The Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy
The Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy
Mihir Rao, Jim Zhong, Steven Yong Keen Hor, Krishanth Ganesan, Heidi Salminen, Reshma Mary Koshy, Atif Khan, Simon Burbidge*, Oliver Hulson
Prostate cancer is the most commonly diagnosed cancer in men in the UK, affecting 1 in 8 men.1 The National Institute for Health and Care Excellence (NICE) recommends multiparametric MRI (mpMRI) as the first-line investigation for suspected localised prostate cancer, with outpatient prostate biopsy being offered to patients with MRI Likert Score of 3 and above. Patients on active surveillance for known prostate cancer may also be recommended mpMRI ± biopsy.2 Recent NICE guidance3 recommends either transrectal ultrasound-guided (TRUS) or transperineal (TP) ultrasound-guided prostate biopsy under local anaesthetic. The rate of infection and sepsis is suggested to be lower in patients undergoing TP vs TRUS biopsy approach, due to lower risk of translocation of the rectal bacteria.4,5 No significant difference in infection rates have been found for patients undergoing TP biopsy with or without antibiotic prophylaxis.6,7 Previous audit of our centre’s TP biopsies demonstrated low infection rates & suggested a review of the need for pre-procedural antibiotic prophylaxis. Our aim was to evaluate complication rates in patients undergoing TP ultrasound-guided prostate biopsy with and without pre-procedural prophylactic antibiotics.
A 2-cycle closed-loop audit was carried out with retrospective data collection (Figure 1). Patients who underwent a TP ultrasound-guided prostate biopsy for either diagnosis or active surveillance of prostate cancer were included in the study. During the first audit cycle (September 2020 to May 2021), 106 patients underwent TP prostate biopsy with prophylactic antibiotics. Following a drive to reduce antibiotic usage, 388 cases without antibiotic prophylaxis were analysed in a second audit cycle (July 2022 to January 2023). Data collection included patient demographics, Charlson Comorbidity Index (CCI), prostate specific antigen (PSA) level, digital rectal examination, prostate volume on MRI, biopsy indication, procedural details, histopathological findings and complications. Post-biopsy complication rates were compared between both groups and against national standards from the British Association of Urological Surgeons (BAUS).8
Figure 1: A flow chart demonstrating the methodology process
Patient demographics were comparable between the two groups (Table 1). Most patients across groups were of White British ethnicity. Whilst all patients (n=106) in the antibiotic prophylaxis cohort underwent TP biopsy for diagnosis of prostate cancer, indications for biopsy in the no antibiotic prophylaxis cohort included diagnosing suspected prostate cancer (n=373) and surveillance biopsy (n=15). The percentage of targeted vs systematic biopsies in the antibiotic prophylaxis and no antibiotic prophylaxis cohorts was 72% vs 28% and 80% vs 20%, respectively. The median number of biopsy cores between the two groups was comparable at 12 and 13, respectively. Prostate cancer-positive findings were seen in 88% (n=93) and 77% (n=298) of the antibiotic and no antibiotic prophylaxis cohorts, respectively. The histopathological diagnosis of prostatitis in the no antibiotic prophylaxis cohort in 3.1% cases (n=12). The overall post-biopsy complication rate was 6.6% (n=7) in the antibiotic prophylaxis cohort and 1.8% (n=7) in the no antibiotic prophylaxis cohort, respectively. Table 2 compares the rates of documented complications between the two groups and against national BAUS standards8.
Table 1: A table illustrating patient demographics, pre-procedural investigation results and biopsy indications.
Table 2: A table comparing rates of documented complications between study groups and national BAUS standards.
The incidence of post-TP prostate biopsy complications, specifically infection, remains low despite the omission of pre-procedural antibiotics and is comparable to national standards. The TP biopsy approach continues to offer a safe way of investigating prostate cancer, whilst the reduction in antibiotic usage may lead to significant improvements in antibiotic stewardship and healthcare savings. References: 1. Prostate Cancer UK. About prostate cancer [Internet]. 2022 [cited 2023 Aug]. Available from: https://prostatecanceruk.org/prostate-information-and-support/risk-and-symptoms/about-prostate-cancer 2. Prostate cancer: diagnosis and management. [Internet]. NICE; 2019. (Clinical Guidance [NG131]). Available from: https://www.nice.org.uk/guidance/ng131/chapter/Recommendations 3. Transperineal biopsy for diagnosing prostate cancer. [Internet]. NICE; 2023. (Diagnostics guidance [DG54]). Available from: https://www.nice.org.uk/guidance/dg54/chapter/1-Recommendations 4. Tamhankar AS, et al. The clinical and financial implications of a decade of prostate biopsies in the NHS: Analysis of Hospital Episode Statistics Data 2008–2019. BJU International. 2020;126(1):133–41. 5. Cheng E, et al. Developments in optimizing transperineal prostate biopsy. Current Opinion in Urology. 2021;32(1):85–90 6. Basourakos SP, et al. Role of prophylactic antibiotics in transperineal prostate biopsy: A systematic review and meta-analysis. European Urology Open Science. 2022;37:53–63. 7. Castellani D, et al. Infection rate after Transperineal prostate biopsy with and without prophylactic antibiotics: Results from a systematic review and meta-analysis of comparative studies. Journal of Urology. 2022;207(1):25–34. 8. British Association of Urological Surgeons. 2021. Transperineal ultrasound-guided biopsies of the prostate gland. [Leaflet]. London: British Association of Urological Surgeons [Online] Available from: https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Transperinealbiopsies.pdf
