Clinical
Contributions
Antibiotic Prophylaxis and Needle Biopsy
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By Jeffrey
Pollen, MD; Daniel Smiley, MD
Introduction
Intensive screening for prostate cancer has led to a phenomenal
increase in the number of biopsies done. To determine incidence of febrile
reactions and to identify the most effective prophylaxis against fever
after prostatic cancer biopsy, we reviewed the medical records of patients
who had transrectal prostatic needle biopsy.
Method
We reviewed 172 consecutive records of patients who had transrectal
prostatic needle biopsy during a three-month period in a health maintenance
organization. We recorded the prophylactic regimens and incidence of
febrile reaction, defined as temperature >101° F accompanied
by shaking chills, with or without urinary infection symptoms.
Results
Patients had transrectal prostatic needle biopsy because
of a clinical suspicion of prostate cancer or because of elevated serum
levels of prostate-specific antigen. Procedures were done in the clinic
without anesthesia or sedation and used an 18-gauge spring-loaded needle
(Microvasive®, Boston Scientific Corporation, Watertown, Mass).
Bowel preparation consisted of a phosphate enema given on the morning
before biopsy. Some patients received an additional enema the night
before biopsy.
The number of digitally directed and ultrasound-guided procedures were
nearly equally distributed. A mean of three to four biopsies were taken
(range, one to eight).
Prophylaxis
As preparation for biopsy, group A (102 patients) did not receive
ciprofloxacin. Fourteen of these patients received a povidone-iodine
enema, intramuscular administration of gentamicin, and oral administration
of either trimethoprim (TMP) or trimethoprim-sulfamethoxazole (TMP-SMX)
in single doses perioperatively. In 88 patients, the povidone-iodine
enema was omitted. These patients received gentamicin alone preoperatively
or gentamicin and either TMP or TMP-SMX in single doses. A small number
of patients continued to receive TMP-SMX for three to five days.
In group B (45 patients), ciprofloxacin was added to the prophylactic
regimen, postoperatively. Of these patients, 28 were given gentamicin
preoperatively and ciprofloxacin, 500 mg every 12 hours for three days
postoperatively. Seventeen patients received gentamicin, TMP, and metronidazole
in single doses perioperatively and ciprofloxacin, 500 mg every 12 hours
for two days postoperatively.
Group C (25 patients) started ciprofloxacin prophylaxis preoperatively.
Ciprofloxacin, 500 mg, was given every 12 hours for three or four doses,
starting the night before the biopsy. No other antibiotics were given.
Fever
Febrile reactions developed in 13 (7.6%) of the patients, 1
usually within one to three days after biopsy (Table
1). There was no correlation of fever with number of biopsy cores.
Fever developed in 11 (10.8%) of the group A patients and in two (4.5%)
of the group B patients. Fever was not seen in group C patients, who
started ciprofloxacin prophylaxis prior to biopsy.
Discussion
Urosepsisusually caused by E. coliis the most feared
complication of transrectal needle biopsy of the prostate. Fever may
be expected to develop in about 23% of patients who do not receive prophylactic
antibiotics (range, 6% to 48%).1,2 Febrile reactions as low
as 1.4% to 2.9% have been reported in patients who receive ultrasound-guided
biopsy without the benefit of antibiotics.3,4 Nonetheless,
most centers would recommend prophylactic antibiotics.5 Introduction
of nonquinolone antibiotics can lower the frequency of febrile reactions
to about 12% (range, 0 to 24%).6,7 Prophylaxis using quinolones
can reduce febrile complications to about 3.2% (range, 0-3.9%).8,9,10
Ciprofloxacin diffuses readily into the prostate. After initially high
serum levels, orally administered ciprofloxacin concentrates in the
prostate during a 12- to 24-hour period.11 Maximal protection
against febrile reactions can be realized when quinolone prophylaxis
is begun one to 12 hours before transrectal biopsy is done.8,9
Although pretreatment with antibiotics is largely responsible
for the reduced complication rate, coverage must be continued for 12
hours to seven days after biopsy.9,12 The value of ciprofloxacin
prophylaxis was underscored by a recent report of 4439 biopsies. Of
patients treated with 500 mg ciprofloxacin twice daily for eight doses
(beginning with three doses before biopsy), febrile E. coli infections
developed in 0.07%.13 Povidone-iodine solution administered
rectally can reduce infectious complications,7,14,15 but
its use was discontinued in our clinic after vasovagal reactions developed
in some patients. Although our findings were not statistically significant,
they support use of quinolones to prevent fever due to transrectal prostatic
needle biopsy. Compared with other prophylactic regimens, ciprofloxacin
prophylaxis substantially lowered the incidence of fever, especially
when started preoperatively. Our current protocol calls for ciprofloxacin
prophylaxis (500 mg every 12 hours for four doses) starting on the night
before biopsy and self-administration of phosphate enema on the morning
of biopsy. Patients are encouraged to minimize consumption of liquids
to maximize the concentration of antimicrobial agent in tissue and urine.
This regimen has reduced the incidence of fever to <2%.
Conclusion
Ciprofloxacin given before and after transrectal prostatic needle
biopsy may prevent febrile complications. Physicians who have not yet
done so might consider a similar cost-effective policy.
Related material presented as a poster at the 13th
World Congress on Endourology and SWL 11th Basic Research Symposium,
Jerusalem, Israel, November 26-December 1, 1995, and published in J
Endourol 1995 Nov;9 Suppl 1:S147.
Reprint requests: Jeffrey Pollen, MD, Department of
Urology, Kaiser Permanente Medical Center, 4647 Zion Avenue, San Diego,
CA 92120-5397. Phone: (619) 528-5458; FAX: (619) 528-5940.
References
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