CHANGING ANTIBIOTIC PROPHYLAXIS FOR TRANSRECTAL ULTRASOUND‐GUIDED PROSTATE BIOPSIES: ARE WE PUTTING OUR PATIENTS AT RISK?

Sir, We read with interest the findings of a UK case series [1] that suggested that oral co-amoxiclav prophylaxis given 1 h before TRUS-guided prostate biopsy (TRUSgpb) and for 3 days afterwards was less likely to prevent sepsis than a historical control group who received ciprofloxacin prophylaxis also administered 1 h before TRUSgpb and for 3 days subsequently. No cases of Clostridium difficile (C. difficile) were identified during the course of the study. In 2008, the UK Department of Health encouraged hospitals to reduce C. difficile infections by using penicillin-based surgical prophylaxis instead of cephalosporins and fluoroquinolones [2]. Consistent with the recommendations of the UK NHS Prostate Cancer Risk Management Programme [3], our standard prophylaxis for TRUSgbp was oral ciprofloxacin 500 mg given 1 h before biopsy plus i.m. gentamicin 120 mg administered 10 min before the procedure. From September 2008, we changed from ciprofloxacin to oral co-amoxiclav 625 mg, but continued with the aminoglycoside. In the 3 weeks following the change, 48 TRUSgpb procedures were performed and seven patients were re-admitted with Gram-negative bacteraemia; of these two required intensive care management for septic shock. Pre-existing resistance to co-amoxiclav was identified in two of seven breakthrough bacteraemia isolates, and ciprofloxacin resistance was found in one isolate. We immediately reverted back to our original prophylactic regimen and performed a root cause analysis. The only critical control point, which had changed was antibiotic prophylaxis. On review of the TRUSgbp sub-population there were no stool samples, which tested positive for C. difficile identified in the 2008 calendar year. No post-TRUSgpb bacteraemic episodes were reported in the 3 months after reverting to the original regimen that used ciprofloxacin. Our experience is consistent with previously published concerns regarding co-amoxiclav-based prophylaxis for TRUSgpb in the UK [1, 4]. Unlike co-amoxiclav, the successful in vivo clinical activity of ciprofloxacin is probably related to its ability to achieve high intra-prostatic concentrations. The emergence of quinolone-resistant Escherichia coli and a Canadian population study that reported rising hospital re-admission rates due to bacterial complications after TRUSgpb over the past decade highlight the need for more research to elucidate risk factors for sepsis in men undergoing this procedure [5].

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