Rising Incidence of Acute Prostatitis

Following Prostate Biopsy:

Fluoroquinolone Resistance and
Exposure Is a Significant Risk Factor
Ashraf A.Mosharafa, Mohamed H.Torky, Wael M.
El said, and Alaa Meshref
INTRODUCTION
Infection-related complications after Prostate
Biopsies are repoted to occur in 1.7-11,3%
patients
Fluoroquinolone prophylaxis is generally
considered the standard care (recommended
by the EAU guidelin/AUA )
Acute Prostatitis is inflamate reaction of
Prostate Gland
Clinical Symptoms and Laboratory Result:
- fever, chills, malaise
- dysuria,urgency, frequency, nocturia
-perineal and LBP
-difficulty voiding
-prostate is enlarged, boggy, tender on exam
-Lab : Elevated WBC, pyuria and bacteriuria on
urinalysis
-Urine culture most commonly grows E Coli
Prostate Biopsy
OBJECTIVE
1. To evaluate :








the
for infection-related complications
after transrectal prostate biopsy
OBJECTIVE
2. To propose






adjustments
in current antimicrobial prophylaxis
recommendations.
MATERIAL AND METHODS
January 2008 June 2010
107 Consecutive patients
underwent transrectal ultrasound-guided
biopsies of the prostate
30 days
Detect for infection-related complications
The procedure was :
Outpatient basis
Urine analysis and coagulation profile (+)
3-5 day : Ciprofloxasin 2x500 mg or
Levofloxasin 1x500 mg
Begun the night before procedure
Enemas (12 hour and 2 hour before biopsy)
10-12 core prostate biopsy

Px with Pyuria (UL :>3 wbc/hpf)
Underwent urine culture and sensitivity
If positive, the biopsy was postponed
Diagnose of Acute Prostatitis secundary of
Prostate Biopsy :
Fever >38 C (100,4 F)
With or without chills in association with
significant LUTS
Absence of other clinically apparent sources of
infection

Potential Risk Factors:
Age
Diabetes Mellitus
Hypertension
Chronic constipation
Diverticular disease
Prior use of Quinolones within 6 months of the
biopsy
Use of the enema
Prostatitis on pathology report
RESULT
107 patients
Mean age (range) : 62,7 (48-81) years
Acute prostatitis : 10 (9,3 %)
95 had follow up data (at least 2 postbiopsy
visits)
No statistical diiference between the ages of
patients who developed and those who did
not developed prostatitis
Acute prostatitis : 1-22 days (mean 3,2,
median 2) of the biopsy procedure.
They all had a fever of 38.0 C (100,4 F) or
higher and had 7 had leukocytosis ( 11.000
cell/mm3)
8 px hospitalized for 2-8 days and 2 were as
outpatients

Risk Factor No.of Biopsied
Patients (%)
No.of Acute
Prostatitis Px (%)
P Value
Prior Fluoro
quinolone use:
.042
- Yes 41 7 (17,1)
- No 66 3(4,5)
Enema .061
- Yes 72 4 (5,6)
- No 35 6 (17,1)
Diabetes Melitus .276
- Yes 31 1(3,2)
- No 75 9(12,0)
Hypertension .322
- Yes 55 7(12,7)
- No 52 3(5,8)
Risk Factor No.of Biopsied
Patients (%)
No.of Acute
Prostatitis Px (%)
P Value
Prior biopsy : .207
- Yes 18 0(00
- No 89 10(11)
Constipation/
Diverticulosis
.361
- Yes 12 1(8,3)
- No 95 9(9,5)
Prostatitis on Biopsy .449
- Yes 28 1(3,6)
- No 79 9(11,4)
Of the 10 px with prostatitis: 8 had positif specimens
( 6 urine and 2 bood specimens)
The Organism isolated were :
- E.Coli (6)
- Klebsiella Pneumonia (1)
- Staph epidermidis (1)
The isolated Gram Negative organism were
Fluoroquinolones resistant in 6 out of 7 samples
(85,7%)
The sample with Staph epidermidis was resistant to
penicillins and fluoroquinolones, and was sensitive to
imipenem,vancomycicn, and amikacyn


COMMENT
Report : High rate of acute prostatitis after TRUS-
guided prostate biopsy (9.3%) despite standard
antimicrobial prophylaxis with fluoroquinolones
Although higher than most other series, the
incidence seems to be in line with number of
reports, suggesting a risisng rate of infection-related
complications after prostate biopsy.
Multiple studies have described a rising antimicrobial
resistance to Fluoroquinolones after Transrectal
Biopsy



These studies concluded that the use of
fluoroquinolone with a first biopsy could be a
risk factor for acute prostatitis on repeat
biopsy because of increase in fluoroquinolone-
resistant E.Coli in the rectum.

Prior Fluoroquinolone intake (whether for
urological or nonurologic indications) in
patients undergoing prostate biopsy, and it
was found to be a statistically significant risk
factor for the development of acute prostatitis

This study shows a trend not reaching
significance (P= .061) toward decreasing risk
of acute prostatitis in patients using enemas

None of the risk factors (DM,HT, prior prostate
biopsy, prostatitis in biopsy report, and
chronic constipation/diverticular disease) was
associated with the development of prostatitis

E.Coli was the chief pathogen , identified in 6-
8 positive samples ( consistent with finding in
other reports)
Fluoroquinolone resistance in Gram-negative
pathogens was 85.7%
Cephalosporin susceptibility of E Coli was
48,2-85,7% in this study
The most effective antimicrobials ( 100 %
susceptibility ) being amikacin and
carbapenems

CONCLUSION
Prior fluoroquinolone intake is a significant
risk factor behind a rising incidence of acute
prostatitis after transrectal biopsy
Identified pathogens are mostly Gram
negative organisms with a high rate of
fluoroquinolone resistance.
Alternative prophylaxis regimens for the
biopsy procedure should be considered in px
with recent history of quinolone intake
For px developing acute prostatitis,
fluoroquinolone resistance must be
anticipated and empirical treatment started
with amikacin, carbapenems, or ceftriaxone