Characterization of ciprofloxacin resistant Escherichia coli isolates among men undergoing evaluation for transrectal ultrasound guided prostate biopsy

The role of a radiopaque peri-rectal hydrogel spacer in aiding accurate daily image-guidance for prostate stereotactic radiotherapy

Introduction

Precise patient positioning with image guidance (IGRT) is essential for safe prostate radiotherapy. We present the first report of utilizing a CT-visible hydrogel spacer, used to decrease rectal radiation dose, as a surrogate fiducial marker to aid in daily IGRT with cone-beam CT (CBCT) in stereotactic radiotherapy (SABR) for prostate cancer.

Materials and methods

Prior to CT simulation, patients underwent placement of three intraprostatic gold fiducial markers and radiopaque hydrogel spacer per standard practice. At treatment, after initial setup, a CBCT was acquired and fused to the planning CT based on 3-dimensional matching of the spacer. A second alignment was then performed based on the fiducial markers. The six directional shifts (three linear and three rotational) were recorded, and the differences compared.

Results

140 individual fractions across 41 consecutive patients were evaluated. Mean/median differences between hydrogel spacer-based and fiducial-based alignment in linear (vertical, longitudinal, lateral) and rotational (rotation, pitch, roll) shifts were 0.9/0.6mm, 0.8/0.5mm, and 0.6/0.4mm, and 0.38/0, 0.62/0, and 0.35/0 degrees, respectively. No difference was observed in 9.9%, 22.9%, and 22.14% of linear shifts, and 65.7%, 65%, and 66.4% rotational shifts, respectively. Significantly smaller differences were observed in the latter 70 fractions vs. the former, and results were consistent across evaluators.

Conclusions

For precise daily IGRT with CBCT for prostate SABR, alignment using a radiopaque hydrogel spacer was highly comparable to intraprostatic fiducial markers. This represents the first report supporting an additional indication of IGRT for a CT-visible hydrogel spacer, to further enhance treatment accuracy and potentially obviate the need for the additional fiducial marker procedure.

Individualized surgical antibiotic prophylaxis – why, when, and how?

"Surgical site infections (SSI) greatly concern clinicians, as they are associated with significant morbidity and mortality, prolonged hospitalization, and costs. Antibiotic prophylaxis plays a pivotal role among the procedures that are usually employed for the prevention of surgical-related infections. This narrative review aims to cover some of the particular situations when the clinician might consider individualizing antibiotic prophylaxis for a patient. With the rising incidence of multi-drug resistant bacteria carriage among not only hospitalized or institutionalized patients but also patients from the community, there might be a tendency to use extended-spectrum antibiotics for longer periods for surgical infection prevention. However, the inappropriate use of antibiotics increases the selection pressure, thus favoring the spreading of resistant bacteria. Moreover, specific patient characteristics or pathologies might need to be considered to customize the type, dose, or length of administration of an antibiotic as surgical prophylaxis. Using prosthetic material or prolonged surgeries with large fluid shifts are other situations when individualized antibiotic prophylaxis might be thought of. Keeping in mind that it is of utmost importance that everyone adheres to the current guidelines for surgical antibiotic prophylaxis, customization of local protocols according to well-thought-out strategies might prove beneficial in SSI prevention."

A review of the research progress of interventional medical equipment and methods for prostate cancer

BACKGROUND

Prostate cancer is a common disease in men and has a relatively high mortality rate. However, the interventional medical equipment used for prostate biopsy and brachytherapy has always been a social concern.

METHODS

To understand interventional medical equipment for prostate cancer, the structure of manual, semi-automatic and automatic medical equipment were considered as the mainline, while the corresponding research on these structures were the auxiliary lines. The characteristics and corresponding research status have been discussed.

RESULTS

Interventional medical equipment for prostate cancer with different degrees of automation and its characteristics were determined, and the imaging principles and characteristics of computed tomography, transrectal ultrasound and magnetic resonance imaging have been briefly described.

CONCLUSION

Certain feasible research suggestions have been proposed for future development from the perspective of structure, accuracy and safety. These include flexible and compact robot structures, high-precision image recognition and guidance, accurate dose planning and monitoring, real-time imaging monitoring without delay, high-precision needle insertion strategy, master-slave control, virtual reality and remote control.

Infections after transrectal ultrasonic guided prostate biopsies - a retrospective study

Background: Transrectal ultrasound guided biopsies (TRUSp) are associated with a risk of serious infections. Recently, there has been a rise in incidence of infections after TRUSp and quinolone-resistant bacteria. The most commonly used prophylaxis is ciprofloxacin (CFLX). Objective: To document the incidence and risk factors of post-TRUSp infections and investigate the microbial resistance patterns for the patients presenting with a serious infection after TRUSp. Materials and methods: Data were collected, including age, comorbidity, previous TRUSp, number of biopsies, previously received antibiotics, time between TRUSp and hospitalization, results of microbiological cultivations, antibiotic prophylaxis, and development of infection for all patients at The University Hospital of Southern Denmark, Esbjerg who underwent TRUSp from November 2014 to November 2016. Results: In total, 590 patients were included and 37 (6.1%) patients were hospitalized with symptoms of infection. Of those 37 patients, 21 (56,8%) patients had positive microbiology (blood and/or urine), 18 (48.6%) patients were infected with E. coli and 11 (29.7%) patients had CFLX-resistant E. coli. If patients had previously received antibiotics, they had a significantly higher risk of developing infection after TRUSp (p = 0.01). Conclusion: Patients who have been exposed to antibiotics before TRUSp are at higher risk of developing serious infections as a complication to TRUSp. CFLX-resistant E. coli were a major reason for hospitalization.

Obesity was an independent risk factor for febrile infection after prostate biopsy: A 10-year single center study in South China

To detect the best antibiotic protocol for prostate biopsy and to assess the potential risk factors postbiopsy in Chinese patients.A total of 1526 patients underwent biopsy were assessed retrospectively. The effect of 3 antibiotic protocols was compared, including fluoroquinolone (FQ) monotherapy, third-generation cephalosporin combined with FQ and targeted antibiotics according to the prebiopsy rectal swab culture result. Postbiopsy infection (PBI) was defined as fever and/or active urinary tract symptoms such as dysuria or frequency with pyuria and/or leucocytosis, sepsis is defined as the presence of clinically or microbiologically documented infection in conjunction with systemic inflammatory response syndrome. The relationship between infections and clinical characteristics of patients was assessed. Data were first picked out in univariate analysis and then enter multivariate logistic regression.Thirty-three (2.2%) patients developed febrile infection. The combination antibiotic prophylaxis could significantly decrease the rate of PBI than FQ monotherapy (1.0% vs 4.0%, P = .000). The infection rate of the targeted antibiotic group was 1.1%, but there was no significant statistic difference compared with FQ alone (P = .349). Escherichia coli was the most predominant pathogen causing infection. Rectal swab revealed as high as 47.1% and 36.0% patients harbored FQ resistant and ESBL-producing organisms, respectively. In univariate analysis, overweight (BMI between 25 and 28 kg/m), obesity (BMI > 28 kg/m), diabetes were picked out as potential risk factors. Obesity remained as risk factor (OR = 12.827, 95% CI: 0.983-8.925, P = .001) while overweight and diabetes were close to significance (P = .052, .053, respectively).The combined cephalosporin with FQ prophylaxis could significantly decrease the risk of infectious complications. Obesity was an independent risk factor for PBI.

Bacterial Urinary Tract Infection after Transrectal Placement of Fiducial Markers prior to Proton Radiotherapy for Prostate Cancer

PURPOSE

To determine the incidence of a bacterial urinary tract infection (UTI) necessitating hospitalization after transrectal placement of fiducial markers prior to proton radiotherapy (RT) for prostate cancer.

MATERIALS AND METHODS

Six hundred sixty six patients returning for follow up after proton RT consented to participate in this institutional review board (IRB) approved study. Patients were queried whether they required hospitalization within 1 month of transrectal placement of fiducial markers. Patients were treated with proton RT between August 2006 and December 2014. Median International Prostate Symptom Score (IPSS) was 7. Sixty four patients (9.6%) had diabetes, 9 patients (1.4%) had chronic obstructive pulmonary disease, 6 patients (0.9%) had prior bladder surgery, 7 patients (1.1%) had a transurethral prostatectomy within 3 months, and 549 patients (82.4%) had a course of antibiotics within 6 months. Fifty five patients (8.3%) were taking tamsulosin, 16 patients (2.4%) were taking finasteride, and 62 patients (9.3%) were taking saw palmetto. The interval between the most recent prostate biopsy prior to fiducial placement and fiducial marker placement was less than 6 months in 609 patients (91.4%). No patient had a prior recent rectal culture.

RESULTS

Ten patients (1.5%) developed a bacterial UTI necessitating hospitalization after transrectal placement of fiducial markers. A bacterial UTI occurred in 3 (0.7%) of 440 patients treated from 2006 to 2012 and in 7 (3.1%) of 226 patients treated from 2013 to 2014. Univariate analysis of potential association of a bacterial UTI with the following parameters revealed: IPSS less than or greater than the median (p=0.3400), diabetes (p=0.6099), tamsulosin (p=0.9999), saw palmetto (p=0.0093), interval between prostate biopsy and placement of fiducials (p=0.9999), year of treatment (p=0.0363), and antibiotics within 6 months (p=0.2233). A bacterial UTI was observed in 4 (6.5%) of 62 patients who were taking saw palmetto versus 6 (1.0%) of 604 patients who were not taking this medication. The incidence of a bacterial UTI between 2006 and 2012 was 3 (0.7%) of 440 patients and from 2013 to 2014 was 7 (3.1%) of 226 patients. Multivariate analysis revealed that the likelihood of a bacterial UTI was increased in patients taking saw palmetto (p=0.0044) and those treated in 2013-2014 (p=0.0303).

CONCLUSION

The incidence of a bacterial UTI requiring hospitalization after transrectal placement of fiducial markers prior to proton RT was 1.5% and was impacted by taking saw palmetto and year of treatment. Patients treated during 2013 and 2014 had a significantly higher risk of a bacterial UTI requiring hospitalization.

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.

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.

[Prostate cancer detection rates: comparison of standard biopsy with prompt rebiopsy and a one-time extended biopsy]

INTRODUCTION

Prostate biopsy is the gold standard for the detection of prostate cancer (PCA). While national and international guidelines recommend the extraction of 10-12 cores at initial biopsy, some authors plead to initially perform more extensive biopsy protocols. We assessed the PCA detection and complication rates of different biopsy schemes.

MATERIALS AND METHODS

We relied on the data of 425 men who underwent their first prostate biopsy from April 2005 to May 2013. Exclusion criteria consisted of PSA > 20 ng/ml, prior surgery of the prostate, or intake of 5-α-reductase inhibitors. Overall 357 underwent a 10- to 12-core biopsy, while 68 patients underwent 20-core biopsy. In case of a negative biopsy in the 10-12 cohort, rebiopsy was performed within 6 months, while in the 20-core group clinical follow-up determined further course of action. Endpoints of the study were the overall PCA detection rate and the rate of severe complications, which were defined as complications requiring hospital admission. The effect of the respective biopsy scheme on the PCA detection rate was assessed using uni- and multivariable logistic regression analysis. In the subanalysis, the PCA detection rates between the two groups were compared solely in patients with PSA values ≤10 ng/ml.

RESULTS

At initial biopsy, the overall PCA detection rate was 50.4% (214/425). In the 10-12 core group, the PCA detection rate at first biopsy was 52.4% (187/357) and rebiopsy detected a further 19 (11.2%) PCA cases, resulting in a cumulative PCA detection rate of 57.7% (206/357). In the 20-core group, the PCA detection rate was 39.7% (27/68). While the different PCA detection rates were not statistically different when the initial biopsies were compared, biopsy scheme reached independent predictor status when the cumulative PCA detection rate of the 10- to 12-core scheme was compared to the 20-core scheme (p=0.01). Comparable results were obtained only when patients with PSA ≤10 ng/ml were considered. The rate of severe complications was statistically higher in the 20-core group (6.1 vs. 2.4%; p=0.01).

CONCLUSION

Our data indicate that an initial 20-core biopsy does not lead to a higher PCA detection rate compared to an initial 10- to 12-core biopsy. Moreover, the cumulative PCA detection rate of a 10- to 12-core biopsy and prompt repeat biopsy was significantly higher compared to a single 20-core biopsy.

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.

Reducing infection rates after prostate biopsy

Over the years, prostate biopsy has become the gold-standard technique for diagnosing prostate carcinoma. Worldwide, several million prostate biopsies are performed every year, most commonly using the transrectal approach. Preoperative antibiotic prophylaxis with fluoroquinolones has been shown to be effective for reducing infection rates. However, in recent years, an increase in febrile infection rates after transrectal prostate biopsy (from 1% to 4%) has been reported in retrospective and prospective studies. The predominant risk factor for infection seems to be the presence of fluoroquinolone-resistant bacteria in faeces. Patients at risk of fluoroquinolone resistance should receive carefully selected antibiotics at sufficient concentrations to be effective. Targeted prophylaxis after rectal flora swabbing has been shown to be efficacious compared with empirical antibiotic prophylaxis. Several forms of bowel preparations are under investigation, although none have yet been shown to significantly reduce infection rates. Perineal prostate biopsy is currently being evaluated as a strategy for preventing the inoculation of rectal flora, but limited data support this approach at present.

Multidrug resistant epididymitis progressing to testicular infarct and orchiectomy

Global testicular infarction is a rare sequela of infectious epididymitis, with few reports in the urologic literature since the introduction of fluoroquinolones in the late 1980s. Ischemia occurs secondary to inflammation and edema of the spermatic cord with compression of arterial flow. We report a case of multidrug resistant epididymitis following prostate biopsy that progressed to global testicular infarction requiring orchiectomy. This case highlights the fact that epididymitis does not always follow an indolent pathway to resolution. Progression of pain should prompt early imaging and intervention. It further highlights the potential urologic consequences of the rising prevalence of multidrug resistant bowel flora in the United States, which will increasingly influence the management of presumed uncomplicated epididymitis, whether being primary or postprocedural.