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Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
This article is intended for primary care clinicians, urologists, and other specialists who care for patients undergoing transrectal ultrasonography-guided prostate (TRUSP) biopsy.
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Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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Infection can be common after transrectal ultrasonography-guided prostate (TRUSP) biopsy, and the authors of the current study provide a review of the practice of antibiotic prophylaxis before this procedure. Although the most effective antibiotic regimen is not firmly established, it appears clear that prophylaxis helps to reduce the rate of symptomatic complications after TRUSP biopsy. Ciprofloxacin is the most commonly prescribed antibiotic for this purpose, and one study found no significant difference in efficacy in comparing 1-day and 3-day regimens of ciprofloxacin. Meanwhile, 2 studies have suggested that amoxicillin-clavulanate ("co-amoxiclav") performs less effectively as antibiotic prophylaxis for TRUSP biopsy.
Nonetheless, there is concern regarding the risk for Clostridium difficile (C diff) infection after treatment with broad-spectrum antibiotics such as ciprofloxacin. The current study by Neal and colleagues examines rates of postbiopsy infection during periods when gentamicin plus amoxicillin-clavulanate was used in place of ciprofloxacin as prophylaxis.
A change in antibiotic regimens in an effort to reduce C diff infections at a UK hospital paradoxically led to higher overall infection rates after prostate biopsy. The hospital has now reverted to the previous standard antibiotic for this common surgical procedure, and this has led to a reduction in postsurgery infections, according to a study published in the November issue of the British Journal of Urology International.
After an audit of 709 records of patients who underwent biopsies to diagnose prostate cancer, the researchers found that 255 patients administered the new antibiotic regimen (co-amoxiclav [amoxicillin-clavulanate] and gentamicin) developed more than 5 times as many postsurgery infections compared with 454 patients administered the previous regimen (ciprofloxacin). The researchers write that the result was significant (P < .001).
Almost 13% of the patients receiving co-amoxiclav and gentamicin developed infections compared with just 2.4% of patients receiving ciprofloxacin. Twelve patients were readmitted with sepsis, and 1 patient was readmitted with septic shock.
"This is the first study to compare the use of co-amoxiclav and gentamicin with the use of ciprofloxacin for [ultrasonography-guided prostate biopsy]," senior author David Neal, FMedSci, FRCS, professor of surgical oncology at Addenbrooke Hospital in Cambridge, United Kingdom, said in a statement. "This audit study supports the use of locally determined prophylactic regimes for this procedure."
The change in antibiotics had been spurred by rising C diff rates in the United Kingdom, which may have been the result of widespread use of broad-spectrum antibiotics such as ciprofloxacin.
"The new regime was introduced on the proviso that both the hospital-acquired infection rates and postoperative infection rates would be closely monitored," Dr. Neal said. "Given that there were no cases of C. difficile recorded in our study, but postoperative infection rates increased significantly, the decision was taken to revert back to the original regime." Once that was done the overall rate of infection went back down to 3.8%.
The researchers write that although ultrasonography-guided prostate biopsy is a common procedure across the United Kingdom, no national guidelines on the use of antibiotics exist, and local protocols vary widely. In this case, that proved significant. They recommended that any alteration in antibiotic use should be based on local C diff rates and on strong clinical evidence to avoid increases in the risk of ill health, "as well as the financial burden of treating new complications," Dr. Neal said.
The authors have disclosed no relevant financial relationships.
BJU Int. 2011;108:1597-1602. Abstract
