Increasing transrectal ultrasound guided prostate biopsy associated infection; is a change in antimicrobial prophylaxis the solution? Authors: Ni Bhuachalla C 1, McNamara E 2, Carroll A 2, Lynch T 1, Boyle B 1 1. St James’s Hospital, Dublin 8, Ireland. 2. Public Health Laboratory HSE, Dublin 10, Ireland.

TRUS biopsy associated infection Surveillance/ diagnostic protocol Post procedure infection rates  1- 3% UTI  % BSI Strategies to reduce rate of infection  Antimicrobial prophylaxis  Pre procedure screening  Decontamination protocol  Operator training

Antimicrobial prophylaxis 1 st lineAlternative EAU 2011 (Updated 2013) FQ*  No clear-cut alternative is evidence-based  Consider need for biopsy  Consider rectal swab AUA 2007 (Updated 2012) FQ*Aminoglycoside plus anaerobic cover National guideline None

“...clear lack of standardization in antibiotic prophylaxis for transrectal prostate biopsy...” “...in nine trials we observed that antibiotic prophylaxis is effective in preventing infectious complications and hospitalization following prostate biopsy...” “...several classes of antibiotics are effective for prophylaxis in prostate biopsy, with the quinolones the best analysed class...”

Antimicrobial resistance  prevalence fluoroquinolone (FQ) resistance  prevalence gentamicin resistance Previous exposure to antimicrobials Previous health care contact

E. coli BSI Resistance in Ireland (EARSS)

E. coli BSI resistance St James’s Hospital % Resistance

Aims To identify all patients with post TRUS biopsy infection from Jan Nov 2012 Review isolates and susceptibilities causing infection Review antimicrobial prophylaxis administered To assess efficacy of change in prophylaxis from Dec 2012 to date

Methods Study period 1 (Retrospective) Jan 2010 – Nov 2012 Prophylaxis gentamicin and FQ ID and susceptibility testing Vitek 2 Typed by PFGE (pulse net protocol) Study period 2 (Prospective) Dec 2012 – Feb 2013 Prophylaxis amikacin and FQ

Study period 1 Jan 2010 – Nov 2012 No. TRUS biopsies conducted1398 Overall infection rate1% (15) Type of post biopsy infection0.4 %BSI/ SSI (6/15) 0.6% UTI (9/15) IsolatesAll E.coli Previous TRUS biopsy60% (9/15) IsolatesAll E.coli Ciprofloxacin resistance73.3% (11/15) Gentamicin resistance40% (4/10) Amikacin resistance0% (5/5) ESBL producer6.7% (1/15)

Number of TRUS associated infections Jan Nov 2012 (until end of Nov 2012) (0.2%) (2.5%)

Study period 1 Jan 2010 – Nov 2012 PFGE 6 available isolates - distinguishable

Study period 2 Dec 2012 – Feb 2013 No. TRUS biopsies conducted 140 Overall infection rate2% (3) Type of post biopsy infection1.3% BSI (2) 0.7% UTI (1) IsolatesAll E.coli Previous TRUS biopsy2/3 IsolatesAll E.coli Ciprofloxacin resistance3/3 Gentamicin resistance1/2 Amikacin resistance0/2 ESBL producer1/3

Post TRUS infection rate Jan 2010 to date Change of prophylaxis 0.2% 2.5% 2%

Local interim Recommendations  Amikacin and FQ?  Avoid fluoroquinolone use in empiric treatment of post biopsy infection  Targeted treatment of post biopsy infection when susceptibilities available  Targeted prophylaxis?

Conclusions  Increase in TRUS biopsy associated infection  Increasing antimicrobial resistance  Prospective surveillance  Potentially multifactorial process