Sepsis Due to Fluoroquinolone-resistant Escherichia coli After Transrectal Ultrasound-guided Prostate Needle Biopsy

The molecular mechanisms of fluoroquinolone resistance found in rectal swab isolates of Enterobacterales from men undergoing a transrectal prostate biopsy: the rationale for targeted prophylaxis

Background

Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) is considered an essential urological procedure for the histological diagnosis of prostate cancer. It is, however, considered a “contaminated” procedure which may lead to infectious complications. Recent studies suggest a significant share of fluoroquinolone-resistant rectal flora in post-biopsy infections.

Methods

The molecular mechanisms of fluoroquinolone resistance, including PMQR (plasmid-mediated quinolone resistance) as well as mutation in the QRDRs (quinolone-resistance determining regions) of gyrA, gyrB, parC and parE, among Enterobacterales isolated from 32 of 48 men undergoing a prostate biopsy between November 2015 and April 2016 were investigated. Before the TRUS-Bx procedure, all the patients received an oral antibiotic containing fluoroquinolones.

Results

In total, 41 Enterobacterales isolates were obtained from rectal swabs. The MIC of ciprofloxacin and the presence of common PMQR determinants were investigated in all the isolates. Nine (21.9%) isolates carried PMQR with qnrS as the only PMQR agent detected. DNA sequencing of the QRDRs in 18 Enterobacterales (E. coli n = 17 and E. cloacae n = 1) isolates with ciprofloxacin MIC ≥ 0.25 mg/l were performed. Substitutions in the following codons were found: GyrA—83 [Ser → Leu, Phe] and 87 [Asp → Asn]; GyrB codon—605 [Met → Leu], ParC codons—80 [Ser → Ile, Arg] and 84 [Glu → Gly, Met, Val, Lys], ParE codons—458 [Ser → Ala], 461 [Glu → Ala] and 512 [Ala → Thr]. Six isolates with ciprofloxacin MIC ≥ 2 mg/l had at least one mutation in GyrA together with qnrS.

Conclusions

This study provides information on the common presence of PMQRs among Enterobacterales isolates with ciprofloxacin MIC ≥ 0.25 mg/l, obtained from men undergoing TRUS-Bx. This fact may partially explain why some men develop post-TRUS-Bx infections despite ciprofloxacin prophylaxis.

Comparison of a combined regimen of fosfomycin and ciprofloxacin with ciprofloxacin alone as antimicrobial prophylaxis for transrectal prostate biopsy in the era of high fluoroquinolone-resistant rectal flora

Background

To assess the prophylactic effect of fosfomycin (FM) and ciprofloxacin combinations for infectious complications of transrectal ultrasound-guided prostate biopsy (TRUSPB) compared to that of ciprofloxacin alone.

Methods

In total, 1,578 patients were enrolled and were divided into two groups according to the prophylactic antibiotics. Group 1 (n = 1234) received ciprofloxacin on the day of the biopsy and for an additional 1–2 days, whereas Group 2 (n = 334) was given FM in addition to ciprofloxacin in the same manner as Group 1. The primary outcome was overall infectious complications within 1 month of TRUSPB. The secondary outcome was the risk factors of infectious complications after TRUSPB.

Results

Infectious complications occurred in 31 patients (2.5%) and 1 patient (0.3%) in Groups 1 and 2, respectively. Our results indicated that fluoroquinolone (FQ) and FM significantly reduced the risk of infectious complications compared to FQ (relative risk: 0.12; 95% confidence interval 0.02–0.87, P = 0.015). Based on the multivariate analysis, previous antibiotic exposure (odds ratio [OR] = 3.59, P = 0.026), and the addition of FM (OR = 0.12, P = 0.038) were associated with infectious complications. Based on the rectal swab, FQ resistance was 28.0% (n = 294) in total. FQ resistance in the FQ and FM group was higher than that in the FQ group (n = 178, 54.9% vs. n = 116, 16.0%, P < 0.001).

Conclusion

The combination of ciprofloxacin and FM exhibited reduced infectious complications after TRUSPB compared with ciprofloxacin monotherapy and may be applicable in the era of the high abundance of FQ-resistant rectal flora.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The prevalence of urinary tract infection, or urosepsis following transrectal ultrasound-guided prostate biopsy in a subset of the Saudi population and patterns of susceptibility to flouroquinolones

Objectives:

To study the prevalence of urinary tract infections (UTI), or sepsis secondary to trans-rectal ultrasound-guided (TRUS) biopsy of the prostate, the pathogens involved, and patterns of antibiotic resistance in a cohort of patients.

Methods:

This is a descriptive study of a consecutive cohort of patients who underwent elective TRUS biopsy at King Abdulaziz Medical City Riyadh, Saudi Arabia between January 2012 and December 2014. All patients who underwent the TRUS guided prostate biopsy were prescribed the standard prophylactic antibiotics. Variables included were patients’ demographics, type of antibiotic prophylaxis, results of biopsy, the rate of UTI, and urosepsis with the type of pathogen(s) involved and its/their antimicrobial sensitivity.

Results:

Simple descriptive statistics were used in a total of 139 consecutive patients. Urosepsis requiring hospital admission was encountered in 7 (5%) patients and uncomplicated UTI was observed in 4 (2.8%). The most common pathogens were Escherichia coli (90.1%) and Klebsiella pneumoniae (9.1%). Resistance to the routinely used prophylaxis (ciprofloxacin) was observed in 10 of these patients (90.9%).

Conclusion:

This showed an increase in the rate of infectious complications after TRUS prostate biopsy. Ciprofloxacin resistance was found in 90.9% of patients with no sepsis.

"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.

Fluoroquinolone-resistant Escherichia coli in intestinal flora of patients undergoing transrectal ultrasound-guided prostate biopsy - possible shift in biopsy prophylaxis

Introduction

Infection of prostate gland following biopsy is common complication. Most common pathogen is E.coli. Since fluorochinolones are commonly prescribed as prophylaxis, infection caused by E.coli leads to complicated infections, especially due to fluoroquinolone-resistant species.

The aim of this study was to evaluate the incidence of fluoroquinolone-resistant E.coli species in rectal swabs of patients undergoing prostate biopsy and to define appropriate antimicrobial agent as prostate biopsy prophylaxis.

Material and methods

Rectal swabs were collected in 159 patients undergoing prostate biopsy. The identification of E.coli was performed using the BBL Crystal E/NF identification (ID) System.

Results

In the rectal swab of 112/159 patients E.coli was found. In 47/159 cases after incubation, the microbiological evaluation showed no E.coli in these swabs. Defining the specific resistance to microbiological agents, we obtained that E.coli resistant to ciprofloxacin was found in 40 out of 112 patients (50.9%). Resistance to I and II generation of cephalosporin were found in 7%, and 5%, respectively. In 40 out of 112 (35.7%) E.coli resistant to trimetoprim/sulfametoksazol was reported. E.coli resistant to amoxicillin with clavulonian acid and ampicillin was found in 16 out of 112 (14.28%), and in 67 out of 112 patients (59.8%), respectively.

Conclusions

In all cases with fluoroquinolone-resistant E.coli species positive rectal swabs I generation of cephalosporin seems to be a best choice for prostate biopsy prophylaxis. Moreover, II generation of cephalosporin should be considered for treatment of the eventual subsequent infection. The evaluation of rectal swabs before prostate biopsy is crucial in determining targeted antimicrobial prophylaxis.

Fluoroquinolone-Resistant Escherichia coli Infections After Transrectal Biopsy of the Prostate in the Veterans Affairs Healthcare System

Background:

Recent reports suggest that infections due to fluoroquinolone-resistant Escherichia coli (E. coli) are an increasingly common complication of transrectal biopsy of the prostate (TBP) in the United States. A better understanding of the magnitude and scope of these infections is needed to guide prevention efforts. Our objective is to determine whether the incidence of infections due to fluoroquinolone-resistant E. coli after TBP has increased nationwide in the Veterans Affairs Health Care System and to identify risk factors for infection.

Methods:

We performed a retrospective, observational cohort study and a nested case-control study within the US Deparment of Veterans Affairs Healthcare System. The primary outcomes were the incidence of urinary tract infection (UTI) and bacteremia with E. coli and with fluoroquinolone-resistant E. coli strains within 30 days after TBP. Secondary endpoints focused on the correlation between fluoroquinolone-resistance in all urinary E. coli isolates and post-TBP infection and risk factors for infection due to fluoroquinolone-resistant E. coli infection.

Results:

245,618 patients undergoing 302,168 TBP procedures from 2000 through 2013 were included in the cohort study, and 59,469 patients undergoing TBP from 2011 through 2013 were included in the nested case-control study. Between 2000 and 2013, there was a 5-fold increase in the incidence of E. coli UTI (0.18%–0.93%) and a 4-fold increase in the incidence of E. coli bacteremia (0.04%–0.18%) after TBP that was attributable to an increase in the incidence of fluoroquinolone-resistant E. coli UTI (0.03%–0.75%) and bacteremia (0.01%–0.14%). The increasing incidence of fluoroquinolone-resistant E. coli infections after TBP occurred in parallel with increasing rates of fluoroquinolone-resistance in all urinary E. coli isolates. By multivariable logistic regression analysis, independent risk factors for fluoroquinolone-resistant E. coli UTI after TBP included diabetes mellitus, fluoroquinolone exposure, prior hospitalization, and prior cultures with fluoroquinolone-resistant gram-negative bacilli.

Conclusion:

In the Veterans Affairs Healthcare System, the incidence of E. coli infection after TBP has increased significantly since 2000 due to a dramatic rise in infections with fluoroquino-lone-resistant E. coli.

A case of infective endocarditis and pyogenic spondylitis after transrectal ultrasound guided prostate biopsy

We report a patient with infective endocarditis and pyrogenic spondylitis occurring simultaneously. The patient was a 59-year-old man. He was suspected of having prostate cancer due to a high prostate-specific antigen concentration noted in a checkup. He then underwent a transrectal ultrasound guided prostate biopsy with cefotiam as antimicrobial prophylaxis. He had a fever higher than 38 °C and lumbar pain for a few days after the biopsy. Enterococcus faecalis was isolated from 2 sets of blood culture. Magnetic resonance imaging revealed an abnormal image at C7/Th1 with a signal decrease in T1-weighted sequences and signal increase in T2-weighted sequences that were suspected to be due to bone destruction. Therefore, he was diagnosed as having pyogenic spondylitis by an orthopedist. At the same time, he complained of palpitation and a heart murmur was detected. Then transesophageal echocardiography was performed by a cardiologist and it revealed vegetation in his left ventricle and aortic regurgitation, and finally acute cardiac insufficiency was determined. He was treated with tazobactam/piperacillin and aortic valve displacement surgery. Based on the results of the prostate biopsy and image inspection, he was diagnosed as having localized prostate cancer. He was treated by androgen deprivation therapy and external beam radiation therapy. We have to keep in mind that E. faecalis can be a potential pathogen for severe infectious complications after prostate biopsy, especially if a cephalosporin is selected for antimicrobial prophylaxis.

Fosfomycin antimicrobial prophylaxis for transrectal ultrasound-guided biopsy of the prostate: A prospective randomised study

Objectives

To compare the incidence of infectious complications after single-dose fosfomycin vs. standard fluoroquinolone (FQ)-based prophylaxis in patients undergoing transrectal ultrasound-guided biopsy of the prostate (TRUSBx), as there is an alarming trend worldwide of increasing resistance to FQs limiting their suitability as appropriate prophylaxis for TRUSBx.

Patients and methods

A prospective study was conducted in 412 consecutive patients undergoing TRUSBx between February 2012 and June 2015. Patients were randomly divided into two groups; Group 1 (202 patients) who received single-dose fosfomycin (3 g, orally) 1–2 h before TRUSBx and Group 2 (210 patients) who received routine empirical prophylaxis in the form of oral ciprofloxacin 500 mg and metronidazole 500 mg at least 1 h before TRUSBx and continued this twice daily for 3 days before TRUSBx. We recorded all febrile and afebrile urinary tract infections (UTIs) within the 4 weeks after the procedure.

Results

There was no difference in baseline demographics between the two groups. Total infectious complications occurred in four (1.9%) and 18 (8.5%) patients in Groups 1 and 2, respectively, which was statistically significant (P = 0.001). Escherichia coli was the most common isolated pathogen from urine cultures in all patients with infectious complications (68%). The other isolated bacterium, Klebsiella pneumoniae, was detected in four patients (18%). Urine cultures revealed FQ-resistant strains (73%), all of which were extended-spectrum β-lactamase-producing E. coli and K. pneumoniae.

Conclusions

Single-dose fosfomycin before TRUSBx significantly reduces infectious complications when compared with standard therapy. Fosfomycin is an effective agent for antimicrobial prophylaxis in patients undergoing TRUSBx, particularly in populations where FQ resistance is common.

Rapid Identification of Rectal Multidrug-resistant Escherichia coli Before Transrectal Prostate Biopsy

OBJECTIVE

To develop and evaluate a rapid multiplex-quantitative polymerase chain reaction (qPCR) to identify fecal carriers of multidrug-resistant extraintestinal pathogenic Escherichia coli (MDR-ExPEC) clonal groups.

METHODS

Men presenting for transrectal prostate biopsy (TPB) at the San Diego Veterans Affairs Medical Center underwent rectal culture immediately before TPB. Rectal swabs were streaked onto ciprofloxacin-supplemented (4 mg/L) MacConkey agar plates, identified, and susceptibility tested. The same swab was sent to the University of Washington for qPCR test (EST200) targeting 2 major MDR-ExPEC clonal groups--ST131 and ST69--that combined were expected to represent majority of fluoroquinolone (FQ)- and trimethoprim-sulfamethoxazole-resistant E coli. We calculate test characteristics including the area under the receiver operative curve (AUC).

RESULTS

We enrolled 104 men from 11/5/2013 to 6/10/2014. FQ-resistant E coli were cultured from 19.2% (20/104) of rectal swabs, and 26% (27/104) of all swabs were positive for EST200 by PCR. The test characteristics comparing the EST200 to the culture-based detection of FQ resistance were 75%, 86%, 94%, and 56%, respectively. The AUC was 0.84 for the EST200 to detect FQ resistance before TPB.

CONCLUSION

Compared to the reference standard rectal culture, EST200 was able to detect majority of FQ-resistant E coli on rectal swabs before prostate biopsy.

Infection after transrectal ultrasound-guided prostate biopsy

Infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-Bx) appear to be increasing, which reflects the high prevalence of antibiotic-resistant strains of Enterobacteriaceae. Identifying patients at high risk for antibiotic resistance with history taking is an important initial step. Targeted prophylaxis with a prebiopsy rectal swab culture or augmented antibiotic prophylaxis can be considered for patients at high risk of antibiotic resistance. If infectious complications are suspected, the presence of urosepsis should be evaluated and adequate antibiotic treatment should be started immediately.

Association between pre-biopsy white blood cell count and prostate biopsy - related sepsis

Introduction

Despite all preventive measures and improved biopsy techniques, serious, life–threatening complications of prostate biopsy, including sepsis, still exist. In the present study, in order to identify the risk factors that may be associated with sepsis development after prostate–biopsy, we aimed to analyze retrospectively the data of our patients who underwent transrectal ultrasound–guided prostate biopsy.

Material and methods

We retrospectively reviewed the data of 889 patients who underwent prostate biopsy at our clinic. We compared pre–biopsy parameters (age, prostate volume, white blood cell (WBC) count, fasting blood glucose, free and total prostate specific antigen levels) between patients who developed sepsis and those who were sepsis–free following prostate biopsy.

Results

28 patients (3.1%) developed sepsis. Among the risk factors evaluated, only pre–biopsy WBC count was found to be a significant risk factor for biopsy–related sepsis. A 5.1 fold increase was detected in the risk for sepsis development, when the cut–off value of WBC was accepted as 11.165/μL, OR: 5.1 (95% CI: 2.3–11.5). The post–biopsy sepsis development rate in patients with pre–biopsy WBC count greater and less than 11.165/μL was 13.7% (n = 10) and 3% (n = 18) respectively.

Conclusions

Patients with a pre–biopsy WBC count greater than 11.165/μL should be informed of the increased risk of developing post–biopsy sepsis.

The comparison of the influence between two different bowel preparation methods on sepsis after prostate biopsies

Introduction

Transrectal ultrasonography (TRUS) guided prostate needle biopsy has been performed to diagnose and stage prostate cancer for many years. There are many different bowel preparation protocols to diminish the infectious complications, but there is no standardized consensus among urologists. Therefore, we aimed to assess two different bowel preparation methods on the rate of infectious complications in patients who underwent TRUS–guided prostate biopsy.

Material and methods

A total of 387 cases of TRUS–guided prostate biopsy were included in this retrospective study. All patients received antibiotic prophylaxis with ciprofloxacin (500 mg) twice a day orally for 7 days starting on the day before the biopsy. The patients were divided into two groups according to the bowel preparation method used. Patients (Group 1, n = 164) only received self–administrated phosphate enema) on the morning of the prostate biopsy. Other patients (Group 2, n = 223) received sennasoid a–b laxatives the night before the prostate biopsy. Infectious complications were classified as sepsis, fever (greater than 38°C) without sepsis, and other clinical infections.

Results

Major complications developed in 14 cases (3.8%), including 3 cases (0.8%) of urinary retention, and 11 (3%) infectious complications, all of which were sepsis. There were 3 and 8 cases of urosepsis in Group 1 and Group 2, respectively. There were no statistically significant differences between both Groups regarding to the rates of urosepsis (p = 0.358).

Conclusions

Despite both methods of bowel preparation, sodium phosphate enema or sennasoid a–b calcium laxatives, before TRUS–guided prostate biopsy have similar effect on the rate of urosepsis, so both methods of bowel preparation can be safely used.

Outbreak of Fluoroquinolone-Resistant Escherichia coli Infections after Transrectal Ultrasound—Guided Biopsy of the Prostate

Design.

We conducted an investigation after identifying a cluster of 4 serious infections following transrectal ultrasound–guided biopsy of the prostate (TRUBP) during a 2-month period.

Setting.

veterans Affairs medical center.

Patients.

Patients with urinary tract infection (UTI) after TRUBP and time-matched controls with no evidence of infection.

Methods.

The incidence of UTI within 30 days after TRUBP was calculated from 2002 through 2010. We evaluated the correlation between infection with fluoroquinolone-resistant gram-negative bacilli (GNB) and fluoroquinolone resistance in outpatient Escherichia coli urinary isolates and performed a case-control study to determine risk factors for infection with fluoroquinolone-resistant GNB. Processes for TRUBP prophylaxis, procedures, and equipment sterilization were reviewed.

Results.

An outbreak of UTI due to fluoroquinolone-resistant E. coli after TRUBP began 2 years before the cluster was identified and was correlated with increasing fluoroquinolone resistance in outpatient E. coli. No deficiencies were identified in equipment processing or biopsy procedures. Fluoroquinolone-resistant E. coli UTI after TRUBP was independently associated with prior infection with fluoroquinolone-resistant GNB (adjusted odds ratio, 20.8; P = .005). A prediction rule including prior UTI, hospitalization in the past year, and previous infection with fluoroquinolone-resistant GNB identified only 17 (49%) of 35 cases.

Conclusions.

The outbreak of fluoroquinolone-resistant E. coli infections after TRUBP closely paralleled rising rates of fluoroquinolone resistance among outpatient E. coli isolates. The delayed detection of the outbreak and the absence of sensitive predictors of infection suggest that active surveillance for infection after TRUBP is necessary in the context of increasing fluoroquinolone resistance in the United States.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quinolone prophylaxis in transrectal ultrasound guided prostate biopsy: an eight-year single center experience

We retrospectively evaluated the efficacy of prophylaxis with pipemidic acid and levofloxacin in transrectal ultrasound guided prostate biopsy (TRUSP-Bx). From January 2002 to December 2004, patients receiving oral pipemidic acid 500 mg twice daily for three days with or without a preoperative intravenous cefazolin 1 gm injection comprised group A. Between January 2005 and December 2009, patients receiving oral levofloxacin 500 mg one hour before biopsy comprised group B. We calculated the annual febrile urinary tract infection (fUTI) rates. Patients' characteristics, including age, prophylactic antibiotics, biopsy core numbers, pathologic results, PSA, and the spectrums and susceptibility of pathogens, were also evaluated. A total of 1313 (35.5%) patients belonged to group A, while 2381 (64.5%) patients belonged to group B. Seventy-three patients experienced postoperative infectious complications. There was a significant difference in the fUTI rate between groups A and B (3.7% versus 1.0%, P < 0.001). The yearly fUTI rates varied from 0.6 to 3.9% between 2002 and 2009. Of the 73 patients with fUTI, those receiving levofloxacin prophylaxis were more likely to harbor fluoroquinolone-resistant pathogens (P < 0.001). E. coli was the most common pathogen in both groups. Levofloxacin remains effective and appears superior to pipemidic acid based prophylaxis.

Pokes, pathogens, and primum non nocere: prudent prophylaxis protocols for prostate biopsy

Infectious complications following transrectal ultrasound-guided biopsy of the prostate (TRUBP)—including urinary tract infections, prostatitis, epididymo-orchitis, and bacteremia—have increased dramatically in recent years. Traditionally, fluoroquinolones have been the mainstay for perioperative prophylaxis. Likely as a result of a combination of this selective pressure and temporal shifts in the clonal composition of the rectal microbiota, most post-TRUBP infections today are caused by fluoroquinolone-resistant Escherichia coli, especially those from sequence type 131 (ST131), an emerging multidrug-resistant strain that is highly prevalent among pre-TRUBP rectal isolates. Clinicians need improved approaches for preventing these complications. Fortunately, helpful guidance is beginning to appear.

Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Transrectal ultrasound guided prostate biopsies (TRUSBx) are associated with a spectrum of complications, including most significantly infection, which affects up to 5% of patients. In the most severe cases, infection leads to sepsis, a life-threatening complication. Escherichia coli is the primary responsible pathogen. Although antibiotic prophylaxis with fluoroquinolones is routinely used, there is evidence that the infection rate after TRUSBx is increasing, and this appears to be due to an increasing prevalence of ciprofloxacin-resistant rectal flora. This is the largest prospective clinical trial to date analysing the rectal flora of men undergoing prostate biopsies. We determined the microbial and antibiotic sensitivity profiles from 849 patients. Ciprofloxacin-resistant Gram-negative organisms were identified in the rectal flora of 19.0% of men. Furthermore, fluoroquinolone use within 6 months preceding a TRUSBx and the presence of a prosthetic heart valve were significant predictors of ciprofloxacin resistance on rectal swab. Determining the prevalence of rectal fluoroquinolone resistance has important implications in evaluation of the suitability of prophylactic regimens. Antimicrobial profiles derived from rectal swabs pre-biopsy may prove useful in guiding targeted antibiotic prophylaxis.

OBJECTIVES

To establish the prevalence of ciprofloxacin-resistant bacteria in patients undergoing transrectal ultrasound guided prostate biopsies (TRUSBx) and to determine whether this predicts subsequent infectious complications. To identify risk factors for harbouring ciprofloxacin-resistant flora.

PATIENTS AND METHODS

Any patient undergoing a TRUSBx from 2009 to 2011 was eligible for enrolment in this prospective study. Pre-biopsy rectal and urine cultures and post-biopsy urine cultures were obtained and antimicrobial susceptibility was determined. Univariate and multivariate analyses were performed to identify independent patient risk factors associated with ciprofloxacin-resistant rectal flora.

RESULTS

A total of 865 patients underwent TRUSBx, of whom 19.0% were found to have ciprofloxacin-resistant Gram-negative coliforms. Escherichia coli was the most prevalent Gram-negative rectal isolate (80.9%) and accounted for 90.6% of ciprofloxacin resistance. Patient characteristics that conferred an increased risk of harbouring ciprofloxacin-resistant organisms included a history of a heart valve replacement (P < 0.05) and ciprofloxacin use in the past 3 months (P < 0.05). Infectious complications were observed in 3.6% (n = 31) of the patient population and 48% of these patients grew ciprofloxacin-resistant organisms on the pre-biopsy rectal swab (P < 0.001).

CONCLUSIONS

Antimicrobial resistance to ciprofloxacin in the rectal flora was common, particularly in patients with recent ciprofloxacin use and a heart valve replacement. Despite a significant correlation between those patients who developed infections and the detection of ciprofloxacin-resistant organisms, only 9.0% (n = 15) of the total group with ciprofloxacin resistance developed an infectious complication. Future studies will need to evaluate the cost effectiveness and clinical utility of a pre-biopsy rectal culture in targeting antibiotic prophylaxis.

Prevalence of ST131 among fluoroquinolone-resistant Escherichia coli obtained from rectal swabs before transrectal prostate biopsy

OBJECTIVE

To identify the prevalence and characteristics of fluoroquinolone-resistant (FQ-R) Escherichia coli ST131 isolates in men undergoing ultrasound-guided transrectal prostate biopsy (TPB).

MATERIALS AND METHODS

Twenty-seven FQ-R E coli isolates from rectal swabs from 136 men undergoing TPB at 3 institutions in southern California (January 2009 to March 2010), with a focus on repeat biopsy patients, were assessed for E coli phylogenetic group, sequence type ST131 status, extended virulence genotype, pulsed-field gel electrophoresis profile, and antimicrobial susceptibility profile.

RESULTS

ST131 accounted for 70% of the 27 FQ-R pre-TPB E coli rectal isolates, including 82% of those from non-Asians vs 20% from Asians (P = .017). ST131 was associated negatively with prebiopsy enemas and positively with previous TPB. Compared with non-ST131 isolates, the ST131 isolates had a significantly higher prevalence of 4 virulence genes (sat, usp, ompT, and malX), distinctive virulence profiles, and numerically higher virulence scores (median, 12 vs 8), but similar antimicrobial resistance scores. Most rectal ST131 isolates exhibited pulsed-field gel electrophoresis profiles typical of clinical ST131 isolates.

CONCLUSION

In our locale, the epidemic multidrug-resistant ST131 clonal group accounts for 70% of FQ-R rectal E coli isolates among men undergoing TPB. Such ST131 isolates have distinctive virulence profiles, are extensively antimicrobial-resistant, and are negatively associated with Asian race. Further investigation is needed regarding risk factors for and clinical consequences of colonization with such strains among men undergoing TPB.

Does intravenous cefuroxime improve the efficacy of ciprofloxacin for preventing infectious complications after transrectal prostate biopsy? A prospective comparative study

Objectives

To compare the frequency of infection after transrectal ultrasonography (TRUS)-guided biopsy of the prostate (TRUSBP) using prophylactic ciprofloxacin with or without adding cefuroxime.

Patients and methods

Between June 2008 and October 2009, 205 consecutive patients had TRUSBP with the use of oral 500 mg ciprofloxacin twice per day, 2 days before and 3 days after the biopsy (defined as group A). Starting from November 2009 and onwards, 250 consecutive patients had TRUSBP using the same previous protocol of antibiotic prophylaxis but with the addition of intravenous 1.5 g cefuroxime given 30 min before the procedure (defined as group B). The incidence of sepsis after TRUSBP, together with the results of urine and blood cultures and antibiotic sensitivity, were compared between the groups.

Results

Fever after TRUSBP was recorded in 18 of 205 patients in group A (8.8%) and in nine of 250 in group B (3.6%); the difference was significant (P = 0.018). Urine culture was positive in 14 and five of patients in groups A and B, respectively, with extended-spectrum β-lactamase-producing (ESBL) Escherichia coli as the most common organism. The blood culture was positive in seven and three patients in groups A and B, respectively, with ESBL E. coli as the most common organism. All patients who had sepsis after TRUSBP sepsis were treated successfully.

Conclusion

Adding a single intravenous injection with 1.5 g of cefuroxime to oral ciprofloxacin significantly reduced the frequency of infectious complications after TRUSBP.

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

PURPOSE

Transrectal ultrasound guided prostate biopsy can lead to urinary tract infections in 3% to 11% and sepsis in 0.1% to 5% of patients. We investigated the efficacy of rectal cleansing with povidone-iodine before transrectal ultrasound guided prostate biopsy to reduce infectious complications.

MATERIALS AND METHODS

Between 2009 and 2011, 865 men were prospectively randomized to rectal cleansing (421) or no cleansing (444) before transrectal ultrasound guided prostate biopsy. Patients received ciprofloxacin prophylaxis and rectal swab cultures were obtained before transrectal ultrasound guided prostate biopsy. Patients completed a telephone interview 7 days after undergoing the biopsy. The primary end point was the rate of infectious complications, a composite end point of 1 or more of 1) fever greater than 38.0C, 2) urinary tract infection or 3) sepsis (standardized definition). Chi-square significance testing was performed for differences between groups and a multivariate analysis was performed to assess risk factors for infectious complications.

RESULTS

Infectious complications were observed in 31 (3.5%) patients, including 11 (2.6%) treated and 20 (4.5%) control patients (p = 0.15). Sepsis was observed in 4 (1.0%) treated and 7 (1.6%) control patients (p = 0.55). On multivariate analysis resistance to ciprofloxacin in the rectal swab culture (p = 0.002) and a history of taking ciprofloxacin in the 3 months preceding transrectal ultrasound guided prostate biopsy (p = 0.009) predicted infectious complications.

CONCLUSIONS

Rectal cleansing with povidone-iodine before transrectal ultrasound guided prostate biopsy was safe, but the 42% relative risk reduction of infectious complications was not statistically significant. Patients who have received ciprofloxacin within 3 months of transrectal ultrasound guided prostate biopsy should be considered for alternate prophylaxis or possibly a delay of biopsy beyond 3 months.

Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: time to reassess antimicrobial prophylaxis?

BACKGROUND

An increasing risk of infectious complications following transrectal ultrasound-guided prostate needle biopsy (PNB) has been observed recently in some centers.

OBJECTIVE

To delineate the risk factors associated with post-PNB bacteremia and/or urinary tract infection (UTI) and determine why this risk has risen over time.

DESIGN, SETTING, AND PARTICIPANTS

A case-control study in a Canadian tertiary-care center. Cases were all patients who developed bacteremia and/or UTIs after PNB between 2002 and 2011; controls were randomly selected among patients who underwent a PNB without such complications.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Crude and adjusted odds ratios and their 95% confidence intervals were calculated using logistic regression.

RESULTS AND LIMITATIONS

A total of 5798 PNBs were performed during the study period, following which there were 48 cases of urinary sepsis (42% with bacteremia). The incidence increased from 0.52 infections per 100 biopsies in 2002-2009 to 2.15 infections per 100 biopsies in 2010-2011 (p<0.001). Escherichia coli was the predominant pathogen (75% of cases). Among 42 patients whose post-PNB infection was caused by aerobic or facultative Gram-negative rods, 22 patients (52%) were infected by pathogens resistant to ciprofloxacin. Independent risk factors for post-PNB infection were diabetes, hospitalization during the preceding month, chronic obstructive pulmonary disease, and performance of the biopsy in 2010-2011. In 2010-2011, the minimal inhibitory concentrations for ciprofloxacin increased compared with 2002-2009 (p<0.03). The major limitation of the study was its retrospective hospital-based nature, which hampered data collection on outpatient antibiotic prescriptions.

CONCLUSIONS

In the past 2 yr, ciprofloxacin resistance contributed to the increasing incidence of post-PNB infections in our center. Novel antibacterial prophylaxis approaches need to be evaluated.

Prospective study of antibiotic prophylaxis for prostate biopsy involving >1100 men

We aimed to compare infection rates for two 3-day antibiotic prophylaxis regimens for transrectal ultrasound-guided prostate biopsy (TRUSgbp) and demonstrate local microbiological trends. In 2008, 558 men and, in 2009, 625 men had TRUSgpb. Regimen 1 (2008) comprised 400 mg Ofloxacin immediately before biopsy and 200 mg 12-hourly for 3 days. Regimen 2 (2009) comprised Ofloxacin 200 mg 12-hourly for 3 days commencing 24 hours before biopsy. 20/558 (3.6%) men had febrile episodes with regimen 1 and 10/625 (1.6%) men with regimen 2 (P = 0.03). E. coli was the most frequently isolated organism. Overall, 7/13 (54%) of positive urine cultures were quinolone resistant and (5/13) 40% were multidrug resistant. Overall, 5/9 (56%) patients with septicaemia were quinolone resistant. All patients were sensitive to Meropenem. There was 1 (0.2%) death with regimen 1. Commencing Ofloxacin 24 hours before TRUSgpb reduced the incidence of febrile episodes significantly. We observed the emergence of quinolone and multidrug-resistant E. coli. Meropenem should be considered for unresolving sepsis.

Escherichia coli bloodstream infection after transrectal ultrasound-guided prostate biopsy: implications of fluoroquinolone-resistant sequence type 131 as a major causative pathogen

BACKGROUND

Transrectal ultrasound-guided (TRUS) prostate biopsy is a commonly performed procedure, and fluoroquinolones are the most frequently given prophylactic antimicrobials. In the context of increasing fluoroquinolone resistance, and the international emergence of fluoroquinolone-resistant sequence type 131 (ST131) Escherichia coli, we describe a large series of E. coli bacteremia after TRUS biopsy.

METHODS

All male patients admitted with community-onset (CO) E. coli bacteremia from January 2006 through December 2010 were included. Patient characteristics, treatment outcomes, and rates of antimicrobial resistance were compared between patients with TRUS biopsy-related bacteremia and other male patients with CO E. coli bacteremia. Molecular typing was performed on E. coli isolates to determine phylogenetic group.

RESULTS

A total of 258 male patients were admitted with CO E. coli bacteremia. Of these, 47 patients (18%) were admitted after TRUS biopsy. Patients who had undergone TRUS biopsy were twice as likely to require intensive care admission (25% vs 12%) and had significantly higher rates of resistance to gentamicin (43%), trimethoprim-sulphamethoxazole (60%), and ciprofloxacin (62%) as well as all 3 agents in combination (19%). Thirty-six percent of post-TRUS biopsy patients did not receive active empirical antibiotic therapy. The ST131 clone accounted for 41% of all E. coli isolates after TRUS biopsy.

CONCLUSIONS

E. coli bacteremia can be a life-threatening complication of TRUS biopsy. Infecting strains are frequently multidrug-resistant and resistant to common empirical antibiotic agents. E. coli ST131 is an important cause of sepsis after TRUS biopsy. Further studies should evaluate colonization with fluoroquinolone-resistant E. coli as a risk factor for postbiopsy sepsis.

Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care

PURPOSE

We evaluated targeted antimicrobial prophylaxis in men undergoing transrectal ultrasound guided prostate biopsy based on rectal swab culture results.

MATERIALS AND METHODS

From July 2010 to March 2011 we studied differences in infectious complications in men who received targeted vs standard empirical ciprofloxacin prophylaxis before transrectal ultrasound guided prostate biopsy. Targeted prophylaxis used rectal swab cultures plated on selective media containing ciprofloxacin to identify fluoroquinolone resistant bacteria. Patients with fluoroquinolone susceptible organisms received ciprofloxacin while those with fluoroquinolone resistant organisms received directed antimicrobial prophylaxis. We identified men with infectious complications within 30 days after transrectal ultrasound guided prostate biopsy using the electronic medical record.

RESULTS

A total of 457 men underwent transrectal ultrasound guided prostate biopsy, and of these men 112 (24.5%) had rectal swab obtained while 345 (75.5%) did not. Among those who received targeted prophylaxis 22 (19.6%) men had fluoroquinolone resistant organisms. There were no infectious complications in the 112 men who received targeted antimicrobial prophylaxis, while there were 9 cases (including 1 of sepsis) among the 345 on empirical therapy (p=0.12). Fluoroquinolone resistant organisms caused 7 of these infections. The total cost of managing infectious complications in patients in the empirical group was $13,219. The calculated cost of targeted vs empirical prophylaxis per 100 men undergoing transrectal ultrasound guided prostate biopsy was $1,346 vs $5,598, respectively. Cost-effectiveness analysis revealed that targeted prophylaxis yielded a cost savings of $4,499 per post-transrectal ultrasound guided prostate biopsy infectious complication averted. Per estimation, 38 men would need to undergo rectal swab before transrectal ultrasound guided prostate biopsy to prevent 1 infectious complication.

CONCLUSIONS

Targeted antimicrobial prophylaxis was associated with a notable decrease in the incidence of infectious complications after transrectal ultrasound guided prostate biopsy caused by fluoroquinolone resistant organisms as well as a decrease in the overall cost of care.

Fluoroquinolone-resistant E. coli in intestinal flora of patients undergoing transrectal ultrasound-guided prostate biopsy--should we reassess our practices for antibiotic prophylaxis?

Although the estimate of the incidence of sepsis following transrectal ultrasound-guided prostate biopsy (TRUSPB) is low, fluoroquinolone-resistant infections after prostate biopsy are being increasingly noted. This study was aimed at determining the prevalence of faecal carriage of fluoroquinolone-resistant Escherichia coli strains before TRUSPB and at evaluating potential predisposing risk factors. The incidence of sepsis after prostate biopsy was determined, and our routine practice for antibiotic prophylaxis for TRUSPB was evaluated. A prospective study was conducted in 342 consecutive patients undergoing prostate biopsy between December 2009 and July 2010. Before TRUSPB, a rectal swab was cultured. The correlation between the presence of fluoroquinolone-resistant strains and plausible risk factors was investigated by the use of a questionnaire. Of the 236 patients included, 22.0% (52/236) harboured ciprofloxacin-resistant E. coli strains. The use of fluoroquinolones in the 6 months before biopsy was associated with an increased risk of faecal carriage of fluoroquinolone-resistant E. coli strains (p <0.01). Faecal carriage of fluoroquinolone-resistant E. coli strains was an important risk factor for infectious complications after TRUSPB (p <0.01). In conclusion, a significant number of patients have faecal carriage of fluoroquinolone-resistant E. coli strains (22.0%) before TRUSPB. The use of fluoroquinolones in the previous 6 months before biopsy is a risk factor for faecal carriage of fluoroquinolone-resistant E. coli strains and for infectious complications after TRUSPB. Hence, the universal administration of fluoroquinolones should be reconsidered.

Catastrophic sepsis and hemorrhage following transrectal ultrasound guided prostate biopsies

We report 2 cases of catastrophic complications following routine transrectal ultrasound guided prostate biopsy. The first patient incurred near-fatal septic shock due to multi-resistant Escherichia coli. Due to the severity of his shock, he developed bilateral leg gangrene requiring amputations. The second patient incurred significant hemorrhage eventually requiring an emergent general anesthesia and surgical management to control hemorrhage after other measures failed. While rare events, these reports emphasize the caution needed for physicians who routinely order prostate biopsies.

Prevalence and significance of fluoroquinolone resistant Escherichia coli in patients undergoing transrectal ultrasound guided prostate needle biopsy

PURPOSE

We estimated the prevalence of fluoroquinolone resistant Escherichia coli in patients undergoing repeat transrectal ultrasound guided prostate needle biopsy and identified high risk groups.

MATERIALS AND METHODS

From January 2009 to March 2010 rectal swabs of 136 men from 3 institutions undergoing transrectal ultrasound guided prostate needle biopsy were obtained. There were 33 men with no previous biopsy who served as the controls. Participants completed questionnaires and rectal swab culture was obtained just before performing the prostate biopsy. Selective media was used to specifically isolate fluoroquinolone resistant E. coli and sensitivities were obtained. The patients were contacted via telephone 7 days after the procedure for a followup questionnaire.

RESULTS

A total of 30 patients had cultures positive for fluoroquinolone resistant bacteria for an overall rate of 22% (95% CI 15, 29). Patients with diabetes and Asian ethnicity had higher risks of resistant rectal flora colonization (OR 2.3 and 2.8, respectively). However, differences did not reach statistical significance (p = 0.09 and p = 0.08, respectively). Patients with no prior biopsy had a positive rate of 15% (5 of 33) compared to 24% (25 of 103) in those with 1 or more prior biopsies (OR 1.8, p = 0.27). Five patients (3.6%) had post-biopsy fever while only 1 of those patients had a positive rectal swab.

CONCLUSIONS

Using selective media to isolate fluoroquinolone resistant E. coli from the rectum before transrectal ultrasound guided prostate biopsy, we isolated organisms in 22% of patients with a wide resistance pattern. This protocol may be used to provide information regarding targeted antibiotic prophylaxis before transrectal prostate biopsies.