Rectal Culture-Guided Targeted Antimicrobial Prophylaxis Reduces the Incidence of Post-Operative Infectious Complications in Men at High Risk for Infections Submitted to Transrectal Ultrasound Prostate Biopsy - Results of a Cross-Sectional Study

Fluoroquinolone-resistant Escherichia coli among the rectal flora is the predominant risk factor for severe infection after transrectal ultrasound-guided prostate biopsy: a prospective observational study

BACKGROUND

Infection of the prostate gland following biopsy, usually with Escherichia coli, is a common complication, despite the use of antimicrobial prophylaxis. A fluoroquinolone (FQ) is commonly prescribed as prophylaxis. Worryingly, the rate of fluoroquinolone-resistant (FQ-R) E. coli species has been shown to be increasing.

OBJECTIVE

This study aimed to identify risk factors associated with infection after transrectal ultrasound-guided prostate biopsy (TRUS-Bx).

METHODS

This was a prospective study on patients undergoing TRUS-Bx in southeast Sweden. Prebiopsy rectal and urine cultures were obtained, and antimicrobial susceptibility and risk-group stratification were determined. Multivariate analyses were performed to identify independent risk factors for post-biopsy urinary tract infection (UTI) and FQ-R E. coli in the rectal flora.

RESULTS

In all, 283 patients were included, of whom 18 (6.4%) developed post-TRUS-Bx UTIs. Of these, 10 (3.5%) had an UTI without systemic inflammatory response syndrome (SIRS) and 8 (2.8%) had a UTI with SIRS. Being in the medium- or high-risk groups of infectious complications was not an independent risk factor for UTI with SIRS after TRUS-Bx, but low-level FQ-resistance (minimum inhibitory concentration (MIC): 0.125-0.25 mg/L) or FQ-resistance (MIC > 0.5 mg/L) among E. coli in the faecal flora was. Risk for SIRS increased in parallel with increasing degrees of FQ-resistance. Significant risk factor for harbouring FQ-R E.coli was travelling outside Europe within the previous 12 months.

CONCLUSION

The predominant risk factor for UTI with SIRS after TRUS-Bx was FQ-R E. coli among the faecal flora. The difficulty in identifying this type of risk factor demonstrates a need for studies on the development of a general approach either with rectal swab culture for targeted prophylaxis, or prior rectal preparation with a bactericidal agent such as povidone-iodine before TRUS-Bx to reduce the risk of FQ-R E. coli-related infection.

Therapeutic failures of targeted antibiotic prophylaxis in urology

Targeted antibiotic prophylaxis (TAP) is required for patients with positive urine culture before urological surgery. Our aim was to determine the efficacy of TAP. This was a prospective single-center study performed in a urology department. All patients who underwent a programmed surgery were included. Urine culture was obtained before surgery requiring a prophylaxis: in the case of sterile urines, antibiotics were used in accordance with national recommendations; for positive urine culture, a TAP was used in accordance with susceptibility testing. The drugs were administered for 2 days before surgery until withdrawal of bladder catheter. The occurrence of healthcare-associated infections was registered until day 30 after surgery. Two hundred three patients were included for 8 non-consecutive weeks in 2020, among whom fifteen were lost of sight before day 30. Among the remaining 188 patients, most frequent surgeries were 75 prostatic diseases (40%), 50 endo-ureteral surgeries for JJ stent insertion (27%), and 23 bladder cancers (12%). One hundred forty-eight (79%) patients required a urine culture before procedure; 142/148 (96%) urine cultures were performed, leading to 74 TAP. The main isolated bacteria were 48 Enterobacteriaceae and 8 Enterococcus spp. TAP was cotrimoxazole (n = 30), aminoglycosides (n = 11), amoxicillin (n = 9), fluoroquinolones (n = 7), and others (n = 17). The rate of healthcare-associated infections was 14.8% (11/74), including six microbiologically documented antibiotic failures. The rate of healthcare-associated infection after urological surgery using TAP was high, implying to discuss the choice and the dosage of the antibiotic molecules.

Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography-guided prostate biopsy

OBJECTIVES

To evaluate the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections following transrectal ultrasonography-guided prostate biopsy.

METHODS

In this prospective interventional study, patients aged between 40 and 70 years with clinical indications for transrectal ultrasonography-guided prostate biopsy were enrolled. Consecutive patients who received intraprostatic injection of amikacin coupled with oral ciprofloxacin were compared with historical controls receiving only prophylactic oral fluoroquinolones prior to biopsy. Patients were followed for 7 days after biopsy for signs and symptoms of infection.

RESULTS

A total of 210 patients were included in this study (mean age 65.7 ± 7.8 years). Among patients without intraprostatic injection, nine (8.6%) developed infectious complications (lower urinary tract infection in seven patients, and prostatitis in two), which led to hospitalization in six patients (5.7%). None of the patients who received intraprostatic antibiotic injection developed infectious complications. The difference in the incidence of post-transrectal ultrasonography-guided biopsy infections between the two groups was statistically significant (P = 0.003).

CONCLUSION

Local intraprostatic antibiotic injection during transrectal ultrasonography-guided prostate biopsy adjuvant to oral fluoroquinolones can significantly reduce the rate of post-biopsy infectious complications.

Multicentre clinical evaluation of the safety and performance of a simple transperineal access system for prostate biopsies for suspected prostate cancer: The CAMbridge PROstate Biopsy DevicE (CamPROBE) study

Objectives:

To report the prospective multicentre clinical evaluation of a first-in-man disposable device, Cambridge Prostate Biopsy Device, to undertake local anaesthetic outpatient transperineal prostate biopsies.

Material and methods:

Disposable single-use Cambridge Prostate Biopsy devices were manufactured based on a previous prototype. The lead site developed a user training course and disseminated the method to other sites. The Cambridge Prostate Biopsy Device (CamPROBE) was offered as an alternative to transrectal ultrasound guided biopsy to men due for a biopsy as part of their clinical management. Data on safety (infections and device performance), clinical utility, patient reported experience, biopsy quality and cancer detection were collected. Procedure time and local anaesthetic use was recorded in the lead site. The study was funded by a United Kingdom National Institute for Health Research (NIHR) i4i product development award.

Results:

A total of 40 patients were recruited (median age 69 y) across six sites; five sites were new to the procedure. Overall, 19/40 were first prostate biopsies and 21/40 repeat procedures. Both image-targeted and systematic biopsy cores taken. There were no infections, device deficiencies or safety issues reported. The procedure was well tolerated with excellent patient-reported perception and low pain scores (median of 3, scale 0–10). Histopathology quality was good and the overall cancer diagnosis rate (first diagnostic procedures) was 68% (13/19) and for significant cancers (⩾ histological Grade Group 2), 47% (9/19). In the lead centre (most experienced), median procedure time was 25 minutes, and median local anaesthetic use 11 ml (n=17).

Conclusions:

Data from this device evaluation study demonstrate that the United Kingdom-developed Cambridge Prostate Biopsy Device/method for transperineal biopsies is safe, transferable and maintains high diagnostic yields. The procedure is well tolerated by patients, suited to the local anaesthetic outpatient setting and could directly replace transrectal ultrasound guided biopsy.

Level of evidence:

Level III

Update on techniques to prevent infections associated with prostate needle biopsy

PURPOSE OF REVIEW

Postbiopsy infections (PBIs) are among the most common complications associated with transrectal ultrasound-guided prostate biopsy (TRUSPB). This article discusses the pathogenesis of TRUSPB-associated infectious complications and reviews the most recent findings on techniques to prevent PBIs.

RECENT FINDINGS

Risk stratification is a powerful tool for identifying TRUSPB candidates whom warrant additional preventive measures. Bowel preparation with povidone-iodine-based enemas and needle disinfection with formalin solution are simple and attractive strategies, but their effectiveness needs to be thoroughly assessed. Antibiotic prophylaxis represents the mainstay for the prevention of PBIs: the prophylactic regimen must respect the principles of antimicrobial stewardship, and local antibiotic resistance patterns among uropathogens should always be considered. Augmented and targeted antibiotic prophylaxes are powerful options, but their role in current clinical practice has yet to be clarified. The transperineal approach has shown a near-zero rate of PBIs, and should therefore be considered for the highest-risk patients.

SUMMARY

Several procedures have been introduced to prevent TRUSPB-related infectious complication, but their utility and applicability in the clinical practice has yet to be elucidated. More robust evidence based on randomized control trials is needed to establish the efficacy of these tools in improving patient outcomes.

Targeted Antimicrobial Prophylaxis Does Not Always Prevent Sepsis after Transrectal Prostate Biopsy

PURPOSE

We compared the effectiveness of targeted prophylaxis to augmented empirical prophylaxis and single agent empirical prophylaxis to prevent sepsis after transrectal prostate biopsy.

MATERIALS AND METHODS

We retrospectively reviewed the records of transrectal prostate biopsies performed during 3 years at 13 Southern California Kaiser Permanente® departments of urology. Targeted prophylaxis was guided by rectal culture bacterial susceptibility for use of a single prophylactic antibiotic while for empirical prophylaxis 1 antibiotic (single agent empirical prophylaxis) or multiple antibiotics (augmented empirical prophylaxis) were given according to the usual practice of the urologist. Sepsis was the primary outcome analyzed.

RESULTS

We reviewed 15,236 transrectal prostate biopsy cases. Targeted prophylaxis, single agent empirical prophylaxis and augmented empirical prophylaxis were administered in 26%, 58% and 16% of cases, respectively. The overall incidence of post-biopsy sepsis was 0.64%. On multivariable analysis there was no significant difference in the rate of post-biopsy sepsis after targeted prophylaxis compared to empirical prophylaxis (single agent and augmented empirical prophylaxis together) (OR 0.86, 95% CI 0.53-1.41, p = 0.561). However, on subanalysis augmented empirical prophylaxis showed a significantly lower incidence of sepsis than single agent empirical or targeted prophylaxis (OR 0.35, 95% CI 0.16-0.76, p = 0.008). Based on blood and urine cultures 38% of the patients with sepsis after transrectal prostate biopsy had been given the correct prophylactic antibiotic prior to biopsy. On multivariable analysis Asian/Pacific Islander or Hispanic/Latino ethnicity was associated with a higher incidence of harboring fluoroquinolone resistant bacteria on rectal swab cultures.

CONCLUSIONS

This large retrospective study showed that augmented empirical prophylaxis was statistically superior to single agent empirical and targeted prophylaxis. Sepsis developed in a significant number of patients despite being given a prophylactic antibiotic to which the sepsis causing bacteria were sensitive.

Rectal E. coli above ciprofloxacin ECOFF associate with infectious complications following prostate biopsy

Transrectal prostate biopsies carry the risk of infection. By using non-selective culture plates, instead of commonly used ciprofloxacin (CIP)-containing plates, we analyzed the association between Escherichia coli CIP minimal inhibitory concentration (MIC) and post-biopsy infectious complications. A pre-biopsy rectal swab was taken from 207 consecutive men, scheduled for transrectal 12-core prostate biopsy with CIP 750 mg as the mostly used prophylaxis. CIP MIC of rectal Gram-negative bacilli was determined from a chromogenic agar. Rectal E. coli were categorized to resistant (R) and intermediate (I) isolates together (R + I, MIC > 0.25 mg/l) and to sensitive (S, MIC ≤ 0.25 mg/l) using EUCAST clinical breakpoints. In addition, epidemiological cutoff (ECOFF R, MIC > 0.064 mg/l) was used for categorization. Eighteen (8.7%) men showed CIP R + I E. coli by the EUCAST breakpoints and 41 (19.8%) using the ECOFF R criteria. During follow-up, 15 (7.2%) men had infectious symptoms, of which 9 (4.3%) were culture-confirmed infections. Only 4 (26.7%) of these 15 patients showed R + I E. coli in the rectal swab according to EUCAST, but 10 (66.7%) using the ECOFF cutoff. Rectal E. coli CIP R + I by the EUCAST clinical breakpoints associated with infectious complications with OR 5.7 (95% CI 1.5-21.8, P = 0.005) and ECOFF R E. coli by OR 10.7 (95% CI 3.0-37.6, P < 0.001). Men carrying rectal E. coli with moderately lowered CIP susceptibility (MIC > ECOFF 0.064 mg/l) were identified and, interestingly, they showed a high risk of developing infectious symptoms after the biopsy. This explains why some men develop infectious complications despite appropriate antibiotics before prostatic biopsies.

TRIAL REGISTRATION

NCT02140502.

The effectiveness of targeted relative to empiric prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy: a meta-analysis

PURPOSE

Rectal culture screening for fluoroquinolone (FQ)-resistant Enterobacteriaceae before transrectal ultrasound guided prostate (TRUSPB) biopsy and targeted antibiotic prophylaxis (TAP) may decrease post-TRUSPB infection rates compared to empiric (EAP) regimens. The objective of this study was to evaluate the effectiveness of targeted relative to empiric prophylaxis regimens on rates of infectious complications after TRUSPB and to determine the baseline prevalence of FQ resistance based on prior rectal swabs.

METHODS

An electronic search within literature databases including EMBASE and Web of Science (all databases) for articles assessing TAP as an approach to TRUSPB prophylaxis was conducted. Quality assessment was performed using the Hoy instrument. Meta-analysis was performed using MetaXL 5.3.

RESULTS

From 15 studies (eight retrospective and seven prospective) representing 12,320 participants, infectious complication incidence was 3.4% in EAP and 0.8% in TAP patients. The number needed to treat with TAP to avoid one more infection when compared to the EAP group was 39. Effect sizes were homogeneous. Prevalence of FQ resistance showed low (15%) and high (28%) subgroups, likely due to region of origin (within and outside USA, respectively).

CONCLUSIONS

Rectal culture prior to TRUSPB and use of TAP adjusts for endemic FQ resistance and is associated with less infectious complications and resulting morbidity when compared to EAP. Overtreatment associated with augmented prophylaxis approaches may be reduced as a result. Further prospective assessment and cost-benefit analyses are required before widespread implementation can be recommended.

Prevalence of fluoroquinolone-resistant rectal flora in patients undergoing transrectal ultrasound-guided prostate needle biopsy: A prospective multicenter study

OBJECTIVES

To estimate the prevalence of fluoroquinolone-resistant rectal flora in patients undergoing transrectal ultrasound-guided prostate needle biopsy and to identify the high-risk groups.

METHODS

From January 2015 to March 2016, rectal swabs of 557 men who underwent transrectal ultrasound-guided prostate needle biopsy were obtained from five institutions. Clinical variables, including demographics, rectal swab culture results and infectious complications, were evaluated. Univariable and multivariable analyses were used to identify the risk factors for fluoroquinolone resistance of rectal flora and infectious complications.

RESULTS

The incidence of fluoroquinolone-resistant and extended-spectrum beta-lactamase production was 48.1 and 11.8%, respectively. The most common fluoroquinolone-resistant bacteria was Escherichia coli (81% of total fluoroquinolone-resistant bacteria, 39% of total rectal flora), and 16 (2.9%) patients had infectious complications. Univariable and multivariable analysis of clinical parameters affecting fluoroquinolone resistance showed no factor associated with fluoroquinolone resistance of rectal flora. The clinical parameter related to infectious complications after prostate biopsy was a history of operation within 6 months (relative risk 6.60; 95% confidence interval 1.99-21.8, P = 0.002).

CONCLUSIONS

These findings suggest that a risk-based approach by history taking cannot predict antibiotic resistance of rectal flora, and physicians should consider targeted antibiotic prophylaxis or extended antibiotic prophylaxis for Korean patients undergoing transrectal ultrasound-guided prostate biopsy because of high antibiotic resistance of rectal flora.

Clostridium difficile Infection in Contemporary Urologic Practice

Clostridium difficile infection (CDI) is a high-impact hospital-acquired condition and a chief driver of excess morbidity, mortality, and treatment cost. The diagnosis, treatment, and prevention of CDI are key components of any hospital-based practice. Urologists see a small percentage of all patients with CDI, but traditionally utilize antibiotic agents that put patients at risk of CDI. Urologic procedures making use of bowel have a significantly higher rate of CDI than other procedures. This review addresses concepts that practicing urologists should be aware of and should be able to put into practice to diagnose, treat, and prevent CDI.