Single-dose oral ciprofloxacin versus placebo for prophylaxis during transrectal prostate biopsy

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is antibiotic prophylaxis still mandatory for transperineal prostate biopsy? Results of a comparative study

Introduction and objectives

This study aimed to assess the incidence of urinary tract infections (UTIs) after transperineal prostate biopsy (TP-PB) comparing patients who underwent antibiotic prophylaxis (AP) with patients who had no prophylaxis.

Materials and methods

This prospective, double-center trial was conducted between August and December 2020. Patient candidates to PB were included with 1:1 allocation to case (Group A-no AP) and control group (Group B-standard AP). All TP-PBs were performed in an outpatient setting under local anesthesia. Data collected 2 weeks after the procedure included incidence of UTIs or bacteriuria, evaluated with a urine culture (UC), main symptoms, and complications related to TP-PBs.

Results

A total of 200 patients were included (100 patients in each group). The mean age was 66.2 ± 7.7 in Group A and 67.4 ± 8 years in Group B (P = 0.134). Mean prostate volume was 65.5 ± 26.7 vs. 51 ± 24.6 cc (P < 0.001), number of biopsy cores was 17.8 ± 2.4 vs. 14.9 ± 0.8 (P < 0.001), and PSA value was 15.9 ± 28.1 vs. 13.3 ± 22.3 ng/ml (P = 0.017). Overall PCa detection rate was 55% vs. 59% (P = 0.567). Postoperative UTI occurred in one patient in Group A vs. zero in Group B. Asymptomatic bacteriuria was present in 3 vs. 5 patients (P = 0.470) and was not treated with antibiotics. Postoperative hematuria was observed in 13 patients vs. 29 (P < 0.05), and acute urinary retention was observed in one patient in each group.

Conclusions

The incidence of bacteriuria and UTIs in TP-PBs is not related to AP. Therefore, AP could be discontinued in TP-PB candidates without the risk of increasing UTI-related complications.

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.

The clinical and financial implications of a decade of prostate biopsies in the NHS: analysis of Hospital Episode Statistics data 2008-2019

OBJECTIVE

To evaluate the clinical and financial implications of a decade of prostate biopsies performed in the UK National Health Service (NHS) through the transrectal (TR) vs the transperineal (TP) route.

METHODS

We conducted an evaluation of the TR vs the TP biopsy approach in the context of 28 days post-procedure complications and readmissions. A secondary evaluation of burden of expenditure in NHS hospitals over the entire decade (2008-2019) was conducted through examination of national Hospital Episode Statistics (HES) data.

RESULTS

In this dataset of 486 467 prostate biopsies (387 879 TR and 98 588 TP biopsies), rates of infection and sepsis were higher for the TR compared to the TP cohort (0.53% vs 0.31%; P < 0.001, confidence interval 99% ). Rates of sepsis have more than doubled for TR biopsies in the last 2 years compared to the previous decade (1.12% vs 0.53%). Infective complications were the main reasons for readmissions in the TR cohort, whereas urinary retention was the predominant reason for readmission in the TP cohort. Over the last decade, non-elective (NEL) readmissions seem higher for the TP group; however, in the last 2 years these have reduced compared to the TR group (3.54% vs 3.74%). The cost estimates for NEL readmissions for the entire decade were £33,589,527.00 and £7,179,926.00 respectively, for TR and TP cohorts (P < 0.001). Estimated costs per patient readmission were £2,225.00 and £1,758.00 in the TR and TP groups (P < 0.001).

CONCLUSIONS

Evaluation of nearly half a million prostate biopsies in the NHS over the entire decade gives sufficient evidence for the distinct advantages of the TP route over the TR route in terms of reduced infections and burden of expenditure. In addition, there is a potential for savings both in upstream and downstream costs if biopsy is performed under a local anaesthetic.

Quality improvement initiative to reduce variability and improve stewardship of antimicrobial prophylaxis for transrectal prostate needle biopsy

PURPOSE

To assess the impact of implementing the recommendations included in the 2014 American Urological Association (AUA) white paper on complications of transrectal prostate needle biopsy (PNB).

METHODS

In the outpatient setting of a single tertiary-care institution, prophylactic antibiotic use and rate of infectious complications were compared before and after implementation by nursing of a standardized algorithm to select antibiotic prophylaxis (derived from the recommendations of the AUA white paper). The 584 patients in cohort A (January 2011-January 2012) received antimicrobial prophylaxis at the discretion of the treating physician; 654 patients in cohort B (January 2014-January 2015) received standardized risk-adapted antibiotic prophylaxis. Data on antibiotics administered and infectious complications were analyzed.

RESULTS

Fluoroquinolone was the most common prophylactic regimen in both cohorts. In cohort A, 73% of men received a single-drug regimen, although 19 different regimens were utilized with duration of 72 h. In cohort B, 97% received 1 of 4 standardized single-drug antibiotic regimens for duration of 24 h. Infectious complications occurred in 19 men (3.3%) in cohort A, and in 18 men (2.8%) in cohort B (difference - 0.5%; one-sided 95% CI 1.1%). No clinically relevant increase in infectious complication rates was found after implementing this quality improvement initiative.

CONCLUSIONS

Use of a standardized risk-adapted approach to select antibiotic prophylaxis for PNB by nursing staff reduced the duration of antimicrobial prophylaxis and number of antibiotic regimens used, without increasing the rate of infectious complications. Our findings validate the current AUA recommendations for antibiotic prophylaxis.

Complications of transrectal prostate biopsy in our context. International multicenter study of 3350 patients

INTRODUCTION

Prostate cancer is the most common visceral neoplasm in men and the second one in the United States with the highest mortality behind lung cancer and ahead of colorectal cancer. While prostate cancer mortality rates have been reduced in the United States, Austria, United Kingdom and France, 5-year survival rates have been incremented in Sweden, probably due to a higher diagnostic activity and non-lethal tumor detection. TRPB usually has low rates of serious complications, with a not negligible number of minor complications. Mortality directly associated with this procedure is low and usually related to septic shock. The main complications derived from prostate biopsy can be infectious (mild or severe) and non-infectious (hematuria consistent with hemorrhage, urethral bleeding, rectal bleeding or hemospermia, acute urinary retention, pain or vasovagal reactions).

MATERIAL AND METHOD

The objective of the study is to compare three usual TRPB protocols and their relationship with the incidence of complications. Retrospective multicenter observational study conducted in three countries (Spain, Italy and Portugal). We have reviewed the medical records of 3350 men who underwent TRPB to evaluate the existence of prostate cancer, with a minimum evolutionary control of 6months.

RESULTS

The mean age was 65,50years, median 66, range 43-79. The subgroup analysis showed that younger patients had higher rates of acute urine retention (AUR) (P=.0000001). Likewise, our results revealed that younger patients presented more procedural pain (P=.0000001) than older patients. Regarding PSA, the mean value was 10.44, SD 7.73, median 8.15, range 0.98-68.09. A higher body mass index (BMI) was not associated with further infection (P=.000004). When performing the multivariate analysis, it was found that the significant variables in the general group were: age (P=.0013), PSA (P=.0402), local infiltration anesthesia (P=.0001) and prophylaxis with metronidazole +tobramycin +amoxicillin/clavulanic acid +gentamicin (P=.0001), presenting a normal distribution with high confidence interval (95%) and significant correlation. Prophylaxis is the most significant variable for no complications and pain (P=.0001), age (P=.0013) and prophylaxis (P=.0001) are for bleeding, age (P=.0013), prophylaxis and PSA (P=.0001) are for infection, and finally, age (P=.0013), anesthesia with local infiltration and prophylaxis (P=.0001) and PSA (P=.0402) are for AUR.

CONCLUSIONS

Sedation has fewer side effects and complications related to the transrectal prostate biopsy procedure with respect to transrectal local anesthesia. The choice of the antibiotic prophylaxis scheme is decisive in the onset of complications arising from the performance of a transrectal prostate biopsy.

Antibiotic prophylaxis for transrectal ultrasound-guided prostate needle biopsy: Compared efficacy of ciprofloxacin vs. the ciprofloxacin/fosfomycin tromethamine combination

INTRODUCTION

Some authors advocate an increase in post-prostate needle biopsy (PNB) infections associated with emergent quinolone resistance in E. coli, urging re-evaluation of antibiotic prophylaxis (antibioprophylaxis). In this study, we compared rates of post-PNB urosepsis associated with two oral regimens of antibioprophylaxis: ciprofloxacin (CIP) vs. ciprofloxacin and fosfomycin tromethamine combination (CIP/FOS).

METHODS

This retrospective pre-/post-intervention study included all patients who underwent PNB in two Canadian hospitals from January 2012 to December 2015. The primary outcome was urosepsis within one month of PNB. Urosepsis rates were analyzed according to antibioprophylaxis using log-binomial regression, considering the propensity score weights of collected risk factor data.

RESULTS

We reviewed 2287 PNB patients. A total of 1090 received CIP and 1197 received CIP/FOS. Urosepsis incidence with CIP was 1.1% (12/1090) and fell to 0.2% (2/1197) with CIP/FOS. Our analysis indicates that CIP/FOS significantly decreased the risk of urosepsis compared to CIP alone (adjusted relative risk [aRR] 0.16; p=0.021). The isolated pathogen was E. coli in 12/14 cases, including seven bacteremias. Among E. coli cases, seven strains were CIP-resistant. Eleven of 12 E. coli, including all CIP-resistant strains, were isolated in patients on CIP alone. One case of B. fragilis bacteremia occurred in the CIP/FOS group. No cases of C. difficile were identified in the three months post-PNB.

CONCLUSIONS

The adoption of CIP/FOS antibiotic prophylaxis significantly lowered the rate of post-PNB urosepsis. Conveniently, this regimen is oral, single-dose, and low-cost.

Acute prostatitis after prostate biopsy under ciprofloxacin prophylaxis with or without ornidazole and pre-biopsy enema: analysis of 3.479 prostate biopsy cases

Objectives:

To investigate the characteristics of cases of NIH category I acute prostatitis developed after transrectal prostate biopsy and clarifiy the risk factors and preventive factors.

Materials and Methods:

We retrospectively reviewed the medical records of 3.479 cases of transrectal ultrasound-guided needle biopsies performed with different prophylactic antibiotherapy regimens at two different institutions between January 2011 and February 2016. The patients of Group I have received ciprofl oxacin (n=1.523, 500mg twice daily) and the patients of Group II have received ciprofl oxacin plus ornidazole (n=1.956, 500mg twice daily) and cleansing enema combination as prophylactic antibiotherapy. The incidence, clinical features and other related microbiological and clinical data, were evaluated.

Results:

Mean age was 62.38±7.30 (47-75), and the mean prostate volume was 43.17±15.20 (21-100) mL. Of the 3.479 patients, 39 (1.1%) developed acute prostatitis after the prostate biopsy procedure. Of the 39 cases of acute prostatitis, 28/3.042 occurred after the first biopsy and 11/437 occurred after repeat biopsy (p=0.038). In Group I, 22 of 1.523 (1.4%) patients developed acute prostatitis. In Group II, 17 of 1.959 (0.8%) patients developed acute prostatitis. There was no statistical difference between the two groups according to acute prostatitis rates (X2=2.56, P=0.11). Further, hypertension or DM were not related to the development of acute prostatitis (P=0.76, X2=0.096 and P=0.83, X2=0.046, respectively).

Conclusions:

Repeat biopsy seems to increase the risk of acute prostatitis, while the use of antibiotics effective for anaerobic pathogens seems not to be essential yet.

Phenotypic screening for quinolone resistance in Escherichia coli

Recent studies show that rectal colonization with low-level ciprofloxacin-resistant Escherichia coli (ciprofloxacin minimal inhibitory concentration (MIC) above the epidemiological cutoff point, but below the clinical breakpoint for resistance), i.e., in the range > 0.06-0.5 mg/L is an independent risk factor for febrile urinary tract infection after transrectal ultrasound-guided biopsy (TRUS-B) of the prostate, adding to the other risk posed by established ciprofloxacin resistance in E. coli (MIC > 0.5 mg/L) as currently defined. We aimed to identify the quinolone that by disk diffusion best discriminates phenotypic wild-type isolates (ciprofloxacin MIC ≤ 0.06 mg/L) of E. coli from isolates with acquired resistance, and to determine the resistance genotype of each isolate. The susceptibility of 108 E. coli isolates was evaluated by ciprofloxacin, levofloxacin, moxifloxacin, nalidixic acid, and pefloxacin disk diffusion and correlated to ciprofloxacin MIC (broth microdilution) using EUCAST methodology. Genotypic resistance was identified by PCR and DNA sequencing. The specificity was 100% for all quinolone disks. Sensitivity varied substantially, as follows: ciprofloxacin 59%, levofloxacin 46%, moxifloxacin 59%, nalidixic acid 97%, and pefloxacin 97%. We suggest that in situations where low-level quinolone resistance might be of importance, such as when screening for quinolone resistance in fecal samples pre-TRUS-B, a pefloxacin (S ≥ 24 mm) or nalidixic acid (S ≥ 19 mm) disk, or a combination of the two, should be used. In a setting where plasmid-mediated resistance is prevalent, pefloxacin might perform better than nalidixic acid.

Fosfomycin trometamol vs ciprofloxacin for antibiotic prophylaxis before transrectal ultrasonography-guided prostate biopsy: A meta-analysis of clinical studies

Objectives: To perform a systematic review and meta-analysis of clinical studies to assess the comparative prophylactic effectiveness of fosfomycin trometamol (FMT) vs ciprofloxacin (CIP) in men who underwent transrectal ultrasonography-guided prostate needle biopsy (TRUS-PNB), as infectious complications are a major concern after TRUS-PNB and although fluoroquinolones are currently the first choice, an increase in resistance has raised the question about its recommendation and FMT is a broad-spectrum oral antibiotic with low bacterial resistance.

Methods: A systematic review was performed between January 1970 and June 2017 using the Web of Science, Scopus and PubMed databases to identify relevant studies. Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria were used for article selection. Outcomes of interest were febrile and afebrile urinary tract infections (UTIs) and the presence of fluoroquinolone-resisitant (FQR)- or extended-spectrum β-lactamase (ESBL)-producing uropathogens in urinary cultures.

Results: Four studies including 2331 men were analysed; 1088 had FMT and 1243 CIP as antibiotic prophylaxis before TRUS-PNB. FMT prophylaxis resulted in significantly less afebrile (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.12–0.38; P < 0.001) and febrile (OR 0.15, 95% CI 0.07–0.31; P < 0.001) UTIs than CIP. Amongst all urine cultures, patients in the FMT arm also had a significantly lower prevalence of FQR and ESBL (E. coli or K. pneumoniae) microorganisms when compared to the CIP group (OR 0.25, 95% CI 0.12–0.21, P = 0.001; and OR 0.24, 95% CI 0.10–0.58, P = 0.001, respectively).

Conclusions: Antibiotic prophylaxis with FMT before TRUS-PNB was associated with lower rates of infectious complications when compared to CIP.

Abbreviations: CIP: ciprofloxacin; ESBL: extended-spectrum β-lactamase; FMT: fosfomycin trometamol; FQR: fluoroquinolone-resisitant; OR: odds ratio; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; TRUS-PNB: TRUS-guided prostate needle biopsy

Comparing infective complications from transrectal ultrasound guided prostate biopsy following transition to single dose oral ciprofloxacin prophylaxis

Purpose

To examine the incidence of infective complications post Transrectal Ultrasound Guided Prostate Biopsy (TRUSPB), after transition to preoperative administration of single dose oral ciprofloxacin.

Materials and Methods

A retrospective study of 766 consecutive patients undergoing TRUSPB at St Vincent's Hospital Melbourne (2002–2016). Antibiotic prophylaxis between 2002–2014 consisted of 3 days of perioperative oral norfloxacin±intravenous (IV) antibiotics (Group A, n=687). From November 2014 patients received a single dose of oral 750 mg ciprofloxacin pre-biopsy (Group B, n=79), to align with the American Urological Association (AUA) and a Cochrane Database Systematic Review on Antibiotic Prophylaxis for TRUSPB. Groups were compared for all postoperative complications requiring representation and/or readmission within 30 days of biopsy.

Results

In Group A, 10 of 687 patients (1.5%) re-presented with post-procedural fever (temperature >38℃), requiring readmission and IV antibiotic treatment, compared to 4 of the 79 patients (5.1%) in Group B (p=0.02). Positive blood cultures were isolated in 0.9% (n=6, Group A) versus 3.8% (n=3, Group B) (p=0.02). The 4 infectious readmissions in Group B had no prior genitourinary infections, no recent travel and all had a Charlson Comorbidity Index scores <2. Two patients in Group B cultured Escherichia coli sensitive to ciprofloxacin despite receiving preoperative ciprofloxacin.

Conclusions

Antibiotic prophylaxis using single dose ciprofloxacin is associated with higher infective complications post TRUSPB. The episodes of ciprofloxacin sensitive E. coli bacteraemia in Group B suggest consideration of a longer course of perioperative antibiotic prophylaxis.

National survey of fiducial marker insertion for prostate image guided radiotherapy

INTRODUCTION

In the United Kingdom fiducial marker IGRT is the second most common verification method employed in radical prostate radiotherapy yet little evidence exists to support centres introducing or developing this practice. We developed a survey to elicit current fiducial marker practices adopted in the UK, to recommend standardisation of practice.

METHODS

A 16 question survey was distributed across UK Radiotherapy centres via promotion at the British Uro-Oncology Group Conference, 2016. Included were questions relating to workforce planning, patient preparation, insertion procedure and verification methods. The survey was open from September 2016 to January 2017.

RESULTS

Results from 15 centres routinely inserting fiducial markers for prostate IGRT are presented. Eleven professional groups insert fiducial markers across the UK. Fourteen centres insert fiducial markers trans-rectally; one trans-perineally. Centres adopting a trans-rectal approach administer prophylactic ciprofloxacin as a single agent or combined with gentamicin or metronidazole; poor agreement between regimes presented. One centre has introduced targeted antibiotic prophylaxis. Five brands of fiducial markers are utilised nationally. Fourteen centres standardly insert three single fiducial markers, two common configurations emerged. Coupled fiducial markers are routinely implanted by one centre. All centres delay at least one week between fiducial marker insertion and planning CT; seven centres wait two weeks. The most common fiducial verification method is two-dimensional, paired kilo Voltage imaging.

CONCLUSION

Variation in fiducial marker practice across the UK is considerable. Standardisation is required to support centres and healthcare professionals developing this service. Seven recommendations, to unify practice, have been proposed based on survey results and literature.

Performance Validation of Selective Screening Agars for Guiding Antimicrobial Prophylaxis in Patients Undergoing Prostate Biopsy

A rectal culture-guided antimicrobial prophylaxis strategy may prevent infections after transrectal ultrasound-guided prostate biopsy (TRUSP). The use of selective culture media could assist the choice of appropriate antibiotic prophylaxis. The objective of our study was to evaluate the performance of four selective media used for guidance of oral antibiotic prophylaxis in TRUSP. In this prospective validation study, we used MacConkey media with vancomycin plus one of the following antibiotics: ciprofloxacin (McC3+CIP/V), trimethoprim (McC3+TMP/V), fosfomycin (McC3+FOF/V), and amdinocillin-amoxicillin-clavulanic acid (McC3+MEC/V). First, clinical strains of Gram-negative bacilli (GNB) (n = 33) were evaluated for growth on the selective media. Thereafter, rectal swabs (n = 97) were randomly collected from residual material of fresh stool samples and plated on a growth control and the four selective media. Levels of recovery of GNB on the growth control and selective media were compared, and the MICs of the antibiotics used in this study were determined. The sensitivity and specificity of the four selective media amounted, respectively, to 90.0% (55.5 to 99.8%) and 98.7% (93.1 to 100.0%) for McC3+CIP/V, 95.7% (85.2 to 99.5%) and 100.0% (91.6 to 100.0%) for McC3+TMP/V, 95.5% (84.5 to 99.4%) and 97.8% (88.2 to 99.9%) for McC3+FOF/V, and 100.0% (76.8 to 100.0%) and 97.6% (87.4 to 99.9%) for McC3+MEC/V. In conclusion, the four selective media were sufficiently sensitive and specific for the identification of rectal GNB resistant to ciprofloxacin, trimethoprim, fosfomycin, or amdinocillin-amoxicillin-clavulanic acid. These media can have added value in streamlining the optimal culture based antibiotic prophylaxis in TRUSP in a non-labor-intensive manner.

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.

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.

Comparison of Single and Prolonged Fluoroquinolone Prophylaxis and Risk Factors for Infectious Complications After Transrectal Prostate Biopsy

Background:

The ideal prophylaxis duration for transrectal ultrasonography-guided prostate biopsy is incompletely defined.

Aims:

To compare the infectious complications of transrectal ultrasonography-guided prostate biopsy with and without extended antibiotic prophylaxis. The secondary aim was to evaluate the risk factors for infectious complications.

Study Design:

Prospective observational study.

Methods:

Four hundred patients who underwent transrectal ultrasonography-guided prostate biopsy were recruited. Patients orally received either 750 mg ciprofloxacin 60 min before the procedure or 500 mg ciprofloxacin twice a day for a duration of 7 days with the initial dose administered 24 h prior to the procedure. All patients were followed-up for 4 weeks after the transrectal ultrasonography-guided prostate biopsy procedure for infectious complications. Screening of urine was carried out in all patients on the 3^rd and 7^th day after the procedure. Medical histories of all patients were collected prior to biopsy. Information on medical history include the following: hospitalization, urethral catheterization, or urinary tract infections within the past 12 months; antibiotic use within the last 3 months, prior urinary tract interventions, and previous transrectal ultrasonography-guided prostate biopsy and Charlson comorbidity indexes. Ultrasound-guided biopsy was carried out using General Electric’s 7 MHz transrectal ultrasound device in the left decubitus position. Patients received one of the two ciprofloxacin-based prophylaxis regimens. Subsequent transrectal ultrasonography-guided prostate biopsy to all patients were followed-up for 30 days. Further follow-up of patients was carried out on the second and fourth weeks after transrectal ultrasonography-guided prostate biopsy, and symptoms, such as dysuria, rectal bleeding, fever, hematospermia, hematuria, and pollakiuria, were recorded.

Results:

Both groups presented similar baseline characteristics and medical history. Infectious complication rates within the 4-week follow-up were similar in both groups (single dose: 3% vs prolonged: 3%) (p>0.05). In both groups, infectious complications significantly increased than that at previous antibiotic usage (single: p=0.028; prolonged: p=0.040). Non-infectious complication ratios showed no significant variation (p>0.05).

Conclusion:

Pre-operative single dose of 750 mg oral ciprofloxacin compared with 7 days prolonged treatment resulted in similar infectious complication outcomes in patients undergoing transrectal ultrasonography-guided prostate biopsy. The use of antibiotics within the last 3 months increases the risk for post-transrectal ultrasonography-guided prostate biopsy infectious complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Antibiotic susceptibility of intestinal Escherichia coli in men undergoing transrectal prostate biopsies: a prospective, registered, multicentre study

OBJECTIVES

To determine, in a prospective, multicentre setting, the prevalence of fluoroquinolone-resistant (FQ-R) and extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) strains in men undergoing transrectal ultrasonography-guided prostate biopsy (TRUS-Bx) in Finland; and to survey the associated risk factors for having the previously mentioned strains.

PATIENTS AND METHODS

This is a substudy of the trial investigating the role of magnetic resonance imaging (MRI) in prostate cancer diagnosis (Improved Prostate Cancer Diagnosis - Combination of Magnetic Resonance Imaging Targeted Biopsies and Biomarkers Multi-institutional Study [multi-IMPROD], NCT02241122). In all, 359 patients from four study centres were recruited to this prospective study. After having signed the informed consent form, these men with suspicion of prostate cancer completed a detailed questionnaire on their medical, smoking, and travelling history, as well as their recent use of antibiotics. After the bi-parametric MRI scan, TRUS-Bx was taken and a rectal swab sample was collected and cultured for determining the antimicrobial susceptibility profile of E. coli strains. The potential risk factors for having FQ-R or third-generation cephalosporin-resistant (3GC-R) E. coli strains were analysed using univariate and multivariate logistic regression analysis.

RESULTS

The percentage of FQ-R and 3GC-R E. coli strains amongst the study population was 13% and 8%, respectively. Amongst patients having E. coli strains, the rate of FQ-R and 3GC-R strains was 14% and 8%, respectively. Of the 3GC-R E. coli strains, 62% proved to be ESBL-producers and 88% were also FQ-R. In multivariate analysis, international travel during the preceding year significantly increased the risk of having a FQ-R E. coli strain (odds ratio [OR] 3.592, P = 0.001) and, unexpectedly, use of antibiotics during the previous year significantly decreased this risk (OR 0.442, P = 0.035). No significant risk factors for having 3GC-R E. coli were identified.

CONCLUSION

The occurrence of intestinal FQ-R and/or 3GC-R (potentially ESBL-producing) E. coli strains in men undergoing TRUS-Bx in Finland is notable. The finding is consistent with the global increase in antimicrobial resistance. International travel appears to be an indisputable risk factor for having intestinal FQ-R E. coli strains. The contemporary antimicrobial resistance situation should be taken into account in the care of post-TRUS-Bx infections.

Atypical small acinar proliferation at index prostate biopsy: rethinking the re-biopsy paradigm

PURPOSE

Guidelines for atypical small acinar proliferation (ASAP) diagnosed on prostate biopsy recommend repeat biopsy within 3-6 months after diagnosis. We sought to discern the rate of detecting clinically significant prostate cancer on repeat biopsy and predictors associated with progression.

MATERIALS AND METHODS

We performed a retrospective chart review of patients who underwent prostate biopsy at our institution from January 1, 2008, to December 31, 2015. Gleason grade group (GGG) system and D'Amico stratification were used to report pathology and risk stratification, respectively. Logistic and linear regression analyses were performed.

RESULTS

A total of 593 patients underwent transrectal ultrasound-guided prostate biopsy, of which 27 (4.6%) had the diagnosis of ASAP. Of these, 11 (41%) had a repeat biopsy. Median time from diagnosis to repeat biopsy was 147 days (IQR 83.5-247.0). Distribution across the GGG system on repeat biopsy was as follows: 7 (63.6%) benign, 3 (27.3%) GG1, and 1 (9.1%) GG2. ASAP was not associated with subsequent diagnosis of clinically significant prostate cancer (OR 0.46, 95% CI 0.064-3.247, P = 0.432). There was no association between ASAP and high cancer risk (ASAP: β = - 0.12; P = 0.204).

CONCLUSIONS

Patients diagnosed with ASAP managed according to guideline recommendations are more likely diagnosed with benign pathology and indolent prostate cancer on repeat biopsy. These findings support prior studies suggesting refinement of guidelines in regard to the appropriateness and timeliness of repeat biopsy among patients diagnosed with ASAP.

"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.

Infective complications in patients after transrectal ultrasound-guided prostate biopsy and the role of ciprofloxacin resistant Escherichia coli colonization in rectal flora

OBJECTIVE

In the present study, we aimed to invastigate the ciprofloxacin resistance in rectal flora of the patients undergoing prostate biopsy in our department. Additionally, the possible effects of the presence of ciprofloxacin resistant bacteria in faecal flora on the risk of infective complications after the procedure as well as the effect of antibiotic prophylaxis on such infectious complications have been evaluated.

MATERIAL AND METHODS

A total of 142 patients undergoing transrectal ultrasound-guided prostate biopsy were included into the study program. Rectal swab samples were taken from all patients prior to biopsy. The presence of complications have been evaluated after a week following the biopsy procedure. Patients with fever were also evaluated. The possible correlation between the presence of ciprofloxacin-resistant bacteria in faecal flora and the risk of urinary tract infection development and the other complications were evaluated.

RESULTS

E. coli bacteria were present in all cultures of rectal swab samples obtained from 142 patients prior to prostate biopsy. Of all these patients, while ciprofloxacin-resistant E. coli (CR E. coli) grew in 76 (53.5%) patients; ciprofloxacin susceptible E. coli (CS E. coli) was obtained in 66 (46.5%) patients. In 16 patients (11.3%), infectious complications were observed. While the infective complications were present in the 14.5% of patients with CR E. coli; they were present in the 7.6% of patients with CS E. coli (p=0.295). High fever was observed in nine patients (6.3%). Of these nine patients, although six had CR E. coli growth as detected during culture sensitivity tests; three had CS E. coli growth in their rectal swab culture tests. Sepsis was observed in three (2.1%) of these patients with high fever. Ciprofloxacin-resistant E. coli grew in all of the rectal swab cultures obtained from these patients with sepsis.

CONCLUSION

In the light of our findings we may say that, it will be appropriate to reconsider the ciprofloxacin prophylaxis and prefer to use other prophylactic agents for a certain period of time in populations with higher rates of resistance to this medical agent. Furthermore, it will be appropriate again to obtain rectal swab specimens for culture tests before biopsy procedure in order to perform targeted prophylaxis according to the culture antibiogram test results. This approach will enable us to evaluate the cost-effectiveness of the procedure in detail.

The incidence and risk factors of resistant E. coli infections after prostate biopsy under fluoroquinolone prophylaxis: a single-centre experience with 2215 patients

We evaluated the incidence and risk factors of resistant Escherichia coli infections after the prostate biopsy under flouroquinolone prophylaxis. From January 2003 to December 2012, we retrospectively evaluated the records of 2215 patients. The risk factors were described for infective complications and resistant E. coli in positive cultures was calculated. Of 2215 patients, 153 had positive urine cultures, such as 129 (84·3%) E. coli, 8 (5·2%) Enterococcus spp., 6 (3·9%) Enterobacter spp., 5 (3·2%) Pseudomonas spp., 3 (1·9%) MRCNS, and 2 (1·3%) Klebsiella spp. Of the positive urine cultures which yielded E. coli, 99 (76·7%) were evaluated for fluoroquinolone resistance. Of those, 83 (83·8%) were fluoroquinolone-resistant and composed of 51 (61·4%) extended-spectrum beta-lactamase (ESBL)-positive. Fluoroquinolone-resistant E. coli ratios were 73·4 and 95·9% before 2008 and after 2008, respectively (P = 0·002). The most sensitive antibiotics for fluoroquinolone-resistant E. coli strains were imipenem (100%), amikacin (84%) and cefoperazone (83%). The use of quinolones in the last 6 months and a history of hospitalization in the last 30 days were found to be significant risk factors. We found that resistant E. coli strains might be a common microorganism in patients with this kind of complication. The risk factors for development of infection with these resistant strains were history of the use of fluoroquinolones and hospitalization.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

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.

The efficacy of duration of prophylactic antibiotics in transrectal ultrasound guided prostate biopsy

Introduction:

We aimed to evaluate the efficacy of the duration of prophylactic antibiotic administration in patients undergoing transrectal ultrasound (TRUS) guided biopsy.

Material and Methods:

A total of 367 patients undergoing a prostate biopsy between September 2007 and June 2009 was reviewed retrospectively and divided into 2 groups according to prophilaxy: oral ciprofloxacin (750 mg every 12 hours) for 3 or more days in Group-1 and single day in Group-2. Demographic characteristics of patients, symptoms, PSA values, IPSS scores, prostate sizes, pathologic results and complications were compared between the groups.

Results:

The mean age of all patients was 63.92 years and the mean PSA was 13.61ng/ dL. The pre-biopsy mean IPSS score was 12.47 and mean prostate volume 52.53 mL. For 78.2% of patients the current biopsy was their first biopsy. Cancer detection rate was 24.2%. Fever was observed in 3 (1.2%) patients in Group-1 and 5 (4.0%) patients in Group-2. Local infections occurred in 2 (0.8%) and 1 (0.8%) patients respectively in Groups 1 and 2. Acute prostatitis was observed in only 1 (0.8%) patient in Group-2. Accepted after revision: None of the patients developed septicemia or other serious infection. There was no statistically significant difference in terms of fever, local infections (epididimitis, orchitis, etc.) and acute prostatitis.

Conclusions:

In a selected patient population single dose prophylaxis with ciprofloxacin can be safely administered compared to other regimens of 3 or more days. Increasing the duration of antibiotic prophylaxis does not decrease infectious complications.

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.

The global burden of major infectious complications following prostate biopsy

We present a systematic review providing estimates of the overall and regional burden of infectious complications following prostate biopsy. A directly standardized prevalence estimate was used because it reflects the burden of disease more explicitly. Complications included sepsis, hospitalization, bacteraemia, bacteriuria, and acute urinary retention after biopsy. There were 165 articles, comprising 162 577 patients, included in the final analysis. Our findings demonstrate that transrectal biopsy was associated with a higher burden of hospitalization (1·1% vs. 0·9%) and sepsis (0·8% vs. 0·1%) compared to transperineal biopsy, while acute urinary retention was more prevalent after transperineal than transrectal biopsy (4·2% vs. 0·9%). The differences were statistically non-significant because of large heterogeneity across countries. We also demonstrate and discuss regional variations in complication rates, with Asian studies reporting higher rates of sepsis and hospitalization.

Oral antibiotics in trans-rectal prostate biopsy and its efficacy to reduce infectious complications: Systematic review

For the diagnosis of prostate cancer trans-rectal prostate biopsy (TRPB) is used commonly, the procedure is associated with infective complications. There is evidence that antibiotics (ABx) decrease infective events after TRPB, but different regimens are used. To systematically review different regimens of prophylactic oral ABx in TRPB. MEDLINE, EMBASE, clinical trials site, and Cochrane library were searched, experts were consulted for relevant studies. Randomized clinical trials conducted in the last 20 years, which investigated the different oral antibiotic regimens in TRPB, and compared their efficacy to reduce infectious complications were analyzed. Primary outcomes were bacteriuria, urinary tract infection (UTI), fever, bacteremia, and sepsis. Secondary outcomes were the hospitalization rate and the prevalence of ABx-resistant bacteria. Nine trials were eligible with 3012 patients. ABx prevented bacteriuria (3.5% vs. 9.88%), UTI (4.46% vs. 9.75%), and hospitalization (0.21% vs. 2.13%) significantly in comparison with placebo or no treatment. No significant difference was found in all the outcomes of the review between the single dose regimen and the 3 days. The single dose regimen was as effective as the multiple doses except in bacteriuria (6.75% vs. 3.25%), and the prevalence of ABx-resistant bacteria (1.57% vs. 0.27%). Quinolones reduced only UTI significantly in comparison with other ABx (chloramphenicol, trimethoprim-sulfamethoxazol). It is essential to prescribe prophylactic ABx in TRPB. No conclusive evidence could be claimed about the superiority of the multiple or the 3 days regimens to the single dose regimen. Unexpectedly, ABx-resistant bacteria were identified more often in the single dose cohorts.

Comparison between ciprofloxacin and trimethoprim-sulfamethoxazole in antibiotic prophylaxis for transrectal prostate biopsy

OBJECTIVE

The aim of this study was to compare the efficacies of oral ciprofloxacin administration and oral trimethoprim-sulfamethoxazole (TMP-SMX) regimens in preventing infectious complications following transrectal ultrasound guided biopsy of the prostate.

MATERIAL AND METHODS

Between 2011-2013, the medical records of 391 (mean age 64.62±7.64 years; range 40 to 87 years) patients who underwent transrectal prostate biopsies, due to suspicion of prostate cancer were retrospectively reviewed. While 500 mg ciprofloxacin was given orally twice daily starting one day before the procedure, continued for 3 days in the first 174 patients (group 1); was given orally twice daily starting one day before the procedure, continued for 3 days in the remaining 217 patients (group 2) for prophylaxis. Urine samples were obtained for urine culture before the procedure. The two groups were compared with respect to findings of urine cultures performed before and after the procedure and complications.

RESULTS

In the ciprofloxacin and groups, any positive urine culture before the procedure was not observed. Complications occured in 93 patients (37 in group 1 and 56 in group 2), after the procedure. Twenty-two (5.6%) (11 in group 1 and 11 in group 2). patients were admitted to our clinic because of high fever occurring after biopsy. Nine ciprofloxacin-treated (5.2%) and 16 TMP-SMX-treated (7.4%) patients had severe dysuria after the procedure. Twenty-one ciprofloxacin recipients (12.1%) and 40 TMP-SMX recipients (18.4%) had macroscopic hematuria. In the ciprofloxacin and TMP-SMX groups, the incidences of new culture positivity were 4% (n=7) and 2.8% (n=6) after the procedure, respectively. All of the isolated bacteria was Escherichia coli. While 11 patients were hospitalized due to signs of complicated urinary tract infections, and 2 patients were treated as outpatients. Rectal bleeding that did not require any intervention was observed in a patient 8 hours after biopsy. SIRS findings were detected in two patients. There were no significant differences between the two groups with respect to age, prostate volume, prostate spesific antigen (PSA) levels, and results of urine culture performed after the procedure (p>0.05).

CONCLUSION

Despite the increasing resistance to antibiotics, ciprofloxacin and TMP-SMX are effective prophylactic treatment modalities for transrectal prostate biopsy. Both three-day ciprofloxacin and TMP-SMX regimens seem to be equally effective in the antibiotic prophylaxis for transrectal prostate biopsy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Short-term prophylaxis with ciprofloxacin in extended 16-core prostate biopsy

Objective

To evaluate the safety, efficacy and possible complications of 16-core transrectal prostate biopsies using two doses of ciprofloxacin for prophylaxis of infectious complications.

Materials and Methods

Sixteen-core prostate biopsies were performed on a number of patients with different signs of potential prostate cancer. Complications were assessed both during the procedure and one week later. After the procedure, urine samples were collected for culture. The rate of post-biopsy complications, hospital visits and hospitalizations were also analyzed. Ciprofloxacin (500 mg) was administered two hours before, and eight hours after the procedure.

Results

The overall rate of post-biopsy complications was 87.32%, being 5.4% of those considered major complications due to hemorrhage, or to urinary retention. Eight patients required hospital treatment post-biopsy. Fever occurred in just one patient (0.29%). There was no incidence of orchitis, epididymitis, prostatitis, septicemia, hospitalization, or death. The urine culture showed positive results in five patients (2.15%).

Conclusion

One-day prophylaxis with ciprofloxacin proved to be safe and effective in the prevention of infectious complications following 16-core prostate biopsies.

Population-based assessment of determining predictors for quality of prostate cancer surveillance

BACKGROUND

Despite recent interest in the overdiagnosis and overtreatment of prostate cancer, the acceptance of expectant management for patients with indolent prostate cancer has remained slow. Moreover, the intensity of surveillance strategies remains to be elucidated. The objective of this study was to determine the population-based intensity of surveillance strategy among patients diagnosed with localized prostate cancer who undergo watchful waiting/active surveillance and those who receive active treatment.

METHODS

Linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify men diagnosed with prostate cancer from 2004 to 2007 who were followed until December 31, 2009. Bivariate and multivariate regression analyses were used to quantify the use of prostate-specific antigen tests, office visits, and second prostate biopsies within 2 years of diagnosis.

RESULTS

Compared with patients who were receiving active treatment, those who were undergoing watchful waiting/active surveillance were less likely to receive prostate-specific antigen testing and to attend office visits within the 2 years after diagnosis (P < .01). Of the 3656 patients who were undergoing watchful waiting/active surveillance, only 166 (4.5%) were on active surveillance (according to the authors' a priori definition), although the number increased over the last 2 years of the study (hazard ratio, 2.18; 95% confidence interval, 1.28-3.71; P < .01). Limitations of the study included data limited to men aged 65 years or older and the lack of ability to discern between watchful waiting and active surveillance.

CONCLUSIONS

Active surveillance is underused, and there is uncertainty regarding the quality of surveillance for patients who undergo watchful waiting/active surveillance. Further research is needed into qualitatively describing the contributing factors that drive decision-making recommendations as well as improved surveillance measures for patients with prostate cancer.

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.

Current practice of prostate biopsy in Australia and New Zealand: A survey

Introduction:

Prostate biopsy remains the gold standard for prostate cancer diagnosis. The field of prostate biopsy is undergoing a rapid change. This study aims to provide a snapshot of the current practice of prostate biopsy in the Urological Society of Australia and New Zealand (USANZ).

Materials and Methods:

A 31-question multiple-choice survey was constructed using a web-based provider and was distributed to 644 members of USANZ. The questionnaire addressed various aspects of prostate biopsy. Questionnaire results were collated and the data were analyzed statistically.

Results:

150 completed surveys were returned, with a response rate of 23.3%: 84.5% of those completing the survey were consultant urologists and 68% were working in a metropolitan setting. 98.6% of clinicians used prophylactic antibiotics before prostate biopsy, most commonly a quinolone. 30.6% had used intravenous (IV) carbapenems at least once. Peri-prostatic local anesthetic (LA) infiltration was used by 39.9% of clinicians with 73% using IV sedation or general anesthetic (GA). 38.4% of clinicians reported performing TPT biopsy of the prostate and 19.6% of clinicians had ordered a MRI of the prostate prior to an initial biopsy with 10.2% routinely ordering a MRI of the prostate before repeat biopsy.

Conclusion:

Frequent prophylactic use of carbapenems suggests concern amongst clinicians about sepsis with quinolone-resistant bacteria. Almost 75% of TRUS biopsies were performed under IV sedation or GA indicating a heavy demand of health resources. TPT biopsy was used commonly and there was significant use of multiparametric MRI prior to prostate biopsy.

Efficacy of two-time prophylactic intravenous administration of tazobactam/piperacillin for transrectal ultrasound-guided needle biopsy of the prostate

BACKGROUND

Prevalence of fluoroquinolone (FQ)-resistant Escherichia coli has been recently increasing worldwide. We analyzed the incidence and characteristics of acute bacterial prostatitis after transrectal ultrasound-guided needle prostate biopsy (TRUSP-Bx) with prophylactic tazobactam/piperacillin (TAZ/PIPC) treatment as an alternative regimen.

METHODS

A total of 391 patients who underwent TRUSP-Bx were included in the study. All patients received intravenous TAZ/PIPC (4.5 g) 30 minutes before and 6 hours after TRUSP-Bx.

RESULTS

Acute bacterial prostatitis developed in six patients (1.5%); the frequency of its occurrence was significantly higher in patients in whom rectal disinfection was not performed (P < 0.05). These six patients developed clinical symptoms of acute bacterial prostatitis a median of 24 hours after the biopsy. Escherichia coli was isolated in urine or blood bacterial cultures in four cases, and Klebsiella pneumoniae in two cases. All of the isolated organisms showed excellent sensitivity to TAZ/PIPC.

CONCLUSIONS

The incidence rate of acute prostatitis with prophylactic TAZ/PIPC was consistent with those reported previously with FQ-based regimens, despite the favorable sensitivity of isolated organisms. Two-time regimen of TAZ/PIPC may not always prevent the post-TRUSP-Bx infection, possibly due to the pharmacokinetic characteristics of TAZ/PIPC. However, if each case was considered individually to select the best setting and frequency of dosage of TAZ/PIPC, this can be an optimal prophylaxis in the era of widespread FQ-resistant microorganisms.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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