Antibiotic Prophylaxis for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and Meta-Analysis

Abstract

Purpose: Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been banned by the European Commission. In this systematic review we summarize the evidence for different antibiotic prophylaxis regimens. Materials and Methods: We searched MEDLINEÒ, EmbaseÒ and Cochrane Database for randomized controlled trials (inception to October 2019) assessing antimicrobial interventions in prostate biopsy. Primary outcome was infectious complications. Exclusion criteria were simultaneous interfering interventions. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used to assess the certainty of evidence. Protocol was registered with PROSPERO (CRD42015026354). Results: Overall 59 randomized controlled trials (14,153 participants) and 7 different antimicrobial interventions were included. Antibiotic prophylaxis reduced infectious complications compared to no prophylaxis (RR 0.56, 95% CI 0.40e0.77, p[0.0005, I 2 [15%, participants 1,753, studies 11). A short-term prophylaxis (single shot to 3 days) was inferior to a long-term prophylaxis (1 to 7 days) with fluoroquinolone (RR 1.89, 95% CI 1.37e2.61, p[0.0001, I 2 [0%, participants 3,999, studies 17). Fosfomycin trometamol was an alternative to fluoroquinolone with reduced rates of infectious complications (RR 0.49, 95 CI 0.27e0.87, p[0.02, I 2 [54%, participants 1,239, studies 3). Empiric prophylaxis was inferior to targeted prophylaxis (RR 1.81, 95% CI 1.28e2.55, p[0.0008, I 2 [48%, participants 1,511, studies 6). Standard prophylaxis was inferior to augmented prophylaxis (using multiple rather than single agent) using a fixed model (RR 2.10, 95% CI 1.53e2.88, p <0.0001, I 2 [71%, participants 2,597, studies 9), but not using a random model (p[0.07). No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. The certainty of evidence was rated as low/very low. Conclusions: In countries where fluoroquinolones are allowed as antibiotic prophylaxis, a minimum of a full 1-day administration as well as targeted therapy in case of fluoroquinolone resistance is recommended. In countries Abbreviations and Acronyms MA [ meta-analysis RCT [ randomized controlled trial RoB [ risk of bias SR [ systematic review UTI [ urinary tract infection

Monoprophylaxis With Cephalosporins for Transrectal Prostate Biopsy After the Fluoroquinolone-Era: A Multi-Institutional Comparison of Severe Infectious Complications

“…Moreover, no significant differences between the usage of cephalosporins vs. fluoroquinolones as a monotherapeutic antibiotic prophylaxis were observed (0.8% vs. 1.1%, p=0.9). These observations are noteworthy, since in a recent meta-analysis among 1141 evaluating antibiotic prophylaxis vs. placebo, the rate of infectious complications was 5.6% ( 10 ). The lower rate in our cohort might be explained by the definition of infectious complications.…”

“…In addition, as a consequence of increasing resistance rates, there were more severe infections during the past years after administration of fluoroquinolones ( 8 ). Since fluoroquinolones have been the antibiotic prophylaxis of choice for transrectal prostate biopsies for decades, no current guideline recommendation exists for other antimicrobial agents in prophylaxis ( 2 , 9 , 10 ). Cephalosporins represent an alternative as a monotherapeutic antibiotic prophylaxis.…”

Comparison of Complication Rates with Antibiotic Prophylaxis with Cefpodoxime Versus Fluoroquinolones After Transrectal Prostate Biopsy

“…In total, 330 men (74.7%) were biopsy-naïve, 83 (18.8%) had one prior biopsy, and 24 (5.4%) had two or more prior prostate biopsies ( Table 1). The median number of cores taken per biopsy was 13 (IQR [12][13][14]. There were no differences in those biopsy characteristics between the cefpodoxime and fluoroquinolone groups (all p > 0.05).…”

“…Since the European Medicines Agency (EMA) recommended more restrictive use of fluoroquinolones because of potentially permanent side effects, several studies have compared the efficacy of antibiotic prophylaxis for prostate biopsy with different antibiotic regimes [12][13][14][15][16]. To the best of our knowledge, no previous study has explicitly investigated complication rates after prostate biopsy with cefpodoxime as oral antibiotic prophylaxis.…”

Editorial Comment from Dr Togo to Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography‐guided prostate biopsy

“…4 A recent systematic review and metaanalysis that summarized the infection-preventing effects of antibacterial drugs used in prostate biopsy cases compared alternative drugs with quinolones regimens, and found that fosfomycin trometamol reduced the rate of infectious complications more than fluoroquinolones. 5 Fluoroquinolones have long been the preferred choice due to numerous reports showing their effectiveness, as well as widespread recognition of good tissue migration to the prostate. In contrast, the frequency of febrile complications after a biopsy due to quinolone-resistant Escherichia coli and extended-spectrum beta-lactamase-producing bacteria has been increasing.…”