Acute bacterial prostatitis after transrectal ultrasound-guided prostate biopsy: Epidemiological, bacteria and treatment patterns from a 4-year prospective study

Fluoroquinolone resistance in urinary tract infections: Epidemiology, mechanisms of action and management strategies

Background

Fluoroquinolone resistance is an issue of concern amongst physicians worldwide. In urology, fluoroquinolones are often used in the treatment of acute pyelonephritis and prostatitis, as well as infections caused by multidrug-resistant pathogens.

Aims

We aim to highlight the importance of antimicrobial stewardship and the need for ongoing biomedical research to discover novel agents in our losing battle against resistant pathogens.

Materials and methods

In this review, we survey the literature and summarise fluoroquinolone resistance as it pertains to pyelonephritis and prostatitis, as well as alternative treatment strategies and prevention of multidrug resistance.

Results

The rise of fluoroquinolone resistance in bacteria has reduced the available treatment options, often necessitating hospital admission for intravenous antibiotics, which places an additional burden on both patients and the healthcare system. Many countries such as Australia have attempted to limit fluoroquinolone resistance by imposing strict prescribing criteria, though these efforts have not been entirely successful. Solutions to overcome resistance include prevention, combination therapy and the development of novel antimicrobial agents.

Conclusions

Prevention of the proliferation of resistant organisms by antimicrobial stewardship is paramount, and urologists are obliged to be aware of responsible prescribing practices such as referring to local guidelines when prescribing. By reserving fluoroquinolones for infections in which they are truly indicated and by prescribing based on both patient and local environmental factors, we can preserve this effective resource for future use.

Rectal culture-based versus empirical antibiotic prophylaxis to prevent infectious complications in men undergoing transrectal prostate biopsy: a randomized, non-blinded multicenter trial

BACKGROUND

An increase of infections after transrectal prostate biopsy (PB), related to an increasing number of patients with ciprofloxacin-resistant rectal flora, necessitates the exploration of alternatives for the traditionally standard used empirical prophylaxis with ciprofloxacin. We compared infectious complication rates after transrectal PB using empirical ciprofloxacin prophylaxis versus culture-based prophylaxis.

METHODS

In this non-blinded, randomized trial, between April 4, 2018 to July 30, 2021, we enrolled 1538 patients from 11 Dutch hospitals undergoing transrectal PB. After rectal swab collection, patients were 1:1 randomized to receive empirical prophylaxis with oral ciprofloxacin (control group; CG), or culture-based prophylaxis (intervention group; IG). Primary outcome was any infectious complication within seven days post-biopsy. Secondary outcomes were infectious complications within 30 days, and bacteremia and bacteriuria within seven and 30 days post-biopsy. For primary outcome analysis, the Chi-square test stratified for hospital was used. Trial registration number: NCT03228108.

RESULTS

Data from 1288 patients (83.7%) were available for analysis (CG: 652 and IG: 636). Infection rates within seven days post-biopsy were 4.3% (n = 28) (CG) and 2.5% (n = 16) (IG) (p-value: 0.08; reduction: -1.8%; 95% CI -0.004 to 0.040). Ciprofloxacin-resistant bacteria were detected in 15.2% (n = 1288). In the CG, the presence of ciprofloxacin-resistant rectal flora resulted in a 6.2 fold higher risk of early post-biopsy infection.

CONCLUSIONS

Our study supports the use of culture-based prophylaxis to reduce infectious complications after transrectal PB. Despite adequate prophylaxis, post-biopsy infections can still occur. Therefore, culture-based prophylaxis must be weighed against other strategies that could reduce post-biopsy infections.

Pharmacotherapeutic interventions for the treatment of bacterial prostatitis

INTRODUCTION

Bacterial prostatitis, acute or chronic, is one of the most prevalent urogenital infections in men. Its diagnosis requires the application of a careful methodology. Gram-negative bacilli are the most frequent causative agents, and in recent years, an increase in the frequency of multiresistant bacteria has been detected. The choice of the optimal antimicrobial treatment requires the selection of drugs with proven in vitro activity associated with good penetration into the prostatic tissue, especially in chronic forms of infection.

AREAS COVERED

The aim of this article is to summarize the current evidence regarding the pathogenesis, etiology, empirical and definitive antimicrobial therapy, and new pharmacotherapeutic interventions to improve the prognosis of bacterial acute or chronic prostatitis.

EXPERT OPINION

Bacterial prostatitis requires the application of an accurate diagnostic protocol to identify the causative agent and establish the optimal antimicrobial treatment. The structural and biochemical characteristics of prostatic tissue result in poor penetration of antimicrobials; therefore, in the choice of treatment, it is essential to select agents with proven antimicrobial activity and pharmacokinetic characteristics that ensure good and sustained concentrations in this area. Patients with chronic forms of infection require prolonged treatment, and relapses of the infectious process are frequent.

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.

A population-based analysis of risk factors and outcomes of prostatic abscess

BACKGROUND

Prostate abscess is a severe complication of acute bacterial prostatitis. To date, a population-based analysis of risk factors and outcomes of prostatic abscess has not been performed.

METHODS

Using the National Inpatient Sample from 2010 to 2015, we identified rates of prostatic abscess among non-elective hospitalizations for acute prostatitis. Significant Elixhauser comorbidities and risk factors were analyzed using survey-weighted logistic regression. Additional survey-weighted regression models were constructed to analyze sepsis, in-hospital mortality, length of hospital stay (LOS), and total hospital charges.

RESULTS

A weighted total of 126,103 hospitalizations for acute prostatitis was identified, with 6,775 (5.4%) hospitalizations with prostatic abscess. Numerous risk factors for prostatic abscess were identified, with a history of prostate biopsy (adjusted OR: 5.7; p < 0.001), complicated diabetes mellitus (adjusted OR: 3.23, p < 0.001), and urethral stricture (adjusted OR: 3.15; p < 0.001) having the greatest magnitude of developing abscess. Moreover, those diagnosed with prostatic abscess had increased odds of sepsis (adjusted OR: 1.71, p < 0.001), in-hospital mortality (adjusted OR: 2.73, p < 0.001), LOS (adjusted Incidence Rate Ratio: 1.86, p < 0.001), and total hospital charges (adjusted Ratio: 2.06, p < 0.001).

CONCLUSIONS

Numerous risk factors were associated with the development of prostatic abscess, with those diagnosed experiencing greater odds of sepsis, in-hospital mortality, longer LOS, and greater hospital charges. Ultimately, better understanding of risk factors associated with this condition will enable clinicians to identify patients at high risk, thereby expediting and tailoring management.

[Acute prostatitis associated with noncancerous prostate at the Lubumbashi University Clinics: epidemioclinical and therapeutic features]

Introduction

les prostatites aiguës sont une entité fréquente en urologie. L'objectif de cette étude était d'analyser les aspects épidémio-cliniques et thérapeutiques des prostatites aiguës sur des prostates non tumorales aux Cliniques Universitaires de Lubumbashi.

Méthodes

il s'est agi d'une étude descriptive transversale et rétrospective rapportant une série de 25 patients souffrant de prostatite aiguë documentée et pris en charge aux Cliniques Universitaires de Lubumbashi durant une période de quatre ans soit de 2015 à 2018. Tous les patients porteurs de tumeurs prostatiques ont été exclus de notre étude. Les données ont été recueillies sur base d´une fiche d´enquête reprenant différents paramètres d´étude répartis en 3 catégories à savoir les données épidémiologiques comprenant l´âge, la période d´étude, la résidence, les données cliniques reprenant les signes subjectifs, les signes objectifs, l´état général, les éléments du toucher rectal ainsi que les données paracliniques réparties en laboratoires et imagerie.

Résultats

la prostatite aiguë sur prostate non tumorale a représenté 1,27% de l´ensemble de la pathologie chirurgicale et 7,66% en urologie. La tranche d´âge la plus touchée était celle de 19 à 37 ans avec 64% des cas, l´âge moyen est de 33,16±2,4 ans. Dix-sept patients (68%) étaient suivis en ambulatoires et 8 (32%) en hospitalisation. Sur le plan clinique, la fièvre au-delà de 38,5°celsius était retrouvée chez 15 patients (60%), la dysurie chez 11 patients (44%), rétention aiguë d´urine chez 3 patients (12%), les brulures mictionnelles chez 8 patients (32%), syndrome douloureux chez 21 patients (84%), la sensibilité prostatique au toucher rectal chez 18 patients (72%). Sur le plan de l´imagerie, l´échographie a été le seul examen réalisé et ce, chez 16 patients (64%). Sur le plan biologique, le bilan inflammatoire était quasi-systématique chez tous nos patients (100%) comprenant la NFS, la VS, la CRP; l´hémoculture réalisée chez 4 patients (16%) parmi lesquels 3 étaient positives. Tous nos patients avaient réalisé l´examen cytobactériologique des urines ou des sécrétions prostatiques recueillies par un massage prostatique. La culture d´urine était stérile chez 6 patients (24%) et positive chez 19 patients (76%) avec Escherichia coli comme germe le plus retrouvé, chez 16 patients sur les 19 (84,21%). Tous nos patients ont été mis sous anti-inflammatoire en intra-rectale et les fluoroquinolones ont été les antibiotiques les plus utilisés dans notre série chez 18 patients (64%) parmi lesquels 12 en monothérapie. Six cas sur les 25 (24%) étaient associés à une orchi-épidydimite. La durée de traitement allait de 2 semaines à 4 semaines avec comme critère d´arrêt de traitement soit la stérilisation des sécrétions ou des urines soit la disparition de la leucocyturie. Ainsi, sur les 19 patients avec culture positive à l´admission, 14 ont réalisé une deuxième culture (73,68%) à 2 semaines de traitement parmi lesquels 3 (12%) étaient encore positives et ont dû réaliser une troisième culture 4 semaines après le début de traitement. L´évolution était bonne chez 22 patients (88%) avec une rémission complète des signes cliniques et biologiques et 3 cas (12%) ont évolué vers une persistance des signes et un passage à la chronicité, aucun cas d´évolution vers un abcès prostatique.

Conclusion

la prostatite aiguë sur prostate non tumorale reste une entité nosologique urologique très préoccupante dont la prise en charge doit être rigoureuse d´autant plus que la population à risque est celle en période d´intense activité sexuelle. L´usage de l´échographie endorectale, la proscription du massage prostatique doivent s´intégrer dans la prise en charge aux cliniques universitaires de Lubumbashi.

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.

Carbapenem sparing in the management of post-transrectal prostate biopsy bacteraemia

BACKGROUND

Sepsis following transrectal ultrasound (TRUS)-guided prostate biopsy is a major complication. With the emergence of multidrug-resistant organisms, empirical use of carbapenem antibiotics has been increasing. This study, conducted in the Illawarra Shoalhaven Local Health District (ISLHD), Australia, quantifies how much we can spare carbapenem use.

METHODS

A retrospective audit of patients who underwent TRUS prostate biopsy and were admitted post-operatively with proven bacteraemia between January 2007 and April 2016.

RESULTS

Of 2719 TRUS procedures, 50 (1.84%) cases had bacteraemia. The most common isolate was Escherichia coli in 44 of 50 (88%) of which six of 50 (12%) were extended-spectrum beta-lactamase (ESBL)-producing. Sixteen different empirical antimicrobial regimens were used, to which 42 of 50 (84%) of isolates were susceptible. Eight (16%) isolates were resistant to the chosen empiric combination, with five switched over to appropriate treatment once antimicrobial sensitivity results became available. Empirical carbapenem was utilized in 12 of 50 (24%) patients with only two of the ESBL isolates covered. A further 10 of 50 patients received carbapenems during their admission. Carbapenems could have been avoided in 18 of 22 (82%). A total of 86% of organisms (n = 43) were susceptible to the combination of amoxicillin-clavulanate and gentamicin.

CONCLUSION

Although the rates of bacteraemia with ESBL-producing organisms post-TRUS biopsy are increasing, use of carbapenem-free combination antimicrobials as empirical therapy appears to be safe and effective in our setting. Clinicians can utilize local resistance patterns to inform targeted and appropriate therapy for septic patients.

Surgical and functional outcomes of radical retropubic prostatectomy after biopsy-related acute prostatitis

Introduction

The present study sought to evaluate the intraoperative, postoperative, oncologic, and functional results of radical prostatectomy (RP) after previous prostatitis.

Material and methods

We retrospectively reviewed available data of 320 patients undergoing open radical prostatectomy between 2010 and 2016. From this group, 23 (7.2%) had previous transrectal prostate biopsy-related acute prostatitis history. The perioperative and postoperative data were statistically compared between Group 1 (with previous prostatitis) and Group 2 (without previous prostatitis). The variables that were evaluated included demographic characteristics, perioperative complications, functional and oncological outcomes.

Results

In Group 1, the operative time, hospitalization and bladder catheterization time was statistically increased by 40 min, 1.9 days, and 2.5 days, respectively (p <0.001, p <0.001, p = 0.02). The positive margin rate was not significantly different between the two groups (p = 0 .64). The rate of complications with Clavien >2 increased in Group 1 (G1 26% vs. G2 12%) (p = 0.02). Neurovascular bundle preservation ratio was statistically higher in Group 2 (G1 46.5% vs. G2 76.9%) (p = 0.02). The functional results were similar for both groups 12 months after surgery.

Conclusions

Previously, transrectal prostate biopsy-related acute prostatitis history was associated with a higher operative time, hospitalization and bladder catheterization time, and perioperative complications during RP. According to our study, although the neurovascular bundle preservation is technically more difficult, potency and urinary continence rate was not affected by previous prostatitis history. However, further studies are still required to confirm these results.

Efficacy of combined prophylactic use of levofloxacin and isepamicin for transrectal prostate needle biopsy: A retrospective single-center study

PURPOSE

To assess the efficacy of a combined regimen of levofloxacin (LVFX) plus isepamicin (ISP) as prophylaxis for transrectal ultrasound-guided needle biopsy of the prostate (TRUSP-Bx).

MATERIALS AND METHODS

Overall, 562 patients undergoing TRUSP-Bx were included in the present study. All patients were administered a single-dose of oral LVFX (500 mg) in the morning and intravenous ISP (400 mg) 60 min before biopsy. All biopsies were performed via TRUSP-Bx with an 18-gauge needle, and 12-core specimens were routinely obtained. Before initiating antibiotic treatment, urine and blood bacterial cultures were tested to determine the causative microorganisms in the patients with acute bacterial prostatitis.

RESULTS

Acute bacterial prostatitis developed in three (0.53%) participants. The incidence rates of acute bacterial prostatitis in the low- and high-risk groups were 0.79% and 0.46%, respectively. These patients showed clinical symptoms of acute bacterial prostatitis 12-24 h after their biopsy. Escherichia coli (E. coli) was isolated in the urine or bladder cultures of all of patients. All three isolates were determined to be LVFX-resistant E. coli, although they had good sensitivity to aminoglycosides, cephalosporins, and carbapenems. All patients were administered antibiotic treatment (cephalosporin or carbapenem) immediately and were treated successfully with no evidence of further disease progression.

CONCLUSION

Antibiotic prophylaxis with LVFX plus ISP was effective, resulting in a lower incidence of acute bacterial prostatitis after TRUSP-Bx in both low- and high-risk patients.

A significant percentage of patients with transrectal biopsy-related infections have positive blood cultures but negative urine cultures. A literature review and meta-analysis

BACKGROUND

Infectious complications after transrectal prostate biopsy are rare. Nevertheless, since these are frequent procedures, the burden of infectious complications is high. Considering the increasing antimicrobial resistance, microbiological confirmation is important to guide antimicrobial therapy.

METHODS

We reviewed PubMed for original studies providing concurrent urine and blood culture data in symptomatic patients with transrectal biopsy-related infectious complications. We performed a proportions meta-analysis (with MedCalc) and calculated the pooled yield of urine and blood cultures and the pooled discordance rate between urine and blood cultures.

RESULTS

Our review identified 41 studies, involving 852 patients with infectious complications after transrectal prostate biopsy and sufficient data to calculate discordance. The pooled yield of urine cultures was 64.6% (95% CI: 56.2-72.3%, I² 83%), the pooled yield of blood cultures was 43% (95% CI: 36.5-49.7%, I² 74%) and the pooled discordance rate was 14% (95% CI: 10.6-17.8%, I² 53%). In subgroup analyses the pooled discordance was; 19.6% (95% CI: 11.8-28.9%, I² 31%) in 113 patients presenting within 2 calendar days after the biopsy and 11.2% (95% CI: 4.5-20%, I² 47%) in 143 patients presenting with fever and symptoms of lower urinary tract symptoms. The statistical and methodological heterogeneity of included studies was high.

CONCLUSION

Obtaining blood cultures is reasonable in all patients presenting with systemic symptoms suggestive of infection after a transrectal prostate biopsy. Blood cultures can provide additional microbiological data in about 1 of 7 patients with post-biopsy infectious complications. Prospective studies are needed to validate these results.

Rectal culture-directed antibiotic prophylaxis before transrectal prostate biopsy: Reduced infectious complications and healthcare costs

BACKGROUND

Transrectal ultrasound-guided prostate biopsy (TUPB) is associated with infectious complications (ICs), which are related to a greater prevalence of ciprofloxacin-resistant bacteria (CRB) in rectal flora. We examined the ICs that occurred in 2 groups: A guided antibiotic prophylaxis (GP) group and an empiric prophylaxis (EP) group. We assessed the financial impact of GP.

MATERIAL AND METHODS

The GP group was studied prospectively (June 2013 to July 2014). We collected rectal cultures (RCs) before the TUPB, which were seeded on selective media with ciprofloxacin to determine the presence of CRB. The patients with sensitive bacteria were administered ciprofloxacin. Patients with resistant bacteria were administered GP according to the RC antibiogram. The EP group was studied retrospectively (January 2011 to June 2009). RCs were not performed, and all patients were treated with ciprofloxacin as prophylaxis. The ICs in both groups were recorded during a period no longer than 30 days following TUPB (electronic medical history).

RESULTS

Three hundred patients underwent TUPB, 145 underwent GP, and 155 underwent EP. In the GP group, 23 patients (15.86%) presented CRB in the RCs. Only one patient (0.7%) experienced a UTI. In the EP group, 26 patients (16.8%) experienced multiple ICs (including 2 cases of sepsis) (P<.005). The estimated total cost, including the management of the ICs, was €57,076 with EP versus €4802.33 with GP. The average cost per patient with EP was €368.23 versus €33.11 with GP. GP achieved an estimated total savings of €52,273.67. Six patients had to undergo GP to prevent an IC.

CONCLUSIONS

GP is associated with a marked decrease in the incidence of ICs caused by CRB and reduced healthcare costs.

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.

New Bacterial Infection in the Prostate after Transrectal Prostate Biopsy

BACKGROUND

The prostate is prone to infections. Hypothetically, bacteria can be inoculated into the prostate during a transrectal prostate biopsy (TRPB) and progress into chronic bacterial prostatitis. Therefore, we examined new bacterial infections in biopsied prostates after TRPB and whether they affect clinical characteristics in the biopsied patients.

METHODS

Of men whose prostate cultures have been taken prior to TRPB, 105 men with bacteria-free benign prostate pathology underwent an additional repeated prostate culture within a year after TRPB.

RESULTS

Twenty out of 105 men (19.05%) acquired new bacteria in their naïve prostates after TRPB. Except for one single case of Escherichia coli infection, 19 men had acquired gram-positive bacteria species. Between the culture-positive and negative groups, there were no significant differences in age, serum prostate-specific antigen (PSA) level, white blood cell (WBC) counts in expressed prostatic secretion (EPS), prostate volume, symptom severities in Korean version of the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) questionnaire, and patient-specific risk factors for biopsy associated infectious complications. Additionally, the TRPB procedure increased the WBC counts in post-biopsy EPS (P = 0.031, McNemar test), but did not increase the serum PSA level and symptoms of NIH-CPSI in 20 men who acquired new bacteria after TRPB.

CONCLUSION

The TRPB procedure was significantly associated with acquiring new bacterial infections in the biopsied prostate, but these localized bacteria did not affect patients' serum PSA level and symptoms after biopsy.

Infection prevention and control in ultrasound - best practice recommendations from the European Society of Radiology Ultrasound Working Group

OBJECTIVES

The objective of these recommendations is to highlight the importance of infection prevention and control in ultrasound (US), including diagnostic and interventional settings.

METHODS

Review of available publications and discussion within a multidisciplinary group consistent of radiologists and microbiologists, in consultation with European patient and industry representatives.

RECOMMENDATIONS

Good basic hygiene standards are essential. All US equipment must be approved prior to first use, including hand held devices. Any equipment in direct patient contact must be cleaned and disinfected prior to first use and after every examination. Regular deep cleaning of the entire US machine and environment should be undertaken. Faulty transducers should not be used. As outlined in presented flowcharts, low level disinfection is sufficient for standard US on intact skin. For all other minor and major interventional procedures as well as all endo-cavity US, high level disinfection is mandatory. Dedicated transducer covers must be used when transducers are in contact with mucous membranes or body fluids and sterile gel should be used inside and outside covers.

CONCLUSIONS

Good standards of basic hygiene and thorough decontamination of all US equipment as well as appropriate use of US gel and transducer covers are essential to keep patients safe.

MAIN MESSAGES

• Transducers must be cleaned/disinfected before first use and after every examination. • Low level disinfection is sufficient for standard US on intact skin. • High level disinfection is mandatory for endo-cavity US and all interventions. • Dedicated transducer covers must be used for endo-cavity US and all interventions. • Sterile gel should be used for all endo-cavity US and all interventions.

Comprehensive overview of prostatitis

Prostatitis is a common urinary tract syndrome that many doctors find problematic to treat effectively. It is the third most commonly found urinary tract disease in men after prostate cancer and Benign Prostate Hyperplasia (BPH). Prostatitis may account for 25% of all office visits made to the urological clinics complaining about the genital and urinary systems all over the world. In the present study, we classified prostatitis and comprehensively elaborated the etiology, pathogenesis, diagnosis, and treatment of acute bacterial prostatitis (category I), chronic bacterial prostatitis (category II), chronic pelvic pain syndrome (CPPS) (category III), and asymptomatic prostatitis (category IV). In addition, we also tried to get some insights about other types of prostatitis-like fungal, viral and gonococcal prostatitis. The aim of this review is to present the detail current perspective of prostatitis in a single review. To the best of our knowledge currently, there is not a single comprehensive review, which can completely elaborate this important topic in an effective way. Furthermore, this review will provide a solid platform to conduct future studies on different aspects such as risk factors, mechanism of pathogenesis, proper diagnosis, and rational treatment plans for fungal, viral, and gonococcal prostatitis.

[Ecology and fluoroquinolon resistance profiles in febrile urinary tract infections (FUTI) after prostate needle biopsy: A retrospective study in 466 biopsies]

OBJECTIVE

The biopsies of prostate are the reference examination to assert the diagnosis of prostate cancer. Even if the urinary infectious complications are rare thanks to the systematic oral antibiotic prophylaxis, they may still be serious. The SPILF (Society of Infectious Pathology and French language) published in 2014, an important increase of the resistances in fluoroquinolones for Escherichia coli (3 to 25%), whereas this is the most bacterium frequently found in the urinary infections (70-80%). The objectives of this study were to estimate the indicence of the febrile urinary tract infections after prostate needle biopsy and to define the ecology and the profile of E. coli's resistance.

METHODS

A total of 466 transrectal ultrasound-guided needle prostate biopsy were included in the study from 2012 to 2015. All the patients were taken care according to the recommendations of the AFU (Ouzzane et al., 2011). We estimated, for all the inclusive patients, if they had presented a clinic sign of urinary infection like fever or burning which suggestive of an urinary infection, and having a urines and blood culture, in the next 30 days the realization of the medical exam.

RESULTS

Among 466 realized biopsies, seven patients developed a febril urinary tract infection (1.5%) [prostatitis (n=6), orchitis (n=1)]. Five infections to E. coli were identified; two were resistant for fluoroquinolones (40%). No germ was able to be identified for two patients.

CONCLUSION

The infectious complications post-biopsy of prostate are rare (1.5%). E. coli is the germ most frequently identified with 40% of resistance with fluoroquinolones.

LEVEL OF EVIDENCE

4.

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.

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

The real practice of antibiotic prophylaxis for prostate biopsy in Korea where the prevalence of quinolone-resistant Escherichia coli is high

Purpose

Transrectal ultrasonography-guided prostate biopsy (TRUS-Bx) is an essential procedure for diagnosing prostate cancer. The American Urological Association (AUA) Guideline recommends fluoroquinolone alone for 1 day during TRUS-Bx. However, this recommendation may not be appropriate in regions where the prevalence of quinolone-resistant Escherichia coli is high. We investigated the real practice of antibiotic prophylaxis for TRUS-Bx in Korea.

Materials and Methods

A total of 77 hospitals performing TRUS-Bx were identified and an e-mail was sent to the Urology Department of those hospitals. The questions in the e-mail included the choice of antibiotics before and after the procedure and the duration of antibiotic therapy after TRUS-Bx.

Results

A total of 54 hospitals (70.0%) responded to the e-mail. Before TRUS-Bx, all hospitals administered intravenous antibiotic prophylaxis. The percentage of hospitals that used quinolone, cephalosporin, and aminoglycoside alone was 48.1%, 20.4%, and 9.3%, respectively. The percentage of hospitals that used two or more antibiotics was 22.2%. After biopsy, all 54 hospitals prescribed oral antibiotics. The percentage of hospitals that prescribed quinolone alone, cephalosporin alone, or a combination of two or more antibiotics was 77.8%, 20.4%, and 1.8%, respectively. The duration of antibiotic use was more than 3 days in most hospitals (79.6%). Only four hospitals (7.4%) followed the AUA recommendation of a 1-day regimen.

Conclusions

The AUA recommendation was not followed by most hospitals in Korea. This clinical behavior might reflect the high quinolone resistance rate in Korea, and further studies on the most efficient prophylactic antibiotics after TRUS-Bx in Korea are warranted.

Impact of benign prostatic hyperplasia pharmacological treatment on transrectal prostate biopsy adverse effects

Background. Benign prostatic hyperplasia (BPH) pharmacological treatment may promote a decrease in prostate vascularization and bladder neck relaxation with theoretical improvement in prostate biopsy morbidity, though never explored in the literature. Methods. Among 242 consecutive unselected patients who underwent prostate biopsy, after excluding those with history of prostate biopsy/surgery or using medications not for BPH, we studied 190 patients. On the 15th day after procedure patients were questioned about symptoms lasting over a week and classified according to pharmacological BPH treatment. Results. Thirty-three patients (17%) were using alpha-blocker exclusively, five (3%) 5-alpha-reductase inhibitor exclusively, twelve (6%) patients used both medications, and 140 (74%) patients used none. There was no difference in regard to age among groups (P = 0.5). Postbiopsy adverse effects occurred as follows: hematuria 96 (50%), hematospermia 53 (28%), hematochezia 22 (12%), urethrorrhagia 19 (10%), fever 5 (3%), and pain 20 (10%). There was a significant negative correlation between postbiopsy hematuria and BPH pharmacological treatment with stronger correlation for combined use of 5-alpha-reductase inhibitor and alpha-blocker over 6 months (P = 0.0027). Conclusion. BPH pharmacological treatment, mainly combined for at least 6 months seems to protect against prostate biopsy adverse effects. Future studies are necessary to confirm our novel results.

Prostatic inflammation enhances basal-to-luminal differentiation and accelerates initiation of prostate cancer with a basal cell origin

Chronic inflammation has been shown to promote the initiation and progression of diverse malignancies by inducing genetic and epigenetic alterations. In this study, we investigate an alternative mechanism through which inflammation promotes the initiation of prostate cancer. Adult murine prostate epithelia are composed predominantly of basal and luminal cells. Previous studies revealed that the two lineages are largely self-sustained when residing in their native microenvironment. To interrogate whether tissue inflammation alters the differentiation program of basal cells, we conducted lineage tracing of basal cells using a K14-CreER;mTmG model in concert with a murine model of prostatitis induced by infection from the uropathogenic bacteria CP9. We show that acute prostatitis causes tissue damage and creates a tissue microenvironment that induces the differentiation of basal cells into luminal cells, an alteration that rarely occurs under normal physiological conditions. Previously we showed that a mouse model with prostate basal cell-specific deletion of Phosphatase and tensin homolog (K14-CreER;Pten(fl/fl)) develops prostate cancer with a long latency, because disease initiation in this model requires and is limited by the differentiation of transformation-resistant basal cells into transformation-competent luminal cells. Here, we show that CP9-induced prostatitis significantly accelerates the initiation of prostatic intraepithelial neoplasia in this model. Our results demonstrate that inflammation results in a tissue microenvironment that alters the normal prostate epithelial cell differentiation program and that through this cellular process inflammation accelerates the initiation of prostate cancer with a basal cell origin.