Fluoroquinolone-resistant Organisms Research Articles

Impact of a Switch From Ciprofloxacin to Ceftriaxone Prophylaxis on Infectious Complications After Transrectal Ultrasound-Guided Biopsy of the Prostate.

In a 12-year single-center quasi-experimental study, a switch from ciprofloxacin to ceftriaxone prophylaxis for transrectal ultrasound-guided prostate biopsy procedures was associated with a significant reduction in 30-day postprocedure urinary tract infection, urinary tract infection-related hospitalizations, antibiotic prescriptions, and isolation of fluoroquinolone-resistant organisms from urine or blood cultures.

Critically important antimicrobial resistant Enterobacteriaceae in Irish farm effluent and their removal in integrated constructed wetlands

This study investigated the ability of Integrated Constructed Wetlands (ICWs) to remove critically important antimicrobial resistant organisms (AROs) from farm wastewater. Influent samples from the untreated farm waste and effluent samples taken at the end of the ICW system were collected monthly from four ICWs, serving four different farm types (suckler, dairy, dairy & poultry and pig). Using selective media to screen for the presence of carbapenemase resistant organisms, plasmid mediated and AmpC β-Lactamase producing organisms (ESBL/pAmpC) and fluoroquinolone resistant organisms, a total of 82 AROs were obtained with the majority being E. coli (n = 79). Statistically significant were the differences on the number of AROs isolated from influent (higher) compared to effluent, as well as a seasonal effect, with less AROs recovered during winter in comparison to other seasons (P < 0.05). On the other hand, there was no significant differences in the recovery of AROs on different farms. The majority of isolates from each of the farms (99%) were multi drug resistant, with 65% resistant to seven or more antimicrobials. A high incidence of tetracycline, trimethoprim/sulfamethoxazole, and ampicillin resistance was common to the isolates from all four farms but there were differences in ESBL levels with 63% of the isolates recovered from Farm 4 (piggery) being ESBLs compared to 18%, 36% and 4.5% recovered from Farms 1 (suckler), 2 (dairy) and 3 (dairy & poultry), respectively. No carbapenemase producing organisms were isolated. Our results showed that ICWs are effective in removing critically important AROs from farm wastewater on all four farm types.

The burden of antimicrobial resistance among urinary tract isolates of Escherichia coli in the United States in 2017.

Urinary tract infections (UTIs) caused by Escherichia coli have been historically managed with oral antibiotics including the cephalosporins, fluoroquinolones and trimethoprim-sulfamethoxazole. The use of these agents is being compromised by the increase in extended spectrum β-lactamase (ESBL)-producing organisms, mostly caused by the emergence and clonal expansion of E. coli multilocus sequence typing (ST) 131. In addition, ESBL isolates show co-resistance to many of oral agents. Management of UTIs caused by ESBL and fluoroquinolone-resistant organisms is becoming increasingly challenging to treat outside of the hospital setting with clinicians having to resort to intravenous agents. The aim of this study was to assess the prevalence of ESBL phenotypes and genotypes among UTI isolates of E. coli collected in the US during 2017 as well as the impact of co-resistance to oral agents such as the fluoroquinolones and trimethoprim-sulfamethoxazole. The national prevalence of ESBL phenotypes of E. coli was 15.7% and was geographically distributed across all nine Census regions. Levofloxacin and trimethoprim-sulfamethoxazole-resistance rates were ≥ 24% among all isolates and this co-resistance phenotype was considerably higher among isolates showing an ESBL phenotype (≥ 59.2%) and carrying blaCTX-M-15 (≥ 69.5%). The agents with the highest potency against UTI isolates of E. coli, including ESBL isolates showing cross-resistance across oral agents, were the intravenous carbapenems. The results of this study indicate that new oral options with the spectrum and potency similar to the intravenous carbapenems would address a significant unmet need for the treatment of UTIs in an era of emergence and clonal expansion of ESBL isolates resistant to several classes of antimicrobial agents, including oral options.

Use of fosfomycin as targeted antibiotic prophylaxis before prostate biopsy: A prospective randomized study.

To investigate whether switching ciprofloxacin to fosfomycin in the case of fluoroquinolone-resistant rectal bacteria influences the incidence of infectious complications after transrectal prostate biopsy. From December 2015 until December 2017, patients undergoing prostate biopsy were randomly assigned to a control group or an intervention group in a prospective, open-label fashion at three different centers. The presence of fluoroquinolone-resistant organisms was detected by rectal swabs. Patients in the control group received ciprofloxacin. Patients in the intervention group received fosfomycin instead of ciprofloxacin in the case of fluoroquinolone-resistant bacteria on rectal swab culture. The primary end-point was the difference in occurrence of major (febrile) and minor (afebrile) infections between both groups. A total of 102 patients were randomized to the control group, and 102 patients to the intervention group. In the control group, nine complications occurred, of which five were major febrile complications. In the intervention group, six complications occurred, of which four were major febrile complications. The total number of complications (major and minor) did not differ between both groups (P=0.59). A subgroup analysis of patients with fluoroquinolone-resistant bacteria on rectal swab showed five complications in the control group and one complication in the intervention group (P=0.09). This represents the first prospective randomized study using rectal cultures for targeted antibiotic prophylaxis. Study findings show promising results for use of fosfomycin in patients with fluoroquinolone resistance.

Targeted antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy during active surveillance: Effect on hospitalization

ObjectivesWe investigated the effect of targeted antibiotic prophylaxis using rectal swab cultures on hospitalization for infectious complications after transrectal ultrasound-guided prostate biopsy (TRUSP). Materials and methodsA cohort of men (1995–2016) with prostate cancer on active surveillance receiving annual TRUSP biopsies was surveyed to determine the incidence of hospitalization for suspected postbiopsy sepsis. We compared biopsy events (i.e., unique biopsies) in the era of empiric prophylaxis to those in the era of targeted prophylaxis based on culture. The effect of fluoroquinolone resistant organisms (FQ-R), and other demographic and clinical factors, on hospitalization was assessed using logistic regression. ResultsOf 1,167 men on active surveillance, 825 responded for a total of 3,361 biopsy events; 7 (0.79%) of 886 biopsies preceded by rectal swab culture resulted in hospitalization compared to 24 (0.97%) of 2,475 biopsies without culture (OR = 0.81, 95% CI: 0.35–1.89, P = 0.63). Among 886 cultures performed, FQ-R organisms were identified in 194 (21.9%); 6 out of 194 (3.1%) biopsies with swabs positive for FQ-R resulted in admission compared to 1 out of 692 (0.14%) biopsies with fluoroquinolone sensitive swabs (OR = 22.1, 95% CI: 2.6–184.3, P<0.01). Smaller prostate volume at diagnosis was significantly associated with hospitalization (OR = 2.57, 95% CI: 1.04–6.31) for<45 g vs. ≥45 g, P = 0.039). ConclusionTargeted antibiotic prophylaxis is not associated with a significant reduction in hospitalization for suspected post-TRUSP biopsy sepsis. FQ-R and prostate volume exhibited strong associations with risk of hospitalization and could be included in a risk-adapted approach to prophylaxis, but better prophylactic strategies are needed for patients identified to be at high risk of subsequent hospitalization.

An Evidence-Based Protocol for Antibiotic Use Prior to Cystoscopy Decreases Antibiotic Use without Impacting Post-Procedural Symptomatic Urinary Tract Infection Rates

Symptomatic urinary tract infection is a complication of office based cystourethroscopy. Studies are mixed regarding the efficacy of antibiotic prophylaxis to prevent urinary tract infections. Our aim was to develop and evaluate an evidence-based protocol that reduces unnecessary antibiotic use while avoiding an increase in urinary tract infections. We created a clinic antibiogram based on all urology office visits performed during a 2-year period. Bacterial resistance rates, institutional risk related data and clinical guidelines were applied to create a protocol for antibiotic administration before cystourethroscopy. We then analyzed 1,245 consecutive patients without a renal transplant who underwent outpatient cystourethroscopy, including 610 after protocol initiation. Urinary tract infection rates and antibiotic use were analyzed for an association with the protocol change using the Fisher exact test. Cultures had an overall 20% rate of resistance to fluoroquinolones, representing 40% of the cultures that grew Escherichia coli. Before the protocol change 602 of 635 patients (94.8%) received a preprocedural antibiotic compared to 426 of 610 (69.9%) after protocol initiation (p <0.01). A total of 19 patients (3.0%) had a symptomatic urinary tract infection prior to the protocol change while 16 (2.6%) had a urinary tract infection after the change (p = 0.69). Regarding resistance, fluoroquinolone resistant organisms grew in the cultures of 12 of 19 patients (63.2%) with a urinary tract infection before the protocol change compared to 5 of 16 (31.3%) with a urinary tract infection after the change. Recent antibiotic administration, hospitalization and chronic catheterization were associated with urinary tract infection in the entire cohort (all p≤0.01). A local antibiogram with infection related risk data effectively risk stratifies patients before cystourethroscopy, decreasing the use of antibiotics without increasing the rate of symptomatic urinary tract infection.

Prostate cancer diagnostics: A review of practice across the northwest of England

Introduction: The aim of this regional audit was to gain an understanding of the different approaches to prostate cancer diagnosis across the northwest of England. This often complicated area of urological practice has undergone many changes in recent years and this audit will attempt to evaluate the degree of diversity in diagnostic pathway across one region. Methods: Electronic questionnaires were distributed to consultant urologists across the northwest. Over a 2-week data collection period 48 responses were received from 19 urology units. Responses were grouped by centre to evaluate practice per urology unit. Results: Written consent was taken for transrectal ultrasound and biopsy in 54% of centres. All centres used a prophylactic antibiotic regime that included ciprofloxacin; however, the duration varied across the region. Units used a 3-day course, 1-day course and single dose at the time of biopsy in 69%, 5% and 21%, respectively. Rectal swabs to detect fluoroquinolone-resistant organisms were not used in 15 of 19 units (79%). Magnetic resonance imaging was not used before the first biopsy in 42% of units. Twenty-one per cent used this study on all men undergoing a first biopsy, while 37% of centres used a more targeted approach. All centres routinely sampled 12 cores during TRUS and biopsy. The majority (74%) sent cores for histology in two containers by side (left/right). The remaining sent two samples from each geographical area in one container. For repeat biopsy indications 42% of units reported they would proceed straight to transrectal ultrasound and biopsy. The remaining 58% utilised another modality such as multiparametric magnetic resonance imaging or transperineal template biopsy in the first instance. Conclusion: This audit has highlighted a wide variation in practice within one UK region. Although there have been measurable advances in prostate cancer management, more standardisation of diagnostic pathways may facilitate data collection and reduce variation in outcomes. Level of evidence: Not applicable in this multicentre audit.

Prevalence of Clostridium difficile and Multidrug Resistant Gram-negative Rods in the Soil from Southeastern Wisconsin

BackgroundPreliminary data suggests that community-onset Clostridium difficile might be more common in rural areas. Thus, farms—specifically livestock farms—might be a major reservoir of C. difficile. Similarly, antibiotic exposures might predispose farm animals for colonization with multidrug resistant Gram-negative organisms. The aim of this study was to determine the prevalence of C. difficile and multidrug resistant gram-negative rods in the soil of Southeastern Wisconsin farms.MethodsFrom July to September of 2016, soil samples were collected from farms with livestock animals. Soil samples were collected using gloves and sample containers. Soil samples were collected from farms specifically in or near Washington, Waukesha, and Milwaukee counties which are within the proximity of Milwaukee Metro area. Soil samples were cultured for C. difficile and Gram-negative rods on selective plates and by broth enrichment.ResultsA total of 20 farms participated in this study with a total of 40 soil samples. Out of the 40 soil samples, 20 were from an area where animals roam or where manure was used and the remaining 20 were from an area where animals are prohibited or where there was no manure. Out of the 20 soil samples where animals roam, 10 (50%), tested positive for C. difficile. Out of 20 soil samples where animals are prohibited, 13 samples (65%) tested positive for C. difficile. 2 of the 23 C. difficile isolates recovered were toxigenic. Eight (40%) of the 20 soil samples where animals roam tested positive for fluoroquinolone-resistant bacteria (FQR). While 5 (25%) of the 20 soil samples where animals are prohibited, tested positive for FQR bacteria. An Acinetobacter calcoaceticus was found to exhibit carbapenem-resistance.ConclusionWe found soil colonization with C. difficile and FQR in 65% and 25%, respectively, where animals are prohibited. Where animals roam we found C. difficile and FQR 50% and 40%, respectively. Our study suggests that farms may be a significant community source for C. difficile and fluoroquinolone resistant organisms. Additional testing should be done to examine factors that might be increasing antibiotic resistance in farms (e.g., antibiotic exposure).Disclosures All authors: No reported disclosures.

634 - Prevalence and significance of fluoroquinolone-resistant bacteria carriage in patients undergoing trans rectal ultra-sonography prostate biopsy

To determine the prevalence of fluoroquinolone-resistant (FQR) bacteria carriage in patients undergoing transrectal ultrasound prostate biopsy (TRUS-Bx), and the relationship between the risk factors and FQR carriers as well as infections after prostate biopsy.Rectal swabs were obtained from 158 patients undergoing TRUS-Bx. The FQR organisms were isolated using selective media, and the antibiotic susceptibility pattern was determined. Moreover, after prostate biopsy, blood and urine samples were collected from patients with post-biopsy infection (PBI) during 30days of follow up.In total, 73 (46.2%) patients were positive for ciprofloxacin-resistant bacteria in rectal cultures. The most dominant isolates were Escherichia coli (95.9%). The antibiotic susceptibility patterns for the FQR rectal and clinical isolates showed high levels of resistance to ampicillin (94%) and trimethoprim-sulfamethoxazole (89.5%), while the resistance to amikacin, fosfomycin and imipenem remained very low. The multivariate analysis showed that previous use of FQs (OR, 2.54; 95% CI, 1.17-5.49; P = .019) and history of hospitalization (OR, 7.85; 95% CI, 2.075-29.744; P = .002) were significantly risk factors for the FQR carriage. On the other hand, the risk of PBI was higher among intestinal carriers of fluoroquinolone resistant bacteria compared with noncarriers, that this difference was statistically significant (24% versus 3.5%, P &lt; .001).The rates of PBI and hospitalization after TRUS-Bx were 12.5%, and 4.43%, respectively.An increase in the rectal FQR bacteria carriage is associated with elevated PBI, which strongly recommendsthe need for an appropriate prophylaxis to reduce infections in patients undergoing TRUS-Bx.

Editorial Comment

Prostate specific antigen (PSA) levels are often evaluated in an attempt to detect early prostate cancer, however false positive PSA tests are common.1 A strategy to limit false positives, surrounding concerns that prostatitis may increase PSA, has been to defer biopsy decisions until after a course of antibiotics and repeat PSA measurement. This strategy has been evaluated in prior studies, including several small randomized trials, with differing conclusions regarding its benefit.2–4 The authors report a prospective, randomized trial investigating the impact of six weeks of fluoroquinolone antibiotics on PSA levels in asymptomatic men with an elevated PSA. This single-institution study randomized 150 of 1,151 eligible patients with a PSA between 4.0 and 20.0 ng/mL to 6 weeks of fluoroquinolone therapy (ciprofloxacin, but due to formulary changes a proportion received levofloxacin) or 6 weeks of observation. The primary endpoint was change in PSA 8 weeks after randomization. Rate of cancer diagnosis was a secondary outcome for patients who received a biopsy. A near significant difference in the change in PSA across groups was reported (−0.68 vs. 0.01 ng/mL for treatment and observation groups, respectively, p=0.052). 62% of treatment patients and 72% of observation patients underwent biopsy with no difference in cancer detection rate (63% vs. 52%, respectively, p=0.60). The authors conclude that asymptomatic patients with elevated PSA should not receive antibiotics prior to determining if a prostate biopsy is warranted. While the authors are commended for completing a prospective randomized trial to inform the debate on this urological practice, one limitation of this study is the lack of a pre-trial power calculation to plan enrollment. Despite this limitation, the post-intervention median PSA levels in both the treatment and observation groups were above most accepted biopsy thresholds (5.1 ng/mL and 5.0 ng/mL, respectively), indicating that even if the study had found a statistically significant difference, it may not have been clinically relevant. Also, as shown in this study, a decrease in PSA does not indicate an absence of prostate cancer. Given this trial and others on the topic have not provided convincing evidence of this practice, the authors are correct in concluding evidence does not support this management strategy. The risks and costs associated with unnecessary antibiotics are not trivial.5 When hospitalizations after transrectal prostate biopsy were assessed in the Michigan Urological Surgery Improvement Collaborative (MUSIC), 95% of hospital admissions were for infectious complications, and the majority of cultures identified fluoroquinolone resistant organisms.6 With rising antibiotic resistance7 and in an era increasingly focused on quality care and appropriate healthcare utilization, we do not recommend antibiotic therapy prior to making decisions about prostate biopsy in asymptomatic men with elevated PSA. This practice is also highlighted within the American Board of Internal Medicine and American Urological Association’s Choosing Wisely campaign as something that physicians and patients should question.8

A novel ciprofloxacin-resistant subclade of H58 Salmonella Typhi is associated with fluoroquinolone treatment failure.

The interplay between bacterial antimicrobial susceptibility, phylogenetics and patient outcome is poorly understood. During a typhoid clinical treatment trial in Nepal, we observed several treatment failures and isolated highly fluoroquinolone-resistant Salmonella Typhi (S. Typhi). Seventy-eight S. Typhi isolates were genome sequenced and clinical observations, treatment failures and fever clearance times (FCTs) were stratified by lineage. Most fluoroquinolone-resistant S. Typhi belonged to a specific H58 subclade. Treatment failure with S. Typhi-H58 was significantly less frequent with ceftriaxone (3/31; 9.7%) than gatifloxacin (15/34; 44.1%)(Hazard Ratio 0.19, p=0.002). Further, for gatifloxacin-treated patients, those infected with fluoroquinolone-resistant organisms had significantly higher median FCTs (8.2 days) than those infected with susceptible (2.96) or intermediately resistant organisms (4.01)(pS. Typhi clade internationally, but there are no data regarding disease outcome with this organism. We report an emergent new subclade of S. Typhi-H58 that is associated with fluoroquinolone treatment failure.

Prevalence, Risk Factors, and Clinical Relevance of Fluoroquinolone-Resistant Organisms in Rectal Cultures: Should We Target Antibiotic Prophylaxis Prior to Prostate Biopsy?

The rise of infectious complications after prostate biopsy has been linked to the growing resistance of enterobacteria to fluoroquinolone (FQ) antibiotics. In this review, we investigated the potential benefit of targeted antibiotic prophylaxis based on rectal cultures prior to prostate biopsy. An electronic search for all related literature published in English was performed from April until June 2015 using the MEDLINE and EMBASE databases. Data were obtained regarding the true prevalence of FQ-resistant bacteria in the rectum of patients, the identification of those patients at risk of harbouring FQ-resistant bacteria, the risk of infectious complications after transrectal prostate biopsy in patients with FQ-resistant bacteria, and the effect of targeted prophylaxis. Although there is limited evidence that a targeted approach might be beneficial, we conclude that current studies on the use of rectal cultures in the prebiopsy setting have too many limitations and confounding variables to definitely accept this approach in clinical practice. Whether this methodology is useful in a certain region will greatly depend on local fluoroquinolone-resistance rates.

Clinical and microbiological determinants of infection after transrectal prostate biopsy.

Increasing numbers of infections following transrectal prostate biopsy (TPB) at our hospital led us to investigate clinical and bacterial risk factors to determine if the colonizing rectal Escherichia coli population is the source. We performed an observational cohort study of men undergoing TPB (1 January 2010-6 February 2014) at the San Diego Veterans Affairs Medical Center. The primary outcome was clinically significant post-TPB infection. Rectal swabs were collected immediately before the biopsy and cultured selectively for fluoroquinolone-resistant gram-negative bacilli. Fluoroquinolone-resistant clinical and rectal E. coli isolates were compared using phylotyping, pulsed-field gel electrophoresis (PFGE) analysis, sequence typing, and virulence gene profiling. Rectal colonization with fluoroquinolone-resistant organisms (98% E. coli) was detected in 121 of 764 subjects (15.8%). Post-TPB infection was more common among fluoroquinolone-resistant-colonized subjects than noncolonized subjects (13/121 [10.7%] vs 8/649 [1.2%]; P < .001). Presence of fluoroquinolone-resistant colonizing E. coli was the most significant host characteristic associated with post-TPB infection (odds ratio, 4.5 [95% confidence interval, 1.2-18.2]; P = .03). Escherichia coli infection isolates (n = 18) did not differ from E. coli rectal culture isolates (n = 68) for any of 49 virulence genes or ST131 status (all P > .05). The rectal and clinical isolates of all 9 men with paired isolates had indistinguishable PFGE patterns and identical antimicrobial susceptibility profiles. The rectal colonizing E. coli population is the source for most fluoroquinolone-resistant post-TPB infections, regardless of clonal background or virulence traits. Screening cultures can identify nearly all patients at risk for fluoroquinolone-resistant post-TPB infection.

Fluoroquinolone Resistant Rectal Colonization Predicts Risk of Infectious Complications after Transrectal Prostate Biopsy

Infection after transrectal prostate biopsy has become an increasing concern due to fluoroquinolone resistant bacteria. We determined whether colonization identified by rectal culture can identify men at high risk for post-transrectal prostate biopsy infection. Six institutions provided retrospective data through a standardized, web based data entry form on patients undergoing transrectal prostate biopsy who had rectal culture performed. The primary outcome was anypost-transrectal prostate biopsy infection and the secondary outcome was hospital admission 30 days after transrectal prostate biopsy. We used chi-square and logistic regression statistical analysis. A total of 2,673 men underwent rectal culture before transrectal prostate biopsy from January 1, 2007 to September 12, 2013. The prevalence of fluoroquinolone resistance was 20.5% (549 of 2,673). Fluoroquinolone resistant positive rectal cultures were associated with post-biopsy infection (6.6% vs 1.6%, p <0.001) and hospitalization (4.4% vs 0.9%, p <0.001). Fluoroquinolone resistant positive rectal culture increased the risk of infection (OR 3.98, 95% CI 2.37-6.71, p <0.001) and subsequent hospital admission (OR 4.77, 95% CI 2.50-9.10, p <0.001). If men only received fluoroquinolone prophylaxis, the infection and hospitalization proportion increased to 8.2% (28 of 343) and 6.1% (21 of 343), with OR 4.77 (95% CI 2.50-9.10, p <0.001) and 5.67 (95% CI 3.00-10.90, p <0.001), respectively. The most common fluoroquinolone resistant bacteria isolates were Escherichia coli (83.7%). Limitations include the retrospective study design, nonstandardized culture and interpretation of resistance methods. Colonization of fluoroquinolone resistant organisms in the rectum identifies men at high risk for infection and subsequent hospitalization from prostate biopsy, especially in those with fluoroquinolone prophylaxis only.

Incidence of infectious complications following transrectal ultrasound-guided prostate biopsy in Calgary, Alberta, Canada: A retrospective population-based analysis.

We have seen an increased risk of infectious complications following transrectal ultrasound-guided prostate biopsy (TRUS-PB). Fluoroquinolone (FQ) antibiotics are common for prophylaxis prior to TRUS-PB. We evaluate whether increasing FQ resistance correlates with increased incidence of post-biopsy infectious complications at our institution. We conducted a retrospective chart and electronic health record review on 927 patients who underwent TRUS-PB between January and July of 2012 in Calgary, Alberta, Canada. We prospectively collected the following variables: age, pre-biopsy prostate-specific antigen, and date of biopsy. We documented presentation to an emergency department within 30 days of TRUS-PB for infectious and non-infectious complications. Of the 927 patients, 58 patients (6.3%) were admitted to the emergency department due to post-TRUS-PB complications within 30 days post-biopsy. The most common infectious complications were sepsis in 21 patients (2.2%), followed by urinary tract infection (UTI) in 9 (0.9%), and prostatitis in 4 (0.4%). We found that 83% of the septic episodes and 66.6% of the UTIs were attributed to ciprofloxacin resistant Escherichia coli (E. coli). The incidence of non-infectious complications was as follows: urinary retention in 12 (1.2%), hematuria in 9 (0.9%), and rectal bleeding in 8 (0.8%). Our results suggest an increased incidence of infectious complications caused by FQ resistant organisms following TRUS-PB. This finding could be attributed to increasing community resistance to ciprofloxacin. The current antimicrobial prophylactic regimen needs to be re-evaluated, and a novel approach may need to be considered.

PD2-01 INFECTION-RELATED HOSPITALIZATIONS AFTER PROSTATE BIOPSY IN A STATE-WIDE QUALITY IMPROVEMENT COLLABORATIVE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I1 Apr 2014PD2-01 INFECTION-RELATED HOSPITALIZATIONS AFTER PROSTATE BIOPSY IN A STATE-WIDE QUALITY IMPROVEMENT COLLABORATIVE Paul R. Womble, MD Maxwell W. Dixon, BS Susan M. Linsell, MHSA Zaojun Ye, MS James E. Montie, MD Brian R. Lane, MD, PhD David C. Miller, andMD, MPH Fank N. BurksMD Paul R. WomblePaul R. Womble More articles by this author , Maxwell W. DixonMaxwell W. Dixon More articles by this author , Susan M. LinsellSusan M. Linsell More articles by this author , Zaojun YeZaojun Ye More articles by this author , James E. MontieJames E. Montie More articles by this author , Brian R. LaneBrian R. Lane More articles by this author , David C. MillerDavid C. Miller More articles by this author , and Fank N. BurksFank N. Burks More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.133AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While transrectal prostate biopsy is the cornerstone of prostate cancer diagnosis, serious post-biopsy infectious complications are reported to be increasing. A better understanding of the true prevalence and microbiology of these events is needed to guide quality improvement in this area and ultimately better early detection practices. METHODS Using data from the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry, we identified all men who underwent transrectal prostate biopsy at 21 practices in Michigan from March 2012 through June 2013. Trained data abstractors recorded pertinent data, including prophylactic antibiotics and all biopsy-related hospitalizations within 30 days of the procedures. For a subset of patients, claims data and follow-up telephone calls were utilized for validation. All men admitted for an infectious complication were identified and their culture data obtained. We then compared the frequency of infection-related hospitalization rates across practices and according to antibiotic prophylaxis in concordance with AUA best practice recommendations. RESULTS The overall 30-day hospital admission rate following prostate biopsy was 0.97%, ranging from 0% to 4.2% across 21 MUSIC practices (Figure). Ninety-five percent of admissions were for infectious complications; the majority of cultures identified fluoroquinolone-resistant organisms. AUA concordant antibiotics were administered in 96.3% of biopsies. Patients receiving noncompliant antibiotic regimens were significantly more likely to be hospitalized for infectious complications (3.8% vs. 0.89%, p = 0.0026). CONCLUSIONS Infection-related hospitalizations occur in approximately 1% of men undergoing prostate biopsy in Michigan. Our findings suggest that many of these events could be avoided by implementing new protocols (e.g., culture-specific or augmented antibiotic prophylaxis) that both adhere with AUA best practice recommendations and address fluoroquinolone resistance. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e15 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Paul R. Womble More articles by this author Maxwell W. Dixon More articles by this author Susan M. Linsell More articles by this author Zaojun Ye More articles by this author James E. Montie More articles by this author Brian R. Lane More articles by this author David C. Miller More articles by this author Fank N. Burks More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Infection Related Hospitalizations after Prostate Biopsy in a Statewide Quality Improvement Collaborative

While transrectal prostate biopsy is the cornerstone of prostate cancer diagnosis, serious post-biopsy infectious complications are reported to be increasing. A better understanding of the true prevalence and microbiology of these events is needed to guide quality improvement in this area and ultimately better early detection practices. Using data from the MUSIC registry we identified all men who underwent transrectal prostate biopsy at 21 practices in Michigan from March 2012 to June 2013. Trained data abstractors recorded pertinent data including prophylactic antibiotics and all biopsy related hospitalizations. Claims data and followup telephone calls were used for validation. All men admitted to the hospital for an infectious complication were identified and their culture data were obtained. We then compared the frequency of infection related hospitalization rates across practices and according to antibiotic prophylaxis in concordance with AUA best practice recommendations. The overall 30-day hospital admission rate after prostate biopsy was 0.97%, ranging from 0% to 4.2% across 21 MUSIC practices. Of these hospital admissions 95% were for infectious complications and the majority of cultures identified fluoroquinolone resistant organisms. AUA concordant antibiotics were administered in 96.3% of biopsies. Patients on noncompliant antibiotic regimens were significantly more likely to be hospitalized for infectious complications (3.8% vs 0.89%, p=0.0026). Infection related hospitalizations occur in approximately 1% of men undergoing prostate biopsy in Michigan. Our findings suggest that many of these events could be avoided by implementing new protocols (eg culture specific or augmented antibiotic prophylaxis) that adhere to AUA best practice recommendations and address fluoroquinolone resistance.

Screening Rectal Culture to Identify Fluoroquinolone-resistant Organisms Before Transrectal Prostate Biopsy: Do the Culture Results Between Office Visit and Biopsy Correlate?

To investigate the performance of screening rectal cultures obtained 2 weeks before transrectal prostate biopsy to detect fluoroquinolone-resistant organisms and again at transrectal prostate biopsy. After institutional review board approval for observational study, we obtained a rectal culture on patients identified for a prostate biopsy but before antibiotic prophylaxis from September 12, 2011 to April 23, 2012. The specimen was cultured onto MacConkey agar with and without 1 μg/mL ciprofloxacin. We then obtained a second rectal culture immediately before prostate biopsy after 24 hours of ciprofloxacin prophylaxis. All cultures were blinded to the practitioner until the end of the study. Of 108 patients enrolled, 58 patients had both rectal cultures for comparison. The median time duration between cultures was 14 (6-119) days. There were 54 of 58 concordant pairs (93%), which included 47 negative cultures and 7 positive cultures; 2 patients (3%) who were culture negative from the first screening culture became positive at biopsy. Sensitivity, specificity, negative, positive predictive values, and area under the operator curve were 95.9%, 77.8%, 95.9%, 77.8%, and 0.868, respectively. When Pseudomonas spp. are removed from the analysis, the area under the curve is increased to 0.927. Screening rectal cultures 2 weeks before prostate biopsy has favorable test performance, suggesting screening cultures give an accurate estimate of fluoroquinolone-resistant colonization.

Editorial Comment

There are widespread international medical studies showing rising infections after prostate biopsy, corresponding to increases in antimicrobial resistance, particularly fluoroquinolones (FQs). 1 Batura D. Rao G.G. The national burden of infections after prostate biopsy in England and Wales: a wake-up call for better prevention. J Antimicrob Chemother. 2013; 68: 247-249 Crossref PubMed Scopus (57) Google Scholar , 2 Loeb S. van den Heuvel S. Zhu X. et al. Infectious complications and hospital admissions after prostate biopsy in a European randomized trial. Eur Urol. 2012; 61: 1110-1114 Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar There are many ways to tackle this problem, which include more selective screening and biopsy, changing the biopsy technique, or improving infectious prophylaxis, or both. Screening Rectal Culture to Identify Fluoroquinolone-resistant Organisms Before Transrectal Prostate Biopsy: Do the Culture Results Between Office Visit and Biopsy Correlate?UrologyVol. 82Issue 1PreviewTo investigate the performance of screening rectal cultures obtained 2 weeks before transrectal prostate biopsy to detect fluoroquinolone-resistant organisms and again at transrectal prostate biopsy. Full-Text PDF ReplyUrologyVol. 82Issue 1PreviewWe would like to thank the author of the editorial comment for the thorough review of our manuscript and for highlighting techniques to counter the current rise in prostate biopsy infections. Additionally, the rise in active surveillance will assuredly lead more patients “at risk” who have previous fluoroquinolone (FQ) exposure from past biopsies. In addition to improving patient selection and accuracy of prostate biopsies, a paradigm shift is needed regarding antimicrobial prophylaxis for transrectal prostate biopsy. Full-Text PDF

Infection in Patients Undergoing Transrectal Ultrasound Guided Prostate Biopsy

With the widespread popularity of prostate specific antigen testing, transrectal ultrasound (TRUS)-guided prostate biopsy has become a common urological procedure. The most common risks and complications associated with TRUS-guided biopsy include hematuria, hematospermia, and hematochezia. In addition, some patients develop urinary tract infections, acute bacterial prostatitis, bacteremia, and, eventually, urosepsis. Although it is commonly accepted that use of a prophylactic antimicrobial agent will lower the incidence of post biopsy infection, there is little consensus regarding the most appropriate antimicrobial regimens. Fluoroquinolone (FQ) was the best analyzed class, with higher numbers of studies and patients. According to recent data, occurrence of infectious complications after prostate biopsy has increased in recent years. Several recent studies have highlighted an increasing trend of infectious complications due to FQ resistant organisms among men undergoing TRUS guided prostate biopsy. TRUS guided prostate biopsy can result in significant morbidity, which is occurring at an increasing rate due to the increasing prevalence of FQ resistant Escherichia coli in rectal flora. Risk factors for harboring FQ resistant E. coli should be considered before prostate biopsy, and rectal swab screening cultures may provide useful evidence for selection of appropriate antimicrobials for prophylaxis and treatment of prostate biopsy-associated infections. The estimate of the incidence of sepsis following TRUS-guided prostate biopsy is low; however, the initial treatment of patients with prophylaxis failure and identification of antibiotic-resistant bacterial strains might be the most important means for prevention of urosepsis.