Risk factors for and prophylactic effect of povidone-iodine rectal cleansing on infectious complications after prostate biopsy: a retrospective cohort study
Int Urol Nephrol
Risk factors for and prophylactic effect of povidone‑iodine rectal cleansing on infectious complications after prostate biopsy: a retrospective cohort study
Eu Chang Hwang 0 1
Seung Il Jung 0 1
Young Ho Seo 0 1
Se Heon Jeong 0 1
Dong Deuk Kwon 0 1
Kwangsung Park 0 1
Jin Woong Kim 0 1
0 J. W. Kim Departments of Radiology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School , Gwangju , Republic of Korea
1 E. C. Hwang · S. I. Jung (
2 ) · Y. H. Seo · S. H. Jeong · D. D. Kwon · K. Park Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School , 322 Seoyang-ro, Gwangju, Hwasun 519-763 , Republic of Korea
Purpose To evaluate the risk factors and efficacy of a povidone-iodine enema on infectious complications after transrectal ultrasound-guided prostate biopsy. Methods A total of 814 males who underwent transrectal ultrasound-guided prostate biopsy from January 2011 to December 2013 were evaluated retrospectively. Clinical variables, including demographics, prior antibiotic, or quinolone exposure, rectal swab culture results, povidoneiodine rectal cleansing, antibiotic prophylaxis, and infectious complications, were evaluated. Results Overall, 16 of 814 (2.0 %) patients developed infectious complications after prostate biopsy. Of the patients with infectious complications, five had fever, two had urinary tract infections, and nine had bacteremia or sepsis. Infectious complication rates were not significantly different between povidone-iodine rectal cleansing (n = 613) and no cleansing (n = 201) groups (1.5 vs. 3.5 %, p = 0.083). However, povidone-iodine rectal cleansing reduced severe infectious complications such as bacteremia and sepsis (0.3 vs. 3.5 %, p = 0.001). A rectal swab culture was performed in 552 patients, and extendedspectrum β-lactamase (ESBL)-producing and quinoloneresistant Escherichia coli were detected in 4.5 and 7.8 % of cultures, respectively. Quinolone and antibiotic exposure within 6 months prior to prostate biopsy were associated with quinolone resistance and ESBL positivity of rectal flora and infectious complications. Conclusions In the era of quinolone resistance, a povidone-iodine enema may reduce the infectious complication rate by reducing bacterial load. Quinolone exposure prior to prostate biopsy was a risk factor for antibiotic resistance to rectal flora and infectious complications.
Prostate; Biopsy; Escherichia coli; Fluoroquinolones; Infection
Introduction
Prostate biopsy is currently an essential procedure for
prostate cancer diagnosis. A systematic review of randomized
controlled studies on antibiotic prophylaxis in patients
undergoing transrectal prostate biopsy showed a significant
reduction in the risk of infectious complications compared
with those of placebo [
1, 2
]. The risk ratios (RRs) and 95 %
confidence intervals (CIs) of antimicrobial prophylaxis for
infectious complications were as follows: bacteriuria (RR
0.25; 95 % CI 0.15–0.42), bacteremia (RR 0.67; 95 % CI
0.49–0.92), fever (RR 0.39; 95 % CI 0.23–0.64), urinary
tract infections (UTIs) (RR 0.37; 95 % CI 0.22–0.62),
and hospitalization (RR 0.13; 95 % CI 0.03–0.55) [
2, 3
].
Fluoroquinolones (FQs) are particularly useful in this
setting due to their broad spectrum of activity against
intestinal flora and high prostatic tissue levels obtained after oral
administration [
4
]. Despite antibiotic prophylaxis, several
reports have recently suggested an increased rate of
infectious complications following transrectal prostate biopsy in
both North America [
5, 6
] and Europe [7].
The most common pathogen implicated in
post-transrectal-ultrasound (TRUS) biopsy sepsis is Escherichia coli,
accounting for 75–90 % of infectious complications. Over
the past decade, antimicrobial-resistant E. coli has been
increasingly described in patients with post-biopsy sepsis
[
3
]. The link between prior FQ exposure, colonization with
FQ-resistant E. coli, and subsequent post-biopsy infection
with FQ-resistant E. coli has also been demonstrated [
8
].
In the era of increasing rates of FQ resistance in E. coli
in many countries, the role of pre-biopsy screening for
resistant pathogens, followed by culture-directed
antimicrobial prophylaxis, has been assessed in several studies
[
8, 9
]. In addition, rectal disinfection with agents adjunct
to antibiotic prophylaxis has been suggested, although data
supporting the efficacy of such an approach are limited
[10].
The aim of this study was to evaluate the incidence of
infective complications post-TRUS biopsy, identify risk
factors for using a rectal swab, and demonstrate the
usefulness of a povidone-iodine enema in an actual Korean
clinical situation.
Methods
Study population
We retrospectively evaluated the records of all patients
(n = 814) who underwent prostate biopsy at our institution
from January 2011 to December 2013. The indications for
biopsy were elevation (...truncated)