prophylaxis of TRPB.

Antibiotic prophylaxis in patients who had undergone to prostate biopsy in between the EMA warning era: effects of fluoroquinolones in diabetic and non-diabetic patients. Results of an observational cohort study

PURPOSE

To investigate the effects of different antibiotic prophylaxis regimens in patients with diabetes mellitus (DM) candidates to trans-rectal ultrasound-guided prostate biopsy (TRUSPB).

METHODS

143 outpatients with DM who underwent TRUSPB during the period 2018-2020 were selected from a cohort of 1150 patients in 3 different institutions. Exclusion criteria were allergies, concomitant anti-platelet therapies and uncontrolled DM. Different antibiotic prophylaxis regimens were adopted. Bacterial resistance levels to fluoroquinolones into the different communities were also collected. Univariable and multivariable binomial logistic regression analyses were used to assess the odds ratio (OR) with 95% confidence intervals (CIs) testing the risk of infective complications' occurrence after adjusting for clinical covariates.

RESULTS

Overall, DM patients were significantly associated with infective complications' occurrence (p < 0.001). No differences on the event of sepsis were found between diabetic and non-diabetic patients. Clinically relevant infections with fever > 37 °C were found in 9.1% and 1.5% (p < 0.001) in diabetic and non-diabetic patients, respectively. Trimethoprim-sulphametoxazole and fluoroquinolones were six times more efficient than Cefixime in non-diabetic patients. Fluoroquinolones confirmed the same effect in diabetic patients although the level of resistance in the period of study decreased only from 56 to 46%.

CONCLUSION

Fluoroquinolones were active in antibiotic prophylaxis of diabetic patients who had undergone to TRUSPB independently from the level of bacterial resistance found in the community. These results conflict with the recent European warning and support the Japanese and American guidelines on the topic.

E. coli bacterial meningitis after transrectal prostate biopsy under antibiotic prophylaxis: a case report and literature review

Prostate biopsy, a frequently performed procedure, is not harmless. In rare cases, life‐threatening complications occur. We document a potential lethal bacterial meningitis after transrectal biopsy. In addition to our overview of all previously documented cases, we highlight the evidence of prevention of infectious complications when performing a prostate biopsy.

Even after antibiotic prophylaxis, severe infections sometimes follow transrectal prostate biopsy. Involvement of the central nervous system is not well known but demands early recognition. In this situation, intravenous antibiotics with a high penetration through the blood–brain barrier are of vital importance. The most effective preventive measure against infectious complications is to change the biopsy approach to transperineal.

[Prostate biopsy 2021: current management]

Infectious complications following prostate biopsy are on the rise due to an increase in antimicrobial resistance, mainly against fluoroquinolones. The use of fluoroquinolones for perioperative prophylaxis is no longer approved by the national authorities in Germany. The EAU guideline group on urological infections has recently published a meta-analysis in two parts based on randomised controlled trials (RCTs). Transperineal prostate biopsy is associated with a significantly reduced rate of infectious complications compared with transrectal biopsy and should therefore be preferred. If transrectal biopsy is performed, intrarectal cleaning with povidone-iodine and antibiotic prophylaxis without fluoroquinolones should be chosen. Antibiotic prophylactic strategies include targeted prophylaxis after susceptibility testing of the rectal flora, augmented prophylaxis with multiple antibiotics and empiric mono-prophylaxis with non-fluoroquinolones. Data from RCTs are available for aminoglycosides, third-generation cephalosporins and fosfomycin trometamol.

Monoprophylaxis With Cephalosporins for Transrectal Prostate Biopsy After the Fluoroquinolone-Era: A Multi-Institutional Comparison of Severe Infectious Complications

Background

To compare severe infectious complication rates after transrectal prostate biopsies between cephalosporins and fluoroquinolones for antibiotic monoprophylaxis.

Material and Methods

In the multi-institutional cohort, between November 2014 and July 2020 patients received either cefotaxime (single dose intravenously), cefpodoxime (multiple doses orally) or fluoroquinolones (multiple-doses orally or single dose intravenously) for transrectal prostate biopsy prophylaxis. Data were prospectively acquired and retrospectively analyzed. Severe infectious complications were evaluated within 30 days after biopsy. Logistic regression models predicted biopsy-related infectious complications according to antibiotic prophylaxis, application type and patient- and procedure-related risk factors.

Results

Of 793 patients, 132 (16.6%) received a single dose of intravenous cefotaxime and were compared to 119 (15%) who received multiple doses of oral cefpodoxime and 542 (68.3%) who received fluoroquinolones as monoprophylaxis. The overall incidence of severe infectious complications was 1.0% (n=8). No significant differences were observed between the three compared groups (0.8% vs. 0.8% vs. 1.1%, p=0.9). The overall rate of urosepsis was 0.3% and did not significantly differ between the three compared groups as well.

Conclusion

Monoprophylaxis with third generation cephalosporins was efficient in preventing severe infectious complications after prostate biopsy. Single intravenous dose of cefotaxime and multiday regimen of oral cefpodoxime showed a low incidence of infectious complications <1%. No differences were observed in comparison to fluoroquinolones.

[Antibiotic prophylaxis for endourological interventions considering antibiotic stewardship]

Perioperative antibiotic prophylaxis in endourology is used to reduce or avoid postoperative surgical site infections and complicated urinary tract infections. Special attention is paid to antibiotic stewardship strategies to avoid the continuing selection of antibiotics and multidrug-resistant uropathogens as well as collateral damage to the microbiome. The individual risk profile, the local resistance situation, the expected pathogen spectrum, the pharmacokinetics and the approval of each substance are important aspects to be considered in the indications and selection of perioperative antibiotic prophylaxis. Furthermore, applicable hygiene regulations and the surgical care of an intervention must be observed.

European Association of Urology Position Paper on the Prevention of Infectious Complications Following Prostate Biopsy

The transperineal approach is preferred to reduce prostate biopsy (PB)-related infections. Fluoroquinolones are suspended for prophylaxis of PB in the European Union; therefore, alternative antibiotics based on local resistance, or targeted prophylaxis, in conjunction with povidone-iodine rectal preparation are recommended for transrectal PB.

[Infectious complications following prostate biopsy-Major changes 2020]

BACKGROUND

Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been suspended in Germany by the national authorities.

OBJECTIVES

This review is intended to highlight current strategies for reducing infectious complications following prostate biopsy.

MATERIALS AND METHODS

The European Association of Urology (EAU) guideline group on urological infections recently published a meta-analysis in two parts based on randomized controlled trials (RCTs). The most important contents shall be presented here.

RESULTS

Transperineal prostate biopsy is associated with significantly reduced infectious complications than transrectal biopsy. If transrectal biopsy is performed, intrarectal cleaning with povidone-iodine and antibiotic prophylaxis without fluoroquinolones should be chosen. Antibiotic prophylactic strategies include targeted prophylaxis after susceptibility testing of the rectal flora, augmented prophylaxis with multiple antibiotics and empiric monoprophylaxis with nonfluoroquinolones. Here data from RCTs are available for aminoglycosides, third generation cephalosporines, and fosfomycin trometamol.

CONCLUSIONS

The transperineal approach is preferred to reduce prostate biopsy-related infections. Fluoroquinolones are no longer approved for prophylaxis. Thus, alternative antibiotics based on local resistance, or targeted prophylaxis, in conjunction with povidone-iodine rectal preparation are recommended for transrectal prostate biopsy.

Antibiotic prophylaxis for transrectal ultrasound-guided prostate needle biopsy: Compared efficacy of ciprofloxacin vs. the ciprofloxacin/fosfomycin tromethamine combination

INTRODUCTION

Some authors advocate an increase in post-prostate needle biopsy (PNB) infections associated with emergent quinolone resistance in E. coli, urging re-evaluation of antibiotic prophylaxis (antibioprophylaxis). In this study, we compared rates of post-PNB urosepsis associated with two oral regimens of antibioprophylaxis: ciprofloxacin (CIP) vs. ciprofloxacin and fosfomycin tromethamine combination (CIP/FOS).

METHODS

This retrospective pre-/post-intervention study included all patients who underwent PNB in two Canadian hospitals from January 2012 to December 2015. The primary outcome was urosepsis within one month of PNB. Urosepsis rates were analyzed according to antibioprophylaxis using log-binomial regression, considering the propensity score weights of collected risk factor data.

RESULTS

We reviewed 2287 PNB patients. A total of 1090 received CIP and 1197 received CIP/FOS. Urosepsis incidence with CIP was 1.1% (12/1090) and fell to 0.2% (2/1197) with CIP/FOS. Our analysis indicates that CIP/FOS significantly decreased the risk of urosepsis compared to CIP alone (adjusted relative risk [aRR] 0.16; p=0.021). The isolated pathogen was E. coli in 12/14 cases, including seven bacteremias. Among E. coli cases, seven strains were CIP-resistant. Eleven of 12 E. coli, including all CIP-resistant strains, were isolated in patients on CIP alone. One case of B. fragilis bacteremia occurred in the CIP/FOS group. No cases of C. difficile were identified in the three months post-PNB.

CONCLUSIONS

The adoption of CIP/FOS antibiotic prophylaxis significantly lowered the rate of post-PNB urosepsis. Conveniently, this regimen is oral, single-dose, and low-cost.

Infectious complications of prostate biopsy: winning battles but not war

BACKGROUND

Prostate biopsy is a standard tool for diagnosing prostate cancer, with more than 4 million procedures performed worldwide each year. Infectious complications and economic burden are reportedly rising with continued use of trans-rectal ultrasound-guided biopsy, despite the transperineal approach being associated with less infectious complications.

OBJECTIVE AND METHODS

In this review, the contemporary literature on pathophysiology, epidemiology, risk factors, causative organisms and emerging approaches for prevention of infectious complications are outlined.

RESULTS

Management of infectious complications after TRUSB has caused significant financial burden on health systems. The most frequent causative agents of infectious complications after prostate biopsy are Gram-negative bacilli are particularly concerning in the era of antibiotic resistance. Increasing resistance to fluoroquinolones and beta-lactam antibiotics has complicated traditional preventive measures. Patient- and procedure-related risk factors, reported by individual studies, can contribute to infectious complications after prostate biopsy.

CONCLUSIONS

Recent literature shows that the transrectal ultrasound-guided prostate biopsy results in higher infectious complication rate than the transperineal prostate biopsy. NAATs, recently introduced technique to detect FQr may detect all antibiotic-resistant rectal microbiota members-included MDRs-although the technique still has limitations and economical burdens. Transient solutions are escalating antibiotic prophylaxis and widening the indications for TPB.