The role of targeted prophylactic antimicrobial therapy before transrectal ultrasonography‐guided prostate biopsy in reducing infection rates: a systematic review

Abstract

To compare the incidence of infective complications after transrectal ultrasonography (TRUS)-guided biopsy with either empirical fluoroquinolone or culture-based targeted antimicrobial prophylaxis, and the prevalence of fluoroquinolone resistance (FQ-R) in men undergoing prostate biopsy. A systematic review of the literature was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included studies of patients undergoing TRUS-guided biopsy that compared infective outcomes of those who received targeted antimicrobial therapy based on the results of preprocedural rectal swab cultures, with those receiving empiric fluoroquinolone antimicrobial prophylaxis. The prevalence of FQ-R was recorded as a secondary outcome measure. Studies with no control group were excluded. From 125 studies screened, nine studies (4 571 patients) met the inclusion criteria. All studies were of cohort design, and included a combination of retrospective and prospective data. Six studies included were undertaken in North America. The remaining studies were undertaken in Spain, Turkey and Columbia. Within these studies, 2 484 (54.3%) patients received empirical fluoroquinolone prophylaxis, whilst 2 087 (45.7%) patients had pre-biopsy rectal swabs and targeted antibiotics. The mean FQ-R was 22.8%. Post-biopsy infection and sepsis rates were significantly higher in groups given empirical prophylaxis (4.55% and 2.21%) compared with groups receiving targeted antibiotics (0.72% and 0.48%). Based on these results 27 men would need to receive targeted antibiotics to prevent one infective complication. Our systematic review suggests that targeted prophylactic antimicrobial therapy before TRUS-guided prostate biopsy is associated with lower rates of sepsis. We therefore recommend changing current pathways to adopt this measure.

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

“…A number of approaches have been considered to prevent infection, including prebiopsy enema, povidone-iodine or chlorhexidine disinfection of the rectum, or bisacodyl suppository, with mixed results (7,15). No recommendations for topical preparation prior to biopsy have currently been established by the AUA.…”

“…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.…”

“…A meta-analysis examining the prevalence of fluoroquinoloneresistant rectal flora in men undergoing transrectal prostate biopsy reported the mean rate of colonization with fluoroquinolone-resistant organisms as 22.8% (15). Nine studies, conducted in North America, Spain, Turkey, and Columbia, were included in the analysis.…”

“…This conclusion is based on a comparison of single-dose fluoroquinolone prophylaxis to culture-directed antimicrobial regimens and does not take into account the use of augmented prophylaxis as an alternative approach (15).…”

Drug-eluting biopsy needle as a novel strategy for antimicrobial prophylaxis in transrectal prostate biopsy

“…11,12 All of these methods have some disadvantages that result in their limited use. 11,12 The transperineal prostate biopsy is a more complicated and painful procedure and requires a general anesthesia.…”