Reduction in Hospital Admission Rates Due to Post-Prostate Biopsy Infections After Augmenting Standard Antibiotic Prophylaxis

Antimicrobial prophylaxis protocol based on rectal swab culture before prostate biopsy to prevent infectious complications: a prospective randomized comparative study

PURPOSE

To evaluate the benefit of targeted antibiotic prophylaxis (TAP) based on rectal swab culture in comparison with standard empiric antimicrobial prophylaxis in patients undergoing transrectal ultrasound-guided needle biopsy of the prostate (TRUS-BP), as well as to assess rate of fecal carriage of Fluoroquinolone-resistant Enterobacterales FQRE.

PATIENTS AND METHODS

We prospectively analyzed data that randomized 157 patients within two groups: (G1) TAP according to rectal swab performed 10 days before PB; (G2): empirical antibiotic prophylaxis with ciprofloxacin. Prevalence of FQRE digestive carriage and risk factors were investigated. Incidence of infectious complications after (TRUS-BP) in each group was compared.

RESULTS

G2 included 80 patients versus 77 in G1. There was no difference between the two groups regarding age, diabetes, prostate volume, PSA, number of biopsy cores, and risk factors for FQRE. In G2, the prevalence of FQRE digestive carriage was 56.3% all related to E. coli species. In the case of digestive carriage of FQRE, TAP according to the rectal swab culture with third-generation cephalosporins was performed in 73.3%. Patients with FQRE had history of FQ use within the last 6 months in 17.8% (p = 0.03). Rate of febrile urinary tract infection after PB was 13% in G1 and 3.8% in G2 (p = 0.02).

CONCLUSIONS

Incidence of FQ resistance in the intestinal flora of our local population was prevalent. Risk factor for resistance was the use of FQ within the last 6 months. TAP adapted to rectal swab, mainly with third-generation cephalosporins, significantly reduced the rate of infectious complications after (TRUS-BP).

Fosfomycin for Antibiotic Prophylaxis in Men Undergoing a Transrectal Prostate Biopsy: A Systematic Review and Meta-Analysis

Background and Objectives: To assess the effects of fosfomycin compared with other antibiotics as a prophylaxis for urinary tract infections (UTIs) in men undergoing transrectal prostate biopsies. Materials and Methods: We searched multiple databases and trial registries without publication language or status restrictions until 4 January 2022. Parallel-group randomized controlled trials (RCTs) and non-randomized studies (NRS) were included. The primary outcomes were febrile UTI, afebrile UTI, and overall UTI. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs. The protocol was registered with PROSPERO (CRD42022302743). Results: We found data on five comparisons; however, this abstract focuses on the primary outcomes of the two most clinically relevant comparisons. Regarding fosfomycin versus fluoroquinolone, five RCTs and four NRSs with a one-month follow-up were included. Based on the RCT evidence, fosfomycin likely resulted in little to no difference in febrile UTIs compared with fluoroquinolone. This difference corresponded to four fewer febrile UTIs per 1000 patients. Fosfomycin likely resulted in little to no difference in afebrile UTIs compared with fluoroquinolone. This difference corresponded to 29 fewer afebrile UTIs per 1000 patients. Fosfomycin likely resulted in little to no difference in overall UTIs compared with fluoroquinolone. This difference corresponded to 35 fewer overall UTIs per 1000 patients. Regarding fosfomycin and fluoroquinolone combined versus fluoroquinolone, two NRSs with a one- to three-month follow-up were included. Based on the NRS evidence, fosfomycin and fluoroquinolone combined may result in little to no difference in febrile UTIs compared with fluoroquinolone. This difference corresponded to 16 fewer febrile UTIs per 1000 patients. Conclusions: Compared with fluoroquinolone, fosfomycin or fosfomycin and fluoroquinolone combined may have a similar prophylactic effect on UTIs after a transrectal prostate biopsy. Given the increasing fluoroquinolone resistance and its ease to use, fosfomycin may be a good option for antibiotic prophylaxis.

Ciprofloxacin Alone vs. Ciprofloxacin plus an Aminoglycoside for the Prevention of Infectious Complications following a Transrectal Ultrasound-Guided Prostate Biopsy: A Retrospective Cohort Study

The purpose of this study was to evaluate the impact of augmented prophylaxis (ciprofloxacin augmented with an aminoglycoside) compared with that of empirical prophylaxis (ciprofloxacin alone) on transrectal post-prostate biopsy infectious complication (PBIC) rates. A retrospective cohort study evaluated 2835 patients receiving either augmented or empirical prophylactic regimen before undergoing a transrectal ultrasound-guided prostate biopsy between January 2010 and October 2018. The patients were compared according to prophylactic regimen received. The incidence of PBICs and the impact of risk factors were evaluated. A total of 1849 patients received the empirical regimen, and 986 patients received the augmented regimen. The composite PBIC rate was 2.1% (n = 39) and 0.9% (n = 9) (p = 0.019), respectively, and the SIRS rate was 1.9% and 0.8% (p = 0.020), respectively. Of the 50 patients presenting with a PBIC, 29 (58%) had positive cultures (blood and/or urine) for Escherichia coli, of which 28 (97%) were ciprofloxacin-resistant. Taking a fluoroquinolone in the previous 6 months and having a previous urinary tract infection within 1 year prior to the biopsy had significant impact on PBIC rates (p = 0.009 and p = 0.011, respectively). Compared with ciprofloxacin alone, augmented prophylaxis was associated with significantly lower PBICs.

Enhanced antibiotic prophylaxis and infection-related complications following prostate biopsy

PURPOSE

Sepsis after prostate biopsy is a costly and potentially lethal complication. We sought to assess whether enhanced antibiotic prophylaxis regimens combining oral and parenteral antibiotics may decrease the risk of post-biopsy urinary tract infection and sepsis compared to regimens with only oral antibiotics.

METHODS

We identified men with commercial insurance who underwent prostate biopsy (2009-2015) with prophylactic antibiotic coverage. Our primary exposure of interest was antibiotic regimen: enhanced, oral-only, and parenteral-only. Post-biopsy outcomes of interest included urinary tract infections and sepsis/bacteremia after prostate biopsy. We used bivariate testing to assess associations between outcomes, exposures, and other covariates of interest. Multivariable regression was used to estimate adjusted odds of infectious outcomes based on antibiotic regimen.

RESULTS

We identified 163,831 men who underwent prostate biopsy. The proportion of men with infectious complications (5.5% in 2009 to 6.9% in 2015, p < 0.001) and sepsis (0.24% in 2009 to 0.30% in 2015, p = 0.327) increased over the timeframe of our analysis. Use of fluoroquinolones was associated with a decreased risk of infectious outcomes (5.8 vs 7.3% without, OR 0.83, 95% CI 0.79-0.88). Use of enhanced antibiotic regimens was associated with an increased risk of infectious outcomes (6.8 vs 5.7% oral, OR 1.23, 95% CI 1.16-1.31) and sepsis (0.34 vs 0.24% oral, OR 1.40, 95% CI 1.08-1.82) among our cohort.

CONCLUSION

We did not observe a significant reduction in infectious complications among men who received enhanced antibiotics regimens before prostate biopsy. This may be due to increased antibiotic resistance or unmeasured risk factors among those receiving enhanced regimens.

Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography-guided prostate biopsy

OBJECTIVES

To evaluate the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections following transrectal ultrasonography-guided prostate biopsy.

METHODS

In this prospective interventional study, patients aged between 40 and 70 years with clinical indications for transrectal ultrasonography-guided prostate biopsy were enrolled. Consecutive patients who received intraprostatic injection of amikacin coupled with oral ciprofloxacin were compared with historical controls receiving only prophylactic oral fluoroquinolones prior to biopsy. Patients were followed for 7 days after biopsy for signs and symptoms of infection.

RESULTS

A total of 210 patients were included in this study (mean age 65.7 ± 7.8 years). Among patients without intraprostatic injection, nine (8.6%) developed infectious complications (lower urinary tract infection in seven patients, and prostatitis in two), which led to hospitalization in six patients (5.7%). None of the patients who received intraprostatic antibiotic injection developed infectious complications. The difference in the incidence of post-transrectal ultrasonography-guided biopsy infections between the two groups was statistically significant (P = 0.003).

CONCLUSION

Local intraprostatic antibiotic injection during transrectal ultrasonography-guided prostate biopsy adjuvant to oral fluoroquinolones can significantly reduce the rate of post-biopsy infectious complications.

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.

Data on the quality and methods of studies reporting healthcare costs of post-prostate biopsy sepsis

This data article presents the supplementary material for the review paper "Healthcare Costs of Post-Prostate Biopsy Sepsis" (Gross et al., 2019). A general overview is provided of 18 papers, including the details about year and journal of publication, country of dataset, data population characteristics, cost basis, and potential for bias evaluation. Quality assessment and the risk of bias of the 18 papers are detailed and summarized.

Comparison of levofloxacin-based prophylaxis regimens for transrectal prostate biopsy: a prospective randomized single-center study

To develop an optimal prophylactic regimen among Chinese patients who accept transrectal prostate biopsy. We enrolled 420 patients who accepted transrectal prostate biopsy. They were randomly classified into three groups (n = 140 for each): Group A received a single 500-mg tablet of levofloxacin without enema; group B received a single 500-mg tablet of levofloxacin plus enema; group C received 3-day levofloxacin orally plus enema. Patients were assessed if they had a febrile urinary tract infection (FUTI). The incidence of FUTI was compared among groups. Subgroup analysis was performed between patients at high and low risk of infection in each group. There were 15 cases developed FUTI: 7 (5%), 6 (4.3%), and 2 (1.4%), respectively, in groups A, B, and C. Of the 15 patients who developed FUTI, Escherichia coli was detected in blood culture in two cases. Urine culture results were all negative. FUTI patients (73.3% (11/15)) had at least one high risk factor. Subgroup analysis showed that the incidence of FUTI in group A was significantly higher than that in group C among high-risk patients. There was no statistical difference between group A and group B among both high- and low-risk patients. A single 500-mg dose of levofloxacin without enema represents excellent prophylaxis for transrectal prostate biopsy in Chinese patients at low risk of infection. For those at high risk, 3-day levofloxacin prophylaxis is the optimal regimen. Prebiopsy enema provides no clinically significant outcome advantage and is unnecessary.

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.

Clinical Importance of Antibiotic Regimen in Transrectal Ultrasound-Guided Prostate Biopsy: A Single Center Analysis of Nine Thousand Four Hundred Eighty-Seven Cases

BACKGROUND

To evaluate the effectiveness of an antibiotic regimen for prostate biopsy by analyzing patients who were hospitalized because of complications after transrectal ultrasound-guided prostate biopsy.

METHODS

We reviewed retrospectively the medical records of 10,339 patients who underwent transrectal ultrasound-guided prostate biopsy at our institution from May 2003 to April 2017. We excluded patients with low quality data. All patients underwent urine culture before transrectal ultrasound-guided prostate biopsy and received intravenous antibiotic agents 30-60 minutes before biopsy. Patients were either given prophylactic quinolone or cephalosporin (second or third generation). Clinicopathologic factors including patient age, antibiotic regimen, number of biopsy cores, body mass index, prostate specific antigen, prostate volume, and infection-related complications that required hospitalization were subsequently analyzed.

RESULTS

A total of 9,487 patients were included in the final analysis, of whom 33 patients (0.35%) were hospitalized because of infection-related complications. Infection-related hospitalization rates were lower in patients who received cephalosporin (0.2%) than in patients who received quinolone (1.59%). At our institution, cephalosporin has been used predominantly to prevent post-biopsy infections since February 2013. Only five patients (0.12%) developed infection-related complications of the 3,863 patient who underwent transrectal ultrasound-guided prostate biopsy since February 2013. Multivariable analysis revealed that use of second- or third-generation cephalosporin was the only independent predictor of infection-related complications.

CONCLUSION

Implementing an effective antibiotic prophylaxis regimen at our institution by using second- or third-generation cephalosporin could reduce infection-related complications after transrectal ultrasound-guided prostate biopsy.

Effectiveness of a transrectal prostate needle biopsy protocol with risk-tailored antimicrobials in a veterans cohort

PURPOSE

To prospectively implement a prostate biopsy protocol to identify high-risk patients for bleeding or infectious complications and use risk-tailored antimicrobials, patient education, and postbiopsy monitoring with the objective of reducing complications.

MATERIALS AND METHODS

Overall, 637 consecutive patients from June 2014 to August 2016 underwent prostate biopsy at our Veterans Affairs hospital. In the protocol cohort, patients were screened before biopsy and prophylaxis was tailored (high risk = ceftriaxone; low risk = ciprofloxacin). Patients were also provided additional education about bleeding and monitored for up to 1-hour. We defined complications as any deviation from normal postbiopsy activities. Comparisons were made between preprotocol/postprotocol cohorts. Logistic regression was used to identify risk factors for admissions or complications.

RESULTS

Median age was 67 years (IQR: 64-69, P = 0.29) in both groups (pre n = 334, post n = 303). Preprotocol, 99% patients received ciprofloxacin; postprotocol, 86% received ciprofloxacin and 14% received ceftriaxone (P<0.001). There were no deaths in either group. There were decreased 30-day complication and hospitalization rates in the postprotocol group (pre 15% vs. post 8.9%, P = 0.025; 3.3% vs. 1.0%, P = 0.048). Sepsis occurred in 2 patients preprotocol and no patients postprotocol. Postprotocol group was associated with decreased 30-day complications on multivariable logistic regression (OR = 0.58, 95% CI: 0.35-0.95, P = 0.031).

CONCLUSIONS

A screening protocol before prostate biopsy is a targeted approach for selecting prophylactic antimicrobials and closer monitoring postbiopsy for bleeding. Our results suggest that the protocol has a favorable effect on complication and hospitalization rates.

Quality of care and economic considerations of active surveillance of men with prostate cancer

The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.g., quality) for acceptable costs. This review discusses quality of care considerations for men contemplating active surveillance, and highlights cost implications at the patient, health-system, and societal level related to pursuit of non-interventional management of men diagnosed with localized prostate cancer. In general, most quality measures are focused on prostate cancer care in general, rather that active surveillance patients specifically. However, most prostate cancer quality measures are pertinent to men seeking close observation of their prostate tumors with active surveillance. These include accurate documentation of clinical stage, informed discussion of all treatment options, and appropriate use of imaging for less-aggressive prostate cancer. Furthermore, interventions that may help improve the quality of care for active surveillance patients are reviewed (e.g., quality collaboratives, judicious antibiotic use, etc.). Finally, the potential economic impact and benefits of broad acceptance of active surveillance strategies are highlighted.

Chemoprophylaxis during transrectal prostate needle biopsy: critical analysis through randomized clinical trial

PURPOSE

To compare the efficacy of three chemoprophylaxis approaches in prevention of post-transrectal biopsy infectious complications (TBICs).

METHODS

Patients were randomly assigned to receive ciprofloxacin 3 days 500 mg B.I.D 3 days starting the night prior to biopsy (standard prophylaxis), augmented prophylaxis using ciprofloxacin and single preprocedure shot of 160 mg gentamicin IM (augmented prophylaxis) and rectal swab culture-based prophylaxis (targeted prophylaxis). Patients were assessed 2 weeks prior to biopsy, at biopsy and 2 weeks after. Primary end point was occurrence of post-TBICs that included simple UTI, febrile UTI or sepsis. Secondary end points were post-biopsy change in the inflammatory markers (TLC, ESR and CRP), unplanned visits, hospitalization and occurrence of fluoroquinolones resistance (FQ-R; bacterial growth on MacConkey agar plate with 10 μg/ml ciprofloxacin) in the fecal carriage of screened men.

RESULTS

Between April/2015 and January/2017, standard, augmented and targeted prophylaxes were given to 163, 166 and 167 patients, respectively. Post-TBICs were reported in 43 (26%), 13 (7.8%) and 34 (20.3%) patients following standard, augmented and targeted prophylaxes protocols, respectively (P = 0.000). Post-TBICs included UTI in 23 (4.6%), febrile UTI in 41 (8.2%) and sepsis in 26 (5.2%) patients. Significantly lower number of post-biopsy positive urine culture was depicted in the augmented group (P = 0.000). The number of biopsy cores was statistically different in the three groups (P = 0.004). On multivariate analysis, augmented prophylaxis had independently lower post-TBICs (OR 0.2, 95% CI 0.1-0.4, P = 0.000) when compared with the other two groups regardless of the number of biopsy cores taken (OR 1.07, 95% CI 0.95-1.17, P = 0.229). Post-biopsy hospitalization was needed in four (2%), one (0.6%) and ten (6%) patients following standard, augmented and targeted prophylaxes, respectively (P = 0.014). However, sepsis-related hospitalization was not statistically different. Post-biopsy changes in the inflammatory markers were significantly less in augmented prophylaxis (P < 0.05). FQ-R was depicted in 139 (83.2%) of the screened men.

CONCLUSION

Augmented prophylaxis with single-dose gentamicin is an effective and practical approach. Targeted prophylaxis might be reserved for cases with contraindication to gentamicin.

Trial Comparing a Combined Regimen of Amikacin and Ciprofloxacin to Ciprofloxacin Alone as Transrectal Prostate Biopsy Prophylaxis in the Era of High Fluoroquinolone-Resistant Rectal Flora

BACKGROUND

To investigate whether addition of amikacin to fluoroquinolone (FQ) antimicrobial prophylaxis reduces infections after transrectal ultrasound-guided prostate biopsy (TRUSPB).

METHODS

A total of 503 patients undergoing rectal swab were divided into three groups. Patients with FQ-sensitive rectal flora (group 1, n = 248) were administered ciprofloxacin before TRUSPB, and patients with FQ-resistant rectal flora were either administered ciprofloxacin (group 2, n = 97) or amikacin and ciprofloxacin (group 3, n = 158) before TRUSPB.

RESULTS

Based on the rectal swab, FQ resistance was 54.9%, and extended-spectrum β-lactamase (ESBL) positivity was 17.2%. The incidence of infectious complication in group 1 was 1.6%. Groups 2 and 3, with FQ-resistant rectal flora, tended to have increased infectious complications (5.2% and 4.4%, respectively) but the difference between those results is not statistically significant. The most common pathogens of infectious complications in patients with FQ-resistant rectal flora were FQ-resistant and ESBL-producing Escherichia coli. E. coli pathogens isolated in Group 3 were amikacin-susceptible species. The operation history and ESBL positivity of rectal flora increased the incidence of infectious complications (odds ratio [OR] = 3.68; P = 0.035 and OR = 4.02; P = 0.008, respectively). DM and antibiotics exposure were risk factors for FQ resistance (OR = 2.19; P = 0.002) and ESBL positivity of rectal flora (OR = 2.96; P = 0.005), respectively.

CONCLUSION

Addition of amikacin to ciprofloxacin prophylaxis could not reduce infectious complications in patients with FQ-resistant rectal flora. Despite the amikacin sensitivity of infectious complications, single-dose amikacin addition to ciprofloxacin prophylaxis has limitations.

Reduced Risk of Sepsis after Prostate Biopsy Using a Cephalosporin-Fluoroquinolone Antibiotic Regimen and Isopropyl Alcohol Needle Washing

OBJECTIVE

To compare 3 prophylactic regimens to assess their impact on postbiopsy sepsis incidence.

METHODS

Data were reviewed for 829 consecutive patients who underwent prostate biopsy in a community practice setting between January 2013 and October 2017. Group 1 patients received ciprofloxacin 500 mg two times a day orally for 4 days starting the day prior to biopsy and gentamicin 80 mg intramuscularly 20 minutes prior to biopsy. From April 2015 to October 2017, 2 groups of patients were followed in parallel in a randomized manner. Group 2 received ciprofloxacin 500 mg two times a day orally for 4 days starting the day prior to biopsy and ceftriaxone 1 g intramuscularly 20 minutes prior to biopsy. Group 3 received the same antibiotic regimen as group 2 and also underwent isopropyl alcohol needle washing.

RESULTS

All study groups were demographically equivalent. Microscopic bacterial counts were substantially decreased after isopropyl alcohol needle washing. Incidence of postbiopsy sepsis in groups 1 (n = 313), 2 (n = 259), and 3 (n = 257) was 3.8%, 2%, and 0%, respectively (analysis of variance; P = .006). Risk factors for sepsis included elevated body mass index, Charlson Comorbidity Score, and presence of type 2 diabetes mellitus.

CONCLUSION

There was a significant reduction in the incidence of sepsis after prostate biopsy using a combination of a ciprofloxacin-ceftriaxone antibiotic regimen and isopropyl alcohol needle washing. The technique for needle washing is inexpensive and quick, and can be easily adopted into current biopsy protocols.

The effectiveness of targeted relative to empiric prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy: a meta-analysis

PURPOSE

Rectal culture screening for fluoroquinolone (FQ)-resistant Enterobacteriaceae before transrectal ultrasound guided prostate (TRUSPB) biopsy and targeted antibiotic prophylaxis (TAP) may decrease post-TRUSPB infection rates compared to empiric (EAP) regimens. The objective of this study was to evaluate the effectiveness of targeted relative to empiric prophylaxis regimens on rates of infectious complications after TRUSPB and to determine the baseline prevalence of FQ resistance based on prior rectal swabs.

METHODS

An electronic search within literature databases including EMBASE and Web of Science (all databases) for articles assessing TAP as an approach to TRUSPB prophylaxis was conducted. Quality assessment was performed using the Hoy instrument. Meta-analysis was performed using MetaXL 5.3.

RESULTS

From 15 studies (eight retrospective and seven prospective) representing 12,320 participants, infectious complication incidence was 3.4% in EAP and 0.8% in TAP patients. The number needed to treat with TAP to avoid one more infection when compared to the EAP group was 39. Effect sizes were homogeneous. Prevalence of FQ resistance showed low (15%) and high (28%) subgroups, likely due to region of origin (within and outside USA, respectively).

CONCLUSIONS

Rectal culture prior to TRUSPB and use of TAP adjusts for endemic FQ resistance and is associated with less infectious complications and resulting morbidity when compared to EAP. Overtreatment associated with augmented prophylaxis approaches may be reduced as a result. Further prospective assessment and cost-benefit analyses are required before widespread implementation can be recommended.

"Targeted" prophylaxis: Impact of rectal swab culture-directed prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy

Purpose

To assess the prevalence of fluoroquinolone resistance among patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy and the impact of rectal swab culture-directed antibiotic prophylaxis on postbiopsy infectious complications.

Materials and Methods

We prospectively analyzed all patients undergoing TRUS-guided prostate biopsy from April 2013 to February 2015. Antibiotic prophylaxis was tailored to the results of rectal swab cultures. If the organism was fluoroquinolone-sensitive, oral ciprofloxacin 500 mg with tinidazole 600 mg was prescribed. If the organism was fluoroquinolone-resistant, then a culture-directed antibiotic was prescribed. In both cases the antibiotic was continued for 3 days. All patients were followed for 14 days after biopsy to record infectious complications.

Results

A total of 247 patients were included, and Escherichia coli was isolated on rectal swab cultures in 99.5% of the patients. Of these, 41.7% harbored fluoroquinolone-resistant E. coli. Piperacillin/tazobactam was the most common culture-directed antibiotic prescribed (59.3%), with amoxicillin/clavulanic being the second most common (25.5%) for the fluoroquinolone-resistant group. Only 2 patients (0.9%) developed postbiopsy fever and none had sepsis.

Conclusions

Colonization of rectal flora with fluoroquinolone-resistant E. coli was seen in 40% of men undergoing prostate biopsy. Targeted prophylaxis, which uses the results of prebiopsy rectal swab culture to direct antibiotic prophylaxis, results in low rates of postbiopsy infections.

Evaluation of targeted antimicrobial prophylaxis for transrectal ultrasound guided prostate biopsy: a prospective cohort trial

BACKGROUND

We evaluated the effectiveness of targeted antimicrobial prophylaxis in transrectal ultrasound guided prostate biopsy (TRUSP).

METHODS

A prospective, non-randomized cohort study was conducted. Rectal swab cultures plated on non-selective blood agar and on selective MacConkey agar supplemented with ciprofloxacin identified ciprofloxacin-susceptible and -resistant gram-negative bacteria (CS-GNB and CR-GNB). Patients with CS-GNB received ciprofloxacin while those with CR-GNB received directed prophylaxis. Infectious complications were defined clinically and microbiologically within 30 days after TRUSP. Data were derived at 7 and 30 days post procedure by questionnaires and electronic medical records. We hypothesized that there would be no difference in the infectious outcomes among the CS and CR groups.

RESULTS

From November 1, 2012 to March 31, 2015, 510 men completed the study; 430 (84.3%) had CS-GNB and 80 (15.7%) had CR-GNB. 484 (94.9%) completed the study per protocol, while 26 (5.1%) had an intention-to-treat (ITT) analysis. Of the 484, 475 (98.1%) had no infections, nine (1.9%) had infections, six of which (1.2%) were culture-proven (CP). The nine infections were as follows: five (1.0%) uncomplicated UTIs, one (0.2%) complicated UTI, and three (0.6%) urosepsis. One case of uncomplicated UTI and two cases of urosepsis were not CP, but were diagnosed clinically. ITT outcomes were similar. The infection rates were not statistically different between the CS-and CR-GNB patients (p-value = 0.314; 95% CI 0.8-3.3). The four patients with complicated UTIs or sepsis were hospitalized for a mean of 2.6 days and discharged without sequelae. Of the nine infections, three were antimicrobial prophylaxis failures (two ciprofloxacin and one amikacin); three were likely due to failure of the collection or processing of the rectal swab or increasing bacterial resistance between the time of swab collection and biopsy, and three developed clinical infections with no isolate recovered.

CONCLUSIONS

Targeted antimicrobial prophylaxis follows the principles of antimicrobial stewardship and achieved a low rate of infectious complications with limited morbidity and no sequelae. This individualized method of prophylaxis may be widely applied. Further studies are needed to explore reasons for targeted prophylaxis failure and to determine comparative efficacy of non-ciprofloxacin-containing targeted prophylaxis regimens.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT01659866 . Registered 9 July 2012. First patient enrolled 1 November 2012.

Cost consideration in utilization of multiparametric magnetic resonance imaging in prostate cancer

The screening, evaluation and management of prostate cancer changed significantly in the last decade. The recommendations regarding prostate cancer screening continue to evolve with new revelations about existing data sets and longer followup of landmark trials. Robotics has gained the vast majority of the marketplace for surgically managed prostate cancer in rapid fashion. The need for intervention in low risk prostate cancer has been closely examined and more men are being expectantly managed than ever before. Amidst all these changes, prostate magnetic resonance imaging (MRI) has emerged as a disruptive technology. Through the use of dynamic contrast-enhanced and diffusion weighted series, prostate tumors that were previously not visible have become identifiable and quantifiable. The ability of MRI to improve staging and identification of clinically significant disease has resulted in increased utilization for different aspects of prostate cancer care. The best studied use is in men with a prior negative transrectal ultrasound guided (TRUS) prostate biopsy and the performance characteristics in this role match well with the clinical question raised. The role for MRI in initial biopsy, in pre-surgical planning before prostatectomy and in men on active surveillance is less well defined. A primary concern in the use of MRI is that of cost. MRI units are expensive, both in initial outlay and ongoing use. The availability of MRI varies widely between countries and even within regions of the same country. Different healthcare models have different approaches for allocating the use of expensive resources, including MRI, in times when they are scarce. Prostate MRI can be used at multiple points in the management algorithm of prostate cancer and each implies different cost concerns. In this review we present an overview of current research in cost and cost efficacy for the use of MRI in the management of prostate cancer. By examining what is known and highlighting areas of ongoing research we hope to provide the reader with a solid foundation for understanding these complex, ever-changing issues.

Routine Ertapenem Prophylaxis for Transrectal Ultrasound Guided Prostate Biopsy does Not Select for Carbapenem Resistant Organisms: A Prospective Cohort Study

PURPOSE

Sepsis after transrectal ultrasound guided prostate biopsy is an increasing problem in this era of rising antibiotic resistance. Although ertapenem prophylaxis has proved effective at our institution to reduce this, it has raised local and regional antimicrobial stewardship concerns. We investigated the possible selective effect of single dose ertapenem prophylaxis on fecal colonization with carbapenem resistant Enterobacteriaceae.

MATERIALS AND METHODS

Patients underwent a rectal swab prior to receiving prebiopsy ertapenem prophylaxis. A second swab was obtained at followup 4 to 6 weeks later. Swabs were screened for carbapenem resistant Enterobacteriaceae using an enhanced CDC (Centers for Disease Control) method. Prebiopsy swabs were also screened for extended spectrum β-lactamase producing and ciprofloxacin resistant Enterobacteriaceae. Patients were monitored for post-biopsy sepsis.

RESULTS

A total of 326 patients were enrolled in the study. At baseline 6.4% and 9.0% of patients had colonization with extended spectrum β-lactamase producing and ciprofloxacin resistant Enterobacteriaceae, respectively. Carbapenem resistant Enterobacteriaceae were not detected at baseline or followup in any patients. Colonization with nonfermentative organisms with intrinsic ertapenem resistance was detected in 29.4% of patients at baseline and followup (p = 1.0). Three cases (0.9%, 95% CI 0.2-2.8) of probable post-biopsy sepsis were identified during the study period. None was bacteremic or required intensive care unit admission.

CONCLUSIONS

Single dose ertapenem prophylaxis did not appear to have a significant selective effect on fecal colonization with carbapenem resistant Enterobacteriaceae or other ertapenem resistant gram-negative organisms in this outpatient group. It is highly effective prophylaxis for transrectal ultrasound guided prostate biopsy. In the right setting ertapenem may represent a useful prophylactic option to prevent post-transrectal ultrasound guided prostate biopsy sepsis.

Prevalence and characteristics of fecal antimicrobial-resistant Escherichia coli in a cohort of Japanese men undergoing prostate biopsy

OBJECTIVES

To examine resistant Escherichia coli in rectal swab culture of Japanese men undergoing prostate biopsy, and to determine its prevalence, genotypic characteristics and carriage risk factors.

METHODS

Rectal swabs of consecutive men undergoing transrectal ultrasound-guided prostate biopsy from April 2013 to March 2015 were cultured to isolate fluoroquinolone-resistant and extended-spectrum β-lactamase-producing E. coli. The prevalence and antimicrobial susceptibility of these resistant E. coli strains and extended-spectrum β-lactamase genotyping were examined. The risk factors of antimicrobial resistance carriage were also examined.

RESULTS

The cohort was 376 men with a mean age of 67.8 years. Fluoroquinolone-resistant E. coli and extended-spectrum β-lactamase-producing E. coli were detected in 37 men (9.8%) and 22 men (5.9%), respectively, with fluoroquinolone-resistant and/or extended-spectrum β-lactamase-producing E. coli in 48 men (13.0%). All 49 antimicrobial-resistant strains were susceptible to tazobactam/piperacillin, amikacin, fosfomycin, meropenem and faropenem. CTX-M-9 and CTX-M-1 group were detected in 14 (63.6%) and eight (36.4%) men, respectively. CTX-M-9 showed relatively higher susceptibility to LVFX and minocycline compared with CTX-M-1. Diabetes mellitus was a significant factor for carriage of resistance by multivariate analysis (odds ratio 2.12, P = 0.039).

CONCLUSIONS

The present study showed the fecal carriage of fluoroquinolone-resistant E. coli and extended-spectrum β-lactamase-producing E. coli at 9.8% and 5.9%, respectively, with CTX-M-9 group of extended-spectrum β-lactamase-producing E. coli comprising 63.6%, in Japanese men receiving prostate biopsy. The carriage of fluoroquinolone-resistant and/or extended-spectrum β-lactamase-producing E. coli was significantly related to diabetes.

Formalin disinfection of prostate biopsy needles may reduce post-biopsy infectious complications

BACKGROUND

We sought to determine whether formalin disinfection of prostate biopsy needles between cores reduces post-biopsy urinary tract infections (UTIs).

METHODS

We reviewed a single-surgeon experience of transrectal prostate biopsies from 2010 to 2014. Biopsies were performed in either an operative suite, where 10% formalin was used to disinfect the needle tip between each biopsy core, or an outpatient clinic, where formalin was not used. Our primary outcome was post-biopsy UTI rates, defined as a positive urine culture within 30 days of biopsy. Infection severity was characterized by the need for admission. Patient demographics, prostate size, prior biopsies, prior UTIs, pre-biopsy antibiotics and cultures and post-biopsy cultures were analyzed. Logistic regression was used to assess predictors of post-biopsy UTIs. Statistical significance was defined as P<0.05.

RESULTS

A total of 756 patients were included for analysis, including 253 who received formalin disinfection and 503 who did not. Of these, 32 patients (4.2%) experienced post-biopsy UTIs, with 8 requiring admission (all without formalin use). Infection rates were more than double in the group that did not receive formalin (5.2% vs 2.3%, P=0.085). More patients in the formalin group had undergone prior biopsies (73.9% vs 31.8%, P<0.001). On multivariable analysis, prior UTI (odds ratio (OR) 3.77, P=0.006) was a significant predictor for post-biopsy infection, whereas formalin disinfection trended towards a protective effect (OR 0.41, P=0.055).

CONCLUSION

Infectious complications following prostate biopsy may be mitigated by the use of formalin disinfection of the biopsy needle between cores.

Addition of Ceftriaxone and Amikacin to a Ciprofloxacin plus Metronidazole Regimen for Preventing Infectious Complications of Transrectal Ultrasound-Guided Prostate Biopsy: A Randomized Controlled Trial

Background. The objective of this study was to evaluate the efficacy of adding single doses of ceftriaxone and amikacin to a ciprofloxacin plus metronidazole regimen on the reduction of infectious complications following transrectal ultrasound-guided prostate biopsy (TRUS Bx). Materials and Methods. Four hundred and fifty patients who were candidates for TRUS Bx were divided into two groups of 225 each. The control group received ciprofloxacin 500 mg orally every 12 hours together with metronidazole 500 mg orally every 8 hours from the day prior to the procedure until the fifth postoperative day. In the second group, single doses of ceftriaxone 1 g by intravenous infusion and amikacin 5 mg/kg intramuscularly were administered 30–60 minutes before TRUS Bx in addition to the oral antimicrobials described for group 1. The incidence of infection was compared between the groups. Results. The incidence of infectious complications in the intervention group was significantly lower than that in the control group (4.6% versus 0.9%, p = 0.017). Conclusion. The addition of single doses of intramuscular amikacin and intravenously infused ceftriaxone to our prophylactic regimen of ciprofloxacin plus metronidazole resulted in a statistically significant reduction of infectious complications following TRUS Bx.

THE INFLUENCE OF TRANSRECTAL MULTIFOCAL PROSTATE BIOPSY UNDER ULTRASOUND CONTROL ON THE DEGREE OF INFRAVESICAL OBSTRUCTION IN DIFFERENT GROUPS OF PATIENTS

Prostate cancer - is a malignant neoplasm arising from prostatic epithelium. [1] It is well known, that prostate cancer is the most common cancer in men population. Most patients, who underwent a biopsy of prostate, have expressed varying degrees of benign prostatic hyperplasia and, accordingly, symptoms, specific to the disease, including symptoms of the lower urinary (LUTS). [2], Uroflowmetry is a method widely used around the world to assess the degree of severity of infravesical obstruction [3]. The aim was to determine the degree of influence of transrectal multifocal biopsy of the prostate under ultrasound control on the degree of infravesical obstruction [4]. The study included patients with elevated serum PSA over 4 ng/ml with the volume (Vpr) of prostate from 20 cm³ to 90 cm³, volume of residual urine no more than 50 cm ³. Uroflowmetry was performed with the determination of the volume of residual urine at the primary treatment. At 21 day after transrectal multifocal prostate biopsy under Ultrasound control all patients underwent uroflowmetry. The age of patients ranged from 40 to 70 years. Patients were divided into 3 groups depending on the volume of the prostate gland. The first group consisted of 28 people where prostate volume ranged from 20 cm³ to 40 cm³, in the second group, consisted of 25 persons, prostate volume ranged from 41 cm³ to 60 cm³, and in the third group, consisted of 30 people, prostate volume ranged from 61 cm³ to 90 cm³. The following indicators of urofloumetry were determined as the following: voided volume, max flow rate, average flow, voiding time, flow time, time to max flow, and the volume of residual urine. This study has demonstrated a high risk of complications in patients with prostate volume of more than 60 cm3 caused by infravesical obstruction after prostate biopsy.

Reducing Infectious Complications Following Transrectal Ultrasound-guided Prostate Biopsy: A Systematic Review

A rise in antimicrobial resistant uropathogens has generated a global increase in infections following transrectal ultrasound-guided prostate biopsy (TRUS-Bx). We performed a systematic search of Ovid MEDLINE® and PubMed to comprehensively review strategies to mitigate infections. Of 1664 articles retrieved, 62 were included. The data suggest that augmented prophylaxis and povidone-iodine bowel preparation warrant consideration in regions with high rates of antimicrobial resistance. Transperineal biopsy may be a safer, equally effective alternative to TRUS-Bx in select cases. Recent international travel appears to increase patients' risk for experiencing infections. These findings can aid clinicians in minimizing post-TRUS-Bx infectious complications.

Clinical importance of the antibiotic regimen in transrectal ultrasound-guided biopsy: quinolone versus cephalosporin

Background

Quinolone is recommended as an antimicrobial prophylaxis to prevent infectious complication after transrectal ultrasound-guided biopsy, but the increased appearance of quinolone-resistant organism has raised concerns about the efficacy of quinolone. The current study was performed to evaluate various clinical factors including antimicrobial regimens associated with infectious complication after transrectal ultrasound-guided prostate biopsy.

Methods

The medical records of 5215 patients who underwent a multicore transrectal ultrasound-guided prostate biopsy between May 2003 and January 2013 at our institution were reviewed. We analyzed clinical variables including prostate-specific antigen, International Prostate Symptom Score, antimicrobial regimen, prostate size, and number of biopsy cores. Univariate and multivariate logistic regression analyses of infection-related hospitalization after prostate biopsy were performed.

Results

The mean age and median prostate-specific antigen of the entire cohort were 66 years and 6.4 ng/ml, respectively. Twenty-eight (0.54 %) patients developed an infectious complication after prostate biopsy that required hospitalization. Patients who received prophylactic quinolone showed a higher infectious hospitalization rate than patients who received prophylactic third-generation cephalosporin (1.5 vs. 0.3 %; p < 0.001). Multivariate logistic regression analysis demonstrated that the International Prostate Symptom Score (odds ratio = 3.18, 95 % confidence interval 1.24–8.13, p = 0.016) and the use of third-generation cephalosporin (odds ratio = 0.21, 95 % confidence interval 0.10–0.44, p < 0.001) were independent predictors of infection-related hospitalization after prostate biopsy.

Conclusion

With the emergence of quinolone-resistant microorganisms, third-generation cephalosporin may effectively reduce the risk of infectious complications after transrectal ultrasound-guided prostate biopsy. Severe lower urinary tract symptoms may also be an independent risk factor for infection-related hospitalization after transrectal ultrasound-guided prostate biopsy.

Complications After Systematic, Random, and Image-guided Prostate Biopsy

CONTEXT

Prostate biopsy (PB) represents the gold standard method to confirm the presence of cancer. In addition to traditional random or systematic approaches, a magnetic resonance imaging (MRI)-guided technique has been introduced recently.

OBJECTIVE

To perform a systematic review of complications after transrectal ultrasound (TRUS)-guided, transperineal, and MRI-guided PB.

EVIDENCE ACQUISITION

We performed a systematic literature search of Web of Science, Embase, and Scopus databases up to October 2015, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Complications and mortality following random, systematic, and image-guided PBs were reviewed. Eighty-five references were included.

EVIDENCE SYNTHESIS

The most frequent complication after PB was minor and self-limiting bleeding (hematuria and hematospermia), regardless of the biopsy approach. Occurrence of rectal bleeding was comparable for traditional TRUS-guided and image-guided PBs. Almost 25% of patients experienced lower urinary tract symptoms, but only a few had urinary retention, with higher rates after a transperineal approach. Temporary erectile dysfunction was not negligible, with a return to baseline after 1-6 mo. The incidence of infective complications is increasing, with higher rates among men with medical comorbidities and older age. Transperineal and in-bore MRI-targeted biopsy may reduce the risk of severe infectious complications. Mortality after PB is uncommon, regardless of biopsy technique.

CONCLUSIONS

Complications after PB are frequent but often self-limiting. The incidence of hospitalization due to severe infections is continuously increasing. The patient's general health status, risk factors, and likelihood of antimicrobial resistance should be carefully appraised before scheduling a PB.

PATIENT SUMMARY

We reviewed the variety and incidence of complications after prostate biopsy. Even if frequent, complications seldom represent a problem for the patient. The most troublesome complications are infections. To minimize this risk, the patient's medical condition should be carefully evaluated before biopsy.

Optimizing prophylactic antibiotic regimen in patients admitted for transrectal ultrasound-guided prostate biopsies: A prospective randomized study

Background

Transrectal ultrasound-guided prostate biopsies (TRUSBx), in spite of being one of the most frequently performed urological office procedures, are associated with a spectrum of complications, most significantly including infection. The aim of the study is to evaluate the prevalence of fluoroquinolone-resistant bacteria in rectal swabs from our local population prior to TRUSBx and to identify risk factors among a patient population harboring fluoroquinolone-resistant organisms.

Methods

We prospectively included 541 men who were submitted for TRUSBx in our center from March 2011 to June 2015. The indications for TRUSBx were an elevated prostate-specific antigen level and/or abnormal digital rectal exam. All patients were randomly divided into two groups: Group 1 (n = 279 cases) who received standard empirical prophylactic antibiotics and Group 2 who received targeted prophylaxis based on a rectal swab culture and susceptibility result. Differences in risk factors between quinolone-resistant and nonresistant patients were compared. Univariate and multivariate analyses were performed to identify independent potential risk factors associated with fluoroquinolone-resistant rectal flora.

Results

Sixteen out of 271 men developed infectious complications after TRUSBx in the group receiving standard empirical prophylaxis (5.7%). No men in the group who received targeted prophylactic antibiotic guided by rectal swab developed infectious complications. Among the 262 patients who underwent prebiopsy rectal swab cultures, 76 men (29%) displayed fluoroquinolone-resistant rectal flora (29%). In the multivariate analysis, a history of antibiotic exposure before prostate biopsy was the only independent factor associated with an increased risk of fluoroquinolone resistance.

Conclusion

Determining the prevalence of fluoroquinolone resistance in rectal flora has important implications in the selection of targeted prophylactic antibiotic regimens. Antimicrobial profiles guided by rectal swabs may prove useful to optimize prophylaxis prior to TRUSBx; this strategy is effective at reducing the rates of infectious complications, including sepsis, especially in men at higher risk of infectious complications.

Prevalence, Risk Factors, and Clinical Relevance of Fluoroquinolone-Resistant Organisms in Rectal Cultures: Should We Target Antibiotic Prophylaxis Prior to Prostate Biopsy?

The rise of infectious complications after prostate biopsy has been linked to the growing resistance of enterobacteria to fluoroquinolone (FQ) antibiotics. In this review, we investigated the potential benefit of targeted antibiotic prophylaxis based on rectal cultures prior to prostate biopsy. An electronic search for all related literature published in English was performed from April until June 2015 using the MEDLINE and EMBASE databases. Data were obtained regarding the true prevalence of FQ-resistant bacteria in the rectum of patients, the identification of those patients at risk of harbouring FQ-resistant bacteria, the risk of infectious complications after transrectal prostate biopsy in patients with FQ-resistant bacteria, and the effect of targeted prophylaxis. Although there is limited evidence that a targeted approach might be beneficial, we conclude that current studies on the use of rectal cultures in the prebiopsy setting have too many limitations and confounding variables to definitely accept this approach in clinical practice. Whether this methodology is useful in a certain region will greatly depend on local fluoroquinolone-resistance rates.

Comparative Effectiveness of Single versus Combination Antibiotic Prophylaxis for Infections after Transrectal Prostate Biopsy

An increase in fluoroquinolone resistance and transrectal ultrasound-guided prostate (TRUS) biopsy infections has prompted the need for alternative effective antibiotic prophylaxis. We aimed to compare ciprofloxacin and other single-agent therapies to combination therapy for efficacy and adverse effects. Men who underwent a TRUS biopsy within the VA Boston health care system with documented receipt of prophylactic antibiotics periprocedure were eligible for inclusion. Postprocedure infections within 30 days were ascertained by chart review from electronic records, including any inpatient, outpatient, or urgent-care visits. Among 455 evaluable men over a 3-year period, there were 25 infections (5.49%), with sepsis occurring in 2.4%, urinary tract infections (UTI) in 1.54%, and bacteremia in 0.44% of patients. Escherichia coli was the most common urine (89%) and blood (92%) pathogen, with fluoroquinolone resistance rates of 88% and 91%, respectively. Ciprofloxacin alone was associated with significantly more infections than ciprofloxacin plus an additional agent (P = 0.014). Intramuscular gentamicin alone was also significantly associated with a higher infection rate obtained with all other regimens (P = 0.004). Any single-agent regimen, including ciprofloxacin, ceftriaxone, or gentamicin, was associated with significantly higher infection rates than any combination regimen (odds ratio [OR], 4; 95% confidence interval [CI], 1.47, 10.85; P = 0.004). Diabetes, immunosuppressive condition or medication, hospitalization within the previous year, and UTI within the previous 6 months were not associated with infection risk. Clostridium difficile infections were similar. These findings suggest that ciprofloxacin, ceftriaxone, and gentamicin alone are inferior to a combination regimen. Institutions with high failure rates of prophylaxis for TRUS biopsies should consider combination regimens derived from their local data.

Prophylactic Antibiotics in Prostate Biopsy: A Meta-Analysis Based on Randomized Controlled Trials

BACKGROUND

Despite frequent use of prophylactic antibiotics for patients undergoing transrectal prostate biopsy (TRPB), the incidences of urinary tract infection (UTI) and bacteria resistance are increasing. The aim of this study is to evaluate the current regimen of antimicrobial prophylaxis in TRPB.

METHODS

A systematic search of PubMed(®), Embase(®), and the Cochrane Library was performed to identify all randomized controlled trials (RCT) related to the effects of antibiotic prophylaxis for TRPB. The outcomes included bacteriuria, bacteremia, drug-resistant bacteria on urine/blood culture, fever, UTI, sepsis, and hospitalization.

RESULTS

A total of 22 RCTs with 3846 patients were identified and included. Nine trials analyzed antibiotics versus placebo/no treatment, with all outcomes substantially favoring antibiotic use (p<0.05), including bacteriuria (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.15-0.42), bacteremia (RR 0.67, 95% CI 0.49-0.92), fever (RR 0.39, 95% CI 0.23-0.64), UTI (RR 0.37, 95% CI 0.22-0.62), and hospitalization (RR 0.13, 95% CI 0.03-0.55). There were no substantial differences between long-course versus short-course treatment and single versus multiple dose respectively, except for a greater risk of bacteriuria for short-course treatment (RR 2.09, 95% CI 1.17-3.73, p=0.01) and single-dose treatment (RR 1.98, 95% CI 1.18-3.33, p=0.01). There were no substantial differences among the groups for bacteriuria, fever, UTI, and hospitalization, when comparing oral versus systemic administration of antibiotics. The efficacy of several classes of antibiotics was compared without any difference among them. Despite the lack of significance, the synthesized data of three RCTs indicated a trend towards the use of combined antibiotics.

CONCLUSIONS

Prophylactic antibiotics could be beneficial for the reduction of infective complications after TRPB. Single-dose or short-course oral administration with any type of antibiotic appears to be optimal. One additional type of antibiotic added to the basic antibiotic agent may contribute to the minimization of severe infection and drug resistance.

Antibiotic prophylaxis with intravenous ceftriaxone and fluoroquinolone reduces infectious complications after transrectal ultrasound-guided prostatic biopsy

Purpose

To assess the rates of infectious complications before and after the change of prophylactic antibiotic regimens in prostate needle biopsy.

Materials and Methods

The records of 5,577 patients who underwent prostate needle biopsy at Asan Medical Center between August 2005 and July 2012 were retrospectively reviewed. Group 1 (n=1,743) included patients treated between 2005 and 2009 with fluoroquinolone for 3 days, group 2 (n=2,723) included those treated between 2009 and 2012 with ceftriaxone once before the biopsy and fluoroquinolone before biopsy and continue therapy for 3 days, and group 3 (n=1,111) received the same treatment for more than 7 days after the biopsy. Univariable and multivariable logistic regression models addressed risk factors associated with infectious complication after prostate needle biopsy.

Results

Infectious complication after prostate needle biopsy developed in 18 (group 1), seven (group 2), and two patients (group 3) (p=0.001). In group 1, seven patients with infectious complication had positive blood cultures and harbored fluoroquinolone-resistant Escherichia coli, four had ceftriaxone susceptible isolates, and three had extended spectrum beta-lactamase-positive E. coli. Two patients in group 1 required intensive care because of septic shock. In multivariable analysis, the patients with combination of fluoroquinolone and ceftriaxone had significantly lower infectious complication rate than the fluoroquinolon alone (p=0.003).

Conclusions

Antibiotic prophylaxis with ceftriaxone and fluoroquinolone before prostate needle biopsy decreased the risk of potentially serious infectious complications.

An antimicrobial prophylaxis protocol using rectal swab cultures for transrectal prostate biopsy

PURPOSE

To evaluate the benefit of an antimicrobial prophylaxis protocol using rectal swab cultures in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy in our Veterans Affairs population.

METHODS

Between June 1, 2013, and June 1, 2014, we implemented an antimicrobial prophylaxis protocol using rectal swab cultures on selective media containing ciprofloxacin for all men scheduled for TRUS-guided prostate biopsy. Data from 2759 patients from Jan 1, 2006 to May 31, 2013, before protocol implementation served as historical controls. Patients with fluoroquinolone (FQ)-susceptible organisms received FQ monotherapy, while those with FQ-resistant organisms received targeted prophylaxis. Our objective was to compare the rate of infectious complications 30 days after prostate biopsy before and after implementation of our antimicrobial protocol.

RESULTS

One hundred and sixty-seven patients received rectal swab cultures using our protocol. Seventeen (14 %) patients had FQ-resistant positive cultures. Patients with positive FQ-resistant culture results were more likely to have had a history of previous prostate biopsy and a positive urine culture in the last 12 months (p = 0.032, p = 0.018, respectively). The average annual infectious complication rate within 30 days of biopsy was reduced from 2.8 to 0.6 % before and after implementation of our antimicrobial prophylaxis protocol using rectal swab cultures, although this difference was not statistically significant (p = 0.13).

CONCLUSION

An antimicrobial prophylaxis protocol using rectal culture swabs is a viable option for prevention of TRUS-guided prostate biopsy infectious complications. After implementation of an antimicrobial prophylaxis protocol, we observed a nonsignificant decrease in the rate of post-biopsy infectious complications when compared to historical controls.

A Statewide Intervention to Reduce Hospitalizations after Prostate Biopsy

PURPOSE

Recent data suggest that increasing rates of hospitalization after prostate biopsy are mainly due to infections from fluoroquinolone-resistant bacteria. We report the initial results of a statewide quality improvement intervention aimed at reducing infection related hospitalizations after transrectal prostate biopsy.

MATERIALS AND METHODS

From March 2012 through May 2014 data on patient demographics, comorbidities, prophylactic antibiotics and post-biopsy complications were prospectively entered into an electronic registry by trained abstractors in 30 practices participating in the MUSIC. During this period each practice implemented one or both of the interventions aimed at addressing fluoroquinolone resistance, namely 1) use of rectal swab culture directed antibiotics or 2) augmented antibiotic prophylaxis with a second agent in addition to standard fluoroquinolone therapy. We identified all patients with an infection related hospitalization within 30 days after biopsy and validated these events with claims data for a subset of patients. We then compared the frequency of infection related hospitalizations before (5,028 biopsies) and after (4,087 biopsies) implementation of the quality improvement intervention.

RESULTS

Overall the proportion of patients with infection related hospitalizations after prostate biopsy decreased by 53% from before to after implementation of the quality improvement intervention (1.19% before vs 0.56% after, p=0.002). Among post-implementation biopsies the rates of hospitalization were similar for patients receiving culture directed (0.47%) vs augmented (0.57%) prophylaxis. At a practice level the relative change in hospitalization rates varied from a 7.4% decrease to a 3.0% increase. Fourteen practices had no post-implementation hospitalizations.

CONCLUSIONS

A statewide intervention aimed at addressing fluoroquinolone resistance reduced post-prostate biopsy infection related hospitalizations in Michigan by 53%.

Transrectal prostate biopsy-associated prophylaxis and infectious complications: report of a query to the emerging infections network of the infectious diseases society of america

Emerging Infection Network members perceive post-prostate biopsy infections as serious, increasingly common, and caused by resistant organisms. Prophylaxis, although in flux, still usually entails ciprofloxacin monotherapy, often for excessively long durations. Better evidence and approaches are needed for preventing post-TRBP infections.

Background. Fluoroquinolone-resistant infections after transrectal prostate biopsy (TRPB) are increasing.

Methods. Members of the Emerging Infections Network, a consortium of adult infectious diseases physicians sponsored by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America, were administered an electronic 9-question survey regarding post-TRPB infections and associated prophylaxis. Results were compared with respondent characteristics.

Results. The overall response rate was 47% (552 of 1180). Of the 552 respondents, 234 (42%) reported that this problem was not applicable to their practice. The remaining 318 (58%) reported that, despite widespread recent changes in prophylactic regimens, fluoroquinolone monotherapy still was most common, but diverse alternate or supplemental oral and parenteral antibiotics (including imipenem) also were used. Reports of culture-guided prophylaxis were rare (9%). The most common duration of prophylaxis was a single prebiopsy antibiotic dose. However, 16%–23% of respondents reported prophylaxis continuing for ≥24 hours postbiopsy. Post-TRPB infections were reported as being more frequent now than 4 years ago, with sepsis and genitourinary presentations predominating, but with osteomyelitis, endocarditis, and epidural abscess also occurring. Infection isolates reportedly were usually resistant to the prophylactic regimen.

Conclusions. Emerging Infections Network members perceive post-TRPB infections as increasingly frequent, caused by resistant strains, and involving serious illness. Prophylactic approaches, although in flux, still usually entail ciprofloxacin monotherapy, which often is given for excessive durations. Multiple opportunities exist for infectious diseases specialists to partner with proceduralists in devising, studying, and implementing improved prophylaxis regimens for TRPB.

Modification of Antimicrobial Prophylaxis Based on Rectal Culture Results to Prevent Fluoroquinolone-Resistant Escherichia coli Infections after Prostate Biopsy

For patients undergoing transrectal ultrasound-guided biopsy of the prostate (TRUBP), use of rectal screening culture results to guide antimicrobial prophylaxis was effective for prevention of fluoro-quinolone-resistant Escherichia coli infections. In practice, elimination of infections after TRUBP required the rectal screening protocol and addition of gentamicin for patients missing prior screening.

Morbidity and psychological impact of prostate biopsy: the future calls for a change

Currently transrectal ultrasound-guided prostate biopsy (TRUS-Bx) is one of the most common urological procedures, with more than 1 million performed per year in Europe and the United States.1 Among patients undergoing TRUS-Bx, approximately one-third will receive a diagnosis of prostate cancer (PCa), while two-thirds receive a negative result on initial biopsy. Negative biopsy patients maintain an estimated risk of repeated biopsy of 12% at 1 year and 38% at 5 years.2 Standard TRUS-Bx is likely to systematically miss significant tumors, particularly in the anterior and apical parts of the gland.3 A crucial aim of urologists in the next decade is to increase the accuracy of the procedure and avoid the use of inappropriate biopsies.

Incidence of infectious complications following transrectal ultrasound-guided prostate biopsy in Calgary, Alberta, Canada: A retrospective population-based analysis

INTRODUCTION

We have seen an increased risk of infectious complications following transrectal ultrasound-guided prostate biopsy (TRUS-PB). Fluoroquinolone (FQ) antibiotics are common for prophylaxis prior to TRUS-PB. We evaluate whether increasing FQ resistance correlates with increased incidence of post-biopsy infectious complications at our institution.

METHODS

We conducted a retrospective chart and electronic health record review on 927 patients who underwent TRUS-PB between January and July of 2012 in Calgary, Alberta, Canada. We prospectively collected the following variables: age, pre-biopsy prostate-specific antigen, and date of biopsy. We documented presentation to an emergency department within 30 days of TRUS-PB for infectious and non-infectious complications.

RESULTS

Of the 927 patients, 58 patients (6.3%) were admitted to the emergency department due to post-TRUS-PB complications within 30 days post-biopsy. The most common infectious complications were sepsis in 21 patients (2.2%), followed by urinary tract infection (UTI) in 9 (0.9%), and prostatitis in 4 (0.4%). We found that 83% of the septic episodes and 66.6% of the UTIs were attributed to ciprofloxacin resistant Escherichia coli (E. coli). The incidence of non-infectious complications was as follows: urinary retention in 12 (1.2%), hematuria in 9 (0.9%), and rectal bleeding in 8 (0.8%).

CONCLUSION

Our results suggest an increased incidence of infectious complications caused by FQ resistant organisms following TRUS-PB. This finding could be attributed to increasing community resistance to ciprofloxacin. The current antimicrobial prophylactic regimen needs to be re-evaluated, and a novel approach may need to be considered.