"Targeted" prophylaxis: Impact of rectal swab culture-directed prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy

Risk Factors for Infection After Transrectal Prostate Biopsy: A Population-based Register Study

Background and objective

Infection after transrectal prostate biopsy (TPBx) is a well-known risk. A comprehensive investigation of risk factors may identify measures for safe TPBx as an alternative to a change in biopsy route. The aim of this study was to identify risk factors for infection after TPBx.

Methods

We included all outpatient TPBx cases in Region Kronoberg, Sweden, from January 2010 to December 2019. The primary outcome was post-TPBx infection, defined as prescription of antibiotics indicated for urinary tract infection (UTI) or inpatient care for infection within 30 d. We analysed the following factors in relation to post-TPBx infection: age, diabetes mellitus, prostate cancer diagnosed at index biopsy, previous prostate biopsy, two or more biopsies in the past 24 mo, a positive urine culture, two or more negative urine cultures (UCs) in the past 24 mo, antibiotic treatment grouped as four types, and medication for benign prostatic hyperplasia (BPH). Logistic regression was used to calculate odds ratios (ORs).

Key findings and limitations

Of 5788 TPBx procedures in 4040 patients, 405 (7.0%) led to an infection and 170 (2.9%) to inpatient care for infection. Risk factors for post-TPBx infection (ORs 1.5-2.5) were diabetes mellitus, antibiotic treatment for a UTI, fluoroquinolone treatment, and a positive urine culture. Weaker risk factors (ORs 1.3-1.5) were non-UTI antibiotic treatment, BPH medication, and negative UCs before TPBx.

Conclusions and clinical implications

Our results confirm that diabetes mellitus and previous UTI are risk factors for infection after TPBx. Lower urinary tract symptoms and treatment with any kind of antibiotic were associated with infection, which has not been previously reported.

Patient summary

In a large population-based study from Sweden, we investigated which clinical factors increase the risk of an infection after transrectal prostate biopsy. Our results confirm that diabetes and a previous urinary tract infection are risk factors. We also found two new factors associated with the risk of infection after biopsy: lower urinary tract symptoms and any antibiotic treatment.

Infection after prostatic transrectal fiducial marker implantation for image guided radiation therapy

PURPOSE

The aim of this retrospective study is to assess the risk of infection after transrectal ultrasound-guided fiducial marker insertion for image-guided radiotherapy of prostate cancer.

MATERIAL AND METHODS

Between January 2016 and December 2020, 829 patients scheduled for intensity-modulated radiotherapy for prostate cancer had an intraprostatic fiducial marker transrectal implantation under ultrasound guidance by radiation-oncologists specialized in brachytherapy. Patients received standard oral prophylactic antibiotic with quinolone. If Gram negative bacteria resistant to quinolone were detected at the time of the prostate cancer biopsies, the antibioprophylaxis regimen was modified accordingly. The resistance to quinolone screening test was not repeated before fiducial marker insertion. Infectious complications were assessed with questionnaires at the time of CT-planning and medical record reviewed. Toxicity was evaluated according to CTCAE v5.0.

RESULTS

The median time between fiducial marker implantation and evaluation was 10 days (range: 0-165 days). Four patients (0.48%) developed urinary tract infection related to the procedure, mostly with Gram-negative bacteria resistant to quinolone (75%). Three had a grade 2 infection, and one patient experienced a grade 3 urosepsis. The quinolone-resistance status was known for two patients (one positive and one negative) and was unknown for the other two patients prior to fiducial marker implantation.

CONCLUSION

Intraprostatic transrectal fiducial marker implantation for image-guided radiotherapy is well tolerated with a low rate of infection. With such a low rate of infection, there is no need to repeat the search of Gram-negative bacteria resistant to quinolone before fiducial marker implantation if it was done at the time of prostate biopsies. Optimal antibioprophylaxis should be adapted to the known status of Gram-negative bacteria resistant to quinolone.

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.

Risk assessment of multi-factorial complications after transrectal ultrasound-guided prostate biopsy: a single institutional retrospective cohort study

BACKGROUND

Transrectal ultrasound-guided prostate biopsy (TRUSPB) is widely used to diagnose prostate cancer (PCa). The aim of this study was to evaluate the risk of multi-factorial complications (febrile genitourinary tract infection (GUTI), rectal bleeding, and urinary retention) after TRUSPB.

METHODS

N = 2053 patients were Japanese patients undergoing transrectal or transperineal TRUSPB for suspicious of PCa. To assess risk of febrile GUTI adequately, the patients were divided into four groups: low-risk patients before starting a rectal culture, low-risk patients after starting a rectal culture, high-risk patients, and patients undergoing transperineal TRUSPB. Furthermore, to identify risk of rectal bleeding and urinary retention, patients were divided into transrectal and transperineal group.

RESULTS

Febrile GUTI significantly decreased owing to risk classification. The frequency of rectal bleeding was 1.43% (transrectal: 25/1742), while it did not happen in transperineal group. The patients with rectal bleeding had a significantly lower body mass index (BMI) (P < 0.01). The frequency of urinary retention was 5.57% (transrectal: 97/1742), while it did not happen in transperineal group. The patients with urinary retention had a significantly higher prostate-specific antigen (PSA) (P = 0.01) in transrectal group.

CONCLUSIONS

Risk classification, rectal swab culture, and selected antimicrobial prophylaxis for transrectal TRUSPB were extremely effective to reduce the risk of febrile GUTI. Furthermore, lower BMI and higher PSA were novel clinical predictors for rectal bleeding and urinary retention, respectively. When urologists perform transrectal TRUSPB to their patients, they can correctly understand and explain each complication risk to their patients based on these novel risk factors.

Effect of targeted prophylaxis with rectal swab on complications after prostate biopsy: prospective randomized study

BACKGROUND

For diagnosis of prostate cancer, prostate biopsy accompanied by TRUS is the current method applied today.

AIM

The aim of this study was to compare targeted antibiotic prophylaxis, chosen according to rectal swab results before the procedure, with routinely administered prophylaxis and to investigate the effect on infective complications.

METHODS

The study included 140 patients with 12-quadrant prostate biopsy accompanied by TRUS in our hospital from 2018 to 2020. The first group had antibiotherapy prophylaxis administered according to the results of rectal swabs before the procedure. The second group had routine ciprofloxacin prophylaxis administered. Patients were followed prospectively for 1 month after the procedure.

RESULTS

When the mean age, systemic diseases and distribution in both groups are examined, there was no significant difference observed. Fever (> 38.5 °C) was observed in 3 patients in the rectal swab group (4.3%), while it was identified in 10 people in the control group (14.1%) (p = 0.047). Major complications were observed in 3 people in the rectal swab group (4.3%) and in 7 people in the control group (9.9%) (p = 0.012).

CONCLUSIONS

The results of the study identified that routine administration of targeted antibiotic prophylaxis may be more effective in preventing infective complications compared to standard prophylaxis. Targeted prophylaxis is recommended for risky patients in the guidelines. However, the lack of difference between the groups in terms of age and comorbidities supports the need to administer targeted prophylaxis not just to risky patients but as well as routine practice.

Antibiotic prophylaxis for transrectal ultrasound-guided prostatic biopsies: a comparison of two regimens

Background

There were controversies about the appropriate antibiotic prophylaxis regimen in order to decrease the incidence of post-transrectal ultrasound-guided prostatic biopsies (TRUS-PB) infectious complications. This study was conducted to compare the efficacy of two antibiotics prophylaxis regimens for TRUS-PB. In group 1, patients received single IV dose of 1 g amikacin 30 min before the procedure followed by oral ciprofloxacin 500 mg immediately after TRUS-PB. Group 2 patients received the same antibiotics, but ciprofloxacin started 1 day prior to TRUS-PB. Then ciprofloxacin was given twice daily for a total of 5 days in both groups.

Results

The study included 146 patients (54 in group 1 and 92 in group 2). The baseline characters (age, comorbidities, ASA score, PSA, prostate size and presence of urethral catheter) were comparable for both groups. Post-biopsy sepsis was observed in three patients (5.6%) in group 1 and one patient in group 2 (1.1%, P = 0.143). Sepsis was successfully managed in three, while one patient (1.9%) from group 1 required ICU admission for management of septic shock.

Conclusions

The incidence of sepsis after TRUS-PB is low when dual antibiotic prophylaxis (ciprofloxacin and amikacin) was used. Starting ciprofloxacin 1 day before TRUS-PB decreased the incidence of sepsis as well as its severity.

A Comprehensive Review of Pharmaceutical and Surgical Interventions of Prostate Cancer

As the second most common cause of death amongst men in the United States, prostate cancer is a type of cancer that is known to develop and originate in the prostate gland. The main function of the prostate gland is to produce seminal fluid in which the sperm bathes. The seminal fluids are necessary for allowing the sperm to move easily through the urethra and also allows successful fertilization by providing an alkaline environment for the sperm in the acidic nature of the vagina. The seminal vesicles are two smaller glands that are attached to either side of the prostate gland and in radical prostatectomies, can get removed. In the event that the seminal vesicles are removed during a radical prostatectomy, the individual is unable to produce any seminal fluids and thus, becoming infertile. Prostate cancer is most commonly seen in patients over the age of 66 years, however, in the presence of predisposing risk factors, may occur as early as in the late 40s. Certain risk factors may speed the presentation of prostate cancer in individuals and thus, mandatory screening is recommended around the age of 45. If no risk factors are present, screening is recommended to begin after the age of 50 years. Screening for prostate cancer is focused on looking for prostate-specific antigen (PSA) in a blood test, though this may not be the most reliable method. The method of diagnosis stems from further testing done following an abnormal PSA test. A digital rectal examination and ultrasonography may also be used to assist with the diagnosis of prostate cancer. Though there are several different types of pharmaceutical interventions currently present in the eradication of prostate cancer, with androgen deprivation therapy being the most commonly used, surgical interventions may be utilized to completely resect cancer from an individual. Different radical prostatectomies are used; the appropriate approach utilized is dependent on the extensiveness of cancer and the type of cancer that is present.