One preoperative dose randomized against 3-day antibiotic prophylaxis for transrectal ultrasonography-guided prostate biopsy

Turkish Urologists' preferences regarding antibiotic prophylaxis for transrectal prostate biopsy

OBJECTIVE

Antibiotic prophylaxis for transrectal prostate biopsy (PB) is very important in preventing infectious complications, and in this study, we aimed to evaluate the antibiotic preferences of Turkish urologist for transrectal PB.

MATERIAL AND METHODS

The survey about PB and antibiotic prophylaxis behaviors was administered to urologists working in Turkey who had previously participated in at least one international and one national congress.

RESULTS

A total of 237 urologists were included in the study. Antibiotic prophylaxis prior to PB was performed by 234 (98.7%) participants. Rectal swabbing prior to PB was not performed by 227 (95.8%) participants. The most common complication associated with PB was prostatitis (63%), followed by urinary tract infection (29%). Only 25.7% of Turkish urologists reported a single dose of antibiotic prophylaxis. Our participants often administered antibiotic prophylaxis for a period of 3, 5, or 7 days (16%, 21.1%, 35.9%, respectively). The most common antibiotic agent preferred for prophylaxis was ciprofloxacin (65%).

CONCLUSION

The biopsy behavior of Turkish urologists was mostly compatible with the literature, but it was revealed that Turkish urologists do not prefer single-dose antibiotic therapy, and their practice patterns regarding the administration of pre-biopsy rectal swabbing are inconsistent with the literature.

Assessment of Guideline Discordance With Antimicrobial Prophylaxis Best Practices for Common Urologic Procedures

IMPORTANCE

The American Urological Association guidelines recommend 24 or fewer hours of antimicrobial prophylaxis for most urologic procedures. Continuing antimicrobial therapy beyond 24 hours may carry more risks than advantages.

OBJECTIVES

To assess guideline discordance of antimicrobial prophylaxis for common urologic endoscopic procedures, and to identify opportunities for improving antimicrobial prescribing through future stewardship interventions.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study conducted manual audits of medical records of 375 patients who underwent 1 of 3 urologic procedures (transurethral resection of bladder tumor [TURBT], transurethral resection of the prostate [TURP], and ureteroscopy [URS]) at 5 Veterans Health Administration facilities from January 1, 2016, to June 30, 2017. Antimicrobial prescribing practices across the national Veterans Health Administration system were assessed using the administrative data for 29 530 records.

MAIN OUTCOMES AND MEASURES

Guideline discordance was assessed in the medical record review. Excessive postprocedural antimicrobial use was measured in the national administrative data analysis.

RESULTS

The medical records of a total of 375 patients were manually reviewed. Among the 375 patients, 366 (97.6%) were male and 9 (2.4%) were female, with a mean (SD) age of 64.2 (10.9) years and a predominantly white race/ethnicity (289 [77.1%]). In addition, 29 530 patient records in the national administrative database were assessed. Among the patient records, 28 938 (98.0%) were male and 592 (2.0%) were female with a mean (SD) age of 69.1 (10.2) years and a predominantly white race/ethnicity (23 297 [78.9%]). Among the manually reviewed medical records, periprocedural or postprocedural antimicrobial prescribing was guideline discordant in 217 patients (57.9%). Postprocedural antimicrobial agents were continued beyond 24 hours in 211 patients (56.3%) and were guideline discordant in 177 patients (83.9%), with a median (interquartile range) duration of 3 (3-5) days of unnecessary antimicrobial therapy. In the analysis of national administrative data, excessive postprocedural antimicrobial agents were prescribed in 10 988 of 29 350 patient records (37.2%), with a median (interquartile range) of 3 (2-6) excess days. For any given facility, a statistically significant correlation was observed in the frequency of postprocedural antimicrobial prescribing between any 2 procedures, indicating that facilities with higher rates of excessive use for 1 procedure also had higher rates for another procedure: TURP and TURBT (ρ = 0.719; 95% CI, 0.603-0.803; P < .001), TURP and URS (ρ = 0.629; 95% CI, 0.476-0.741; P < .001), and TURBT and URS (ρ = 0.813; 95% CI, 0.724-0.873; P < .001).

CONCLUSIONS AND RELEVANCE

In this study of patients who underwent common urologic procedures, the rate of guideline-discordant antimicrobial use was high mostly because of overprescribing of postprocedural antimicrobial agents; future antimicrobial stewardship interventions should target the postprocedural period.

Effect of Augmented Antimicrobial Prophylaxis and Rectal Swab Culture-guided Targeted Prophylaxis on the Risk of Sepsis Following Transrectal Prostate Biopsy

BACKGROUND

Sepsis is a severe complication following transrectal ultrasound-guided prostate biopsy (TRUSPBx). Ciprofloxacin is commonly used for prophylaxis; however, there is an increasing incidence of resistant enteric organisms worldwide.

OBJECTIVE

To investigate the effect of a targeted prophylactic antimicrobial regimen based on rectal swab cultures in reducing the rate of sepsis.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1012 patients were included. Group A (609 patients) received an empirical prophylactic antimicrobial regimen of gentamicin, metronidazole, and ciprofloxacin. Targeted antimicrobial prophylaxis was introduced due to significant ciprofloxacin and gentamicin resistance in patients admitted with sepsis following TRUSPBx. The remaining 403 patients (Group B) had rectal swab cultures performed prior to biopsy. Patients with organisms resistant to ciprofloxacin or gentamicin received a targeted prophylaxis regimen of fosfomycin, amikacin, and metronidazole.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We retrospectively collected and analysed data on sepsis and bacteraemia for all patients as well as data on rectal swab culture, recent foreign travel, and recent antibiotic use for patients in Group B.

RESULTS AND LIMITATIONS

In group A, 12 (2.0%) patients developed sepsis following TRUSPBx, while in group B, 9 (2.2%) patients developed sepsis despite targeted prophylaxis (p=0.82). Patients with ciprofloxacin-resistant rectal flora had a significantly higher rate of sepsis (9.1% vs 1.1%; p=0.003). There was a reduction in patients admitted with bacteraemia and severe sepsis between group A (1.2%) and group B (0.3%) which did not reach statistical significance (p=0.16). In group B, 55 of 403 (13.6%) patients had ciprofloxacin-resistant rectal flora, while 66 (16.4%) had organisms resistant to both ciprofloxacin and gentamicin. A recent foreign travel history was associated with an increased incidence of ciprofloxacin-resistant rectal flora (23.6% vs 10.8%; p=0.007). The main limitations of our study include its retrospective nature and potential under-reporting of less severe infectious complications.

CONCLUSIONS

Rectal swab cultures identify patients with ciprofloxacin-resistant rectal flora who have an eight-fold risk of sepsis. Targeted antimicrobial prophylaxis may not be beneficial in reducing the sepsis rate when compared with augmented empirical prophylaxis. In an era of increasing antimicrobial resistance, transperineal prostate biopsies should be considered to reduce the risk of infective complications.

PATIENT SUMMARY

Performing rectal swab culture prior to transrectal prostate biopsy can help identify patients at risk of developing sepsis despite targeted prophylactic antibiotics.

Antibiotic prophylaxis and its appropriate timing for urological surgical procedures in patients with asymptomatic bacteriuria: A systematic review

Objective

To review the existing literature on when and how to treat patients with asymptomatic bacteriuria (AB) who undergo urological surgery, as uncertainty about this issue persists.

Methods

A systematic review was conducted to compare the different timing of administration of antibiotic prophylaxis in patients with AB undergoing urological surgery. We used predefined inclusion and exclusion criteria, and we also developed a specific quality scale to assess the quality of the papers included.

Results

Nine studies met the inclusion criteria. Of the nine studies included, eight evaluated antibiotic prophylaxis regardless of the presence of AB, as their purpose was to evaluate the effectiveness of antibiotic prophylaxis for urological procedures. Of these, four studies showed a significant reduction in the rate of infections in the intervention group compared with placebo, or with the same antibiotic therapy but using different durations of therapy. Four studies found no significant differences in infectious complications between the intervention and comparison arms. Only one study assessed the duration of antibiotic prophylaxis in patients with AB.

Conclusions

With the available evidence, antibiotic therapy should be considered only for procedures in which studies have shown a clinical benefit in the prevention of infection. It is important to establish the duration and type of treatment for antimicrobial therapy for surgical prophylaxis in patients with AB who are going to receive urological invasive procedures.

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.

Escherichia coli isolates from patients with bacteremic urinary tract infection are genetically distinct from those derived from sepsis following prostate transrectal biopsy

BACKGROUND

Transrectal ultrasound-guided (TRUS) prostate biopsy is a very common procedure that is generally considered relatively safe. However, severe sepsis can occur after TRUS prostate biopsies, with Escherichia coli being the predominant causative agent. A common perception is that the bacteria that cause post-TRUS prostate biopsy infections originate in the urinary tract, but this view has not been adequately tested. Yet other authors believe on the basis of indirect evidence that the pathogens are introduced into the bloodstream by the biopsy needle after passage through the rectal mucosa.

METHODS

We compared E. coli isolates from male patients with bacteremic urinary tract infection (B-UTI) to isolates of patients with post prostate biopsy sepsis (PPBS), in terms of their sequence types, determined by multi-locus sequence typing (MLST) and their virulence markers.

RESULTS

B-UTI isolates were much richer in virulence genes than were PPBS isolates, supporting the hypothesis that E. coli causing PPBS derive directly from the rectum. Sequence type 131 (ST131) strains and related strain from the ST131 were common (>30%) among the E. coli isolates from PPBS patients as well as from B-UTI patients and all these strains expressed extended spectrum beta-lactamases.

CONCLUSIONS

Our finding supports the hypothesis that E. coli causing PPBS derive directly from the rectum, bypassing the urinary tract, and therefore do not require many of the virulence capabilities necessary for an E. coli strain that must persist in the urinary tract. In light of the increasing prevalence of highly resistant E. coli strains, a new approach for prevention of PPBS is urgently required.

The Value of Rectal Cultures in Treatment of Sepsis Following Post-Transrectal Ultrasound-Guided Prostate Biopsy

BACKGROUND

Cases with sepsis after transrectal ultrasound-guided prostate biopsy (TRUSPB) were documented, with special focus on cultures and susceptibility of isolates. We also evaluated the contribution of concomitant rectal cultures to the treatment of selective cases.

MATERIALS AND METHODS

Patients with sepsis after TRUSPB were followed prospectively. Manifestations and risk factors for antimicrobial resistance were documented. Results of urine and blood cultures and antimicrobial susceptibility were recorded for all participating patients. In 40 patients, rectal swab cultures were obtained concomitantly.

RESULTS

Ninety-five patients were consecutively studied. Sepsis symptoms started showing up within 48 h after biopsy in 93% of patients. At least one of the cultures was positive in 72 patients. E. coli grew in 70 cases; isolates were highly resistant: 67% displayed multidrug-resistance. Rectal cultures grew E. coli in 38 cases. In patients with positive E. coli in rectum and in at least one additional culture (blood and/or urine), the antibiogram was identical in all cases but one. Eight cases had negative cultures.

CONCLUSION

The prevalence of antimicrobial resistance among E. coli isolates from patients with TRUSPB sepsis was alarming. Susceptibilities of rectal E. coli isolates used for deescalation of initial empiric treatment in culture-negative TRUSPB sepsis can contribute to the reduction of broad-spectrum antibiotics exposure.

Pre-procedural antibiotics for endoscopic urological procedures: Initial experience in individuals with spinal cord injury and asymptomatic bacteriuria

OBJECTIVE

The objective of this study was to compare the safety, efficacy, quality-of-life impact, and costs of a single dose or a longer course of pre-procedural antibiotics prior to elective endoscopic urological procedures in individuals with spinal cord injury and disorders (SCI/D) and asymptomatic bacteriuria.

DESIGN

A prospective observational study.

SETTING

Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA.

PARTICIPANTS

Sixty persons with SCI/D and asymptomatic bacteriuria scheduled to undergo elective endoscopic urological procedures.

INTERVENTIONS

A single pre-procedural dose of antibiotics vs. a 3-5-day course of pre-procedural antibiotics.

OUTCOME MEASURES

Objective and subjective measures of health, costs, and quality of life.

RESULTS

There were no significant differences in vital signs, leukocytosis, adverse events, and overall satisfaction in individuals who received short-course vs. long-course antibiotics. There was a significant decrease in antibiotic cost (33.1 ± 47.6 vs. 3.6 ± 6.1 US$, P = 0.01) for individuals in the short-course group. In addition, there was greater pre-procedural anxiety (18 vs. 0%, P < 0.05) for individuals who received long-course antibiotics.

CONCLUSION

SCI/D individuals with asymptomatic bacteriuria may be able to safely undergo most endoscopic urological procedures with a single dose of pre-procedural antibiotics. However, further research is required and even appropriate pre-procedural antibiotics may not prevent severe infections.

Emergency hospital admissions attributable to infective complications of prostate biopsy despite appropriate prophylaxis: need for additional infection prevention strategies?

PURPOSE

To report the incidence of emergency admissions attributable to infective complications of transrectal ultrasound-guided prostate biopsy (TGB) and evaluate appropriateness of antimicrobial prophylaxis.

METHODS

Retrospective cross-sectional study of patients undergoing TGB at the North West London Hospitals in 2009-2011. Demographic information of patients who had emergency admission within 30 days of TGB, length of hospital stay and microbiology results were obtained from the hospital's information system, medical records and laboratory information system. All patients received ciprofloxacin and amikacin prophylaxis.

RESULTS

1,419 TGB were performed in 1,276 patients. Forty-eight (3.3 %) patients had emergency admissions. Thirty-three (2.3 %) admissions were due to complications from TGB, while 15 (1 %) were for unrelated reasons. 30/33 (90 %, overall 2.1 %) of admissions from TGB complications were due to confirmed infections or systemic inflammatory response syndrome (SIRS). The rest were admitted with urinary retention. Admission rates due to TGB complications and infection/SIRS remained consistent over the 3 years (2009: TGB complications-2 %, TGB infection/SIRS-1.8 %; 2010: TGB complications-2.4 %, TGB infections/SIRS-2.2 %; 2011: TGB complications-2.6 %, TGB infection/SIRS-2.4 %; P > 0.05). All 11 cases with bacteraemia were caused by ciprofloxacin-resistant but amikacin-susceptible E. coli.

CONCLUSIONS

We observed a consistent rate of emergency admissions for complications following TGB; 90 % of these were due to infections. Ciprofloxacin-resistant but amikacin-sensitive E. coli was isolated in all bacteriologically confirmed infections. These results suggest that infective complications of TGB cannot be altogether eliminated despite appropriate antimicrobial prophylaxis. Therefore, additional strategies for reduction in biopsy-related admissions due to infections have to be considered.

Systematic review of complications of prostate biopsy

CONTEXT

Prostate biopsy is commonly performed for cancer detection and management. The benefits and risks of prostate biopsy are germane to ongoing debates about prostate cancer screening and treatment.

OBJECTIVE

To perform a systematic review of complications from prostate biopsy.

EVIDENCE ACQUISITION

A literature search was performed using PubMed and Embase, supplemented with additional references. Articles were reviewed for data on the following complications: hematuria, rectal bleeding, hematospermia, infection, pain, lower urinary tract symptoms (LUTS), urinary retention, erectile dysfunction, and mortality.

EVIDENCE SYNTHESIS

After biopsy, hematuria and hematospermia are common but typically mild and self-limiting. Severe rectal bleeding is uncommon. Despite antimicrobial prophylaxis, infectious complications are increasing over time and are the most common reason for hospitalization after biopsy. Pain may occur at several stages of prostate biopsy and can be mitigated by anesthetic agents and anxiety-reduction techniques. Up to 25% of men have transient LUTS after biopsy, and <2% have frank urinary retention, with slightly higher rates reported after transperineal template biopsy. Biopsy-related mortality is rare.

CONCLUSIONS

Preparation for biopsy should include antimicrobial prophylaxis and pain management. Prostate biopsy is frequently associated with minor bleeding and urinary symptoms that usually do not require intervention. Infectious complications can be serious, requiring prompt management and continued work into preventative strategies.

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

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

Catastrophic sepsis and hemorrhage following transrectal ultrasound guided prostate biopsies

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