Evaluation of targeted antimicrobial prophylaxis for transrectal ultrasound guided prostate biopsy: a prospective cohort trial

Teresa R Zembower, Kelly M Maxwell, Robert B Nadler, John Cashy, Marc H Scheetz, Chao Qi, Anthony J Schaeffer, Teresa R Zembower, Kelly M Maxwell, Robert B Nadler, John Cashy, Marc H Scheetz, Chao Qi, Anthony J Schaeffer

Abstract

Background: We evaluated the effectiveness of targeted antimicrobial prophylaxis in transrectal ultrasound guided prostate biopsy (TRUSP).

Methods: A prospective, non-randomized cohort study was conducted. Rectal swab cultures plated on non-selective blood agar and on selective MacConkey agar supplemented with ciprofloxacin identified ciprofloxacin-susceptible and -resistant gram-negative bacteria (CS-GNB and CR-GNB). Patients with CS-GNB received ciprofloxacin while those with CR-GNB received directed prophylaxis. Infectious complications were defined clinically and microbiologically within 30 days after TRUSP. Data were derived at 7 and 30 days post procedure by questionnaires and electronic medical records. We hypothesized that there would be no difference in the infectious outcomes among the CS and CR groups.

Results: From November 1, 2012 to March 31, 2015, 510 men completed the study; 430 (84.3%) had CS-GNB and 80 (15.7%) had CR-GNB. 484 (94.9%) completed the study per protocol, while 26 (5.1%) had an intention-to-treat (ITT) analysis. Of the 484, 475 (98.1%) had no infections, nine (1.9%) had infections, six of which (1.2%) were culture-proven (CP). The nine infections were as follows: five (1.0%) uncomplicated UTIs, one (0.2%) complicated UTI, and three (0.6%) urosepsis. One case of uncomplicated UTI and two cases of urosepsis were not CP, but were diagnosed clinically. ITT outcomes were similar. The infection rates were not statistically different between the CS-and CR-GNB patients (p-value = 0.314; 95% CI 0.8-3.3). The four patients with complicated UTIs or sepsis were hospitalized for a mean of 2.6 days and discharged without sequelae. Of the nine infections, three were antimicrobial prophylaxis failures (two ciprofloxacin and one amikacin); three were likely due to failure of the collection or processing of the rectal swab or increasing bacterial resistance between the time of swab collection and biopsy, and three developed clinical infections with no isolate recovered.

Conclusions: Targeted antimicrobial prophylaxis follows the principles of antimicrobial stewardship and achieved a low rate of infectious complications with limited morbidity and no sequelae. This individualized method of prophylaxis may be widely applied. Further studies are needed to explore reasons for targeted prophylaxis failure and to determine comparative efficacy of non-ciprofloxacin-containing targeted prophylaxis regimens.

Trial registration: ClinicalTrials.gov. NCT01659866 . Registered 9 July 2012. First patient enrolled 1 November 2012.

Keywords: Antibacterial agents; Biopsy; Infection; Urology.

Figures

Fig. 1
Fig. 1
Study Subjects. TRUSP, Transrectal ultrasound guided prostate biopsy
Fig. 2
Fig. 2
Antimicrobial Susceptibility Profile of 76* Ciprofloxacin-resistant E. coli Isolates. Tmp/smx, Trimethoprim/Sulfamethoxazole. *Not all isolates were tested for all antimicrobial agents, **Number of isolates tested for this particular antimicrobial agent, ***Carbapenems tested included imipenem (n = 49), meropenem (n = 76)

References

    1. Loeb S, Carter HB, Berndt SI, et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011;186:1830–1834. doi: 10.1016/j.juro.2011.06.057.
    1. Loeb S, Vellekoop A, Ahmed HU, et al. Systematic review of complications of prostate biopsy. Eur Urol. 2013;64:876–892. doi: 10.1016/j.eururo.2013.05.049.
    1. Carlson WH, Bell DG, Lawen JG, et al. Multi-drug resistant E.Coli urosepsis in physicians following transrectal ultrasound guided prostate biopsies--three cases including one death. Can J Urol. 2010;17:5135–5137.
    1. Zani EL, Clark OA, Rodrigues Netto N Jr. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev. 2011; doi:10.1002/14651858.
    1. Taylor A, Murphy A, Cashy J, et al. Targeted antimicrobial prophylaxis using rectal swab (RS) cultures in men undergoing transrectal ultrasound guided prostate biopsy (TRUSP) significantly reduces the incidence of post procedure infectious complications and cost of care. Presented at the 2011 American Urological Association Annual Meeting; May 12, 2011; Washington, DC.
    1. Nam RK, Saskin R, Lee Y, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol. 2010;183:963–968. doi: 10.1016/j.juro.2009.11.043.
    1. Womble PR, Linsell SM, Gao Y, et al. A statewide intervention to reduce hospitalizations after prostate biopsy. J Urol. 2015;194:403–409. doi: 10.1016/j.juro.2015.03.126.
    1. Carignan A, Roussy JF, Lapointe V, et al. Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: time to reassess antimicrobial prophylaxis? Eur Urol. 2012;62:453–459. doi: 10.1016/j.eururo.2012.04.044.
    1. Mosharafa AA, Torky MH, El Said WM, et al. Rising incidence of acute prostatitis following prostate biopsy: fluoroquinolone resistance and exposure is a significant risk factor. Urology. 2011;78:511–514. doi: 10.1016/j.urology.2011.04.064.
    1. Dalhoff A. Global fluoroquinolone resistance epidemiology and implications for clinical use. Interdiscip Perspect Infect Dis. 2012; doi:10.1155/2012/97627.
    1. Adibi M, Hornberger B, Bhat D, et al. Reduction in hospital admission rates due to post-prostate biopsy infections after augmenting standard antibiotic prophylaxis. J Urol. 2013;189:535–540. doi: 10.1016/j.juro.2012.08.194.
    1. Liss MA, Kim W, Moskowitz D, et al. Comparative effectiveness of targeted vs empirical antibiotic prophylaxis to prevent sepsis from transrectal prostate biopsy: a retrospective analysis. J Urol. 2015;194:397–402. doi: 10.1016/j.juro.2015.03.110.
    1. Gil-Vernet Sedo JM, Alvarez-Vijande GR. Effect of intrarectal povidone-iodine in the incidence of infectious complications after transrectal prostatic biopsy. Arch Esp Urol. 2012;65:463–466.
    1. Taylor AK, Zembower TR, Nadler RB, et al. Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care. J Urol. 2012;187:1275–1279. doi: 10.1016/j.juro.2011.11.115.
    1. Dai J, Leone A, Mermel L, et al. Rectal swab culture-directed antimicrobial prophylaxis for prostate biopsy and risk of postprocedure infection: a cohort study. Urology. 2015;85:8–14. doi: 10.1016/j.urology.2014.09.035.
    1. Duplessis CA, Bavaro M, Simons MP, et al. Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates. Urology. 2012;79:556–561. doi: 10.1016/j.urology.2011.09.057.
    1. Walker JT, Singla N, Roehrborn CG. Reducing infectious complications following transrectal ultrasound-guided prostate biopsy: a systematic review. Rev Urol. 2016;18:73–89.
    1. Remel Technical Manual of Microbiological Media. . Accessed April 17, 2017.
    1. Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing; approved standard; 25th informational supplement. CLSI document M100-S25. Clinical and Laboratory Standards Institute, Wayne, PA, 2015.
    1. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383. doi: 10.1016/0021-9681(87)90171-8.
    1. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Med. 2003;31:1250–1256.
    1. Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect Mar. 2012;18(3):268–281. doi: 10.1111/j.1469-0691.2011.03570.x.
    1. Suwantarat N, Dumford DM, Ponce-Terashima R, et al. Modification of antimicrobial prophylaxis based on rectal culture results to prevent fluoroquinolone-resistant Escherichia coli infections after prostate biopsy. Infect Control Hosp Epidemiol. 2013;34:973–976. doi: 10.1086/671734.
    1. Summers SJ, Patel DP, Hamilton BD, et al. An antimicrobial prophylaxis protocol using rectal swab cultures for transrectal prostate biopsy. World J Urol. 2015;33:2001–2007. doi: 10.1007/s00345-015-1571-y.
    1. Van Besien J, Uvin P, Van den Abeele AM, et al. Prevalence, risk factors, and clinical relevance of fluoroquinolone-resistant organisms in rectal cultures: should we target antibiotic prophylaxis prior to prostate biopsy? Adv Urol. 2016; doi:10.1155/2016/5392107.
    1. Williamson DA, Freeman JT, Porter S, et al. Clinical and molecular correlates of virulence in Escherichia coli causing bloodstream infection following transrectal ultrasound-guided (TRUS) prostate biopsy. J Antimicrob Chemother. 2013;68:2898–2906. doi: 10.1093/jac/dkt276.
    1. Siriboon S, Tiengrim S, Taweemongkongsup T, et al. Prevalence of antibiotic resistance in fecal flora of patients undergoing transrectal ultrasound-guided prostate biopsy in Thailand. Urol Int. 2012;88:187–193. doi: 10.1159/000335506.
    1. Taylor S, Margolick J, Abughosh Z, et al. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int. 2013;111:946–953. doi: 10.1111/j.1464-410X.2012.11637.x.
    1. Minamida S, Satoh T, Tabata K, et al. Prevalence of fluoroquinolone-resistant Escherichia coli before and incidence of acute bacterial prostatitis after prostate biopsy. Urology. 2011;78:1235–1239. doi: 10.1016/j.urology.2011.07.1392.
    1. Chrisofos M, Papatsoris AG, Dellis A, Varkarakis IM, et al. Can prostate biopsies affect erectile function? Andrologia. 2006;38:79–83. doi: 10.1111/j.1439-0272.2006.00714.x.
    1. Batura D, Rao GG, Nielsen PB. Prevalence of antimicrobial resistance in intestinal flora of patients undergoing prostatic biopsy: implications for prophylaxis and treatment of infections after biopsy. BJU Int. 2010;106:1017–1020. doi: 10.1111/j.1464-410X.2010.09294.x.
    1. Steensels D, Slabbaert K, De Wever L, et al. Fluoroquinolone-Resistant E. Coli in intestinal flora of patients undergoing transrectal ultrasound-guided prostate biopsy--should we reassess our practices for antibiotic prophylaxis? Clin Microbiol Infect. 2012;18:575–581. doi: 10.1111/j.1469-0691.2011.03638.x.

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