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Abstract

We agree with the Editorial Comment asserting that the prophylactic regimen used in our study was longer than required. This regimen was selected from noting its common use in past years 1 Aron M. Rajeev T.P. Gupta N.P. Antibiotic prophylaxis for transrectal needle biopsy of the prostate: a randomized controlled study. BJU Int. 2000; 85: 682-685 Crossref PubMed Google Scholar and the empiric attempt at arresting the increased incidence of severe adverse post prostatic biopsy events (sepsis). In fact, several authors have clearly reported no benefit from increasing the duration of prophylaxis beyond the preprocedural dose. In the meta-analysis cited in the article, there were no significant differences identified for the outcomes tested (bacteriuria, bacteremia, fever, and need for hospitalization) based on the antimicrobial agent selected for prophylaxis, route of administration (oral vs systemic; intravenous vs intramuscular), and duration of administration. 2 Zani E. Clark O. Rogrigues N. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev. 2011; 11 (CD006576) Google Scholar Indeed, several trials reported no significant difference in adverse infectious-related clinical outcomes between a 1-day versus a 3-day course of prophylactic antibiotic use. 3 Zaytoun O.M. Vargo E.H. Rajan R. et al. Emergence of fluoroquinolone resistant Escherichia coli as cause of postprostate biopsy infection: implications for prophylaxis and treatment. Urology. 2011; 77: 1035-1041 Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar , 4 Zaytoun O.M. Anil T. Moussa A.S. et al. Morbidity of prostate biopsy after simplified versus complex preparation protocols: assessment of risk factors. Urology. 2011; 77: 910-914 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar , 5 Schaeffer A.J. Montorsi F. Scattoni V. et al. Comparison of a 3-day with a 1-day regimen of an extended-release formulation of ciprofloxacin as antimicrobial prophylaxis for patients undergoing transrectal needle biopsy of the prostate. BJU Int. 2007; 100: 51-57 Crossref PubMed Scopus (50) Google Scholar , 6 Briffaux R. Coloby P. Bruyere F. et al. One preoperative dose randomized against 3-day antibiotic prophylaxis for transrectal ultrasonography-guided prostate biopsy. BJU Int. 2009; 103: 1069-1073 Crossref PubMed Scopus (26) Google Scholar , 7 Madden T. Doble A. Aliyu S.H. et al. Infective complications after transrectal ultrasound-guided prostate biopsy following a new protocol for antibiotic prophylaxis aimed at reducing hospital-acquired infections. BJU Int. 2011; 108: 1597-1602 Crossref PubMed Scopus (21) Google Scholar , 8 Sabbagh R. McCormack M. Péloquin F. et al. A prospective randomized trial of 1-day versus 3-day antibiotic prophylaxis for transrectal ultrasound guided prostate biopsy. Can J Urol. 2004; 11: 2216-2219 PubMed Google Scholar Physiologically, this clinical observation is supported, given the fact that bacteremia induced by dental procedures, 9 Lockhart P.B. Brennan M.T. Sasser H.C. et al. Bacteremia associated with toothbrushing and dental extraction. Circulation. 2008; 117: 3118-3125 Crossref PubMed Scopus (527) Google Scholar and gastrointestinal, respiratory, and urological instrumentation is transient, typically lasting only minutes, far shorter than any clinically relevant antimicrobial half-life. Therefore, the intent of prophylaxis should be to have a sufficient concentration of the antibiotic in the blood as well as bathing the prostatic tissues at the time of the incipient bacterial seeding. Therefore, it is most important to understand the pharmacokinetics of each antimicrobial agent chosen, with preprocedural administration performed at such time as to achieve the antimicrobial's peak serum concentration at the time of the scheduled procedure. Further dosing is intuitively superfluous, only engendering increased risk of adverse effects. The only plausible counter-argument to these assertions centers on the possible infection cultivated within the prostatic tissues subsequently seeding the blood in delayed fashion (which admittedly is only conjecture on our part at this time). We know of no data supporting this contention, nor does it seem to be supported by the clinical data. For example, infectious complications are similar regardless of the propensity for the prophylactic antibiotic used to attain elevated prostatic tissue concentrations. For example, there is no difference in infectious complications using an FQ compared to trimethoprim-sulfamethoxazole. 10 Isen K. Küpeli B. Sinik Z. et al. Antibiotic prophylaxis for transrectal biopsy of the prostate: a prospective randomized study of the prophylactic use of single dose oral fluoroquinolone versus trimethoprim-sulfamethoxazole. Int Urol Nephrol. 1999; 31: 491-5495 Crossref PubMed Scopus (62) Google Scholar We do believe that future investigations may wish to carefully control for prior prostatic biopsies, histopathologic evidence of inflammation, and risk for infectious complications. Editorial CommentUrologyVol. 79Issue 3PreviewA significant increase in antimicrobial resistance has substantially increased the risk of antimicrobial therapy and prophylaxis. Transrectal ultrasound–guided biopsy of the prostate is a common procedure that was carried out previously with minimal infectious complications. Traditionally, urologists recommended an enema and a fluoroquinolone prophylaxis before the biopsy. However, over the last several years, significant infectious complications of the urinary tract and urosepsis have increased. Full-Text PDF