A prospective randomized trial of povidone-iodine prophylactic cleansing of the rectum before transrectal ultrasound guided prostate biopsy

Preventing Infectious Complications Following Prostate Biopsy: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials of Alternative Approaches to Transrectal Biopsy with Empirical Antibiotic Prophylaxis Therapy

BACKGROUND AND OBJECTIVE

Prostate biopsy, conducted frequently through the transrectal route, is associated with significant risks of infectious complications. This study aimed to compare the efficacy of various strategies to reduce these complications, using a network meta-analysis approach.

METHODS

Our study included randomized controlled trials (RCTs) identified from PubMed/MEDLINE, Embase, and the Cochrane database as of March 1, 2024. We included studies that involved adults undergoing transrectal or transperineal prostate biopsy with either standard empirical antibiotic prophylaxis or alternative interventions. The primary outcomes were assessment of sepsis, fever, urinary tract infections (UTIs), and readmissions. The study was registered with PROSPERO (CRD42024532225).

KEY FINDINGS AND LIMITATIONS

Our search yielded 28 RCTs eligible for analysis, encompassing a total of 10 179 participants. Rectal cleansing had the highest rankogram score to reduce infectious complications such as sepsis (odds ratio 0.40, 95% confidence interval [0.28-0.58]; rankogram, p score = 0.917), followed by transperineal biopsy (p score = 0.496). The overall analysis also highlighted a lower incidence of UTIs and readmissions with this method. Heterogeneity among studies was minimal (I2 < 50% for all outcomes).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Rectal cleansing might be the most effective strategy to reduce infectious complications following transrectal prostate biopsy and could be more effective than rectal culture-based antibiotic prophylaxis and transperineal biopsy. Given the indirect nature of our comparisons, further RCTs are needed to determine the safest approach for prostate biopsy, particularly between transperineal biopsy and transrectal biopsy with rectal cleansing or rectal culture-based antibiotic prophylaxis.

PATIENT SUMMARY

In this review, we analyzed different techniques to reduce infectious complications after a prostate biopsy. We found that rectal cleansing prior to performing a transrectal prostate biopsy reduced infectious complications and might be the most effective strategy. We conclude that either transperineal or transrectal prostate biopsies are acceptable approaches, albeit with rectal cleansing or rectal culture-based antibiotic prophylaxis, respectively.

Infection risk reduction with povidone-iodine rectal disinfection prior to transrectal prostate biopsy: an updated systematic review and meta-analysis

BACKGROUND

To prevent infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-PB), some studies have investigated the efficacy of rectal disinfection using povidone-iodine (PI) and antibiotic prophylaxis (AP).

OBJECTIVE

To summarize available data and compare the efficacy of rectal disinfection using PI with non-PI methods prior to TRUS-PB.

EVIDENCE ACQUISITION

Three databases were queried through November 2023 for randomized controlled trials (RCTs) analyzing patients who underwent TRUS-PB. We compared the effectiveness of rectal disinfection between PI groups and non-PI groups with or without AP. The primary outcomes of interest were the rates of overall infectious complications, fever, and sepsis. Subgroups analyses were conducted to assess the differential outcomes in patients using fluoroquinolone groups compared to those using other antibiotics groups.

EVIDENCE SYNTHESIS

We included ten RCTs in the meta-analyses. The overall rates of infectious complications were significantly lower when rectal disinfection with PI was performed (RR 0.56, 95% CI 0.42-0.74, p < 0.001). Compared to AP monotherapy, the combination of AP and PI was associated with significantly lower risk of infectious complications (RR 0.54, 95% CI 0.40-0.73, p < 0.001) and fever (RR 0.47, 95% CI 0.30-0.75, p = 0.001), but not with sepsis (RR 0.49, 95% CI 0.23-1.04, p = 0.06). The use of fluoroquinolone antibiotics was associated with a lower risk of infectious complications and fever compared to non-FQ antibiotics.

CONCLUSION

Rectal disinfection with PI significantly reduces the rates of infectious complications and fever in patients undergoing TRUS-PB. However, this approach does not show a significant impact on reducing the rate of sepsis following the procedure.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

The effect of povidone-iodine rectal cleansing on post-biopsy infectious complications

OBJECTIVE

To evaluate the effect of pre-biopsy povidone-iodine rectal cleansing on post-biopsy hospitalization rates due to prostate biopsy-related infectious complications.

MATERIAL AND METHODS

In this retrospective study, we reviewed 552 patients who underwent ultrasonography-guided transrectal prostate biopsy between 2014 and 2022. Group 1, 361 patients (January 2014-October 2020) were not applied povidone-iodine rectal cleansing, and group 2, 191 patients (November 2020-January 2022) were applied povidone-iodine rectal cleansing since we changed our biopsy protocol. All patients were given the same antibiotic prophylaxis, ciprofloxacin 500 mg, and ornidazole 500 mg twice daily starting 24 h before the biopsy and lasting a total of 5 days. Sodium phosphate enema was applied to all patients in the biopsy morning. The outcome was the hospitalization rates of patients because of infectious complications a month after the biopsy.

RESULTS

No patients were hospitalized in the povidone-iodine rectal cleansing group because of biopsy related complications. The hospitalization rate of group 1 was 3% and there was a statistical difference between groups.

CONCLUSION

The povidone-iodine solution is cheap, safe and easy to apply. The povidone-iodine rectal cleansing method seems to decrease infectious complications related to prostate biopsy procedure, but we need a randomized controlled trial to confirm our study.

TRIAL REGISTRATION

We got permission for this retrospective study from the Karabuk university ethics council with the number 2021/649 on 1 October 2021.

GEOGRAPHIC VARIATION OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSY IN THE UNITED STATES: RESULTS FROM A POPULATION-BASED COHORT OF PRIVATELY INSURED PATIENTS

OBJECTIVE

To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database.

MATEREIAL AND METHODS

Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications.

RESULTS

During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 to 0.2 in 2015 (p=0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (p=0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (p<0.05).

CONCLUSIONS

While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Antimicrobial resistance profiles for bacteria isolated from rectal swabs in patients candidate for prostate biopsy

Objective:

Infection is one of the common complications of post-prostate biopsy. Therefore, prophylaxis with fluoroquinolones and/or cephalosporins is recommended. We aimed to evaluate the prevalence of antibiotic-resistant bacteria isolated from rectal swabs in candidates for transrectal ultrasound-guided (TRUS) biopsy. The possible patient’s related risk factors attributing to resistance to antibiotics were also assessed.

Methods:

This cross-sectional study was performed on 126 male patients who were candidates for TRUS biopsy. Rectal swabs were collected and the samples were transferred to the laboratory in Amies transport medium during 2 hours and cultured on MacConkey agar with ciprofloxacin 1 mg/L and ciprofloxacin-resistant strains were identified. Kirby-Bauer disc diffusion method was used to determine the antibiotic susceptibility of the isolates.

Results:

In total, 59 bacterial isolates were obtained, which were Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa, respectively, in terms of frequency. They showed the lowest resistance to levofloxacin. Smoking was associated with positive culture results. Age was a factor with a significant effect on carrying ciprofloxacin-resistant strains.

Conclusion:

Ciprofloxacin resistance was high in almost all strains, but post-biopsy infectious complications were very low.

Level of evidence:

Not applicable

A novel enema method can prevent infectious complications of transrectal ultrasound-guided prostate biopsy: A single-centre experience

BACKGROUND

TRUS biopsy is the preferred method for diagnosing prostate cancer, but it can cause infectious complications that arise with the contribution of fluoroquinolone resistance. We aimed to explore the potential protective effect of a second rectal enema before biopsy.

METHODS

From January 2015 to December 2020, 419 patients were assessed retrospectively. Patients with a history of anticoagulant use, uncontrolled diabetes, urological surgery, prostate biopsy or recent hospitalisation or overseas travel, as well as those with the previous prostatitis, were excluded from the study. The patients were subsequently divided into two groups: Group 1 (n = 223) had received one enema, on the morning of the biopsy and Group 2 (n = 196) had received two, with the additional enema administered half an hour before the procedure.

RESULTS

There was no significant difference between the groups in terms of age(P = .076), BMI (P = .489), diabetes (P = .265), prostate-specific antigen (PSA) level (P = .193), free/total PSA (f/t PSA) ratio (P = .518) and prostate size (P = .661) or in relation to cancer detection (P = .428). The median hospitalisation date was significantly higher in Group 1 (P = .003) as was urinary tract infection (UTI) development (P = .004). However, there was no significant difference in terms of fever and sepsis (P = .524 and P = .548, respectively). Additionally, subgroup analysis demonstrated that UTI was significantly lower in patients with diabetes mellitus who had received a second enema (P = .004), though there was no significant difference in UTI between the groups in those without diabetes mellitus (P = .215). Multivariable analysis showed that age and diabetes were significant risk factors for the development of UTI (OR: 1.074, 95% CI: 1.027-1.130, P = .002 and OR: 1.220, 95% CI: 0.131-0.665, P = .003, respectively). Furthermore, the second enema was a significant protective factor for preventing UTI (OR: -1.794, 95% CI: 2.208-16.389, P < .001).

CONCLUSION

Older age and the presence of diabetes mellitus are independent risk factors for UTI after prostate biopsy. A second enema procedure before biopsy may protect patients from related infectious complications and could therefore be used as an alternative preventative method.

Transrectal povidone-iodine efficiency in reducing infections occurring after transrectal ultrasound guided biopsy of the prostate

ABSTRACT

The present study aimed to compare infectious complications in men undergoing transrectal ultrasound-guided prostate biopsy (TRUS-Bx) with and without povidone-iodine transrectal injection using a gavage syringe.The records of 112 patients, who underwent TRUS-Bx between January 2016 and December 2019, were retrospectively reviewed. The biopsy indication was considered high prostate-specific antigen (PSA) level and/or suspicious digital rectal prostate examination findings. Patients' ages, underlying diseases, PSA levels, prostate volumes, pathologic results, and infectious complications after the biopsy were investigated. All the patients received 1500 mg of ciprofloxacin (750 mg twice a day) for 5 days, starting from the day before the procedure. Forty-seven (41.96%) patients received ciprofloxacin prophylaxis with povidone-iodine transrectal injection, while 65 (58.03%) only received ciprofloxacin prophylaxis. All the patients, who were readmitted to the hospital after the procedure, especially with a temperature of higher than 37.8°C, were detected. For the purposes of the study, the priority was placed on the emergence of the rate of febrile infectious complications. Differences in febrile infectious complications in patients, who received ciprofloxacin prophylaxis with transrectal povidone-iodine, and those, who received ciprofloxacin prophylaxis alone before TRUS-Bx, were studied.Febrile infectious complications developed in 10 cases (15.38%) in patients, who received ciprofloxacin antibiotics prophylaxis alone. In the povidone-iodine rectal disinfection group, there was only 1 case of febrile infectious complication (2%). There was no significant difference by clinicopathologic features, age, PSA level, and cancer detection rate between both groups (P > .05). Multivariate logistic regression analysis did not identify any patient subgroups at a significantly higher risk of infection after prostate biopsy. There was no significant side effect associated with povidone iodine.In addition to the use of prophylactic antibiotics, transrectal povidone-iodine was useful in reducing the febrile infection complications following TRUS-Bx.

Minimizing transrectal prostate biopsy-related infections; A prospective randomized trial of povidone-iodine intrarectal cleaning versus formalin needle disinfection

INTRODUCTION

Transrectal prostate biopsies are associated with post biopsy infection and sepsis. We compared the efficacy of povidone-iodine rectal disinfection versus formalin needle disinfection in preventing post biopsy infection among patients undergoing transrectal ultrasound-guided prostate biopsy.

METHODS

Patients scheduled to undergo ultrasound-guided transrectal prostate biopsy (n = 621) over 20 months were randomized into 2 groups to receive either povidone-iodine intrarectal disinfection or formalin disinfection of needle after each core. These were compared to assess which methodology better prevented postprocedure infection. Statistical analysis were used to identify independent factors promoting infections.

RESULTS

Two hundred and ninety-eight patients from povidone-iodine intrarectal disinfection were compared with 300 from formalin needle disinfection group. Formalin needle disinfection was associated with significantly more infections (P = 0.02). Escherichia coli was the dominant pathogen, with >50% of cases being quinolone resistant. Type of disinfection (P = 0.002), BMI (P = 0.001), chronic prostatitis (P = 0.002), and diabetes mellitus (P = 0.01) were independent predictors of infections. BMI at 28.95 kg/m2 provided the best predictive cut-off point for infections, irrespective of method of disinfection. Area under the curve for all these parameters together was 0.91.

CONCLUSIONS

We conclude that along with oral cephalosporin prophylaxis, povidone-iodine intrarectal disinfection is a superior to formalin needle disinfection alone in preventing post biopsy infection. Patients with BMI >28.95 kg/m2 should be considered at a higher risk for infections.

Prevention and management of infectious complications in prostate biopsy: A review

Prostate biopsies are common procedures for urologists, performed in order to detect and diagnose prostate cancer. Procedures continue to evolve, for instance, recently there has been an increase in the use of the transperineal approach, and the emergence of antibiotic-resistant bacteria has become a challenge. This review examines the recent prostate biopsy literature as well as the guidelines of three urological associations. We review the recent literature, including our own recent studies, and the Japanese Urological Association, European Association of Urology and American Urological Association guidelines, and summarize the current recommendations regarding the prevention of infectious complications that can occur after prostate biopsy, including the use of antimicrobial agents, and the management and treatment of such complications. Current recommendations include single-dose or 1-day use of oral quinolones for infection control, along with consideration of high-risk patients with diabetes, steroid use, large prostates, or high residual urine volume for instance. Targeted therapies based on the results of rectal swabs carried out prior to transrectal prostate biopsy, which can provide better inhibitory data with regard to post-prostate biopsy infectious complications, can also be considered. In conclusion, oral quinolones for low-risk patients and targeted therapies for high-risk patients are recommended when using a transrectal approach to prostate biopsy, and oral quinolones are recommended when using a transperineal approach. Further randomized controlled trials are necessary to draw more definitive conclusions.

Infection rate and complications after 621 transperineal MRI-TRUS fusion biopsies in local anesthesia without standard antibiotic prophylaxis

PURPOSE

The aim of this study was to assess the post biopsy infection rate, feasibility and prostate cancer (PCa) detection rate (CDR) by performing transperineal MRI-TRUS fusion biopsy of the prostate (TPBx) under local anesthesia (LA) without antibiotic prophylaxis (AP).

METHODS

We prospectively screened 766 men with suspicious lesions on mpMRI, an elevated PSA level or a suspect digital examination undergoing MRI-TRUS-TPBx in LA, from May 2019 to July 2020. Patients with the need for antibiotic prophylaxis or without a PI-RADS target lesion were excluded from final analyses. We reported CDR, perioperative pain (0-10) and postoperative complications. PCa with an ISUP grade ≥ 2 was classified as clinically significant PCa (csPCa).

RESULTS

We included 621 patients with a median age of 68 years (IQR 62-74), a PSA of 6.43 ng/mL (IQR 4.72-9.91) and a prostate volume of 45 cc (IQR 32-64). In median, 4 targeted (TB) (IQR 3-4) and 6 (IQR 5-7) systematic biopsies (SB) detected in combination overall 416 (67%) PCa and 324 (52%) csPCa. Overall CDR of TB for PI-RADS 3, 4 and 5 was 26%, 65% and 84%, respectively. Patients reported a median perioperative pain level of 2 (IQR 1-3). Four patients (0.6%) developed a post biopsy infection, one experienced urosepsis.

CONCLUSION

Our results demonstrate that transperineal MRI-TRUS fusion-guided prostate biopsy under LA without AP is feasible, safe and well tolerated.

Anatomical Considerations and Procedure-Specific Aspects Important in Preventing Operative Morbidity during Transanal Total Mesorectal Excision

As transanal total mesorectal excision (taTME) becomes increasingly utilized, its technical challenges and potential pitfalls have become more clearly appreciated. This chapter explores the differences in how anatomy presents itself from the taTME vantage point as compared with traditional approaches to taTME, and how special problems unique to taTME pose a new set of operative challenges. Morbidity related, specifically, to the technique of taTME is also delineated with particular focus on male urethral injury.

Prostate biopsy techniques and pre-biopsy prophylactic measures: variation in current practice patterns in the Netherlands

BACKGROUND

The clinical landscape of prostate biopsy (PB) is evolving with changes in procedures and techniques. Moreover, antibiotic resistance is increasing and influences the efficacy of pre-biopsy prophylactic regimens. Therefore, increasing antibiotic resistance may impact on clinical care, which probably results in differences between hospitals. The objective of our study is to determine the (variability in) current practices of PB in the Netherlands and to gain insight into Dutch urologists' perceptions of fluoroquinolone resistance and biopsy related infections.

METHODS

An online questionnaire was prepared using SurveyMonkey® platform and distributed to all 420 members of the Dutch Association of Urology, who work in 81 Dutch hospitals. Information about PB techniques and periprocedural antimicrobial prophylaxis was collected. Urologists' perceptions regarding pre-biopsy antibiotic prophylaxis in an era of antibiotic resistance was assessed. Descriptive statistical analysis was performed.

RESULTS

One hundred sixty-one responses (38.3%) were analyzed representing 65 (80.3%) of all Dutch hospitals performing PB. Transrectal ultrasound guided prostate biopsy (TRUSPB) was performed in 64 (98.5%) hospitals. 43.1% of the hospitals (also) used other image-guided biopsy techniques. Twenty-three different empirical prophylactic regimens were reported among the hospitals. Ciprofloxacin was most commonly prescribed (84.4%). The duration ranged from one pre-biopsy dose (59.4%) to 5 days extended prophylaxis. 25.2% of the urologists experienced ciprofloxacin resistance as a current problem in the prevention of biopsy related infections and 73.6% as a future problem.

CONCLUSIONS

There is a wide variation in practice patterns among Dutch urologists. TRUSPB is the most commonly used biopsy technique, but other image-guided biopsy techniques are increasingly used. Antimicrobial prophylaxis is not standardized and prolonged prophylaxis is common. The wide variation in practice patterns and lack of standardization underlines the need for evidence-based recommendations to guide urologists in choosing appropriate antimicrobial prophylaxis for PB in the context of increasing antibiotic resistance.

Comparisons of cancer detection rate and complications between transrectal and transperineal prostate biopsy approaches - a single center preliminary study

Background

Prostate biopsy remains the gold standard approach to verify prostate cancer diagnosis. Transrectal (TR) biopsy is a regular modality, while transperineal (TP) biopsy is an alternative for the patients who display persistently high levels of prostate-specific antigen (PSA) and thus have to undergo repeat biopsy. This study aimed to compare the cancer detection rates between TR and TP approaches and assess the post-bioptic complications of the two procedures. Besides, the feasibility of performing TP biopsies under local anesthesia was also evaluated.

Methods

A total of 238 outpatient visits meeting the criteria for prostate cancer biopsy were enrolled for this study. They were divided into two groups: the TP group (n = 130) consists of patients destined to undergo local anesthetic TP biopsy; and the TR group (n = 108) contained those who received TR biopsy as comparison. Age, PSA level, digital rectal exam (DRE) finding, prostate volume, and biopsy core number were used as the parameters of the multivariable analyses. The comparable items included cancer detection rate, complication rate, admission rate and visual analog scale (VAS) score.

Results

The cancer detection rates between TP and TR groups were quite comparable (45% v.s. 49%) (p = 0.492). However, the TP group, as compared to the TR group, had significantly lower incidence of infection-related complications (except epididymitis and prostatitis) that commonly occur after biopsies. None of the patients in the TP group were hospitalized due to the post-bioptic complications, whereas there was still a minor portion of those in the TR group (7.4%) requiring hospitalization after biopsy. Medians (25–75% quartiles) of visual analog scale (VAS) were 3 [3, 4] and 4 [3–5] respectively for the TP and TR procedures under local anesthesia, but no statistical significance existed between them (p = 0.085).

Conclusions

Patients receiving TP biopsy are less likely to manifest infection-related complications. Therefore, TP biopsy is a more feasible local anesthetic approach for prostate cancer detection if there are concerns for infectious complications and/or the risk of general anesthesia.

Update on techniques to prevent infections associated with prostate needle biopsy

PURPOSE OF REVIEW

Postbiopsy infections (PBIs) are among the most common complications associated with transrectal ultrasound-guided prostate biopsy (TRUSPB). This article discusses the pathogenesis of TRUSPB-associated infectious complications and reviews the most recent findings on techniques to prevent PBIs.

RECENT FINDINGS

Risk stratification is a powerful tool for identifying TRUSPB candidates whom warrant additional preventive measures. Bowel preparation with povidone-iodine-based enemas and needle disinfection with formalin solution are simple and attractive strategies, but their effectiveness needs to be thoroughly assessed. Antibiotic prophylaxis represents the mainstay for the prevention of PBIs: the prophylactic regimen must respect the principles of antimicrobial stewardship, and local antibiotic resistance patterns among uropathogens should always be considered. Augmented and targeted antibiotic prophylaxes are powerful options, but their role in current clinical practice has yet to be clarified. The transperineal approach has shown a near-zero rate of PBIs, and should therefore be considered for the highest-risk patients.

SUMMARY

Several procedures have been introduced to prevent TRUSPB-related infectious complication, but their utility and applicability in the clinical practice has yet to be elucidated. More robust evidence based on randomized control trials is needed to establish the efficacy of these tools in improving patient outcomes.

A prospective randomized trial of povidone-iodine suppository before transrectal ultrasonography-guided prostate biopsy

OBJECTIVES

To investigate a way to reduce infectious complication after transrectal ultrasonography-guided prostate biopsy (TRUS-Bx), we planned a randomized trial to determine whether the use of the povidone-iodine suppository is effective in preventing infectious complications.

METHODS

This study prospectively assessed 250 patients who underwent TRUS-Bx during December 2014 and May 2016. Clinical questionnaire responses and safety were evaluated. Povidone-iodine suppository after glycerin enema was performed 1 to 2 hours before TRUS-Bx. Both groups received the prophylactic antibiotics (ceftriaxone 2.0 g) 30 to 60 minutes before TRUS-Bx. No antibiotics were prescribed after TRUS-Bx.

RESULTS

The 120 were assigned in the treatment group using povidone-iodine suppository and 130 were assigned in the control group. There was no significant difference of clinicopathologic features including age, prostate-specific antigen and cancer detection rate in both groups (P > .05). No infectious and non-infectious complications were reported in both groups. Povidone-iodine suppository-related side effects were not reported. No significant differences in international prostate symptom score, sexual health inventory for men score, and European Organization for Research and Treatment of Cancer Quality of Life questionnaire scores were found between the 2 groups (P > .05). No changes in each questionnaire scores between before and after TRUS-Bx were observed.

CONCLUSIONS

Despite satisfying the predefined sample size, we could not prove the hypothesis that the use of povidone-iodine suppositories after TRUS-Bx would reduce infectious complications. A large-scale, multicenter, prospective study is needed to fully evaluate the clinical efficacy and safety of povidone-iodine suppository prior to TRUS-Bx.

Update on Strategies to Reduce Infectious Complications After Prostate Biopsy

CONTEXT

Prostate biopsy is one of the most performed procedures in urology. As a diagnostic procedure it should be of low risk. However, morbidity following prostate biopsy is common due to infectious complications.

OBJECTIVE

To describe how to reduce infectious complications following prostate biopsy. We report on antibiotic and technical interventions to reduce infectious complications.

EVIDENCE ACQUISITION

The data presented are based on a narrative review. Search in PubMed and Medline was performed until May 2018 with a focus on randomised controlled trials and meta-analyses. Articles were reviewed for data on symptomatic infections, hospitalisation, and adverse events.

EVIDENCE SYNTHESIS

Antibiotic prophylaxis is the standard of care. However, the duration of antibiotic preemptive treatment is still under debate. The use of augmented antibiotic prophylaxis as well as targeted antibiotic prophylaxis might be of potential value, but evidence is currently limited. Moreover, no antibiotic class was shown to be clearly superior to another. The evaluation of the technical aspects during prostate biopsy reveals that rectal preparation with povidone-iodine is clearly effective to reduce infectious complications. Transperineal biopsy has a potential benefit to reduce infectious complications, but powerful randomised controlled studies are missing. Finally, the number of biopsy cores, the application of periprostatic nerve block, or the use of a cleansing enema has no impact on prostate biopsy in terms of infectious complications.

CONCLUSIONS

The available data only suggest that rectal preparation with povidone-iodine as well as antibiotic prophylaxis is of significant advantage to reduce infectious complications following prostate biopsy. The augmented and targeted antibiotic prophylaxis shows some potential, but need further validation.

PATIENT SUMMARY

In this review we evaluate the best management strategy to prevent infectious complications following prostate biopsy. We show that antibiotic prophylaxis is essential for prostate biopsy and that rectal preparation with povidone-iodine is mandatory.

Topical rectal antiseptic at time of prostate biopsy: how a resident patient safety project has evolved into institutional practice

PURPOSE

To report outcomes 5 years after a resident quality initiative incorporated topical rectal antiseptic into our ultrasound-guided prostate needle biopsy (TRUS PNB) protocol.

METHODS

A chart review was conducted on 1007 men who underwent TRUS PNB between 2010 and 2017. Comparison groups include those who received a topical rectal antiseptic (N = 437) compared to those who did not (N = 570). Povidone-iodine (N = 303) or 4% chlorhexidine solution without alcohol (N = 134) were topical agents. Outcomes of interest included post-biopsy infection (urinary tract infection and/or sepsis), hospital admission, and need for ICU monitoring.

RESULTS

Median age and PSA of men included in this study were 64 years and 12 ng/mL. Almost 90% of patients were Caucasian, 13% had diabetes, 3% were on immunosuppression, 32% had at least one prior biopsy, 14% received antibiotics, and 7% were hospitalized in the past 6 months. 22 patients (2.2%) developed a post-biopsy infection with a significant reduction in the group receiving topical rectal antiseptic (0.8 vs. 3.3%, p = 0.01). Post-biopsy UTI rates (p = 0.04) and hospital admission (p = 0.03) were also lower in the topical antiseptic group with trends to reduction in sepsis and need for ICU monitoring.

CONCLUSIONS

What started as a resident quality safety project 5 years ago has demonstrated a reduction in infections and hospital admissions following TRUS PNB. Our institutional practice now routinely uses povidone-iodine or chlorhexidine as an adjunct to oral quinolones for TRUS PNB perioperative prophylaxis.

Antimicrobial Lubricant Did Not Reduce Infection Rate in Transrectal Biopsy Patients in a Large Randomized Trial Due to Low Complication Rates

BACKGROUND

Transrectal prostate biopsy (pbx) is the most frequent outpatient procedure in the urological field. Septic complications are a major health issue.

OBJECTIVE

To evaluate complication rates with or without an antimicrobial lubricant.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1000 patients received pbx between 2013 and 2015. Information about complications was collected by a 3-wk questionnaire. Return rate was 73.2% (n=732).

INTERVENTION

Randomization for pbx with the instillation of an antimicrobial lubricant (intervention group, n=385) or the standard lubricant (control group, n=347) was performed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable analyses assessed the association between infectious complications at biopsy and use of an antimicrobial lubricant, International Prostate Symptom Score (IPSS), history of urogenitourinary infections, and several other confounders.

RESULTS AND LIMITATIONS

The use of an antimicrobial lubricant did not reduce infection rate. Overall complication rate was very low. Of all patients, 69.3% described the procedure as pain free. Fever ≥38.5°C was reported in overall 1.9% of patients. Urinary retention with catheterization occurred in 3.1%. Most common complications were hematospermia (47.4%), macrohematuria (23.8%), and rectal bleeding (7.4%). Readmission rate was 1% (n=7). In multivariable analyses, IPSS and previous infectious complications were associated with a higher risk of infectious complications. Our results stem from a large German single center and therefore are limited to this patient group.

CONCLUSIONS

No significant reduction was shown in infectious complications in the intervention group with the antimicrobial agent. Low incidence of those complications may be the underlying cause. Severe morbidity at pbx is uncommon. Specifically, the rate of infection was very low.

PATIENT SUMMARY

Severe complications at prostate biopsy are rare. Among participants, 69.3% had no pain. Fever was rare (1.9% of patients). Voiding issues with catheterization occurred in 3.1%. Most common complications were blood in the semen (47.4%), urine (23.8%), or stool (7.4%). Men with voiding issues or previous infectious complications had a higher risk of infectious complications.

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.

Antimicrobial lubricant reduces rectal bacteria at transrectal prostate biopsy: results from a prospective randomized trial

PURPOSE

Antibiotic resistance may lead to increasing infection rates at transrectal prostate biopsy. Local antimicrobial agents might help to reduce bacterial load. The aim of this study was to test the potency of antimicrobial lubricants to reduce local bacterial loads and specifically fluoroquinolone-resistant strains.

PATIENTS AND METHODS

Overall, 384 prostate biopsy (PBx) patients of a larger prospective randomized trial (n = 1000) were included. Patients were randomized for biopsy with pre-interventional instillation of an antimicrobial lubricant (intervention group n = 256) or with the standard lubricant (control group n = 128). Bacteria were recovered on pre- and post-biopsy rectal swab cultures from both patient groups. Bacterial colonization was semi-quantitatively recorded and analyzed for the presence of ciprofloxacin-resistant isolates.

RESULTS

Within the intervention group, where antimicrobial lubricant was instilled for PBx, the post-biopsy bacterial count was statistically significantly lower compared to prior biopsy bacterial count (p < 0.001), while in the control group, no statistically significant difference was shown. Moreover, our results demonstrated the tendency for reduction in ciprofloxacin-resistant bacteria growth when instillation of antimicrobial lubricant was used (9.4% versus 5.9%, p = 0.5 prior- and post-biopsy). No reduction in ciprofloxacin-resistant bacterial growth was demonstrated for the control group. Ciprofloxacin-resistance was shown in overall 30 (7.8%) patients.

CONCLUSION

Our data demonstrated that the antimicrobial lubricant prior biopsy leads to reduced bacterial load. Moreover, our data show the tendency for reduced ciprofloxacin-resistant bacteria growth when antimicrobial lubricant was instilled prior biopsy. However, the incidence of ciprofloxacin-resistant bacteria is low in our patient population. Rectal swabs should assess fluoroquinolone-resistance rates at prostate biopsy.

Antibiotic Prophylaxis in Prostate Biopsies: Contemporary Practice Patterns in Germany

Purpose

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

Methods

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

Results

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

Conclusion

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

Transrectal prostate biopsy sepsis rate following reduced quinolone antibiotic prophylaxis from six doses to single dose

BACKGROUND

This study aimed to evaluate the rates of infective complication related to transrectal prostate biopsy (TRPB) as our centre changed its protocol from six doses over 3 days to a single pre-procedure prophylactic dose.

METHODS

This prospective cohort study identified infective complication in patients who attended and subsequently underwent TRPB at the time of their one-stop prostate clinic at our public tertiary hospital between August 2011 and April 2017. Patients who underwent TRPB between August 2011 and November 2014 received six doses of 500 mg of ciprofloxacin, taken twice daily over 3 days. This protocol was changed to a single dose of 500 mg of ciprofloxacin prior to biopsy from February 2015 to April 2017. Patients who had travelled to South East Asia in the 6 months prior to TRPB received a single dose of 1 g intravenous ertapenem prior to biopsy, and this remained unchanged throughout the study period. The rates of infective complication were recorded and compared between the groups of patients who had undergone six doses versus a single dose of prophylactic ciprofloxacin.

RESULTS

A total of 766 patients underwent TRPB from August 2011 to April 2017. Of these, 357 patients received the 3-day course of prophylaxis (Group 1) and 409 patients received the single dose prophylaxis (Group 2). Fifty-five patients were excluded from analysis. There was no significant difference in infective complications between the two groups (3.4% (11/326) Group 1 versus 4.9% (19/385) Group 2, P = 0.40).

CONCLUSION

Our study supports the use of a single dose of ciprofloxacin as sufficient antibiotic prophylaxis prior to TRPB.

Prevalence of fluoroquinolone-resistant rectal flora in patients undergoing transrectal ultrasound-guided prostate needle biopsy: A prospective multicenter study

OBJECTIVES

To estimate the prevalence of fluoroquinolone-resistant rectal flora in patients undergoing transrectal ultrasound-guided prostate needle biopsy and to identify the high-risk groups.

METHODS

From January 2015 to March 2016, rectal swabs of 557 men who underwent transrectal ultrasound-guided prostate needle biopsy were obtained from five institutions. Clinical variables, including demographics, rectal swab culture results and infectious complications, were evaluated. Univariable and multivariable analyses were used to identify the risk factors for fluoroquinolone resistance of rectal flora and infectious complications.

RESULTS

The incidence of fluoroquinolone-resistant and extended-spectrum beta-lactamase production was 48.1 and 11.8%, respectively. The most common fluoroquinolone-resistant bacteria was Escherichia coli (81% of total fluoroquinolone-resistant bacteria, 39% of total rectal flora), and 16 (2.9%) patients had infectious complications. Univariable and multivariable analysis of clinical parameters affecting fluoroquinolone resistance showed no factor associated with fluoroquinolone resistance of rectal flora. The clinical parameter related to infectious complications after prostate biopsy was a history of operation within 6 months (relative risk 6.60; 95% confidence interval 1.99-21.8, P = 0.002).

CONCLUSIONS

These findings suggest that a risk-based approach by history taking cannot predict antibiotic resistance of rectal flora, and physicians should consider targeted antibiotic prophylaxis or extended antibiotic prophylaxis for Korean patients undergoing transrectal ultrasound-guided prostate biopsy because of high antibiotic resistance of rectal flora.

"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.

Transperineal vs. transrectal biopsy in MRI targeting

Prostate biopsy is typically performed via either the transrectal or transperineal approach. MRI-targeted biopsy, whether using any of the three options of cognitive fusion, MRI-ultrasound fusion software, or in-bore MRI-guided biopsy, can also be performed via either transrectal or transperineal approaches. As an extension of traditional random prostate biopsy, the transrectal approach is far more commonly used for MRI-targeted biopsy due to its convenience. However, in the context of today’s increasing multi-drug resistance of rectal flora, the transperineal approach is being used more often due to its lack of septic complications. In addition, only a first-generation cephalosporin, not a fluoroquinolone, is required as antibiotic prophylaxis. Evidence shows excellent detection rates of significant prostate cancer using magnetic resonance imaging (MRI)-targeted and/or systematic transperineal biopsy (TPB). However, there are no head-to-head studies comparing the different MRI-targeted methods within TPB. To provide truly patient-centred care, the biopsy technique using the safest method with the highest detection rate of significant cancer should be used. Depending on healthcare context and hospital resource utilization, MRI-targeted TPB is an excellent option and should be performed wherever available and feasible. Whilst building capacity for TPB in one’s practice, the routine use of rectal culture swabs prior to any transrectal biopsies is strongly encouraged. Independent of biopsy route, the addition of systematic cores needs to be discussed with the patient weighing maximal detection of significant cancer against increased detection of insignificant lesions.

Prevention of infectious complications after prostate biopsy procedure

Although febrile complications are rarely encountered after a prostate biopsy procedure, in recent years the number of cases of fatal infection after that have increased along with increases in resistant bacteria. The available biopsy approaches are transrectal and transperineal, with the transrectal approach primarily used. As the invasion path of the puncture needle differs between these approaches, pretreatment and the method of administration of preventive antimicrobial drugs should be separately considered for infection prevention. Recently, the Japanese guidelines for perioperative infection prevention in the field of urology were revised after receiving approval from the Japanese Urological Association. With use of the transrectal approach, attempts have been made to selectively administer prophylactic antibiotics by confirming the presence or absence of resistant bacteria in rectal swab culture results before carrying out a prostate biopsy procedure because of potential problems associated with resistant bacteria in rectal flora. For preventive antibiotics, a single dose of oral quinolone is recommended for patients with low risk, whereas daily administrations of piperacillin/tazobactam are recommended for those considered to be high risk. In contrast, for the transperineal procedure, a single dose of oral quinolone is recommended as a preventive antibiotic. With both approaches, it is important to empirically administer broad-spectrum antimicrobials when occurrence of a febrile infection after a prostate biopsy procedure is confirmed.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dutasteride is associated with reduced risk of transrectal prostate biopsy-associated urinary tract infection and related hospitalizations

OBJECTIVES

To evaluate whether the use of dutasteride is associated with a lower risk of transrectal prostate biopsy-associated urinary tract infection (TPBA-UTI) among men in the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) study.

METHODS

Retrospective analysis of 6045 men undergoing 2-year repeat prostate biopsy in REDUCE. Participants were randomized to receive dutasteride 0.5 mg or placebo daily. TPBA-UTI was defined as the presence of urinary symptoms and the prescription of antibiotics by the treating physician within 30 days after biopsy. Severe TPBA-UTI was defined as TPBA-UTI requiring hospitalization. Comparison of TPBA-UTI between treatment arms was done using Chi-square test and logistic regression adjusting for participant characteristics.

RESULTS

Of the subjects included in the study, 3067 (50.7%) were randomized to the placebo arm and 2978 (49.3%) to the dutasteride arm. A total 51 (0.8%) men had TPBA-UTI, including 38 (1.2%) in the placebo arm and 13 (0.4%) in the dutasteride arm (univariable relative risk [RR] = 0.35, P = 0.001; multivariable odds ratio [OR] = 0.34, P = 0.003). The number needed to treat (NNT) to prevent one TPBA-UTI was 125 subjects. Of these, 14 (28%) had severe TPBA-UTI, including 12 (0.4%) in the placebo arm and only 2 (0.07%) in the dutasteride arm (univariable RR = 0.17, P = 0.021; multivariable OR = 0.17, P = 0.031). The NNT to prevent one severe TPBA-UTI was 309 subjects.

CONCLUSION

Among men undergoing a 2-year repeat prostate biopsy, the use of dutasteride for 2 years was associated with a reduced the risk of overall and severe TBPA-UTI. CLINICALTRIALS.

GOV IDENTIFIER

NCT00056407.

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.

Prostate Biopsy-related Infection: A Systematic Review of Risk Factors, Prevention Strategies, and Management Approaches

A systematic review to identify risk factors for prostate biopsy-related infection, preventative strategies, and optimal management of infectious complications was conducted. Significant risk factors for postbiopsy infection include urogenital infection, antibiotic use, international travel, hospital exposure, bacteriuria, previous transrectal biopsy, and resistance of fecal flora to antibiotic prophylaxis (especially fluoroquinolones). Patients at risk may benefit from an adjusted biopsy protocol comprising transrectal biopsy under targeted prophylaxis, and/or the use of rectal disinfection techniques or using a transperineal approach. Management of biopsy-related infection should be based on individual risk and local resistance profiles with input from multiple specialties.

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.

Increase of prostate biopsy-related bacteremic complications in southern Finland, 2005-2013: a population-based analysis

BACKGROUND

The most severe manifestations of prostate biopsy complications are bacteremic infections. These complications are increasing alarmingly.

METHODS

A retrospective cohort study of 17 183 transrectal prostate biopsies performed at the Helsinki and Uusimaa hospital district in southern Finland during 2005-2013. Biopsies were linked to a database of positive blood cultures, yielding 111 bacteremic cases, and yearly bacteremia rates were determined. By multiple regression analysis, demographic risk factors of the whole biopsy cohort for developing bacteremia or fluoroquinolone (FQ)-resistant bacteremia were studied. Clinical risk factors for bacteremia caused by an FQ-resistant organism and for serious bacteremic outcomes were studied by univariate and multivariate analyzes.

RESULTS

The average bacteremia rate was 0.7% (111 of 17 183 biopsies) and an increase was observed from 0.5% in 2005 (95% confidence interval (CI): 0.3-0.9) to 1.2% in 2012 (95% CI 0.8-1.8); 53.2% were caused by an FQ-resistant organism. In univariate regression analysis, previous biopsy sessions and increasing calendar year of biopsy associated with the risk of developing bacteremia (odds ratio (OR) 1.232, 95% CI: 1.020-1.488, P=0.030 and OR 1.164, 95% CI: 1.079-1.255, P<0.001, respectively), but only increasing calendar year of biopsy remained statistically significant (OR 1.155, 95% CI: 1.070-1.247, P<0.001) in multivariate analysis. Foreign travel within 3 months was associated with FQ resistance in multivariate analysis (OR 7.158, 95% CI: 1.042 to infinite, P=0.045). The study failed to show any significant clinical risk factors for serious bacteremic outcomes (requiring intensive care, developing deep infection foci or death).

CONCLUSIONS

The postbiopsy bacteremia rate doubled during the study period and half of the cases were caused by FQ-resistant organisms. Recent foreign travel increased the risk for FQ resistance. Future research efforts should be aimed at better identifying risk factors, targeted prophylaxis and reducing the need for biopsies.

Strategies for prevention of ultrasound-guided prostate biopsy infections

Prostate cancer is the most common cancer in male patients and the second leading cause of cancer-related mortality in males. To confirm the diagnosis of prostate cancer, an ultrasound-guided needle biopsy is necessary to obtain prostate tissue sufficient for histologic analysis by pathologists. Ultrasound-guided prostate needle biopsy can be accomplished via a transperineal or transrectal approach. The latter biopsy technique involves placing an ultrasound probe into the rectum, visualizing the prostate located just anterior to it, and then obtaining 12-14 biopsies. Each biopsy core requires piercing of the rectal mucosa which can inherently contribute to infection. The increasing infectious risk of prostate needle biopsy requires refinement and re-evaluation of the process in which the technique is performed. Such processes include (but are not limited to) prebiopsy risk stratification, antibiotic prophylaxis, use of rectal preparations, and equipment processing. In the subsequent review, we highlight the current available information on different strategies to reduce the risk of infection following prostate needle biopsy.

Fluoroquinolone resistance colonization from initial to repeat prostate biopsy

Purpose:

Fluoroquinolone (FQ) resistant (FQR) bacteria are a major cause of infection after transrectal prostate biopsy (TRPB). We determined the prevalence of FQR in initial and subsequent rectal cultures from men undergoing repeat prostate biopsies.

Materials and methods:

After IRB approval, men presenting for TRPB at the San Diego Veterans Affairs Medical Center between January 1, 2010, and February 6, 2014, underwent pre-TRPB rectal culture. The rectal swab was collected from the patient immediately prior to TRPB. Rectal swabs were streaked onto locally prepared ciprofloxacin-supplemented (4 mg/L) MacConkey agar plates. A representative colony was selected for identification and susceptibility testing.

Results:

Of 617 patients who had rectal cultures done, 7% (43/617) had a repeat rectal culture performed in relation to a second prostate biopsy. All cipro-resistant bacteria isolated were Escherichia coli. The median time and interquartile range between first and second biopsy was 2.3 years (range 1.2–3.6 years). On first biopsy, 16.3% (7/43) had FQR, which was not statistically different from the 18.6% of patients who had FQR on their second biopsy ( p=0.78). Overall, 74% (32/43) of patients tested absent for FQR at both prostate biopsies, and 9.3% (4/43) tested present at both ( p=0.015). However, 9.3% (4/43) converted from absent to present FQR, and 7.0% (3/43) converted from present FQR to absent ( p=0.69). Seventy percent of the FQR E. coli were also resistant to gentamicin, and 22% were resistant to cefepime.

Conclusions:

Patients undergoing prostate biopsy should be examined for FQR prior to each individual biopsy because prior culture results do not always predict whether a patient will be colonized with FQR E. coli.

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.

Critical concepts and important anatomic landmarks encountered during transanal total mesorectal excision (taTME): toward the mastery of a new operation for rectal cancer surgery

Over the past 3 years, colorectal surgeons have begun to adapt the technique of transanal total mesorectal excision. As international experience has been quickly forged, an improved recognition of the pitfalls and the practical details of this disruptive technique have been realized. The purpose of this technical note was to express the various nuances of transanal total mesorectal excision as learned during the course of its clinical application and international teaching, so as to rapidly communicate and share important insights with other surgeons who are in the early adoption phase of this approach. The technical points specific to transanal total mesorectal excision are addressed herein. When correctly applied, these will likely improve the quality of surgery and decrease morbidity attributable to inexperience with the transanal approach to total mesorectal excision.

Prevention of sepsis prior to prostate biopsy

Purpose

Urosepsis is the most feared complication of transrectal prostate biopsy. The incidence may be increasing from <1% to 2%–3% in contemporary series. Historically, fluoroquinolones have been effective antibiotic prophylaxis to prevent infective complications but antibiotic resistance is increasing. The increase in antibiotic resistance may contribute to reported increases in urosepsis and hospitalization after transrectal biopsy. This article will review other methods clinicians may employ to reduce the incidence of infective complications after prostate biopsy.

Materials and Methods

A systematic review of the literature was conducted using literature databases PubMed and Ovid MEDLINE in August 2015 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) criteria.

Results

Effective strategies to reduce infective complications after transrectal prostate biopsy include augmented prophylaxis with other antibiotics, rectal swab culture directed antibiotic prophylaxis or a transperineal biopsy approach. Needle disinfection, minimizing the number of biopsy needles and rectal disinfectants may also be of use. These methods may be of particular utility in patients with risk factors for developing urosepsis such as recent antibiotic use and overseas travel.

Conclusions

The scientific literature describes various techniques designed to reduce infective complications caused by prostate biopsy. Clinicians should consider incorporating these novel techniques into their contemporary practice.

Does Leaving the Biopsy Needle in Povidone-Iodine Solution Reduce Infective Complications after Biopsy?

Aim. The aim of this study is to evaluate whether leaving the biopsy needle used during prostate needle biopsy in 10% povidone-iodine (betadine) solution affects the infectious complications forming after biopsy. Material and Method. This study retrospectively evaluated the data of 176 patients with prostate biopsy performed between December 2012 and April 2014. Patients in Group 1 (n = 89) were given ofloxacin as a prophylactic antibiotic before biopsy. Patients in Group 2 (n = 87) had the biopsy needle left in povidone-iodine solution for 1 minute before each use, in addition to antibiotic prophylaxis. The two groups were compared in terms of infective complications developing after biopsy. Results were analyzed using the Mann–Whitney U test and Fisher's exact test. Results. The distribution of infective complications after biopsy according to group was as follows. Group 1, not using betadine, had 15.7% fever, 13.5% hospital stay, 12.4% urinary retention, 10.1% prostatitis, and 5.6% sepsis. The distribution of the same complications in Group 2 using betadine was identified as 5.7% fever, 4.6% hospital stay, 3.4% urinary retention, 2.3% prostatitis, and 0% sepsis. The use of betadine was found to significantly reduce the infectious complications after biopsy compared to the control group (p < 0.05). Conclusion. At the end of this study leaving the prostate needle in povidone-iodine solution before each use during prostate biopsy was found to reduce the infective complications and hospital stay after biopsy.

Risk factors for infection following prostate biopsy - a case control study

Background

Infection is a complication of TRUS prostate biopsy, despite the use of antimicrobial prophylaxis. Worryingly the rate of infectious complications following TRUS biopsy has been shown to be increasing. We aimed to determine the rate, severity, risk factors, standard patterns of care and microbiology resistance profiles associated with TRUS biopsy sepsis.

Methods

A retrospective case–control study was conducted. Using electronic coding all patients who presented to Cabrini Hospital with sepsis following a TRUS biopsy from 2009 to 2013 were identified. Validated cases were matched to controls in a ratio of 1:3. Eligible controls were required to have undergone a TRUS biopsy at the same surgical institution as the case and in the closest period of time. Demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. Univariate logistic regression models were constructed and used to determine risk factors associated with infection.

Results

71 cases developed sepsis following TRUS biopsy and were matched to 213 controls. The average rate of sepsis over the 5-year study period was 1.5 %. A SOFA score ≥ 2 was identified in 28 % of cases. We found a high prevalence of antimicrobial resistant E. coli, with 61 % of blood culture isolates classified as Multidrug resistant organisms. Eight different prophylactic antimicrobial regimens were identified with 33 % of cases receiving ineffective antimicrobial prophylaxis. Statistically significant risk factors included previous antimicrobial use and prior international travel within the six months prior to biopsy.

Conclusions

TRUS biopsy is an elective procedure and as such needs to be associated with minimal morbidity. The patterns of care surrounding periprocedural variables for TRUS biopsies were non-uniform and diverse. A wide variety of different prophylaxis regimens and bowel preparation routines were recorded. Patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. Alternative preventative options include augmented prophylaxis, tailored prophylaxis or the TP biopsy approach either as a first line biopsy modality or based on epidemiological risk factors.

Epidural abscess with associated spondylodiscitis following prostatic biopsy

Spondylodiscitis is often iatrogenic in nature. We report the case of a 69-year-old man presenting with spondylodiscitis and associated epidural abscess following transrectal ultrasonography guided prostate biopsy despite ciprofloxacin cover. To our knowledge, this is the first case of spondylodiscitis secondary to fluoroquinolone resistant Escherichia coli.