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Rectal Swab Culture-Directed Antimicrobial Prophylaxis for Prostate Biopsy and Risk of Post-Procedure Infection: A Retrospective Cohort Study
Jessica C. Dai, Sc.B, Andrew Leone, M.D., Kathleen Hwang, M.D., Leonard Mermel, M.D., Gyan Pareek, M.D., Stephen Schiff, M.D., Dragan Golijanin, M.D., Joseph Renzulli, M.D..
The Warren Alpert School of Brown University, Providence, RI, USA.

INTRODUCTION: The incidence of transrectal ultrasound-guided (TRUS) prostate biopsy- related infections has continued to rise and the growing rate of fluoroquinolone resistance is believed to be a major contributing factor. Within the urologic community, there has been increasing interest in the utility of pre-biopsy rectal swab cultures for detecting rectal carriage of fluroquinolone-resistant organisms, directing the selection of antimicrobial prophylaxis and decreasing risk of post-biopsy infections. Herein, we determine the local rectal carriage rate of fluoroquinolone resistance in men undergoing prostate biopsy and examine the effect of culture-directed prophylaxis on the incidence of infectious complications after prostate biopsy.
MATERIALS AND METHODS: We included all men who received prostate biopsies between February 2013 to February 2014 at our institution in an IRB-approved retrospective cohort study. All patients received either a pre-procedural rectal swab and culture that was used to guide antimicrobial prophylaxis, or routine prophylaxis with a fluoroquinolone antibiotic at the discretion of the attending physician. Basic patient demographic and clinical information were collected, as well as data on any infectious complications treated within 30 days of biopsy. Chi-squared test, Fisher’s exact test and Welch’s t-test were used for statistical analysis. Potential confounding variables were controlled for using a multivariate logistic regression model.
RESULTS: Of the 487 patients included in the study, 314 patients received pre-procedure rectal cultures and theremaining 173 did not. Average patient age was 62.7 and 64.1 years, respectively (p=0.07). There was no difference in mean PSA value (p=0.9), Charlson co-morbidity score (p=0.8), or ethnicity (p=0.1) between the two groups. The rectal swab group was more likely to have received supplemental intramuscular gentamicin at the time of biopsy (p<0.001). Fluoroquinolone-resistant microorganisms were isolated from 12.8% of rectal cultures. Infectious complications occurred in 1.9% of the rectal swab group and 2.9% of the control group (p=0.5). There association between post-biopsy infection and rectal swab culture-directed antibiotic prophylaxis did not reach significance on univariate analysis (OR 0.65, p=0.5, 95% CI 0.20-2.18) or multivariate analysis after controlling for gentamicin use (OR 0.70, p=0.6, 95% CI 0.20-2.50). However, our study was underpowered.
CONCLUSIONS: Using multivariate analysis, we found a 30% reduction in the odds of post-biopsy infection with rectal swab-directed of antimicrobial prophylaxis. This did not reach statistical significance due to the low event rate. The incidence of fluoroquinolone resistance in our patient population is relatively high and consistent with that reported elsewhere in the literature. Our findings suggest that a large, prospective, randomized, controlled trial is warranted to further define the impact of this intervention.


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