Use of Outpatient Parenteral Antimicrobial Therapy for Transrectal Ultrasound-guided Prostate Biopsy Prophylaxis in the Setting of Community-associated Multidrug-resistant Escherichia coli Rectal Colonization

doi:10.1016/j.urology.2013.12.039

Urology

Volume 83, Issue 4, April 2014, Pages 710-713

https://doi.org/10.1016/j.urology.2013.12.039 Get rights and content

Objective

To study the use of ertapenem delivered in an outpatient parenteral antimicrobial therapy (OPAT) hospital-based unit setting for targeted transrectal ultrasound-guided prostate biopsy (TRUSPBx) prophylaxis in the setting of multidrug-resistant (MDR) Escherichia coli rectal colonization. E coli is the pathogen most commonly associated with post-TRUSPBx complications, and there is increasing prevalence of community-associated MDR E coli.

Methods

Prospective data analysis of all patients admitted to the OPAT unit for administration of intravenous antibiotics for prophylaxis for TRUSPBx over 18-month period was performed. Patients had identification of MDR E coli in rectal swab cultures and/or intolerance to available oral agents. Microbiologic data and tolerability of administered antibiotics and outcome after TRUSPBx were tabulated.

Results

Nine patients (median age 74 years) were referred because of antibiotic-resistant E coli from rectal swabs (all fluoroquinolone resistant, 7 MDR). All patients received ertapenem 1 g intravenously 1 day before TRUSPBx and the day of the procedure before TRUSPBx. None of the patients experienced infectious complications immediately after TRUSPBx or several weeks or months later, and no patient was lost to urologic follow-up.

Conclusion

Increasing worldwide reports of prostatitis, urinary tract infections, and septicemia after TRUSPBx because of MDR E coli suggest rectal screening before procedure may be useful in decreasing complications. Targeted prophylaxis in these instances is necessary. Although carbapenems are used for treatment, they are not routinely used for prophylaxis. We report successful use of ertapenem delivered in a hospital-based OPAT unit for TRUSPBx prophylaxis.

Section snippets

Methods

A prospective study of tolerability and outcome of intravenous antibiotic administration for TRUSPBx prophylaxis in urology patients referred to The Dr. James J. Rahal Jr. Division of Infectious Diseases at New York Hospital Queens after rectal cultures were performed. All patients had identification of MDR E coli and/or intolerance to available oral agents. Patients requiring outpatient intravenous treatment were admitted to the hospital-based Infectious Disease OPAT unit, open 9 hours a day,

Results

Nine patients were referred to the Dr. James J. Rahal Jr. Division of Infectious Diseases at New York Hospital Queens for treatment in our OPAT unit before TRUSPBx as a result of preceding rectal cultures (Table 1). Median age was 74 years (range, 62-82), and all patients underwent TRUSPBx because of elevated prostate-specific antigen. All E coli were FQ resistant, 2 of 9 additionally tetracycline resistant, and 7 of 9 MDR. ESBL testing was reported for 4 isolates, with 3 of 4 exhibiting

Comment

E coli account for approximately 75%-90% of infectious complications after TRUSPBx, with most because of FQ-resistant strains.⁴ A recent report documented hospitalizations after TRUSPBx associated with MDR E coli (resistant to FQ, amoxicillin, and trimethoprim/sulfamethoxazole) that occurred in approximately 3% of patients within the first week after the procedure, with 10% requiring intensive care unit admission.⁵ Various antibiotics have been used to reduce post-TRUSPBx–related infections,

Conclusion

As a result of increasing FQ and MDR E coli resistance, pre-TRUSPBx surveillance rectal cultures and “targeted” prophylaxis will be an increasingly common modality to decrease TRUSPBx-related complications. Local outpatient antibiotic resistance patterns are crucial to choosing optimal agent(s), and we need to be prepared for the lack of oral options and hospital-based OPAT units that can be a significant real-time resource to practicing urologists. Patients receiving intravenous ertapenem in

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Cited by (13)

Recommendations for outpatient parenteral antimicrobial therapy in Brazil
2017, Brazilian Journal of Infectious Diseases
Citation Excerpt :
Patients with conditions related to other agents or without microbiological proof are not considered eligible for OPAT in Brazil; Complicated infections of the urinary tract15,16; Intra-abdominal infections, including secondary peritonitis, abscess, sepsis, cholecystitis with perforation or abscess, intra-abdominal abscess, appendicitis with perforation or abscess, stomach or intestinal perforation, peritonitis, diverticulitis with perforation, peritonitis or abscess.17,18
A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to determine the recommendations for outpatient parenteral antimicrobial therapy (OPAT) in Brazil. The following aspects are covered in the document: organization of OPAT programs; patient evaluation and eligibility criteria, including clinical and sociocultural factors; diagnosis of eligibility; venous access and antimicrobial infusion devices; protocols for antimicrobial use and monitoring and cost-effectiveness.
Routine Ertapenem Prophylaxis for Transrectal Ultrasound Guided Prostate Biopsy does Not Select for Carbapenem Resistant Organisms: A Prospective Cohort Study
2017, Journal of Urology
Citation Excerpt :
There are limited other reports of ertapenem prophylaxis for TGB. However, a small study of 9 patients using a 2 to 3 dose intravenous regimen in patients with fluoroquinolone resistant or multidrug resistant E. coli colonization did not demonstrate post-biopsy sepsis in any patient.19 At the institutional level we have not observed any significant increase in CRE detection subsequent to the introduction of ertapenem prophylaxis for TGB, despite the fact that all clinically significant Enterobacteriaceae from hospital patients are screened for carbapenem resistance at our laboratory (unpublished data).
Sepsis after transrectal ultrasound guided prostate biopsy is an increasing problem in this era of rising antibiotic resistance. Although ertapenem prophylaxis has proved effective at our institution to reduce this, it has raised local and regional antimicrobial stewardship concerns. We investigated the possible selective effect of single dose ertapenem prophylaxis on fecal colonization with carbapenem resistant Enterobacteriaceae.
Patients underwent a rectal swab prior to receiving prebiopsy ertapenem prophylaxis. A second swab was obtained at followup 4 to 6 weeks later. Swabs were screened for carbapenem resistant Enterobacteriaceae using an enhanced CDC (Centers for Disease Control) method. Prebiopsy swabs were also screened for extended spectrum β-lactamase producing and ciprofloxacin resistant Enterobacteriaceae. Patients were monitored for post-biopsy sepsis.
A total of 326 patients were enrolled in the study. At baseline 6.4% and 9.0% of patients had colonization with extended spectrum β-lactamase producing and ciprofloxacin resistant Enterobacteriaceae, respectively. Carbapenem resistant Enterobacteriaceae were not detected at baseline or followup in any patients. Colonization with nonfermentative organisms with intrinsic ertapenem resistance was detected in 29.4% of patients at baseline and followup (p = 1.0). Three cases (0.9%, 95% CI 0.2–2.8) of probable post-biopsy sepsis were identified during the study period. None was bacteremic or required intensive care unit admission.
Single dose ertapenem prophylaxis did not appear to have a significant selective effect on fecal colonization with carbapenem resistant Enterobacteriaceae or other ertapenem resistant gram-negative organisms in this outpatient group. It is highly effective prophylaxis for transrectal ultrasound guided prostate biopsy. In the right setting ertapenem may represent a useful prophylactic option to prevent post-transrectal ultrasound guided prostate biopsy sepsis.
Trends in Antibiotic Resistance in Urologic Practice
2016, European Urology Focus
Citation Excerpt :
In addition, the resistance rate reported for fosfomycin was lower compared to fluoroquinolone (41.9% vs 69.2%). While it has been reported that carbapenems are a suitable alternative in preventing post-TRUPB infections [102,103], subsequent development of resistance is of major concern. It has been suggested that a tailored approach to prophylaxis may be more clinically useful and cost-effective.
The significant global upsurge in antimicrobial resistance, particularly among Enterobacteriaceae, represents a serious threat to health care systems. The implications for urologic practice are of particular concern.
To review trends in antibiotic resistance in urologic practice.
We report current European trends of resistance in Gram-negative uropathogens.
In addition to β-lactam resistance, Gram-negative pathogens are often resistant to multiple drug classes, including aminoglycosides, fluoroquinolones, and carbapenems, commonly used to treat urologic infections. Interest is renewed in old antibiotics, and several new antibiotics are in the pipeline to meet the challenge of treating these infections. In this review, we summarise emerging trends in antimicrobial resistance and its impact on urologic practice. We also review current guidelines on the treatment and prevention of urologic infections with these organisms, and some key antibiotics in the era of resistance.
Increasing antimicrobial resistance represents a challenge to urologic practice for both treatment and prophylaxis. Antibiotic choice should be determined according to risk factors for multidrug resistance. Good knowledge of the local microbial prevalence and resistance profile is required to guide antimicrobial therapy.
Antimicrobial resistance represents a challenge in urology. We summarise emerging trends in antimicrobial resistance and review current guidelines on the treatment and prevention of urologic infections, as well as some key antibiotics in the era of resistance.
Plasma and intraprostatic concentrations of ertapenem following preoperative single dose administration: a single-centre prospective experience and clinical implications—the ERTAPRO study
2016, International Journal of Antimicrobial Agents
Citation Excerpt :
Finally, the prostate-to-plasma ratio strongly suggested that the prostate tissue homogenate concentration reflected the unbound plasma ertapenem concentration [34]. As prophylaxis, although there are no site-specific evaluations of ertapenem in the prostate, some authors reported successful use of ertapenem for reducing sepsis following transrectal biopsy of the prostate [35,36]. To our knowledge, we are the first to demonstrate the site-specific penetration of ertapenem.
The incidence of urinary tract infections caused by extended-spectrum β-lactamase (ESBL)-producing pathogens is increasing. These infections are associated with a long hospital stay in patients undergoing urological procedures. We aimed to demonstrate that significant intraprostatic diffusion of ertapenem is achieved after a single preoperative administration. A referred sample of 19 patients requiring surgery for benign prostatic hyperplasia was prospectively included. Patients received a 1 g intravenous (i.v.) dose of ertapenem 1 h (n = 10, group A) or 12 h (n = 9, group B) before blood and prostatic samples were collected. Plasma and intraprostatic concentrations of ertapenem were measured using LC-MS/MS. Intraprostatic concentrations were considered satisfactory when higher than the MIC₉₀ value of urinary-targeted pathogens perioperatively and for 40% of the dosing interval. The Wilcoxon test and a pharmacokinetic predictive model were used. Median plasma concentrations of ertapenem were 144.3 mg/L (95% CI 126.5–157.9) in group A and 30.7 mg/L (95% CI 22.9–36.4) in group B (P < 0.001); median intraprostatic concentrations were 16.6 mg/L (95% CI 13.3–31.4 mg/L) and 4.2 mg/L (95% CI 3.1–4.9 mg/L), respectively (P < 0.001), which were above the MIC₉₀ values of bacteria, including ESBL-producers, during surgery and for 40% of the dosing interval. The plasma-to-prostate concentration ratio was not significantly different between groups (P = 0.97). Single-dose i.v. ertapenem reached satisfactory intraprostatic concentrations, suggesting that it could be a relevant prophylactic strategy for carriers of ESBL-producing bacteria undergoing prostatic procedures, which needs to be confirmed by further prospective trials.
Culture Directed Antibiotic Prophylaxis Reduces Post-Prostate Biopsy Infectious Complications in the Community: A "How-to" for Urologists in the Trenches
2015, Urology Practice
The rate of post-prostate biopsy infection is increasing. We noted this trend in our practice and began using prebiopsy rectal swab cultures to direct antibiotic prophylaxis. Clinical investigation has shown that culture directed antibiotic prophylaxis is effective. We report our methods and results as validation that culture directed antibiotic prophylaxis works in the community.
We retrospectively reviewed the charts of 686 consecutive patients who underwent transrectal prostate biopsy from March 2010 to April 2013. The electronic medical record was queried for the antibiotic prophylaxis used, rectal swab culture, post-biopsy infection, culture data and post-biopsy hospitalization if applicable. Prebiopsy rectal swab was incorporated into our practice in May 2012. Each patient received 3 days of fluoroquinolone prophylaxis or culture directed antibiotic prophylaxis. If antibiotic resistance to standard fluoroquinolone prophylaxis was identified, antibiotic prophylaxis was adjusted appropriately.
Of 543 patients who received standard fluoroquinolone prophylaxis 17 (3.1%) had infectious complications. Eight patients were hospitalized for post-biopsy sepsis and 4 received outpatient treatment for urinary tract infection. A total of 143 patients underwent prebiopsy rectal swabs and received culture directed antibiotic prophylaxis. Compared to standard antibiotic prophylaxis no patient treated with culture directed antibiotic prophylaxis after a rectal swab had infectious complications (p = 0.03). However, 19.5% of the patients in this group had resistant bacteria requiring alternative antibiotic prophylaxis.
A prebiopsy rectal swab to direct antibiotic prophylaxis decreased post-biopsy infectious complications in the community setting. The strategy is simple and it improves patient safety.
Acute bacterial prostatitis: Diagnosis and management
2016, American Family Physician
Citation Excerpt :
In patients who are at increased risk of harboring fluoroquinolone-resistant bacteria, preoperative stool cultures may allow for tailoring of antibiotics at the time of the procedure.17,30
Acute bacterial prostatitis is an acute infection of the prostate gland that causes pelvic pain and urinary tract symptoms, such as dysuria, urinary frequency, and urinary retention, and may lead to systemic symptoms, such as fevers, chills, nausea, emesis, and malaise. Although the true incidence is unknown, acute bacterial prostatitis is estimated to comprise approximately 10% of all cases of prostatitis. Most acute bacterial prostatitis infections are community acquired, but some occur after transurethral manipulation procedures, such as urethral catheterization and cystoscopy, or after transrectal prostate biopsy. The physical examination should include abdominal, genital, and digital rectal examination to assess for a tender, enlarged, or boggy prostate. Diagnosis is predominantly made based on history and physical examination, but may be aided by urinalysis. Urine cultures should be obtained in all patients who are suspected of having acute bacterial prostatitis to determine the responsible bacteria and its antibiotic sensitivity pattern. Additional laboratory studies can be obtained based on risk factors and severity of illness. Radiography is typically unnecessary. Most patients can be treated as outpatients with oral antibiotics and supportive measures. Hospitalization and broad-spectrum intravenous antibiotics should be considered in patients who are systemically ill, unable to voluntarily urinate, unable to tolerate oral intake, or have risk factors for antibiotic resistance. Typical antibiotic regimens include ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam. The risk of nosocomial bacterial prostatitis can be reduced by using antibiotics, such as ciprofloxacin, before transrectal prostate biopsy.

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: Financial Disclosure: The authors declare that they have no relevant financial interests.

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Ambulatory and Office UrologyUse of Outpatient Parenteral Antimicrobial Therapy for Transrectal Ultrasound-guided Prostate Biopsy Prophylaxis in the Setting of Community-associated Multidrug-resistant Escherichia coli Rectal Colonization

Objective

Methods

Results

Conclusion

Section snippets

Methods

Results

Comment

Conclusion

Eur Urol

Diagn Microbiol Infect Dis

J Urol

Urology

Clin Microbiol Infect

J Urol

Int J Antimicrob Agents

Clinical and molecular correlates of virulence in Escherichia coli causing bloodstream infection following transrectal ultrasound-guided (TRUS) prostate biopsy

J Antimicrob Chemother

Prevalence of antibiotic resistance in fecal flora of patients undergoing transrectal ultrasound-guided prostate biopsy in Thailand

Urol Int

Infectious complications following ransrectal ultrasound-guided prostate biopsy: new challenges in the era of multidrug-resistant Escherichia coli

Clin Infect Dis

Infection-related hospital admissions after transrectal biopsy of the prostate

ANZ J Surg

Ambulatory and Office Urology
Use of Outpatient Parenteral Antimicrobial Therapy for Transrectal Ultrasound-guided Prostate Biopsy Prophylaxis in the Setting of Community-associated Multidrug-resistant Escherichia coli Rectal Colonization