Urosepsis Due to Fluoroquinolone-Resistant Escherichia coli after Ultrasonographic-Guided Transrectal Implantation of Fiducial Markers

Abstract

Cancer Control 233 guidelines 9 and deemed to be an intermediate risk with regard to recurrence as defined by the National Comprehensive Cancer Network and the American Urologic Association (AUA). 10,11 Treatment options, including radical prostatectomy, external beam radiation therapy, and interstitial brachytherapy, were discussed with the patient in detail. After he opted for external beam radiation therapy, the patient agreed to a treatment protocol inclusive of intensity-modulated radiation therapy (IMRT) and the prerequisite placement of gold fiducial markers. Thus, 3 months following prostatic biopsy, he was given an oral dose of 500 mg of levofloxacin prior to the transrectal ultrasound (TRUS)-guided placement of four gold fiducial markers within the prostate gland. He also received levofloxacin 500 mg daily by mouth for two days after the procedure. Two days following the placement of fiducial markers, he returned to our facility complaining of fever, nausea, and vomiting. He was also experiencing perineal discomfort, awakening chills, and malaise. He denied difficulty with voiding. On physical examination, the patient was febrile (101.8° F), exhibited regular tachycardia (125 beats per minute), was normotensive (140/78 mmHg), and was without tachypnea (20 breaths per minute). His abdomen was benign and the bladder was not palpable. No costovertebral angle tenderness was present. A gentle DRE demonstrated a firm, nontender prostate without masses. There was no gross blood in the rectal vault. Serological evaluation noted a slight leukocytosis (12,500 k/μL) with the differential noting a left shift. The patient was not anemic (16.6 g/dL), and he was slightly thrombocytopenic (86 k/μL). Urinalysis displayed yellow urine with a high specific gravity (1.080) consistent with dehydration, a normal pH (6.0), trace protein (30 mg/dL), negative nitrites, large leukocyte esterase, pyuria (51-100 white blood cells/ high-powered field), and trace bacteria consistent with an infectious process, and microscopic hematuria.