Post-biopsy Infectious Complications Research Articles

Infectious complications of transrectal prostate biopsy in patients receiving targeted antibiotic prophylaxis after urethral and rectal swab versus standard prophylaxis: A prospective comparative study

BackgroundTo evaluate the role of targeted antibiotic prophylaxis (TAP) after rectal and urethral swab cultures compared to empiric antibiotic prophylaxis (EAP) for the prevention of infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-Bx). MethodsWe conducted a prospective comparative study on 141 patients who underwent TRUS-Bx and were allocated in two groups. The first group (n = 71) received EAP with ciprofloxacin and the second (n = 70) received TAP according to rectal and urethral cultures. Post-biopsy infectious complications rates were compared between the two groups. Fluoroquinolone resistance (FQ-R) in the urethral and rectal swabs was recorded. Baseline characteristics were analyzed to assess their relationship with infectious complications and antibiotic resistance. ResultsA total of 8 infectious complications were observed, 7 of them in the EAP group (9.85%) and 1 in the TAP group (1.4%). There was a statistically significant difference in febrile UTIs between the two groups (6 vs 0, P = 0.028). FQ-R rate was 4.3% and 12.9% for rectal and urethral samples, respectively. Recent antibiotic exposure was associated with higher post-biopsy infection rates for EAP group and FQ-R rates for TAP group. ConclusionCombination of rectal and urethral swab cultures for TAP was able to detect FQ-R bacteria carriers and was associated with fewer infectious complications compared to EAP.

The effect of povidone-iodine rectal cleansing on post-biopsy infectious complications

Objective To evaluate the effect of pre-biopsy povidone-iodine rectal cleansing on post-biopsy hospitalization rates due to prostate biopsy-related infectious complications. Material and methods In this retrospective study, we reviewed 552 patients who underwent ultrasonography-guided transrectal prostate biopsy between 2014 and 2022. Group 1, 361 patients (January 2014–October 2020) were not applied povidone-iodine rectal cleansing, and group 2, 191 patients (November 2020–January 2022) were applied povidone-iodine rectal cleansing since we changed our biopsy protocol. All patients were given the same antibiotic prophylaxis, ciprofloxacin 500 mg, and ornidazole 500 mg twice daily starting 24 h before the biopsy and lasting a total of 5 days. Sodium phosphate enema was applied to all patients in the biopsy morning. The outcome was the hospitalization rates of patients because of infectious complications a month after the biopsy. Results No patients were hospitalized in the povidone-iodine rectal cleansing group because of biopsy related complications. The hospitalization rate of group 1 was 3% and there was a statistical difference between groups. Conclusion The povidone-iodine solution is cheap, safe and easy to apply. The povidone-iodine rectal cleansing method seems to decrease infectious complications related to prostate biopsy procedure, but we need a randomized controlled trial to confirm our study. Trial registration We got permission for this retrospective study from the Karabuk university ethics council with the number 2021/649 on 1 October 2021.

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.

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

Positive urine culture prior to transrectal prostate biopsy was not associated with infectious complications development.

Prostate cancer is one of the most common cancers worldwide. Its histological diagnosis is based on prostate biopsy. The transrectal procedure is one of the most common procedures performed by urologists. Although it is considered safe, post-biopsy infectious complications are frequently observed in practice. The aim of this study is to investigate the value of urine culture before the transrectal biopsy. Secondly, we assessed potential risk factors for infectious complications following TR-PB. We performed a retrospective analysis of all patients who underwent urine culture tests before transrectal prostate biopsy between January 2019 and July 2020. The inclusion criteria for the study were all indications for prostate biopsy (PSA>4ng/mL or abnormal digital rectal examination). Baseline characteristics and the incidence of post-biopsy urinary tract infection were compared between patients showing positive pre-biopsy culture results and those showing negative findings. Multivariate logistic regression analyses were used to determine risk factors for infectious complications following TR-PB. Out of 163 patients included in our study, 19 patients (11.65%) had positive urine culture results before the biopsy. Age (P=0.068); history of hospitalization (P>0.999), history previous of quinolone use (P=0.75), history of UTI (P=0.64); median PSA level at diagnosis (P=0.267); prostate volume (P=0.78); post-void residual volume (P=0.374); percentage of patients testing positive for cancer on biopsy (P=0.81); and percentages of patients with a history of biopsy (P=0.889), diabetes mellitus (P=0.524), hypertension (P=0.714) and immunosuppressive medication use (P>0.999) were similar between the two groups. One patient in the positive urine culture group had post-biopsy prostatitis. However, 3.24% (five patients) of the negative urine culture group had the disease (P=0.789) (four patients with prostatitis and one with epididymitis). Among them, four patients were diagnosed by urine culture at the time of post-biopsy urinary tract infection. Multivariate logistic regression analysis demonstrated that history of hospitalization and history of previous quinolone use were risk factors for infection after transrectal prostate biopsy. Our study suggests that systematically performing urine cultures before transrectal prostate biopsy does not reduce the rate of infectious complications after biopsy. Positive pre-biopsy cultures were not associated with the development of post-biopsy infectious complications.

Antimicrobial resistance profiles for bacteria isolated from rectal swabs in patients candidate for prostate biopsy

Objective: Infection is one of the common complications of post-prostate biopsy. Therefore, prophylaxis with fluoroquinolones and/or cephalosporins is recommended. We aimed to evaluate the prevalence of antibiotic-resistant bacteria isolated from rectal swabs in candidates for transrectal ultrasound-guided (TRUS) biopsy. The possible patient’s related risk factors attributing to resistance to antibiotics were also assessed. Methods: This cross-sectional study was performed on 126 male patients who were candidates for TRUS biopsy. Rectal swabs were collected and the samples were transferred to the laboratory in Amies transport medium during 2 hours and cultured on MacConkey agar with ciprofloxacin 1 mg/L and ciprofloxacin-resistant strains were identified. Kirby-Bauer disc diffusion method was used to determine the antibiotic susceptibility of the isolates. Results: In total, 59 bacterial isolates were obtained, which were Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa, respectively, in terms of frequency. They showed the lowest resistance to levofloxacin. Smoking was associated with positive culture results. Age was a factor with a significant effect on carrying ciprofloxacin-resistant strains. Conclusion: Ciprofloxacin resistance was high in almost all strains, but post-biopsy infectious complications were very low. Level of evidence: Not applicable

The Effect of Different Types of Prostate Biopsy Techniques on Post-Biopsy Infectious Complications.

The aim of our study was to compare infectious complication rates between different prostate biopsy techniques with various number of biopsy cores. In this retrospective study, all patients from 2 hospitals who underwent prostate biopsy between 2012 and 2019 were identified. Cohorts with different types of prostate biopsies were compiled within these hospitals. Primary outcome measure was any registered infectious complication within 7 days post-biopsy. Secondary outcomes were infectious complications within 30 days, hospitalization and bacteremia. To compare the risk of infection following different prostate biopsy techniques, data was fitted into a logistic regression model adjusting for potential confounders. In total, 4,233 prostate biopsies in 3,707 patients were included. After systematic transrectal ultrasound-guided prostate biopsy (TRUSPB; 12±1.4 biopsy cores), 4.0% (2,607) of all patients had infectious complications within 7 days post-biopsy. Transperineal magnetic resonance imaging (MRI)-ultrasound fusion guided prostate biopsy (16±3.7 biopsy cores) was associated with significantly lower infection rates than systematic TRUSPB (adjusted OR: 0.29 [0.09-0.73] 95% confidence interval [CI]). Transrectal targeted MRI-ultrasound fusion guided prostate biopsy (3.1±0.8 biopsy cores) and transrectal targeted in-bore MRI guided prostate biopsy (2.8±0.8 biopsy cores) also showed fewer infectious complications than systematic TRUSPB (adjusted OR: 0.41 [0.12-1.12] 95% CI and 0.68 [0.37-1.20] 95% CI, respectively). Transperineal prostate biopsy, or transrectal prostate biopsy with reduced number of biopsy cores, could lower the risk of infectious complications.

MP43-11 GEOGRAPHIC VARIATION OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSY IN THE UNITED STATES: RESULTS FROM A PRIVATELY INSURED COHORT

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV (MP43)1 Sep 2021MP43-11 GEOGRAPHIC VARIATION OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSY IN THE UNITED STATES: RESULTS FROM A PRIVATELY INSURED COHORT Jeffrey Morrison, Boris Gershman, Badrinath Konety, Peter Clark, Michael Bronsert, Alexander Kutikov, Anessa Sax-Bolder, Miguel Rodriguez-Homs, Granville Lloyd, Rodrigo Rodrigues Pessoa, and Simon Kim Jeffrey MorrisonJeffrey Morrison More articles by this author , Boris GershmanBoris Gershman More articles by this author , Badrinath KonetyBadrinath Konety More articles by this author , Peter ClarkPeter Clark More articles by this author , Michael BronsertMichael Bronsert More articles by this author , Alexander KutikovAlexander Kutikov More articles by this author , Anessa Sax-BolderAnessa Sax-Bolder More articles by this author , Miguel Rodriguez-HomsMiguel Rodriguez-Homs More articles by this author , Granville LloydGranville Lloyd More articles by this author , Rodrigo Rodrigues PessoaRodrigo Rodrigues Pessoa More articles by this author , and Simon KimSimon Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002064.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Clinical practice guidelines recommend antibiotic prophylaxis for transrectal prostate biopsy. However, infectious complications following biopsy have been an emerging concern due to the antibiotic resistance and lack of an established surveillance system. National trends and geographic variation for post-biopsy infectious complications remains poorly understood. Herein, we sought to elucidate trends and variation of infectious complications from a national privately insured database. METHODS: Using MarketScan, we identified all men who underwent a transrectal prostate biopsy due to prostate cancer screening from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes on a national and state level. We analyzed the unadjusted and adjusted rates of infectious complications from ER visits and hospital admission per 100 prostate biopsies. RESULTS: During the study interval, we identified 193,490 patients who underwent a prostate biopsy. The mean age was 57.6 years (SD: 5.0). Overall, national rates of post-biopsy infectious complications for ER visits and hospital admissions were 0.4 and 0.9 per 100 prostate biopsies, respectively. Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 to 0.3 in 2015 (p=0.83), and 0.9 hospital admissions per 100 prostate biopsies in 2010 to 0.8 in 2015 (p=0.58). At a state level, and averaged over the time period 2010 to 2015, the states with the five highest and five lowest rates of ER visits and hospital admission per 100 prostate biopsies are displayed in Table 1. For ER visits, South Dakota was highest (1.71) and New Hampshire was lowest (0.08). For hospital admissions, Alaska was highest (1.74) and Colorado was lowest (0.39). CONCLUSIONS: While ER visits and hospital admissions attributable from infectious complications due to prostate biopsies remain relatively stable, significant variations exist on a state level. Further research is needed to assess the causes for this regional variation for these infectious complications from prostate biopsies. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e785-e786 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Morrison More articles by this author Boris Gershman More articles by this author Badrinath Konety More articles by this author Peter Clark More articles by this author Michael Bronsert More articles by this author Alexander Kutikov More articles by this author Anessa Sax-Bolder More articles by this author Miguel Rodriguez-Homs More articles by this author Granville Lloyd More articles by this author Rodrigo Rodrigues Pessoa More articles by this author Simon Kim More articles by this author Expand All Advertisement Loading ...

Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography-guided prostate biopsy.

To evaluate the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections following transrectal ultrasonography-guided prostate biopsy. In this prospective interventional study, patients aged between 40 and 70years with clinical indications for transrectal ultrasonography-guided prostate biopsy were enrolled. Consecutive patients who received intraprostatic injection of amikacin coupled with oral ciprofloxacin were compared with historical controls receiving only prophylactic oral fluoroquinolones prior to biopsy. Patients were followed for 7days after biopsy for signs and symptoms of infection. A total of 210 patients were included in this study (mean age 65.7±7.8years). Among patients without intraprostatic injection, nine (8.6%) developed infectious complications (lower urinary tract infection in seven patients, and prostatitis in two), which led to hospitalization in six patients (5.7%). None of the patients who received intraprostatic antibiotic injection developed infectious complications. The difference in the incidence of post-transrectal ultrasonography-guided biopsy infections between the two groups was statistically significant (P=0.003). Local intraprostatic antibiotic injection during transrectal ultrasonography-guided prostate biopsy adjuvant to oral fluoroquinolones can significantly reduce the rate of post-biopsy infectious complications.

MP58-18 TRANSRECTAL MRI/US FUSION BIOPSY DOUBLES THE RISK OF INFECTIOUS HOSPITALIZATION - ANALYSIS OF A STATEWIDE COLLABORATIVE

INTRODUCTION AND OBJECTIVE: Infectious complications following prostate biopsy remain a significant cause of patient morbidity driven by increasing antibiotic resistance. Fusion biopsy and transperineal biopsy are recently introduced biopsy techniques with increasing levels of adoption. We aim to evaluate effect of biopsy type with infectious complications. METHODS: The Michigan Urologic Surgery Improvement Collaborative (MUSIC) maintains a high quality, prospective prostate cancer registry with biopsy outcomes manually abstracted and reported at 30 days post-procedure. A review of all patients undergoing prostate biopsy from January 2012 – August 2019 was performed. Patient characteristics, biopsy-type, and 30-day complications were analyzed. Multivariable analysis was performed to assess risk factors for infectious complications and hospitalizations. RESULTS: A total of 66,525 biopsies were performed, of which 62,040 (93.26%) were transrectal ultrasound guided (TRUS), 1068 (1.61%) were transperineal (TP), 3322 (4.99%) were transrectal MRI-fusion (TRF), and 95 (0.14%) were transperineal MRI-fusion (TPF). In total, 1081 (1.62%) patients experienced an infectious-complication and 515 (0.77%) were hospitalized with for an infection-related indication. There were 83 (2.5%) men in the TRF biopsy group with an infectious complication compared to 989 (1.59%) in the TRUS, 9 (0.84%) in the TP and 0 (0%) in the TPF groups. When controlling for patient characteristics, TRF biopsy type was associated with increased odds of an infectious complication (OR 1.62, p<0.001) and infectious hospitalization (OR 2.16, p<0.001) when compared to TRUS patients. Total cores and diabetes were associated with an increased risk of an infectious complication. The transperineal approach and biopsies performed after the implementation of a state-wide antibiotic pathway designed to decrease these complications were less likely to result in an infection-related hospitalization. CONCLUSIONS: Transrectal fusion biopsy was associated with an increased risk of post-biopsy infectious complications and hospitalizations. Alternative biopsy techniques, including transperineal fusion biopsy, may mitigate this risk.Source of Funding: Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnership program

The Role of Ciprofloxacin Resistance and Extended-spectrum beta-lactamase (ESBL) Positivity in Infective Complications Following Prostate Biopsy.

To evaluate ciprofloxacin resistance (CR) and extended-spectrum beta-lactamase (ESBL) positivity in the rectal flora, antibiotic prophylaxis received, and post-biopsy infectious complications in patients undergoing prostate biopsy. Rectal swab samples collected from 99 patients suspected of prostate cancer two days before prostate biopsy were tested for microbial susceptibility and ESBL production. All patients were given standard ciprofloxacin and ornidazole prophylaxis. Ten days post-biopsy, the patients were contacted by phone and asked about the presence of fever and/or symptoms of urinary tract infection. Escherichia coli (E.coli) was the most common isolate detected in 82 (75%) of the rectal swab samples. Ciprofloxacin resistance was detected in 33% and ESBL positivity in 22% of the isolated E.coli strains. No microorganisms other than E.coli were detected in blood, urine, and rectal swab cultures of patients who developed post-biopsy complications. CR E.coli strains also showed resistance to other antimicrobial agents. The lowest resistance rates were to amikacin (n = 2, 7.4%) and nitrofurantoin (n = 1, 3.7%). Seven patients (7.6%) developed infectious complications. There was no significant difference in probability of hospitalization between patients with CR strains (14.3%) and those with ciprofloxacin-susceptible strains (14.3% vs. 4.7%; p = 0.194). However, strains that were both CR and ESBL-positive were associated with significantly higher probability of hospitalization compared to ciprofloxacin-susceptible strains (28.6% vs. 3.8%; p = 0.009). The higher rate of infectious complications with CR and ESBL-positive strains suggests that the agents used for antibiotic prophylaxis should be reevaluated. It is important to consider local resistance data when using extended-spectrum agents to treat patients presenting with post-biopsy infectious complications.

Does The Use Of Povidone Iodine Suppository Decrease The Infective Complications Of TRUS Guided Prostate Biopsies? A Randomized Prospective Study

Abstract Purpose Trans rectal ultrasound guided prostate biopsy can lead to urinary tract infections in 3% to 11% and sepsis in 0.1% to 5% of patients. We investigated the prevalence of different organisms among rectal flora in our community, the virulence of the most prevalent one and the effect of combined standard antibiotic prophylaxis with the use of povidone iodine suppository prior to TRUS guided biopsy of the prostate in decreasing post biopsy infectious complications. Materials and Methods Between December 2016 and September 2017, 50 men were prospectively randomized to povidone iodine rectal cleansing (50) or no cleansing (50) before transrectal ultrasound guided prostate biopsy. Rectal swab cultures, urinalaysis, urine cultures, total leukocytic count and CRP were obtained before transrectal ultrasound guided prostate biopsy. Patients received ciprofloxacin prophylaxis and attended at 1 week follow up visit. Urinalaysis, urine cultures, total leukocytic count and CRP were obtained at follow up visit and asked about fever, UTI symptoms and examined for prostatitis and epididymo-orchitis. Results Infectious complications were observed in 5 (10%) patients, including 2 (8%) in the treatment group and 3 (12%) in the control group (p = 0.0001). No cases of sepsis were recorded. Mean increase of CRP was higher in control group (P = 0.011). 17 patients among study population had Ciprofloxacin resistant rectal organisms on rectal swab cultures (34%). Conclusion Usage of pre TRUS-Bx intrarectal povidone iodine suppository together with standard antibiotic prophylaxis with ciprofloxacin helps decrease post procedure infectious complications and proved to decrease incidence of infection among patients having ciprofloxacin resistant rectal organisms.

Preoperative urine culture is unnecessary in asymptomatic men prior to prostate needle biopsy.

To determine the clinical utility of preoperative urine cultures in asymptomatic men undergoing prostate needle biopsy (PNB). One hundred fifty asymptomatic men had urine cultures obtained 14-days prior to PNB. As per study protocol, positive cultures were not treated. Antibiotic prophylaxis prior to PNB included ciprofloxacin 500mg the night before and morning of the biopsy. Repeat urine cultures were obtained immediately prior to PNB with colony-forming units (CFUs) annotated. Infectious complications post-biopsy were recorded. Of the 150 men, six patients (4%) had evidence of asymptomatic bacteriuria with>10,000CFU/mL on office urine culture. Repeat urine cultures on morning of biopsy in all 150 patients noted a mean bacterial count of 55CFU/mL (range 0-1000). All six patients with positive office urine cultures had<100CFU/mL at time of PNB. Following biopsy, four patients (2.7%) developed an infectious complication including two with sepsis and two with culture-positive UTIs. The causative organism in all cases was quinolone-resistant E. coli. None of the six patients with preoperative positive urine cultures developed an infectious complication following PNB. In this prospective observational study, under 5% of asymptomatic men had positive office cultures prior to PNB. Furthermore, repeat urine culture on the morning of biopsy showed resolution in these patients, and none developed post-biopsy infectious complications. Routine office urine culture in the asymptomatic male prior to PNB was unnecessary.

Formalin disinfection of prostate biopsy needles may reduce post-biopsy infectious complications.

We sought to determine whether formalin disinfection of prostate biopsy needles between cores reduces post-biopsy urinary tract infections (UTIs). We reviewed a single-surgeon experience of transrectal prostate biopsies from 2010 to 2014. Biopsies were performed in either an operative suite, where 10% formalin was used to disinfect the needle tip between each biopsy core, or an outpatient clinic, where formalin was not used. Our primary outcome was post-biopsy UTI rates, defined as a positive urine culture within 30 days of biopsy. Infection severity was characterized by the need for admission. Patient demographics, prostate size, prior biopsies, prior UTIs, pre-biopsy antibiotics and cultures and post-biopsy cultures were analyzed. Logistic regression was used to assess predictors of post-biopsy UTIs. Statistical significance was defined as P<0.05. A total of 756 patients were included for analysis, including 253 who received formalin disinfection and 503 who did not. Of these, 32 patients (4.2%) experienced post-biopsy UTIs, with 8 requiring admission (all without formalin use). Infection rates were more than double in the group that did not receive formalin (5.2% vs 2.3%, P=0.085). More patients in the formalin group had undergone prior biopsies (73.9% vs 31.8%, P<0.001). On multivariable analysis, prior UTI (odds ratio (OR) 3.77, P=0.006) was a significant predictor for post-biopsy infection, whereas formalin disinfection trended towards a protective effect (OR 0.41, P=0.055). Infectious complications following prostate biopsy may be mitigated by the use of formalin disinfection of the biopsy needle between cores.

MP36-05 IS PRE-OPERATIVE URINE CULTURE NECESSARY IN ASYMPTOMATIC MEN PRIOR TO TRANSRECTAL PROSTATE NEEDLE BIOPSY?

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia II1 Apr 2016MP36-05 IS PRE-OPERATIVE URINE CULTURE NECESSARY IN ASYMPTOMATIC MEN PRIOR TO TRANSRECTAL PROSTATE NEEDLE BIOPSY? David Qi, Kathleen Lehman, Kalyan Dewan, Girish Kirimanjeswara, and Jay Raman David QiDavid Qi More articles by this author , Kathleen LehmanKathleen Lehman More articles by this author , Kalyan DewanKalyan Dewan More articles by this author , Girish KirimanjeswaraGirish Kirimanjeswara More articles by this author , and Jay RamanJay Raman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1639AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Infectious complications following transrectal prostate needle biopsy (PNB) continue to rise. These infections are thought to occur from translocation of bacteria in the rectal vault into the highly vascular prostate. The contribution (if any) of pre-biopsy bacteriuria on infectious sequelae following the procedure remains unclear. We investigate the utility of pre-operative urine culture in a cohort of patients undergoing PNB. METHODS Between March 2013 and August 2015, 150 asymptomatic male patients were prospectively enrolled in an IRB approved study investigating infections following PNB. Routine office urine cultures were obtained 14-days prior to PNB with reports of 10,000 flora or greater recorded. Per study protocol, positive cultures were not treated. Antibiotic prophylaxis regimen prior to PNB included Ciprofloxacin 500mg the day before and morning of the biopsy. Urine cultures were obtained immediately prior to PNB with plating onto Mueller- Hinton agar plates with colony forming units (CFUs) determined after incubation at 37°C for 48 hours. Infectious complications post-biopsy were recorded. RESULTS 150 men with a mean PSA of 11.4 ng/mL were included. 64% were undergoing an initial biopsy and 19% had a history of antibiotic use within the previous 6 months. Six patients (4%) had evidence of asymptomatic bacteriuria on office urine culture including 2 with > 100,000 CFU/mL E.Coli, 1 with > 100,000 CFU/mL Klebsiella, 1 with 10,000 CFU/mL E.Coli, and 2 with 10,000 CFU/mL mixed flora. Just prior to PNB, repeat urine cultures in all 150 patients noted a mean bacterial count of 55 CFU/mL with the highest urine bacterial count being 1000 CFU/mL. All 6 patients with positive office urine cultures had < 100 CFU/mL just prior to PNB. Following PNB, 4 patients (2.7%) developed an infectious complication including 2 with sepsis and 2 with culture positive UTIs. The causative organism in all cases was quinolone resistant E. Coli. None of the 6 patients with pre-operative positive urine cultures developed an infectious complication following PNB. CONCLUSIONS In this prospective study of 150 patients, < 5% had positive office cultures prior to PNB. Repeat urine culture on the morning of biopsy showed resolution in these patients and none developed post-biopsy infectious complications. Routine office urine culture in the asymptomatic male prior to PNB is likely unnecessary © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e491 Advertisement Copyright & Permissions© 2016MetricsAuthor Information David Qi More articles by this author Kathleen Lehman More articles by this author Kalyan Dewan More articles by this author Girish Kirimanjeswara More articles by this author Jay Raman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

An antimicrobial prophylaxis protocol using rectal swab cultures for transrectal prostate biopsy.

To evaluate the benefit of an antimicrobial prophylaxis protocol using rectal swab cultures in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy in our Veterans Affairs population. Between June 1, 2013, and June 1, 2014, we implemented an antimicrobial prophylaxis protocol using rectal swab cultures on selective media containing ciprofloxacin for all men scheduled for TRUS-guided prostate biopsy. Data from 2759 patients from Jan 1, 2006 to May 31, 2013, before protocol implementation served as historical controls. Patients with fluoroquinolone (FQ)-susceptible organisms received FQ monotherapy, while those with FQ-resistant organisms received targeted prophylaxis. Our objective was to compare the rate of infectious complications 30 days after prostate biopsy before and after implementation of our antimicrobial protocol. One hundred and sixty-seven patients received rectal swab cultures using our protocol. Seventeen (14 %) patients had FQ-resistant positive cultures. Patients with positive FQ-resistant culture results were more likely to have had a history of previous prostate biopsy and a positive urine culture in the last 12 months (p = 0.032, p = 0.018, respectively). The average annual infectious complication rate within 30 days of biopsy was reduced from 2.8 to 0.6 % before and after implementation of our antimicrobial prophylaxis protocol using rectal swab cultures, although this difference was not statistically significant (p = 0.13). An antimicrobial prophylaxis protocol using rectal culture swabs is a viable option for prevention of TRUS-guided prostate biopsy infectious complications. After implementation of an antimicrobial prophylaxis protocol, we observed a nonsignificant decrease in the rate of post-biopsy infectious complications when compared to historical controls.

Culture Directed Antibiotic Prophylaxis Reduces Post-Prostate Biopsy Infectious Complications in the Community: A “How-to” for Urologists in the Trenches

IntroductionThe rate of post-prostate biopsy infection is increasing. We noted this trend in our practice and began using prebiopsy rectal swab cultures to direct antibiotic prophylaxis. Clinical investigation has shown that culture directed antibiotic prophylaxis is effective. We report our methods and results as validation that culture directed antibiotic prophylaxis works in the community. MethodsWe retrospectively reviewed the charts of 686 consecutive patients who underwent transrectal prostate biopsy from March 2010 to April 2013. The electronic medical record was queried for the antibiotic prophylaxis used, rectal swab culture, post-biopsy infection, culture data and post-biopsy hospitalization if applicable. Prebiopsy rectal swab was incorporated into our practice in May 2012. Each patient received 3 days of fluoroquinolone prophylaxis or culture directed antibiotic prophylaxis. If antibiotic resistance to standard fluoroquinolone prophylaxis was identified, antibiotic prophylaxis was adjusted appropriately. ResultsOf 543 patients who received standard fluoroquinolone prophylaxis 17 (3.1%) had infectious complications. Eight patients were hospitalized for post-biopsy sepsis and 4 received outpatient treatment for urinary tract infection. A total of 143 patients underwent prebiopsy rectal swabs and received culture directed antibiotic prophylaxis. Compared to standard antibiotic prophylaxis no patient treated with culture directed antibiotic prophylaxis after a rectal swab had infectious complications (p = 0.03). However, 19.5% of the patients in this group had resistant bacteria requiring alternative antibiotic prophylaxis. ConclusionsA prebiopsy rectal swab to direct antibiotic prophylaxis decreased post-biopsy infectious complications in the community setting. The strategy is simple and it improves patient safety.

Single Dose of Levofloxacin versus Three Dosages for Prophylaxis in Prostate Biopsy.

Transrectal ultrasound-guided core prostate biopsy is a key event in the diagnosis of prostate cancer, transient side events such as local pain, haematuria, haematospermia, dysuria, and rectal bleeding are reported in a large number of patients. Antimicrobial agents lower the incidence of postbiopsy infectious complications. The timing and duration of the regimen and the route of administration remain controversial. We developed a standard prophylactic regimen, in which safety and efficiency were maximized, while costs and variability were minimized. Accordingly we prospectively evaluated 425 consecutive patients, who underwent outpatient transrectal ultrasound-guided prostate biopsy after a single dose versus three doses of levofloxacin.

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.

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.

Reduction in Hospital Admission Rates Due to Post-Prostate Biopsy Infections After Augmenting Standard Antibiotic Prophylaxis

We evaluated the incidence of infectious complications requiring hospitalization after transrectal ultrasound guided prostate biopsy, comparing an augmented regimen of antibiotic prophylaxis to the standard regimen, and established cost-effectiveness at our center. Our standard antibiotic prophylaxis regimen consisted of 3 days of ciprofloxacin or Bactrim™ DS in the perioperative period. An increase in hospital admissions related to infection after transrectal ultrasound guided biopsy from January 2010 through December 2010 led us to initiate an augmented regimen of 3 days of ciprofloxacin or Bactrim DS in addition to 1 dose of intramuscular gentamicin before biopsy from January 2011 to December 2011. Urine and blood cultures along with bacterial susceptibilities were obtained at admission and compared between the 2 groups. Cost analysis was done to determine the cost-effectiveness of standard and augmented regimens. The rate of hospitalization due to post-biopsy infections was 3.8% (11 patients among 290 biopsies) in 2010, which decreased to 0.6% (2 patients among 310 biopsies) in 2011 (p <0.001). Of the admitted patients who received standard prophylaxis, 73% had fluoroquinolone resistant Escherichia coli urinary infection and/or bacteremia and only 9% had strains resistant to gentamicin. Multivariate analysis showed that the standard regimen was significantly associated with hospital admission due to post-biopsy infection (HR 2.078 ± 0.84, p = 0.013). The augmented regimen resulted in a cost savings of $15,700 per 100 patients compared to the standard regimen. The addition of gentamicin to current prophylactic regimens significantly reduced the rate of hospitalization for post-biopsy infectious complications and was shown to be cost-effective.