Update on techniques to prevent infections associated with prostate needle biopsy

Nonantibiotic strategies to decrease the postbiopsy hospitalization rates because of infectious complications after transrectal prostate biopsy

OBJECTIVES

To compare the effect of biopsy needle disinfection with 10% formalin solution alone and with povidone-iodine rectal cleaning on preventing infectious complications requiring hospitalization.

METHODS

The data of 902 patients who underwent prostate biopsy by transrectal route were retrospectively analyzed. Inclusion criteria were prophylactic antibiotic use and negative urine culture before the biopsy. Three groups occurred according to the methods used during the biopsy procedure. In Group 1, 501 patients, biopsy needle disinfection was made using 10% formalin solution during the biopsy procedure. Group 2, 164 patients, applied only prophylactic antibiotics. Group 3, 237 patients, applied both 10% formalin disinfection of the biopsy needle and prebiopsy povidone-iodine rectal cleansing. Hospitalized patients because of infectious complications a month after the biopsy were our outcome measures.

RESULTS

Hospitalization rates because of biopsy-related infectious complications, according to Groups 1, 2, and 3, were 2.7%, 8.5%, and 0%, respectively. The best results were observed in Group 3 and the worst in Group 2.

CONCLUSIONS

The two nonantibiotic strategies, biopsy needle disinfection with formalin solution and rectal cleaning with povidone-iodine, look more effective when applied together. However, further prospective studies are required to confirm our analysis.

Effectiveness of fosfomycin-based antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy: A Korean multicenter study

PURPOSE

Recent studies have highlighted increasing infectious complications due to fluoroquinolone (FQ)-resistant organisms in men undergoing transrectal ultrasound-guided prostate biopsy (TRUSPB). This study investigated whether fosfomycin (FM)-based antibiotic prophylaxis reduces infections after TRUSPB and identified risk factors for infective complications.

MATERIALS AND METHODS

A multicenter study was conducted in the Republic of Korea from January 2018 to December 2021. Patients undergoing prostate biopsy with FQ or FM-based prophylaxis were included. The primary outcome was the post-biopsy infectious complication rate after FQ (group 1) or FM-based antibiotic prophylaxis with FM alone (group 2) or FQ and FM (group 3). Risk factors for infectious complications after TRUSPB were secondary outcomes.

RESULTS

Patients (n=2,595) undergoing prostate biopsy were divided into three groups according to the type of prophylactic antibiotics. Group 1 (n=417) received FQ before TRUSPB. Group 2 (n=795) received FM only and group 3 (n=1,383) received FM and FQ before TRUSPB. The overall post-biopsy infectious complication rate was 1.27%. The infectious complication rates were 2.4%, 1.9%, and 0.5% in groups 1, 2, and 3, respectively (p=0.002). In multivariable analysis, predictors of post-biopsy infectious complications included an association with health care utilization (adjusted odds ratio [OR], 4.66; 95% confidence interval [CI], 1.74-12.4; p=0.002) and combination antibiotic prophylaxis (FQ and FM) (adjusted OR, 0.26; 95% CI, 0.09-0.69; p=0.007).

CONCLUSIONS

In comparison with monotherapy with FM or FQ, combination antibiotic prophylaxis (FQ and FM) showed a lower rate of infectious complications after TRUSPB. Utilization of health care was an independent risk factor for infectious complications after TRUSPB.

Post-prostate biopsy acute bacterial prostatitis and screening cultures using selective media: An overview

The development of several culture media and the availability to isolate and treat pathogens prior to a surgical procedure give us the ability to minimize treatment-related complications, and ultimately results in better outcomes for patients and avoidance of unwanted post-procedure inpatient admissions. In the last decade, an increasing incidence of multidrug-resistant Escherichia coli, especially extended-spectrum beta-lactamase-producing E. coli and fluoroquinolone-resistant pathogens, has been reported. These resistant species frequently colonize the rectal flora and gain access to the systemic circulation via the rectal plexus following a prostate biopsy. The bacteria can eventually lead to life-threatening complications, which is especially important in high-risk patients with multiple co-morbidities. Previously published studies have focused on the isolation of these pathogens with selective media before an invasive procedure and the potential benefits of incorporating the use of selective media as a mandatory pre-operative step. This preventive measure will allow us to offer a tailored prophylactic treatment that benefits patients and reduces the economic burden for the hospital.

The negative aftermath of prostate biopsy: prophylaxis, complications and antimicrobial stewardship: results of the global prevalence study of infections in urology 2010-2019

PURPOSE

To evaluate and report the complications, and to analyse antimicrobial stewardship aspects following prostate biopsies (P-Bx) based on the data from a 9-year global study.

METHODS

The primary outcome was to compare complications after P-Bx between patients of two cohorts: 2010-2014 and 2016-2019. Primary outcomes included symptoms of lower and severe/systemic urinary tract infection (LUTIS and SUTIS, respectively), and positive urine culture. Readmission to hospital after P-Bx, need for additional antimicrobial therapy, consumption of different antimicrobial agents for prophylaxis and therapy were evaluated. Students t test and chi-square test were used for comparative analyses.

RESULTS

Outcome data were available for 1615 men. Fluoroquinolones-based prophylaxis rate increased from 72.0% in 2010-2014 to 78.6% in 2015-2019. Overall rates of complications increased from 6 to 11.7% including an increase in symptomatic complications from 4.7 to 10.2%, mainly due to an increase in LUTIS. Rates of patients seeking additional medical help in primary care after P-Bx increased from 7.4 to 14.4%; cases requiring post P-Bx antibiotic treatment increased from 6.1 to 9.7%, most of which received fluoroquinolones. Transperineal P-Bx was significantly associated with LUTIS. Following transrectal P-Bx, 2.8% developed febrile infections and 4.0% required hospitalisation. Two men (0.12%) died after transrectal P-Bx due to sepsis.

CONCLUSIONS

The rates of complications after P-Bx tended to increase in time, as well as rates of patients seeking additional medical help in the post-P-Bx period. To reduce the risk of infectious complications and to comply with the principles of antibiotic stewardship, clinicians should switch to the transperineal biopsy route.

Major post-prostate biopsy complications under antibiotic augmentation prophylaxis protocol

Objective:

To identify risk factors for major post-biopsy complications under augmented prophylaxis protocol. The risk factors already described mainly comprise outdated antibiotic prophylaxis protocols.

Material and methods:

This retrospective cohort study included patients that underwent transrectal ultrasound-guided biopsies, from 2011 to 2016. All patients had received antibiotic prophylaxis with ciprofloxacin and gentamicin. Patients were grouped according to the presence or absence of post-biopsy complications. Demographic variables and possible risk factors based on routine clinical assessment were registered. Correlation tests, univariate and multivariate analyses were used to identify risk factors for post-biopsy complications.

Results:

Of the 404 patients that were included, 25 (6.2%) presented 27 post-biopsy complications, distributed as follows: acute urinary retention ( n = 14, 3.5%), infections ( n = 11, 2.7%) and hemorrhage ( n = 2, 0.5%). On univariate analysis, patients who presented complications showed higher body mass index and post-voiding residual volumes. Multivariate analysis identified ethnicity and prostate-specific antigen (PSA) density as possible risk factors for biopsy complications. The presence of bacterial resistance identified by rectal swabs did not correlate with the incidence of complications and infections.

Conclusions:

Non-infectious post-biopsy complications were more frequent than infectious ones in this cohort. Higher post-voiding residual volumes and PSA density, that indicates prostate enlargement, were identified as risk factors and interpreted as secondary to bladder outlet obstruction. The higher body mass index and ethnicity were also identified as risk factors and attributed to the heterogeneity of the patients included.

Level of evidence:

Not applicable for this multicentre audit.