after prostate biopsy is fluoroquinolone prophylaxis still ...deborah steensels 30 maart 2010...

Deborah Steensels30 maart 2010

Bacterial sepsis withfluoroquinolone resistant E. coli

after prostate biopsy –

Is fluoroquinolone prophylaxisstill effective?

Supervisie: Prof. Dr. J. VerhaegenProf. Dr. H. Van Poppel

Why this topic and why now?

Concern of increasing fluoroquinolone resistance

Perception that increased numbers of patients are being admitted for post-TRUSPB sepsis @ UZ Leuven

No agreement on the antibiotic agent to be used forprophylaxis

No agreement on the duration of prophylaxis

LITERATURE

Value of AB prophylaxis

Author Study type Population

Control/

intervention

Inclusion criteria Intervention/

control

Outcome

Kapoor et

al,

1998

RCT, double

blinded

N= 457

230 / 227

-No bacteriuria

-No AB or endoscopic

manipulation 1 wk prior

-No indwelling catheter

-Single dose ciprofloxacin 500 mg

p.o.

-Placebo

-Incidence bacteriuria: Placebo 8%

Cipro 3%

- Incidence symptomatic UTI: Placebo 5%

Cipro 3%

Isen et al,

1999

RCT N= 110

23 / 42 / 45

-No AB 3d prior

-No VHD, indwelling

catheter, DM, steroid use,

prostatitis

-Single dose ofloxacin 400 mg p.o.

-Single dose TMP/SMX 160/800

mg p.o.

-No AB

-Incidence bacteriuria: No AB 26.1%

Ofloxacin 4.8%

TMP/SMX 6.7%

Aron et al,

2000

RCT, patient

blinded

N= 231

75 / 79 / 77

-No UTI


-Single dose ciprofloxacin 500 mg +

tinidazole 600 mg p.o. + placebo

until 3d

-Ciprofloxacin 500 mg + tinidazole

600 mg p.o. twice daily for 3d

-Placebo 3d

-Incidence bacteriuria: Placebo 18.6%

Prophylaxis 5-7.8%

-incidence fever: Placebo 6.7%

Prophylaxis 2.5-2.6%

-Incidence bacteraemia: Placebo 2.7%

Prophylaxis 0-1.3%

-Incidence overall infective complications:

Placebo 25.3%


Puig et al,

2006

Retrospective

study

N= 1018

614 / 404

-No prior history of urinary

infection or prostatitis

-no AB

-ciprofloxacin 500 mg/12h p.o. from

12h before until 5d after biopsy

-Number of patients with minor infectious

complications: No AB group 32

Cipro group 5

-Number of patients with major infectious


Cipro group 10



Control/

intervention


control

Outcome

Kapoor et

al,

1998

RCT, double

blinded

N= 457

230 / 227

-No bacteriuria





p.o.

-Placebo

- Incidence bacteriuria: Placebo 8%

Cipro 3%


Cipro 3%

Isen et al,

1999

RCT N= 110

23 / 42 / 45

-No AB 3d prior

-No VHD, indwelling


prostatitis



mg p.o.

-No AB


Ofloxacin 4.8%

TMP/SMX 6.7%

Aron et al,

2000

RCT, patient

blinded

N= 231

75 / 79 / 77

-No UTI




until 3d



-Placebo 3d


Prophylaxis 5-7.8%




Prophylaxis 0-1.3%


Placebo 25.3%


Puig et al,

2006

Retrospective

study

N= 1018

614 / 404



-no AB





Cipro group 5



Cipro group 10



Control/

intervention


control

Outcome

Kapoor et

al,

1998

RCT, double

blinded

N= 457

230 / 227

-No bacteriuria





p.o.

-Placebo


Cipro 3%


Cipro 3%

Isen et al,

1999

RCT N= 110

23 / 42 / 45

-No AB 3d prior

-No VHD, indwelling


prostatitis



mg p.o.

-No AB


(7-10 d after biopsy) Ofloxacin 4.8%

TMP/SMX 6.7%

Aron et al,

2000

RCT, patient

blinded

N= 231

75 / 79 / 77

-No UTI




until 3d



-Placebo 3d


Prophylaxis 5-7.8%




Prophylaxis 0-1.3%


Placebo 25.3%


Puig et al,

2006

Retrospective

study

N= 1018

614 / 404



-no AB





Cipro group 5



Cipro group 10



Control/

intervention


control

Outcome

Kapoor et

al,

1998

RCT, double

blinded

N= 457

230 / 227

-No bacteriuria





p.o.

-Placebo


Cipro 3%


Cipro 3%

Isen et al,

1999

RCT N= 110

23 / 42 / 45

-No AB 3d prior

-No VHD, indwelling


prostatitis



mg p.o.

-No AB


Ofloxacin 4.8%

TMP/SMX 6.7%

Aron et al,

2000

RCT, patient

blinded

N= 231

75 / 79 / 77

-No UTI



+ tinidazole 600 mg p.o. + placebo

until 3d



-Placebo 3d


Prophylaxis 5-7.8%

-Incidence fever: Placebo 6.7%



Prophylaxis 0-1.3%


Placebo 25.3%


Puig et al,

2006

Retrospective

study

N= 1018

614 / 404



-no AB





Cipro group 5



Cipro group 10



Control/

intervention


control

Outcome

Kapoor et

al,

1998

RCT, double

blinded

N= 457

230 / 227

-No bacteriuria





p.o.

-Placebo


Cipro 3%


Cipro 3%

Isen et al,

1999

RCT N= 110

23 / 42 / 45

-No AB 3d prior

-No VHD, indwelling


prostatitis



mg p.o.

-No AB


Ofloxacin 4.8%

TMP/SMX 6.7%

Aron et al,

2000

RCT, patient

blinded

N= 231

75 / 79 / 77

-No UTI




until 3d



-Placebo 3d


Prophylaxis 5-7.8%




Prophylaxis 0-1.3%


Placebo 25.3%


Puig et al,

2006

Retrospective

study

N= 1018

614 / 404



-no AB

-ciprofloxacin 500 mg/12h p.o.

from 12h before until 5d after

biopsy



Cipro group 5



Cipro group 10

Prophylaxis regimen: which AB agent?

Antibiotic requirements for a genitourinary tissue infection/bacteremia after TRUSPB:

activity against potential uropathogens

• trimethoprim/sulfamethoxazole: R < enterococcus & PSSP

• nitrofurantoin: R < proteus & PSSP

• cephalosporins: R < enterococcus & PSSP

• aminoglycosides: R < anaerobic bacteria

• fluoroquinolones: R < most anaerobic bacteria & streptococci









bacteriocidal









bacteriocidal

high serum levels









bacteriocidal

high serum levels

high tissue levels: high lipid solubility and minimal binding to serum proteins required to penetrate prostate









bacteriocidal

high serum levels

high tissue levels: high lipid solubility and minimal binding to serum proteins required to penetrate prostate

minimal toxicity



Control/

intervention


control

Outcome

Ho et al,

2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 741

374 / 367

-No bacteriuria

-No ciprofloxacin or

gentamicin allergy and/or

renal impairment

-No VHD

-No other sources of fever

-Retrospective: Ciprofloxacin 500 mg

p.o. twice daily for 3d

-Prospective: Ciprofloxacin 500 mg p.o.

twice daily for 3d + gentamicin 80 mg

I.M.

- Incidence of sepsis: Cipro-only 3.3%

Cipro + Genta 1.3%

-Number of positive blood cultures with ciprofloxacin

resistant E. coli: Cipro-only 9/10

Cipro + Genta 1/10

Horjacada et

al, 2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 411

204 / 207

-No positive urinary dipstick

test

-No non-adherence to AB

prophylaxis

-No altered coagulation

parameters

-Retrospective:

Amoxicillin/clavulanate 2x500 mg/d

starting 1 day before biopsy for 3 days

-Prospective:

Cefoxitin 2g 1h before biopsy +

ciprofloxacin 2x750 mg/d p.o. starting

1 day before for 4 days

-Incidence of bacteremia:

Old protocol 4.4% (ESBL)

New protocol 0.9% (non-ESBL)

-Incidence of septic shock:

Old protocol 1.4%

New protocol 0%

Cam et al,

2008

RCT N= 400

139 / 131 / 130

- No AB prior

-No bacteriuria

-Ceftriaxone 1g I.M. 30 min before

biopsy

- Ciprofloxacin 500 mg p.o. twice daily

for 3 days

-Single dose ciprofloxacin 500 mg p.o.

60 min before biopsy

-Incidence of minor complications: Group 1: 108.7%

Group 2: 113%

Group 3: 110.8%

-Incidence of major complications: Group 1: 2.1%

Group 2: 2.4%

Group 3: 1.6%

Cormio et al,

2002

RCT N= 138

72 / 66


-No AB or immunosuppressive

drugs

-No positive mid-stream urine

cultures before biopsy

-Piperacillin/tazobactam (P/T) 2250 mg

I.M. twice daily for 2 days

-Ciprofloxacin 500 mg p.o. twice daily

for 7 days

-Incidence of positive MSU cultures:

P/T group 2.8%

Cipro group 4.5%



Control/

intervention


control

Outcome

Ho et al,

2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 741

374 / 367

-No bacteriuria



renal impairment

-No VHD




-Prospective: Ciprofloxacin 500 mg

p.o. twice daily for 3d + single dosis

gentamicin 80 mg I.M. 30 min before

biopsy


Cipro + Genta 1.3%



Cipro + Genta 1/10

Horjacada et

al, 2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 411

204 / 207


test


prophylaxis


parameters

-Retrospective:



-Prospective:








Old protocol 1.4%

New protocol 0%

Cam et al,

2008

RCT N= 400

139 / 131 / 130

- No AB prior

-No bacteriuria


biopsy


for 3 days




Group 2: 113%

Group 3: 110.8%


Group 2: 2.4%

Group 3: 1.6%

Cormio et al,

2002

RCT N= 138

72 / 66



drugs






for 7 days


P/T group 2.8%

Cipro group 4.5%



Control/

intervention


control

Outcome

Ho et al,

2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 741

374 / 367

-No bacteriuria



renal impairment

-No VHD






I.M.


Cipro + Genta 1.3%



Cipro + Genta 1/10

Horjacada et

al, 2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 411

204 / 207


test


prophylaxis


parameters

-Retrospective:



-Prospective:








Old protocol 1.4% (3)

New protocol 0% (0)

Cam et al,

2008

RCT N= 400

139 / 131 / 130

- No AB prior

-No bacteriuria


biopsy


for 3 days




Group 2: 113%

Group 3: 110.8%


Group 2: 2.4%

Group 3: 1.6%

Cormio et al,

2002

RCT N= 138

72 / 66



drugs






for 7 days


P/T group 2.8%

Cipro group 4.5%



Control/

intervention


control

Outcome

Ho et al,

2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 741

374 / 367

-No bacteriuria



renal impairment

-No VHD






I.M.


Cipro + Genta 1.3%



Cipro + Genta 1/10

Horjacada et

al, 2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 411

204 / 207


test


prophylaxis


parameters

-Retrospective:



-Prospective:








Old protocol 1.4%

New protocol 0%

Cam et al,

2008

RCT N= 400

139 / 131 / 130

- No AB prior

-No bacteriuria


biopsy


for 3 days




Group 2: 113%

Group 3: 110.8%


Group 2: 2.4%

Group 3: 1.6%

Cormio et al,

2002

RCT N= 138

72 / 66



drugs






for 7 days


P/T group 2.8%

Cipro group 4.5%



Control/

intervention


control

Outcome

Ho et al,

2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 741

374 / 367

-No bacteriuria



renal impairment

-No VHD






I.M.


Cipro + Genta 1.3%



Cipro + Genta 1/10

Horjacada et

al, 2009

Retrospective

cohort study

& prospective

interventional

cohort study

N= 411

204 / 207


test


prophylaxis


parameters

-Retrospective:



-Prospective:








Old protocol 1.4%

New protocol 0%

Cam et al,

2008

RCT N= 400

139 / 131 / 130

- No AB prior

-No bacteriuria


biopsy


for 3 days




Group 2: 113%

Group 3: 110.8%


Group 2: 2.4%

Group 3: 1.6%

Cormio et al,

2002

RCT N= 138

72 / 66



drugs



-Piperacillin/tazobactam (P/T) 2250

mg I.M. twice daily for 2 days


for 7 days


P/T group 2.8%

Cipro group 4.5%

! Patients in cipro-group required further treatment


Fluoroquinolonesbroad spectrum of activity against gram + and gram -

bacteria

excellent oral absorption

peak serum levels: 1-3 hours

good penetration prostatic tissue

long-lasting urinary bacteriocidal activity

non-toxic

BUT resistance of E. coli increasing worldwide

Prophylaxis regimen: Duration

Single dose versus 3-day course of fluoroquinolone? antibiotic efficiency

antibiotic resistance

cost-effectiveness


Single dose versus 3-day course of fluoroquinolone? antibiotic efficiency

antibiotic resistance

cost-effectiveness

Arguments against a longer duration of antibiotics low incidence of post-biopsy sepsis

sepsis often caused by resistant organisms, not inadequate duration

increased cost of antibiotics

contribution to worsening resistance to chosen antibiotic



Control/

intervention


control

Outcome

Briffaux et al,

2008

RCT N= 288

139 / 149

-No contra-indications to

ciprofloxacin

-No risk factors for infection

-No AB 1 wk prior

-No UTI

-No VHD

-Single dose ciprofloxacin2x 500mg 2h

before biopsy

-3-day dose ciprofloxacin (2x500 mg 2h

before biopsy + 1x500 mg every 12h

for a total of 3 days)

-Number of patients with bacteriuria:

Single dose group: 1 (cipro S)

3-day group: 1 ( cipro R)

-Incidence of clinical symptoms:

Single dose group: 2.4%

3-day group: 9.2%

Schaeffer et

al, 2007

RCT,

double

blinded

N= 497

247 / 250

-No bacteriuria

-No allergy to quinolones

-No VHD

-No renal or hepatic

insufficiency

-No CNS disorder that might

predispose to seizures


-No AB 7d prior

-1-day ciprofloxacin XR 1000 mg


-Bacteriological succes rates: 1-day group 94.8%

3-day group 98.0%

-Clinical succes rates: 1-day group 96.7%

3-day group 98.5%

-Potential predictors of microbiological failure: DM

-Potential predictors of clinical failure: history of

prostatitis

Shigemura et

al, 2005

Non-

randomized

prospective

study

N= 236

124 / 112

-No pyuria -Levofloxacin 600 mg for 1 day

-Levofloxacin 300 mg for 3 days

-Incidence of febrile infectious complications:

1-day group 1.61%

3-day group 1.79%

-Mean serum WBC count & CRP:

No significant difference between 2 groups but WBC

count and CRP elevation tends to be smaller in 1-day

group

Petteffi et al,

2002

RCT, simple

blinded

N= 105

51 / 54

-No allergy to norfloxacin

-No long term indwelling

catheter

-No AB (chronic or within 30d)

-No leucopenia with

granulocytes count < 1000 mL

-No VHD or valvular prothesis

-Short term: norfloxacin 400 mg p.o.

single dose 1h before biopsy

-Long term: nofloxacin 400 mg p.o. 1h

before + twice daily during 72h

-Incidence of minor complications: Short term 78%

Long term 74%

-Continuous variables: no statistical difference

- rates of fever: Short term 15%

Long term 2%

-positive urine cultures: Short term 29%

Long term 7%



Control/

intervention


control

Outcome

Briffaux et al,

2008

RCT N= 288

139 / 149


ciprofloxacin


-No AB 1 wk prior

-No UTI

-No VHD

-Single dose ciprofloxacin 2x 500mg 2h

before biopsy

-3-day dose ciprofloxacin (2x500 mg

2h before biopsy + 1x500 mg every

12h for a total of 3 days)






3-day group: 9.2%

Schaeffer et

al, 2007

RCT,

double

blinded

N= 497

247 / 250

-No bacteriuria


-No VHD


insufficiency




-No AB 7d prior




3-day group 98.0%


3-day group 98.5%



prostatitis

Shigemura et

al, 2005

Non-

randomized

prospective

study

N= 236

124 / 112




1-day group 1.61%

3-day group 1.79%




group

Petteffi et al,

2002

RCT, simple

blinded

N= 105

51 / 54



catheter


-No leucopenia with








Long term 74%



Long term 2%


Long term 7%

No argument for the use of more than one dose



Control/

intervention


control

Outcome

Briffaux et al,

2008

RCT N= 288

139 / 149


ciprofloxacin


-No AB 1 wk prior

-No UTI

-No VHD


before biopsy









3-day group: 9.2%

Schaeffer et

al, 2007

RCT,

double

blinded

N= 497

247 / 250

-No bacteriuria


-No VHD


insufficiency




-No AB 7d prior


(single dose 2h before + 2 doses

placebo)


(single dose 2h before + once daily for

2 days)


3-day group 98.0%


3-day group 98.5%



prostatitis

Shigemura et

al, 2005

Non-

randomized

prospective

study

N= 236

124 / 112




1-day group 1.61%

3-day group 1.79%




group

Petteffi et al,

2002

RCT, simple

blinded

N= 105

51 / 54



catheter


-No leucopenia with








Long term 74%



Long term 2%


Long term 7%

3-day regimen: DM and

prostatitis



Control/

intervention


control

Outcome

Briffaux et al,

2008

RCT N= 288

139 / 149


ciprofloxacin


-No AB 1 wk prior

-No UTI

-No VHD


before biopsy









3-day group: 9.2%

Schaeffer et

al, 2007

RCT,

double

blinded

N= 497

247 / 250

-No bacteriuria


-No VHD


insufficiency




-No AB 7d prior




3-day group 98.0%


3-day group 98.5%



prostatitis

Shigemura et

al, 2005

Non-

randomized

prospective

study

N= 236

124 / 112


(200 mg 2h before, 2 and 8h after)


(100 mg 2h before, 2 and 8h after +

100 mg tid for 2 days)


1-day group 1.61%

3-day group 1.79%




group

Petteffi et al,

2002

RCT, simple

blinded

N= 105

51 / 54



catheter


-No leucopenia with








Long term 74%



Long term 2%


Long term 7%



Control/

intervention


control

Outcome

Briffaux et al,

2008

RCT N= 288

139 / 149


ciprofloxacin


-No AB 1 wk prior

-No UTI

-No VHD


before biopsy









3-day group: 9.2%

Schaeffer et

al, 2007

RCT,

double

blinded

N= 497

247 / 250

-No bacteriuria


-No VHD


insufficiency




-No AB 7d prior




3-day group 98.0%


3-day group 98.5%



prostatitis

Shigemura et

al, 2005

Non-

randomized

prospective

study

N= 236

124 / 112




1-day group 1.61%

3-day group 1.79%




group

Petteffi et al,

2002

RCT, simple

blinded

N= 105

51 / 54



catheter


-No leucopenia with








Long term 74%



Long term 2%


Long term 7%

Prophylaxis regimen: guidelines

Antimicrobial prophylaxis for urologic surgery < American Urological Association 2008

Procedure Organisms Prophylaxisindicated

Antimicrobial(s) of choice Alternativeantimicrobial(s)

Duration

Transrectalprostate biopsy

Intestine All - Fluoroquinolone- 2nd/3rd gen. Cephalosporin

Aminoglycoside +Metronidazole orClindamycin

≤24 hours

Benefits of pre-biopsy enema?

Author Population Complications – Enema Complications – No enema Remarks

Park et al,

2009

N= 481 0.3% 6.6%

Huang et al,

2006

N= 222 0% 9.23% phosphate enema combined with

povidone-iodine administered by a doctor

at the hospital versus

phosphate enema administered by the

patient at home

Lindert et al,

2000

N= 50 4% 28% Transient bacteremia

Vallencien et al, 1991 N=59 20% 9%

Brown et al,

1981

N= 40 19% 69% Transient bacteremia

No consensus in the literature regarding the impact of a bowel-cleansing enemabefore biopsy enemas are not given before biopsy @ UZ Leuven

Objectives

What is the incidence of sepsis following TRUSPB at our center? Did rates of infectious complicationsincrease in recent years?

What are predisposing factors of sepsis afterTRUSPB?

What is the incidence of ciprofloxacin resistantfaecal strains before TRUSPB at our center? Is fluoroquinolone prophylaxis still effective?

RETROSPECTIVE STUDY

Sepsis after TRUSPB @ UZ Leuven:a retrospective study

Material and Methods TRUSPB from 01/01/2003 to 31/12/2009: screening for positive HC

positive blood cultures with E. coli within 30 days after biopsy date

medical records of all patients with sepsis occurring within 30 days after biopsy were reviewed for:

history of prostate pathology (including prostatitis)

medical comorbidities

risk factors for urosepsis

use of prophylactic antibiotics

onset of sepsis in relation to TRUS biopsy

length of hospitalization

causative organisms

antibiotic sensitivity patterns in both blood and urine cultures

average cost that was associated with the hospitalization


Results INCIDENCE

Overall incidence of urosepsis: 0.95% (54/5663 biopsy procedures)BUT estimate of incidence was likely an underestimation!

Incidence of sepsis 2003-2005: 0.39% (10/2550) Incidence of sepsis 2006-2009: 1.41% (44/3112)

P-value< 0.01


Results INCIDENCE

RISK FACTORS

1st biopsy: incidence of sepsis = 1.01% (33/3264)

chronic prostatitis 10/33

repeat biopsy: incidence of sepsis = 2.23% (21/940)

chronic prostatitis 15/21

possible explanation: higher incidence of chronic prostatitis in patients who underwent repeat biopsy

P-value< 0.01


Results INCIDENCE

RISK FACTORS: are rebiopsy cases at higher risk of infection?

retrospective study: P-value < 0.01

prospective study: Djavan et al. J Urol 2001; 166:856-860

Delayed morbidity of transrectal ultrasound guided biopsy

No. First Biopsy (%) No. Re-biopsy (%) P-value

Urinary tract infections 115 (10.9) 93 (11.3) 0.07

Fever 30 (2.9) 19 (2.3) 0.08

Urinary tract infections, fever 22 (2.1) 16 (1.9) 0.02

Urinary retention 9 (0.9) 10 (1.2) 0.09

Hematospermia 103 (9.8) 84 (10.2) 0.1

Recurrent mild hematuria 167 (15.9) 143 (16.6) 0.06

Persistent dysuria 76 (7.2) 56 (6.8) 0.12


Results INCIDENCE

RISK FACTORS

PATIENT PARAMETERSTotal

% (range)

First biopsy

% (range)

Repeat biopsy

% (range)

Percentage patients with

urosepsis

1.28 1.01 2.23

Median age 61.5 (45-82) 60.4 (46-82) 63.3 (45-75)

Median PSA before biopsy 7.4 (0.7-20.3) 6.9 (0.7-20.3) 8.1 (1.8-14.3)

PSA at presentation 44.0 (6.0-160.1) 49.3 (6.0-160.1) 31.2 (8.8-51.4)

CRP at presentation 103.8 (3.4-330.2) 110.6 (7.4-330.2) 92.5 (3.4-257.9)

WBC count at presentation 10.4 (1.6-27.4) 10.4 (2.7-27.4) 10.5 (1.6-25.6)

Creatinine at presentation 1.2 (0.6-2.6) 1.1 (0.8-2.09) 1.2 (0.6-2.6)

Mean interval of biopsy to sepsis

(days)

3 (1-26) 2 (1-10) 4 (1-26)

Mean length of hospitalization

(days)

5 (2-12) 5 (2-11) 5 (2-12)


Results INCIDENCE

RISK FACTORS

PATIENT PARAMETERSTotal

% (range)

First biopsy

% (range)

Repeat biopsy

% (range)

Percentage patients with

urosepsis

1.28 1.01 2.23

Median age 61.5 (45-82) 60.4 (46-82) 63.3 (45-75)

Median PSA before biopsy 7.4 (0.7-20.3) 6.9 (0.7-20.3) 8.1 (1.8-14.3)

PSA at presentation 44.0 (6.0-160.1) 49.3 (6.0-160.1) 31.2 (8.8-51.4)

CRP at presentation 103.8 (3.4-330.2) 110.6 (7.4-330.2) 92.5 (3.4-257.9)

WBC count at presentation 10.4 (1.6-27.4) 10.4 (2.7-27.4) 10.5 (1.6-25.6)

Creatinine at presentation 1.2 (0.6-2.6) 1.1 (0.8-2.09) 1.2 (0.6-2.6)

Mean interval of biopsy to sepsis

(days)

3 (1-26) 2 (1-10) 4 (1-26)

Mean length of hospitalization

(days)

5 (2-12) 5 (2-11) 5 (2-12)

Average cost/patient /day:

620 €


Results INCIDENCE

RISK FACTORS

PATIENT PARAMETERS

BACTERIOLOGY

Antibiotic % resistance (number of patients)

Amoxicillin 74.1% (40/54)

Amoxicillin-clavulanate7.4% (4/54)

Cefuroxime1.8% (1/54)

Piperacillin/tazobactam0% (0/54)

Levofloxacin59.3% (32/54)

Gentamicin20.4% (11/54)

Tobramycin3.7% (2/54)

Trimethoprim/sulfamethoxazole 64.4% (29/45)

Nitrofurantoin3.4% (1/29)


Results INCIDENCE

RISK FACTORS

PATIENT PARAMETERS

BACTERIOLOGY

Antibiotic% sensitivity of ciprofloxacin resistant strains

(number of patients)

Amoxicillin 18.75% (6/32)

Amoxicillin-clavulanate 71.87% (23/32)

Cefuroxime 87.5% (28/32)

Piperacillin/tazobactam 100% (32/32)

Gentamicin 71.87% (23/32)

Tobramycin 68.75% (22/32)

Trimethoprim/sulfamethoxazole 37.5% (12/32)

Nitrofurantoin 89.47% (17/19)


Conclusions incidence of sepsis is low, but it is potentially fatal



need for reporting these complications and for randomizedcontrolled trials to standardize antimicrobial prophylaxis




inform patients of the risk of infectious complications after a TRUSPB and caution them to consult a hospital immediately if feveroccurs





letter to present to health care providers if they develop signs of sepsis which indicates that ciprofloxacin should not be used fortreatment





letter to present to health care providers if they develop signs of sepsis which indicates that ciprofloxacin should not be used fortreatment

no single protocol can guarantee a perfect prophylaxis regimen

PROSPECTIVE STUDY

Faecal carriage of quinolone resistantstrains: a prospective study

Material and Methods

all patients undergoing TRUSPB

starting 1 december 2009

rectal swab just before biopsy MacConkey

MacConkey + ciprofloxacin 1 mg/L

potential risk factors > questionnaire antibiotic prophylaxis

number of previous biopsies

presence of chronic prostatitis

use of fluoroquinolones


Naam Patiënt:

EAD nummer:

Datum biopsie:

Initiële PSA :

PPA :

Aantal voorafgaande biopsies :

Antibioticum voor chemoprofylaxe 1u voor biopsie :

o Ciprofloxacineo Levofloxacineo Andere:

Chronische prostatitis : Ja / Nee

Langdurig gebruik van chinolones in het verleden :

Ja / NeeZoja:

reden van gebruik: aantal dagen: tijdstip van inname: < 6 maanden geleden

> 6 maanden geleden

Opmerkingen:

Results Incidence of ciprofloxacin resistant strains in the rectum before biopsy

21/100 E. coli

1/100 P. aeruginosa




Percentage resistance E. coli strains in urine samples 2003 2009

Antibiotic agent 2003 2004 2005 2006 2007 2008 2009

ciprofloxacin 14.94 % (140/937) 17.28 % (192/1111) 16.45 % (189/1149) 21.33 % (269/1261) 22.21 % (309/1391) 22.57 % (321/1422) 22.19 % (286/1289)

levofloxacin / / / 22.19 % (249/1122) 22.49 % (318/1414) 22.77 % (326/1432) 23.04 % (300/1302)

norfloxacin 13.98 % (131/937) 16.92 % (188/1111) 16.00 % (184/1149) 20.29 % (255/1261) 20.33 % (282/1391) 21.45 % (305/1422) 22.78 % (293/1286)

ofloxacin 15.43 % (148/959) 17.25 % (193/1119) 16.97 % (198/1167) 17.22 % (26/151) // /

ampicillin 43.47 % (416/957) 46.20 % (517/1119) 46.87 % (547/1167) 48.74 % (619/1270) 50.57 % (715/1414) 52.83 % (757/1433) 53.92 % (702/1302)

amoxicillin-clavulanate

6.14 % (59/961) 5.54 % (62/1119) 6.17 % (72/1167) 5.91 % (75/1270) 7.57 % (107/1414) 10.33 % (148/1433) 12.90 % (168/1302)

piperacillin-tazobactam

0.42 % (4/958) 0.63 % (7/1119) 0.43 % (5/1167) 0.16 % (2/1270) 0.21 % (3/1414) 0.28 % (4/1433) 0.77 % (10/1301)

cefotaxim 1.56 % (15/959) 5.27 % (59/1119) 2.06 % (24/1167) 1.10 % (14/1269) 2.97 % (42/1414) 3.42 % (49/1433) 4.45 % (58/1302)

ceftazidim 1.77 % (17/960) 5.36 % (60/1119) 0.60 % (7/1167) 0.39 % (5/1269) 0.99 % (14/1414) 1.05 % (15/1433) 1.46 % (19/1302)





ciprofloxacin 14.94 % (140/937) 17.28 % (192/1111) 16.45 % (189/1149) 21.33 % (269/1261) 22.21 % (309/1391) 22.57 % (321/1422) 22.19 % (286/1289)

levofloxacin / / / 22.19 % (249/1122) 22.49 % (318/1414) 22.77 % (326/1432) 23.04 % (300/1302)

norfloxacin 13.98 % (131/937) 16.92 % (188/1111) 16.00 % (184/1149) 20.29 % (255/1261) 20.33 % (282/1391) 21.45 % (305/1422) 22.78 % (293/1286)

ofloxacin 15.43 % (148/959) 17.25 % (193/1119) 16.97 % (198/1167) 17.22 % (26/151) // /

ampicillin 43.47 % (416/957) 46.20 % (517/1119) 46.87 % (547/1167) 48.74 % (619/1270) 50.57 % (715/1414) 52.83 % (757/1433) 53.92 % (702/1302)

amoxicillin-clavulanate

6.14 % (59/961) 5.54 % (62/1119) 6.17 % (72/1167) 5.91 % (75/1270) 7.57 % (107/1414) 10.33 % (148/1433) 12.90 % (168/1302)

piperacillin-tazobactam

0.42 % (4/958) 0.63 % (7/1119) 0.43 % (5/1167) 0.16 % (2/1270) 0.21 % (3/1414) 0.28 % (4/1433) 0.77 % (10/1301)

cefotaxim 1.56 % (15/959) 5.27 % (59/1119) 2.06 % (24/1167) 1.10 % (14/1269) 2.97 % (42/1414) 3.42 % (49/1433) 4.45 % (58/1302)

ceftazidim 1.77 % (17/960) 5.36 % (60/1119) 0.60 % (7/1167) 0.39 % (5/1269) 0.99 % (14/1414) 1.05 % (15/1433) 1.46 % (19/1302)

16.3% 22.1%




Quinolones are the mainstay for the treatment of UTI’s and TRUSPB prophylaxis

BUT

high percentage of quinolone resistance of E. coli in rectaland urine samples at our center



Percentage of sensitivity of ciprofloxacin resistant E. coli strains from urine samples 2003 2009


ampicillin 17.86 % (25/140) 14.06 % (27/192) 13.23 % (25/189) 11.15 % (30/269) 13.27 % (41/309) 9.35 % (30/321) 11.19 % (32/286)

amoxicillin-clavulanate 51.43 % (72/140) 54.69 % (105/192) 65.08 % (123/189) 60.97 % (164/269) 61.81 % (191/309) 47.98 % (154/321) 39.51 % (113/286)

piperacillin-tazobactam 98.56 % (137/140) 91.67 % (176/192) 96.83 % (183/189) 96.65 % (260/269) 97.09 % (300/309) 97.51 % (313/321) 93.36 % (267/286)

cefuroxim 53.96 % (75/139) 47.92 % (92/284) 52.38 % (99/189) 58.36 % (157/269) 57.28 % (177/309) 57.94 % (186/321) 51.75 % (148/286)

cefazolin 32.35 % (33/102) 26.32 % (10/38) 27.51 % (52/189) 18.52 % (5/27) / / /

cefotaxim 94.29 % (132/140) 72.92 % (140/192) 84.13 % (159/189) 92.19 % (248/269) 86.41 % (267/309) 82.76 % (264/321) 84.62 % (242/286)

ceftazidim 94.29 % (132/140) 72.40 % (139/192) 82.54 % (156/189) 92.19 % (248/269) 84.47 % (261/309) 81.31 % (261/321) 82.87 % (237/286)

meropenem 100.0 % (140/140) 100.0 % (192/192) 100.0 % (189/189) 100.0 % (269/269) 100.0 % (309/309) 100.0 % (321/321) 100.0 % (286/286)


Results First 100 patients: 3 cases of sepsis with ciprofloxacin resistant E. coli

3% prospective vs. 1.41% retrospective!


Results First 100 patients: 3 cases of sepsis = 3% vs. 1.41%!

Patient No. 1 2 3

Age (year) 70 70 61

Biopsy indication elevated PSA elevated PSA elevated PSA

Biopsy date 22/12/2009 28/12/2009 30/12/2009

Date of hospitalization 23/12/2009 29/12/2009 01/01/2010

History of biopsy third first first

PSA (µg/L) 14.33 13.0 4.66

Pathology no malignancy invasive adenocarcinoma no malignancy

Medical history

-chronic prostatitis & orchitis

- post-TRUSPB sepsis (2007)

- sleep apnea

drug eluting stent 05/2009- hip prosthesis

- sleep apnea

Antimicrobial historyseveral cures of

fluoroquinolone in the past

30 days fluoroquinolone before

biopsy

6 weeks fluoroquinolone

starting from 09/09/2009


Results risk factors for faecal carriage of cipro resistant E. coli

1st biopsy: 9/55 patients = 16.4%

Repeat biopsy: 13/45 patients = 28.9%

use of fluoroquinolones < 6 months before biopsy

history of prostatitis

P-value= 0.15

Yagci et al, 2009Shigehara et al,

2008


Conclusions high percentage of ciprofloxacin resistant E. coli isolated from

rectal swabs



rectal swabs

incidence of sepsis after TRUSPB is higher than determinedwith our retrospective study



rectal swabs


need to re-evaluate our antimicrobial prophylaxis regimen



rectal swabs


need to re-evaluate our antimicrobial prophylaxis regimen

importance of reviewing a patient’s history before prescribinga prophylaxis regimen

RECOMMENDATIONS

Recommendations

Antibiotic resistance patterns in this highlyselected population suggests that prophylaxisregimen should be re-evaluated:

Consideration of 1g IM ceftriaxone (Rocephine®) 30 minutes before biopsy for high risk patients

Recommendations



prior quinolone use < 6 months before biopsy prior infectious complications of TRUSPB recurrent bacterial prostatitis, UTI’s indwelling catheter Diabetes Mellitus

Recommendations



Rectal swab in patients with a history of fluoroquinoloneuse to screen for faecal carriage of quinolone resistant E. coli strains

Recommendations

Proposal to protocol for antimicrobial prophylaxis

Patients without risk factors:

Single dose Ciprofloxacin 500 mg 12 to 1h before biopsy

versus

Ciprofloxacin 500 mg 12 to 1h before biopsy + once dailyfor 3 days

No arguments for the use of more than one dose

Recommendations


Patients without risk factors

Patients with quinolone use in the previous 6 months, no other risk factors: RECTAL SWAB

cipro S: Ciprofloxacin 500 mg

cipro R: Rocephine® 1g IM 30 min before biopsy

Recommendations



Patients with quinolone use in the previous 6 months, no other risk factors

Patients with 1 or more risk factors:

Rocephine® 1g IM 30 min before biopsy

Recommendations



Patients with quinolone use in the previous 6 months, no other risk factors

Patients with 1 or more risk factors

What about patients allergic to penicillin? the widely quoted cross-allergy risk of 10% between

penicillin and cephalosporins is a myth

patients who have had a true IgE-mediated reaction to a penicillin: avoid using cephalosporins with a similar side chain (cephalothin, cephalexin, cefadroxil, and cefazolin)

alternative: gentamicin 240 mg IV 1h before biopsy

TO DO’S

To Do’s

Continue our prospective study at the University Hospital of Leuven

To Do’s


Create a system to report post-biopsy complications involving fluoroquinolone-resistant E. coli

To Do’s


Create a system to report post-biopsy complications involving fluoroquinolone-resistant E. coli

Review our current antimicrobial prophylaxis regimen for TRUSPB in consultation with the urologists

QUESTIONS?

after prostate biopsy is fluoroquinolone prophylaxis still ...deborah steensels 30 maart 2010...

Documents