Antibiogram Directed Prophylaxis for Transrectal Prostate Biopsy: An Application of Recommendations in the Setting of High Fluoroquinolone Escherichia coli Resistance

Abstract

IntroductionWe investigated local resistance patterns to guide antibiotic use for the prevention of infections associated with transrectal prostate biopsy with ultrasound guidance. MethodsPer the AUA (American Urological Association) recommendations (2014 and 2016) for transrectal prostate biopsy with ultrasound guidance prophylaxis, local antibiogram resistance was reviewed. Rates of Escherichia coli fluoroquinolone resistance were between 20% and 28%. Thus, the antibiotics chosen were a single dose of oral ciprofloxacin and intramuscular ceftriaxone at least 30 minutes before transrectal prostate biopsy with ultrasound guidance. Data were reviewed retrospectively between July 2012 and December 2015. There was no standard prophylaxis before protocol implementation in August 2014. Univariable analyses were performed with appropriate testing followed by multivariable logistic regression. ResultsOf 2,351 biopsies 799 were performed in patients in the protocol group. Before protocol implementation 26 different antibiotic regimens were used. The protocol group had significantly more cases of chronic kidney disease, a history of cancer, larger prostate volume and greater number of cores during transrectal prostate biopsy with ultrasound guidance. The overall hospital admission rate after transrectal prostate biopsy with ultrasound guidance was 1.35% for the nonprotocol group and 0.4% for the protocol group (p = 0.026). The incidence of organisms with antimicrobial resistance in blood and urine decreased from 20.7% (23 cases) in the nonprotocol group and 7.1% (4) in the protocol group (p=0.030). All positive blood cultures occurred in the nonprotocol group and all were ciprofloxacin resistant E. coli. On multivariable logistic regression those patients requiring hospitalization were 12.9 (95% CI 2.81–58.96) times more likely to have resistant organisms cultured (p=0.001). ConclusionsThe transrectal prostate biopsy with ultrasound guidance antibiotic prophylaxis protocol decreased unwanted variation among practitioners, which is ultimately associated withimproved quality. Antibiogram directed prophylaxis where there is high fluoroquinolone resistance maintains low infection and hospital admission rates after transrectal prostate biopsy with ultrasound guidance.