Novel Approaches May Decrease Prostate Biopsy Infection Risk
Alcohol washing of biopsy needles, changes in prophylactic antibiotic regimens, and pre-biopsy rectal cultures may help decrease the risk of infectious complications from prostate biopsy.
Recent studies may improve urologists' ability to decrease the risk of infectious complications from prostate biopsies.
A study by Matthew N. Simmons, MD, PhD, and colleagues showed that prophylaxis with a combination of ciprofloxacin and ceftriaxone in conjunction with isopropyl alcohol needle washing can significantly reduce the incidence of sepsis following prostate biopsy compared with a ciprofloxacin-gentamicin regimen. The needle washing technique is quick and inexpensive and can be incorporated easily into existing biopsy protocols, the authors reported in Urology.1 A systematic review and meta-analysis Bhavan Prasad Rai, MSc, FRCS (Urol), which was published in Prostate Cancer and Prostatic Diseases,2 found that fosfomycin can significantly lower the rate of urinary tract infections (UTIs) and antimicrobial resistance compared with quinolone-based regimens. In another systematic review and meta-analysis, investigators led by Matthew J. Roberts, MBBS, PhD, reported in the World Journal of Urology3 that targeted antibiotic prophylaxis based on rectal cultures prior to biopsy can decrease the risk of infectious complications.
“I spent many years during my doctorate doing molecular cloning and plating out bacteria,” related Dr Simmons, of Urology Specialists of Oregon in Bend. “I considered bacterial inoculation/sterilization from that perspective and figured that fecal matter inside the core biopsy needle could be the main source of infection. I reviewed the literature and saw little addressing that possibility, and came up with the cleaning method described in the paper.”
He and his colleagues had been using a gentamicin/ciprofloxacin regimen, but then changed to ciprofloxacin/ceftriaxone in 2014 after reviewing the current evidence, Dr Simmons said. For their investigation, the investigators enrolled 829 consecutive patients scheduled to undergo prostate biopsy and divided them into 3 groups based on prophylactic regimen: ciprofloxacin plus gentamicin (group1), ciprofloxacin plus ceftriaxone (group 2), and ciprofloxacin plus ceftriaxone and needle washing (group 3). The incidence of post-biopsy sepsis was 3.8%, 2%, and 0%, respectively.
All prostate biopsy patients at his practice now receive ceftriaxone/ciprofloxacin and undergo needle washing. So far, only 1 post-biopsy infection occurred in 350 consecutive patients undergoing prostate biopsy.
The washing technique may seem simple and trivial, but it appears to be highly effective, he stated. “At the end of the day, I enjoyed doing this study more than any I have ever done due to the possibility that it may have an actual tangible impact on practice,” Dr Simmons told Renal & Urology News. “In this clinic, we have reduced our biopsy infection rate to less than 1%. I have not had to admit a patient for post-biopsy sepsis for 3 full years, and that is golden.”
Fosfomycin more effective
Dr Rai said he and his colleagues were not surprised that fosfomycin was more effective at preventing UTIs and lower the rate of antimicrobial resistance. “There is a trend towards increasing quinolone resistance globally and hence alternate antibiotics are likely to be more effective,” said Dr Rai, a Consultant Urologist and Robotic Surgeon at James Cook University Hospital, Middlesbrough, UK.
The meta-analysis included 5 studies comparing fosfomycin and non-fosfomycin prophylaxis in men undergoing TRUS-guided prostate biopsy. In these studies, 1,447 men received fosfomycin and 1,665 patients received quinolone-based prophylaxis. The researchers found no significant differences in adverse event rates between the 2 cohorts. “I think it's important to review our antibiotic practices,” Dr Rai said.
Benefit of rectal cultures
In the rectal culture study, Dr Roberts' team analyzed the effectiveness of targeted antibiotic prophylaxis (TAP) compared with empiric prophylaxis regimens on rates of post-biopsy infectious complications. They identified 15 studies (8 retrospective and 7 prospective) with 12,320 participants. Infectious complication incidence rates were 3.4% among those receiving empiric regimens compared with 0.8% among TAP recipients.\
“Our meta-analysis confirmed that targeted prophylaxis resulted in less infectious complications and essentially removed antimicrobial resistance as an influential factor,” said Dr Roberts, a urology resident and lecturer in the Faculty of Medicine at The University of Queensland, Australia. “These findings were similar to our previous report from 2014, but with more studies and patients. The findings were unsurprising and reflective of why many urology departments have incorporated a targeted prophylaxis approach.”
Dr Roberts stated that it may be preferable to perform to transperineal biopsy rather than transrectal biopsy because the former is associated with significantly fewer infections. When transrectal biopsy is only method available, Dr Roberts said that delaying the procedure until risk factors (such as recent overseas travel to areas of high antibiotic resistance, antibiotic use in last 6–12 months, and immunosuppression) resolve or are reduced is worth considering, as are adjunct antiseptic methods such as rectal and needle disinfection.
Urine Culture Prior to Prostate
Biopsy May be Unnecessary
Routine office urine cultures performed on asymptomatic men prior to prostate needle biopsy (PNB) may be unnecessary, a new study suggests.
In a prospective observational study, investigators led by Jay D. Raman, MD, FACS, of Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania, found that fewer than 5% of asymptomatic men had positive office cultures prior to PNB.
The study, published in International Urology and Nephrology, included 150 asymptomatic men who had urine cultures obtained 14 days prior to PNB. Positive cultures were not treated and antibiotic prophylaxis prior to PNB included ciprofloxacin 500 mg the night before and morning of the biopsy. The study showed that only 6 men (4%) had evidence of asymptomatic bacteriuria with more than 10,000 CFU/mL on office urine culture. Infectious complications developed in only 4 men (2.7%) following biopsy, (2 with sepsis and 2 with culture-positive UTIs). In all 4 cases, the causative pathogen was quinolone-resistant Escherichia coli. Post-biopsy infectious complications did not develop in any of the 6 patients who had preoperative positive urine cultures. “Our study confirmed that preoperative urine culture in asymptomatic men without urinary tract symptoms is unnecessary before prostate biopsy, Dr Raman told Renal & Urology News. “This was not a surprise, but reaffirmed that this test is unnecessary and omitting this is prudent for reducing unnecessary costs.”
Consulting with local antibiograms to assess for microbial sensitivities, coupled with rectal swab cultures when feasible and topical rectal antiseptic at time of biopsy, could help reduce the risk of infections dramatically, Dr Raman said.
Qi DZ, Lehman K, Dewan K, et al. Preoperative urine culture is unnecessary in asymptomatic men prior to prostate needle biopsy. Int Urol Nephrol. 2018;50:21-24. doi: 10.1007/s11255-017-1752-2.
1. 1. Simmons MN, Neeb AD, Johnson-Mitchell M. Reduced risk of sepsis after prostate biopsy using a cephalosporin-fluoroquinolone antibiotic regimen and isopropyl alcohol needle washing. Urology. 2018.
2. 2. Noreikaite J, Jones P, Fitzpatrick J, et al. Fosfomycin vs. quinolone-based antibiotic prophylaxis for transrectal ultrasound-guided biopsy of the prostate: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2018.
3. 3. Scott S, Harris PN, Williamson DA, et al. The effectiveness of targeted relative to empiric prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy: a meta-analysis. World J Urol. 2018.