Assessment of antimicrobiral prophylaxis in transperineal prostate biopsy: A single-center retrospective study of 485 cases

Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis

CONTEXT

Transperineal prostate biopsy is associated with a significantly lower risk of infectious complications than the transrectal approach. In fact, the risk of infectious complications with transperineal prostate biopsy is so low that the utility of administering periprocedural antibiotics with this procedure has come under question.

OBJECTIVE

To perform a systematic review and meta-analysis to assess for differences in the rates of infectious complications (septic, nonseptic, and overall) after performing transperineal prostate biopsy with and without the administration of periprocedural antibiotic prophylaxis.

EVIDENCE ACQUISITION

Three electronic databases (PubMed, Embase, and MEDLINE) were searched, and studies were included if they included patients who underwent transperineal prostate biopsy, were published after January 2000, included information on periprocedural antibiotic administration, and reported postbiopsy complications. Preferred Reporting Items for Systematic Reviews and Meta-analyses and Agency for Healthcare Research and Quality guidelines were utilized.

EVIDENCE SYNTHESIS

A total of 106 unique studies describing 112 cohorts of patients were identified, of which 98 (37 805 men) received antibiotic prophylaxis and 14 (4772 men) did not receive it. All patients were included in the analysis of septic complications. In total, there were 19/37 805 (0.05%) episodes of sepsis in the group of men who received antibiotics, which was similar to the no antibiotic group with 4/4772 (0.08%) episodes (p = 0.2). For overall infections (septic plus nonseptic), there were 403/29 880 (1.35%) versus 58/4772 (1.22%) events among men with evaluable data who received and did not receive antibiotic prophylaxis, respectively (p = 0.8). Restricting our analysis to studies with a comparable low number of biopsy cores (<25 cores), there remained no difference in the rates of sepsis between groups, but there was a small, statistically significant lower risk of infectious complications with antibiotic administration-67/12 140 (0.55%) versus 58/4772 (1.22%; p < 0.01).

CONCLUSIONS

The likelihood of septic infections after transperineal prostate biopsy is low with and without antibiotic prophylaxis. The omission of periprocedural antibiotics with this procedure stands to benefit patients by avoiding potential drug reactions. Furthermore, this practice is in line with calls throughout the medical community for improved antibiotic stewardship.

PATIENT SUMMARY

In a large systematic review and meta-analysis, we evaluated infectious complications after transperineal prostate biopsy with or without the administration of prophylactic antibiotics. We conclude that prophylactic antibiotics do not decrease the rate of postbiopsy sepsis but may have a small benefit in terms of preventing less serious infections.

Outcomes of Freehand Transperineal Prostate Biopsy with Omission of Antibiotic Prophylaxis

OBJECTIVE

To assess the utility of antimicrobial prophylaxis when performing freehand systematic transperineal biopsy.

PATIENTS AND METHODS

From 1/2012 to 2/2020, freehand transperineal prostate biopsy via angiocatheters or the PrecisionPoint Transperineal Access System was performed on consecutive men with clinical suspicion of prostate cancer or confirmed prostate cancer. Biopsies were performed by a single urologist (developer of the PrecisionPoint system). Clinical data was collected retrospectively. Pre-procedural antibiotics were given to all patients through September 6th, 2016. After this date, antibiotics were omitted from those without risk factors (chronic catherization, concurrent endoscopic procedure, history of sepsis after transrectal (TR) biopsy, history of TR biopsy within the last year, prosthetic joints/heart valves). Patients were assessed one week after biopsy for symptoms, Emergency Department visits, and hospital admissions. Patients who received antimicrobial prophylaxis were compared to those who did not and infectious complications were analyzed. Additionally, oncologic outcomes are reported.

RESULTS

988 biopsies (median PSA 7.7 ng/ml) were included in the analysis on 756 men. 538 biopsies (54.4%) received prophylaxis and 450 (48.6%) did not receive prophylaxis. There was a statistical difference in the median age (67 vs 69 years, p < 0.001), abnormal DRE (13% vs 5%, p < 0.001), and history of mpMRI (15% vs 31%, p < 0.001) between the prophylaxis and no prophylaxis cohorts, respectively. There were no documented complications in those who received antibiotics. Within the no prophylaxis cohort, there were three (0.66%) complications (p = 0.09). Two (0.44%) patients had UTIs and one (0.22%) patient experienced post-procedural urinary retention. No patients required hospital admission or ED visit. Clinically significant cancer was detected in 152 (40.0%) and 64 (39.0%) men on initial biopsy and prior negative biopsy, respectively.

CONCLUSIONS

This data suggests that antimicrobial prophylaxis may be safely omitted in selected patients when utilizing the freehand transperineal approach.

[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.

[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.

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.