To compare the incidence of infective complications after transrectal ultrasonography (TRUS)-guided biopsy with either empirical fluoroquinolone or culture-based targeted antimicrobial prophylaxis, and the prevalence of fluoroquinolone resistance (FQ-R) in men undergoing prostate biopsy. A systematic review of the literature was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included studies of patients undergoing TRUS-guided biopsy that compared infective outcomes of those who received targeted antimicrobial therapy based on the results of preprocedural rectal swab cultures, with those receiving empiric fluoroquinolone antimicrobial prophylaxis. The prevalence of FQ-R was recorded as a secondary outcome measure. Studies with no control group were excluded. From 125 studies screened, nine studies (4 571 patients) met the inclusion criteria. All studies were of cohort design, and included a combination of retrospective and prospective data. Six studies included were undertaken in North America. The remaining studies were undertaken in Spain, Turkey and Columbia. Within these studies, 2 484 (54.3%) patients received empirical fluoroquinolone prophylaxis, whilst 2 087 (45.7%) patients had pre-biopsy rectal swabs and targeted antibiotics. The mean FQ-R was 22.8%. Post-biopsy infection and sepsis rates were significantly higher in groups given empirical prophylaxis (4.55% and 2.21%) compared with groups receiving targeted antibiotics (0.72% and 0.48%). Based on these results 27 men would need to receive targeted antibiotics to prevent one infective complication. Our systematic review suggests that targeted prophylactic antimicrobial therapy before TRUS-guided prostate biopsy is associated with lower rates of sepsis. We therefore recommend changing current pathways to adopt this measure.

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An otherwise fit 58-year-old male presented with a sudden-onset rash on the buttocks and tenderness under the arms and left breast. His 25-year-old son had a similar rash on his torso and tenderness around the nipples bilaterally. Both patients were apyrexial. Over the next 24 hours redness developed at the site of tenderness under the arms and around the areolae. The family had bought a hot tub 3 weeks earlier and the father and son had longer immersion in the water compared with other family members, who were not affected.On examination there were tender erythematous nodules in the axillae (Figure 1) and around the left areola (Figure 2). There was follicular erythema with pustules over the buttocks (Figure 3). The son had similar changes in the axillae and around the areolae bilaterally with papules and pustules over the back (Figure 4).After 2 days pus started to discharge from the breast nodule of the son and a swab grew Pseudomonas aeruginosa. A diagnosis of Pseudomonas folliculitis with mastitis and axillary lymphadenopathy was given. Both patients took 500 mg ciprofloxacin twice daily for a week with complete resolution of the affected areas.The hot tub was drained, cleaned with domestic bleach products, and rinsed.