Munich, Germany (UroToday.com) In today’s state of the art lecture at the 2016 EAU annual meeting, Dr. Tommaso Cai presented his work on prevention and management of biopsy complications. He began with a clinical case: a 68 year old male who underwent transrectal 12-core re-biopsy of the prostate after being on AS. He was given ciprofloxacin as prophylaxis before the procedure through the 3rd day post-procedure. In an all-too-familiar story, he was readmitted on postoperative day 2 febrile to 38.5 C, hypotensive, elevated WBC, with blood cultures growing ESBL E.
Coli with quinolone resistance. After a 9-day hospital course with broad-spectrum antibiotics, he was discharged home. The predictability of this clinical situation depended on the three actors of infection: the antibiotics used, the pathogen, and the patient.
Epidemiologic studies have shown high rates of quinolone resistance in Europe, including up to 45% resistance in northern Italy where this case was performed. One serious error is that we are clearly ignoring epidemiological data. The second error is that we often ignore important information from the patient history, namely prior infections and/or antibiotic use. In this case, the patient had 2 prior biopsies, with previous prophylaxis using cipro, and a previous UTI treated with Cipro. Patients who had previous use of antibiotics are 3 times more likely to have an infectious complication. Other important risk factors to consider include age, nutritional status, diabetes, smoking, obesity, coexisting remote infection, long recent hospitalization, history of recurrent infections, prior bowel surgery, microorganism colonization, long term drainage, urinary obstruction, and nephrolithiasis.
Aside from improved focus on patient-related factors, another opportunity for improvement is in the microbiological evaluation of fecal flora to identify antibiotic resistance. Taylor and colleagues demonstrated in a rectal swab-based treatment paradigm that they were able to eliminate infectious complications in men with positive rectal swabs who underwent prostate biopsy following targeted antibiotic prophylaxis.
Alternatively, avoiding a transrectal approach altogether may have utility in reducing rates of post-biopsy infection. Grummet and associates performed a pooled analysis of perineal vs. transrectal biopsy approach and demonstrated a negligible rate of sepsis in the transperineal group. They concluded that a perineal approach should be considered in general, and offered especially in cases of repeat biopsy.
A third approach to curbing rates of infection involves finding alternative antibiotic regimens. Sen and colleagues studied single dose fosfomycin compared to ciprofloxacin in a prospective controlled RCT, and found a significantly lower rate of UTIs in the fosfomycin group (1.3% vs. 6%, p=0.032).
Fourth, based on data suggesting that the risk of infection is strongly associated with the number of biopsy cores obtained, fusion biopsy offers the opportunity for similar or better cancer detection rates with fewer samples taken.
Dr. Cai concluded that our ability to reduce the rate of infection after prostate biopsy depends on more serious consideration of epidemiological data and patient history. Improving our ability to risk stratify at-risk patients, bolstering our arsenal of antibiotics with new drugs with good susceptibility and spectrum of activity, and finally, the flexibility to regularly update our guidelines to reflect the current clinical picture in our war against sepsis.
Presented By:
T. Cai, Trento (IT)
Reported By:
Nikhil Waingankar, MD, at the 31st Annual EAU Congress - March 12 - 15, 2016 – Munich, Germany
Fox Chase Cancer Center