Preprostate Biopsy Rectal Culture and Postbiopsy Sepsis

Post-prostate biopsy acute bacterial prostatitis and screening cultures using selective media: An overview

The development of several culture media and the availability to isolate and treat pathogens prior to a surgical procedure give us the ability to minimize treatment-related complications, and ultimately results in better outcomes for patients and avoidance of unwanted post-procedure inpatient admissions. In the last decade, an increasing incidence of multidrug-resistant Escherichia coli, especially extended-spectrum beta-lactamase-producing E. coli and fluoroquinolone-resistant pathogens, has been reported. These resistant species frequently colonize the rectal flora and gain access to the systemic circulation via the rectal plexus following a prostate biopsy. The bacteria can eventually lead to life-threatening complications, which is especially important in high-risk patients with multiple co-morbidities. Previously published studies have focused on the isolation of these pathogens with selective media before an invasive procedure and the potential benefits of incorporating the use of selective media as a mandatory pre-operative step. This preventive measure will allow us to offer a tailored prophylactic treatment that benefits patients and reduces the economic burden for the hospital.

Recent Advances and Current Role of Transperineal Prostate Biopsy

"Approximately 1 million prostate biopsies are performed each year in the United States. This procedure has traditionally been performed using a transrectal approach, which is associated with a significant risk of infectious complications including sepsis. In recent years, transperineal prostate biopsy has been increasingly adopted due to its lower associated infectious risk. In this review, we explore the benefits of the transperineal approach for performing prostate biopsy and detail technical advancements that have allowed for this procedure to now be routinely performed in the outpatient settings under local anesthesia."

Selective culture of Escherichia coli to prevent infective complications of transrectal ultrasound-guided prostate biopsy: Clinical efficacy and analysis of characteristics of quinolone-resistant Escherichia coli

OBJECTIVES

To evaluate a regimen of targeted prophylaxis using rectal swab culture in patients undergoing transrectal ultrasound-guided prostate biopsy, and to investigate the characteristics of isolated fluoroquinolone-resistant Escherichia coli.

METHODS

A prospective study was carried out from June 2013 through December 2014. Rectal swabs were cultured on agar plates containing either 2 μg/mL levofloxacin or 1 μg/mL sitafloxacin before transrectal ultrasound-guided prostate biopsy. Patients with susceptible organisms received levofloxacin or sitafloxacin, whereas those with resistant organisms received directed antimicrobial prophylaxis according to the results of the antimicrobial susceptibility test. Patients with infectious complications after prostate biopsy were identified, and characteristics of patients carrying fluoroquinolone-resistant Escherichia coli were analyzed.

RESULTS

A total of 397 men underwent transrectal ultrasound-guided prostate biopsy. Of these patients, 74 (18.6%) had fluoroquinolone-resistant Escherichia coli. All fluoroquinolone-resistant Escherichia coli were susceptible to amikacin and meropenem. The risk factor for possible fluoroquinolone-resistant Escherichia coli was age of ≥73 years. Three (0.7%) patients who received appropriate antimicrobial prophylaxis had high-grade fever after the prostate biopsy. However, the pathogens were not fluoroquinolone-resistant Escherichia coli.

CONCLUSIONS

Targeted antimicrobial prophylaxis in patients undergoing transrectal ultrasound-guided prostate biopsy can be associated with reducing severe infectious complications caused by fluoroquinolone-resistant Escherichia coli.

Risk factors for infectious complications following transrectal ultrasound-guided prostate biopsy

Objective

To explore risk factors of infectious complications following transrectal ultrasound-guided prostate biopsy (TRUSPB).

Methods

We retrospectively analyzed 1,203 patients with suspected prostate cancer who underwent TRUSPB at our center between December 2012 and December 2016. Demographics, clinical characteristics, and data regarding complications were collected, and then univariate and multivariate logistic regression analyses were used to identify independent risk factors for infectious complications after prostate biopsy.

Results

Multivariate logistic analysis demonstrated that body mass index (BMI) (OR=2.339, 95% CI 2.029–2.697, P<0.001), history of diabetes (OR=2.203, 95% CI 1.090–4.455, P=0.028), and preoperative catheterization (OR=2.303, 95% CI 1.119–4.737, P=0.023) were risk factors for infection after prostate biopsy. The area under the receiver operating characteristics curve for infectious complications was 0.930 (95% CI 0.907–0.953, P<0.001). BMI=28.196 kg/m² was the best cut-off threshold for predicting infection after TRUSPB.

Conclusion

BMI >28.196 kg/m², history of diabetes, and preoperative catheterization are independent risk factors for infection after prostate biopsy.

Outbreak of Achromobacter xylosoxidans and Ochrobactrum anthropi Infections after Prostate Biopsies, France, 2014

We report an outbreak of healthcare-associated prostatitis involving rare environmental pathogens in immunocompetent patients undergoing transrectal prostate biopsies at Hôpital Édouard Herriot (Lyon, France) during August 13-October 10, 2014. Despite a fluoroquinolone-based prophylaxis, 5 patients were infected with Achromobacter xylosoxidans and 3 with Ochrobactrum anthropi, which has not been reported as pathogenic in nonimmunocompromised persons. All patients recovered fully. Analysis of the outbreak included case investigation, case-control study, biopsy procedure review, microbiologic testing of environmental and clinical samples, and retrospective review of hospital records for 4 years before the outbreak. The cases resulted from asepsis errors during preparation of materials for the biopsies. A low-level outbreak involving environmental bacteria was likely present for years, masked by antimicrobial drug prophylaxis and a low number of cases. Healthcare personnel should promptly report unusual pathogens in immunocompetent patients to infection control units, and guidelines should explicitly mention asepsis during materials preparation.

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

OBJECTIVES

We 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 METHODS

A 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.

RESULTS

Of 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).

CONCLUSION

Targeted 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.