A Statewide Intervention to Reduce Hospitalizations after Prostate Biopsy

Abstract

A statewide intervention aimed at addressing fluoroquinolone resistance reduced post-prostate biopsy infection related hospitalizations in Michigan by 53%.

Complications After Systematic, Random, and Image-guided Prostate Biopsy

“…Fluoroquinolone resistant organisms have been identified in 10-30% of patients undergoing rectal swab culture before PB 47,[49][50][51][52] , although rates of clinical infectious complications are lower at approximately 1-17.5% 7,45,46,48,[53][54][55][56][57] . Most infections are self-limiting and can be managed in the outpatient setting 7,45 .…”

“…Most infections are self-limiting and can be managed in the outpatient setting 7,45 . However, the incidence of more serious infectious complications requiring hospitalization has dramatically increased over time 2,15,[58][59][60] , with fluoroquinolone-resistant (FQR) Escherichia Coli as the most recognized risk factor 2,45,47,[49][50][51]53 . In this scenario, patients with biopsy-related bacterial acute prostatitis have a higher risk of sepsis when compared to those with spontaneous acute prostatitis, probably due to a different pathogenic bacterial strain among the two groups 61 .…”

“…Other relevant studies 7,11,16,48,49,59,[68][69][70] reporting a similar hospitalization rate are summarized in Table 2. A recent statewide study from the Michigan Urological Surgery Improvement Collaborative (MUSIC) group, reported a reduction in hospitalization rates for infectious complications from 1.19% to 0.56%, when adopting a specific protocol for antibiotic prophylaxis (by shifting from a monotherapy to a multi-drug prophylaxis or performing culture-directed prophylaxis) 51 . Although transperineal approach for PB is infrequently used in many parts of the world largely due to logistical reasons, the incidence of re-admissions for urinary infection or sepsis is lower, ranging from 0% to 0.7% in published reports 9,10,25,26 (Table 2).Despite the currently limited available body of literature, the lower incidence of infections and hospitalizations among patients undergoing MRI-targeted PB appears mostly related to the transperineal access, rather than the number of cores taken 29,64 .…”

Cutting to the Core of the Issue: Emerging Strategies To Reduce Prostate Biopsy-Related Infections

“…Common augmented regimens that have been described include addition of a second antimicrobial, such as gentamicin, cefazolin, or piperacillin-tazobactam, to a fluoroquinolone or the use of gentamicin with or without clindamycin (17). Targeted regimens described in the literature generally involve the use of a single antimicrobial agent to which an identified ciprofloxacin-resistant organism is shown to test as susceptible, typically a cephalosporin, gentamicin, or trimethoprim-sulfamethoxazole (15,17). An advantage of the augmented prophylaxis approach is that it does not require a patient visit for prebiopsy culture collection or the costs associated with the culture.…”

“…Two of the largest studies to address these questions were quality improvement initiatives in the state of Michigan and urology departments in Southern California that evaluated infection rates following a quality intervention (17,30). The Michigan study demonstrated a 53% decrease in biopsy-infection-related hospitalizations for the combined intervention of either augmented or targeted prophylaxis compared to the standard prophylaxis chosen by the physician (17).…”