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

Ciprofloxacin Alone vs. Ciprofloxacin plus an Aminoglycoside for the Prevention of Infectious Complications following a Transrectal Ultrasound-Guided Prostate Biopsy: A Retrospective Cohort Study

The purpose of this study was to evaluate the impact of augmented prophylaxis (ciprofloxacin augmented with an aminoglycoside) compared with that of empirical prophylaxis (ciprofloxacin alone) on transrectal post-prostate biopsy infectious complication (PBIC) rates. A retrospective cohort study evaluated 2835 patients receiving either augmented or empirical prophylactic regimen before undergoing a transrectal ultrasound-guided prostate biopsy between January 2010 and October 2018. The patients were compared according to prophylactic regimen received. The incidence of PBICs and the impact of risk factors were evaluated. A total of 1849 patients received the empirical regimen, and 986 patients received the augmented regimen. The composite PBIC rate was 2.1% (n = 39) and 0.9% (n = 9) (p = 0.019), respectively, and the SIRS rate was 1.9% and 0.8% (p = 0.020), respectively. Of the 50 patients presenting with a PBIC, 29 (58%) had positive cultures (blood and/or urine) for Escherichia coli, of which 28 (97%) were ciprofloxacin-resistant. Taking a fluoroquinolone in the previous 6 months and having a previous urinary tract infection within 1 year prior to the biopsy had significant impact on PBIC rates (p = 0.009 and p = 0.011, respectively). Compared with ciprofloxacin alone, augmented prophylaxis was associated with significantly lower PBICs.

ESCMID/EUCIC clinical practice guidelines on perioperative antibiotic prophylaxis in patients colonized by multidrug-resistant Gram-negative bacteria before surgery

SCOPE

The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant Gram-negative bacteria (MDR-GNB) before surgery.

METHODS

These evidence-based guidelines were developed after a systematic review of published studies on PAP targeting the following MDR-GNB: extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant Enterobacterales (CRE), aminoglycoside-resistant Enterobacterales, fluoroquinolone-resistant Enterobacterales, cotrimoxazole-resistant Stenotrophomonas maltophilia, carbapenem-resistant Acinetobacter baumannii (CRAB), extremely drug-resistant Pseudomonas aeruginosa, colistin-resistant Gram-negative bacteria, and pan-drug-resistant Gram-negative bacteria. The critical outcomes were the occurrence of surgical site infections (SSIs) caused by any bacteria and/or by the colonizing MDR-GNB, and SSI-attributable mortality. Important outcomes included the occurrence of any type of postsurgical infectious complication, all-cause mortality, and adverse events of PAP, including development of resistance to targeted (culture-based) PAP after surgery and incidence of Clostridioides difficile infections. The last search of all databases was performed until April 30, 2022. The level of evidence and strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included in the recommendation development.

RECOMMENDATIONS

The guideline panel reviewed the evidence, per bacteria, of the risk of SSIs in patients colonized with MDR-GNB before surgery and critically appraised the existing studies. Significant knowledge gaps were identified, and most questions were addressed by observational studies. Moderate to high risk of bias was identified in the retrieved studies, and the majority of the recommendations were supported by low level of evidence. The panel conditionally recommends rectal screening and targeted PAP for fluoroquinolone-resistant Enterobacterales before transrectal ultrasound-guided prostate biopsy and for extended-spectrum cephalosporin-resistant Enterobacterales in patients undergoing colorectal surgery and solid organ transplantation. Screening for CRE and CRAB is suggested before transplant surgery after assessment of the local epidemiology. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship teams before implementing the screening procedures or performing changes in PAP are warranted. High-quality prospective studies to assess the impact of PAP among CRE and CRAB carriers performing high-risk surgeries are advocated. Future well-designed clinical trials should assess the effectiveness of targeted PAP, including the monitoring of MDR-GNB colonization through postoperative cultures using European Committee on Antimicrobial Susceptibility Testing clinical breakpoints.

Occurrence and significance of fluoroquinolone-resistant and ESBL-producing Escherichia coli and Klebsiella pneumoniae complex of the rectal flora in Ghanaian patients undergoing prostate biopsy

Background

Reports suggest that fluoroquinolone (FQ)-resistant and ESBL-producing rectal flora are associated with infectious complications in men undergoing transrectal ultrasound-guided prostate needle biopsy (TRUS-B)

Objectives

We investigated the relationship between carriage of FQ-resistant and ESBL-producing Escherichia coli and Klebsiella pneumoniae complex of the rectal flora, and the 30 day incidence rate of post-TRUS-B infectious complications.

Methods

From 1 January 2018 to 30 April 2019, rectal swabs of 361 patients were cultured pre-TRUS-B for FQ-resistant and ESBL-producing flora. Patients were followed up for 30 days for infectious complications post-biopsy. Multivariable logistic regression analyses were used to identify risk factors.

Results

Overall, 86.4% (n = 312/361) and 62.6% (n = 226/361) of patients carried FQ-resistant and ESBL-producing E. coli and K. pneumoniae complex, respectively. Approximately 60% (n = 289/483) of the FQ-resistant and 66.0% (n = 202/306) of the ESBL-positive isolates exhibited in vitro resistance to the pre-biopsy prophylactic antibiotic regimen of levofloxacin and gentamicin. Amikacin and meropenem were the most effective antibiotics against the MDR rectal E. coli and K. pneumoniae complex (78.7% and 84.3%, respectively). The 30 day incidence rate for post-biopsy infections was 3.1% (n = 11/361), with an overall high probability (96.9%) of staying free of infections within the 30 day period post-TRUS-B. Antibiotic use in the previous 3 months was a risk factor for rectal carriage of FQ-resistant and ESBL-positive isolates. Rectal colonization by ESBL-positive E. coli and K. pneumoniae complex comprised an independent risk factor for post-biopsy infectious complications.

Conclusions

The findings suggest that a change in prophylactic antibiotics to a more targeted regimen may be warranted in our institution.

Comparison of amikacin with fosfomycin as an add-on to ciprofloxacin for antibiotic prophylaxis in transrectal prostate biopsy: A single-center retrospective study

PURPOSE

To assess the effect of ciprofloxacin (CP) and fosfomycin compared with CP and amikacin in patients with a fluoroquinolone (FQ)-resistant rectal flora who have undergone transrectal ultrasound-guided prostate biopsy (TRUSPB).

MATERIALS AND METHODS

In total, 516 patients with FQ-resistant rectal flora based on rectal swab cultures were divided into two groups according to prophylactic antibiotics. Patients in both groups were administered CP (400 mg, intravenous [IV], twice daily) on the same day as TRUSPB and 1 day after biopsy. The amikacin group (n=260) was administered a single injection of amikacin (1 g, IV) 1 hour before TRUSPB, whereas the fosfomycin group (n=256) was administered fosfomycin (3 g, orally) the night before the procedure. The primary endpoint was the rate of infectious complications in the two groups.

RESULTS

Overall, 13 patients (2.5%) reported infectious complications: 12 patients (4.62%) in the amikacin group compared with 1 patient (0.39%) in the fosfomycin group (risk ratio, 0.09; 95% confidence interval [CI], 0.01-0.65), respectively, which was a statistically significant difference (p=0.017). This corresponds to a number needed to treat of 24 patients (95% CI, 15-65) to prevent one infectious complication. In the multivariate analysis to assess variables related to infectious complications, prophylactic antibiotics with added fosfomycin was associated with infectious complications (odds ratio, 0.060; 95% CI, 0.008-0.459).

CONCLUSIONS

In the era of FQ resistance, CP and fosfomycin may reduce the rate of infectious complications compared with CP and amikacin prophylaxis.

Comparison of drug susceptibility between Escherichia coli detected in stool cultures of patients undergoing transrectal prostate needle biopsy and Escherichia coli in hospital-wide urine antibiograms

A prostate biopsy is essential for prostate cancer diagnosis. However, infections are one of the biopsy-associated complications, and post-biopsy fever is estimated to occur in approximately 1% of all cases. It may thus be beneficial to perform a rectal swab culture before a transrectal prostate biopsy to confirm the presence of resistant bacteria and select preventive antibacterial agents according to the drug susceptibility results. This study aimed to determine whether there is a difference between the drug susceptibility of bacteria detected in the stool of patients who were scheduled to undergo prostate biopsy and the hospital-wide urine antibiogram. Patients suspected of having prostate cancer who underwent transrectal prostate biopsy via transrectal ultrasonography between August 1, 2016, and June 30, 2020, were included in this study. Stool samples were collected and cultured before biopsy. Overall, 99 patients underwent prostate biopsy, and of these, culture results were available for 81 patients (81.8%). Escherichia coli was detected in 74.0% (60 samples) of the stool culture samples, of which 4 samples were extended-spectrum β-lactamase-producing types. We found greater susceptibility of Escherichia coli to ampicillin, fluoroquinolones, sulfamethoxazole/trimethoprim, and cefixime in the stool culture antibiogram than in the hospital-wide urine antibiogram. We also found a significantly low incidence of ESBL-positive Escherichia coli in the stool culture antibiogram with p-values of 0.009, 0.007, and 0.03 compared to the hospital-wide urine antibiograms for 2017, 2018, and 2019, respectively. Stool culture of prostate cancer patients undergoing biopsy may provide useful information for selecting prophylactic antimicrobial agents.

Comparison of a combined regimen of fosfomycin and ciprofloxacin with ciprofloxacin alone as antimicrobial prophylaxis for transrectal prostate biopsy in the era of high fluoroquinolone-resistant rectal flora

Background

To assess the prophylactic effect of fosfomycin (FM) and ciprofloxacin combinations for infectious complications of transrectal ultrasound-guided prostate biopsy (TRUSPB) compared to that of ciprofloxacin alone.

Methods

In total, 1,578 patients were enrolled and were divided into two groups according to the prophylactic antibiotics. Group 1 (n = 1234) received ciprofloxacin on the day of the biopsy and for an additional 1–2 days, whereas Group 2 (n = 334) was given FM in addition to ciprofloxacin in the same manner as Group 1. The primary outcome was overall infectious complications within 1 month of TRUSPB. The secondary outcome was the risk factors of infectious complications after TRUSPB.

Results

Infectious complications occurred in 31 patients (2.5%) and 1 patient (0.3%) in Groups 1 and 2, respectively. Our results indicated that fluoroquinolone (FQ) and FM significantly reduced the risk of infectious complications compared to FQ (relative risk: 0.12; 95% confidence interval 0.02–0.87, P = 0.015). Based on the multivariate analysis, previous antibiotic exposure (odds ratio [OR] = 3.59, P = 0.026), and the addition of FM (OR = 0.12, P = 0.038) were associated with infectious complications. Based on the rectal swab, FQ resistance was 28.0% (n = 294) in total. FQ resistance in the FQ and FM group was higher than that in the FQ group (n = 178, 54.9% vs. n = 116, 16.0%, P < 0.001).

Conclusion

The combination of ciprofloxacin and FM exhibited reduced infectious complications after TRUSPB compared with ciprofloxacin monotherapy and may be applicable in the era of the high abundance of FQ-resistant rectal flora.

Clinical Importance of Antibiotic Regimen in Transrectal Ultrasound-Guided Prostate Biopsy: A Single Center Analysis of Nine Thousand Four Hundred Eighty-Seven Cases

BACKGROUND

To evaluate the effectiveness of an antibiotic regimen for prostate biopsy by analyzing patients who were hospitalized because of complications after transrectal ultrasound-guided prostate biopsy.

METHODS

We reviewed retrospectively the medical records of 10,339 patients who underwent transrectal ultrasound-guided prostate biopsy at our institution from May 2003 to April 2017. We excluded patients with low quality data. All patients underwent urine culture before transrectal ultrasound-guided prostate biopsy and received intravenous antibiotic agents 30-60 minutes before biopsy. Patients were either given prophylactic quinolone or cephalosporin (second or third generation). Clinicopathologic factors including patient age, antibiotic regimen, number of biopsy cores, body mass index, prostate specific antigen, prostate volume, and infection-related complications that required hospitalization were subsequently analyzed.

RESULTS

A total of 9,487 patients were included in the final analysis, of whom 33 patients (0.35%) were hospitalized because of infection-related complications. Infection-related hospitalization rates were lower in patients who received cephalosporin (0.2%) than in patients who received quinolone (1.59%). At our institution, cephalosporin has been used predominantly to prevent post-biopsy infections since February 2013. Only five patients (0.12%) developed infection-related complications of the 3,863 patient who underwent transrectal ultrasound-guided prostate biopsy since February 2013. Multivariable analysis revealed that use of second- or third-generation cephalosporin was the only independent predictor of infection-related complications.

CONCLUSION

Implementing an effective antibiotic prophylaxis regimen at our institution by using second- or third-generation cephalosporin could reduce infection-related complications after transrectal ultrasound-guided prostate biopsy.