Targeted Antimicrobial Prophylaxis Does Not Always Prevent Sepsis after Transrectal Prostate Biopsy
We compared the effectiveness of targeted prophylaxis (TP) to single agent empirical prophylaxis (SAEP) and augmented empirical prophylaxis (AEP) in preventing sepsis after transrectal prostate biopsy (TRPB).
We retrospectively reviewed TRPB's performed over three years at 13 Southern California Kaiser Permanente Departments of Urology. For TP, rectal culture bacterial susceptibilities guided selection of a single prophylactic antibiotic while for empirical prophylaxis, one antibiotic (SAEP) or multiple antibiotics (AEP) were given according to the urologist's usual practice. The decision to institute TP, SAEP or AEP was left to the discretion of the individual urologist. Sepsis was the primary outcome analyzed.
15,236 TRPB cases were reviewed. TP, SAEP and AEP were used in 26%, 58%, and 16% of cases, respectively. The overall incidence of post-biopsy sepsis was 0.64%. On sub-analysis, TP with ciprofloxacin had a significantly lower incidence of sepsis than SAEP with ciprofloxacin (0.3% vs. 0.79%, p=0.008) and AEP had a significantly lower incidence of sepsis than SAEP (0.3% vs. 0.78%, p=0.008) but the difference in sepsis between TP and AEP was not statistically significant (0.56% vs. 0.29%, p = 0.118). (see Figure 1) 29% of all the patients who became septic were given ciprofloxacin monotherapy yet still developed sepsis with ciprofloxacin-sensitive bacteria. The bacteria causing post-TRPB sepsis were sensitive to the antibiotic initially given as prophylaxis in 73%, 28% and 0% of cases that developed sepsis after TP, SAEP and AEP, respectively. (see Table 1)
This large retrospective study showed superiority of TP over SAEP when only ciprofloxacin was given. In addition, AEP was shown to be statistically superior to SAEP but not to TP. Importantly, a significant number of patients developed sepsis despite being given the correct prophylactic antibiotic.
Funding: Kaiser Permanente