Prospective Implementation of a Point-of-Care PCR-Based Detection Method to Guide Antibiotic Use Prior to Prostate Biopsy Compared to Targeted Prophylaxis and Physician Choice.

OBJECTIVE: To perform pilot testing regarding implementation of a point-of-care qPCR-based test (EST200) targeting bacterial clonal groups representing the majority of sepsis-causing Escherichia coli before prostate biopsy to determine antibiotic selection. MATERIALS AND METHODS: After IRB approval, we obtained rectal swabs to compare real-time qPCR analysis on a Rotor-Gene Q instrument (Qiagen, Hilden, Germany) to standard culture on ciprofloxacin infused (10mg/L) MacConkey agar and susceptibility testing. Techniques are compared by an area under the receiver operative curve (AUC). RESULTS: A total of 140 men participated in the study, 102 prebiopsy cultures were utilized to guide prophylaxis. We did not meet our accrual for the randomized portion of the clinical study, yet we did randomized 38 men without prebiopsy cultures to physician choice of antibiotic versus PCR-based approach. Regarding predicting Fluoroquinolone Resistant (FQR) at biopsy, prebiopsy cultures had an AUC of 0.91 (95%CI 0.84-1.00, P > .001) and polymerase chain reaction (PCR) had an AUC of 0.71 (95%CI 0.58-0.84, P = .005) (AUC comparison; Z = 2.31, P = .02). PCR correctly identified 4 of 5 FQR specimens. The PCR test attained an AUC of 0.79 (95%CI 0.56-1.00, P = .044) for detection of total FQR on the day of the biopsy. Risk-based techniques may overcompensate with additional antibiotics (21% versus 0%, P = .10). CONCLUSION: EST200 is a rapid PCR-based microbial detection system that has moderate ability to detect total FQR at the time of biopsy. Our study is underpowered, yet provide opportunities to improve the point of care PCR method, such as table tope testing in less than 20 minutes and include additional antibacterial resistant genes.

Local Antibiogram Predicts Appropriate Antibiotic Selection for Prostate Biopsy Prophylaxis.

INTRODUCTION: We evaluated our local antibiogram to determine the accuracy of its use in antibiotic augmentation before transrectal prostate biopsy. METHODS: We analyzed pre-transrectal prostate biopsy rectal swabs from January 2016 to September 2017 at the South Texas Veterans Health Care System (STVHCS). A query was run on pre-procedure rectal swabs positive for fluoroquinolone resistance in men undergoing transrectal prostate biopsy during this time. Culture results and antibiotic resistance profiles were recorded and compared to the proportion of antibiotic resistance in the STVHCS 2016 antibiogram. RESULTS: We identified 611 patients who underwent rectal culture before transrectal prostate biopsy, of which 98 were ciprofloxacin resistant Escherichia coli isolates. Our cohort demonstrated 80% sensitivity to ciprofloxacin compared to the STVHCS antibiogram sensitivity of 65% (p <0.001). Gentamicin demonstrated similar sensitivities between the antibiogram and cohort (90% and 88%, respectively). There were no statistically significant differences between the STVHCS antibiogram and the sensitivity profiles of our rectal swab cohort except for ampicillin/sulbactam, which was 57% in the antibiogram and 32% in our cohort (p=0.019). Of the ciprofloxacin resistant E. coli identified 4% (4 of 98) were considered extended spectrum beta-lactamase producers. CONCLUSIONS: Overall, resistance patterns in ciprofloxacin resistant E. coli isolates from our study population are consistent with the STVHCS antibiogram. Therefore, a local antibiogram may be used in an implementation strategy for targeted antibiotics or augmentation of fluoroquinolone prophylaxis for transrectal prostate biopsy.

The Challenges of Precision Medicine and New Advances in Molecular Diagnostic Testing in Hematolymphoid Malignancies: Impact on the VHA.

The Hematopathology Molecular Genetics subcommittee presents recommendations for molecular diagnostic testing in acute myeloid leukemia, myeloproliferative neoplasms, myelodysplastic syndrome, and lymphomas and for the development of an interfacility consultation service.

A prospective randomised study of a rotary powered device (OnControl) for bone marrow aspiration and biopsy.

INTRODUCTION: Bone marrow aspiration and biopsy is an invasive procedure associated with morbidity and mortality risk. We compared a powered bone marrow aspiration and biopsy device to the traditional method by relatively assessing pain scores, procedure times, biopsy capture rates, quality of material retrieved, and safety and operator satisfaction. METHODS: Two large academic medical centres participated in this trial. Patients were randomised to have procedures carried out using the powered system or the manual technique. A visual analogue scale pain score was recorded immediately following skin puncture and once again at the end of the procedure for each patient. Procedure time was measured from skin puncture to core specimen acquisition. Pathologic assessment of 30 randomised samples was carried out. Operator satisfaction with devices was measured on a scale of 0-10, with 10 as the highest rating. RESULTS: Five operators from two sites enrolled 50 patients (powered, n=25; manual, n=25). Groups were evenly matched, with no significant differences in the means for age, weight and height. The powered system was superior to the manual system with respect to patient perceived pain from needle insertion (2.6±2.0 vs 4.1±2.5, p=0.022) and procedural time (100.0±72.8 s vs 224.1±79.0 s, p<0.001). Overall pain scores at the end of both procedures were comparable (3.2±2.2 vs 3.8±3.0, p=0.438). No complications were observed in either arm of the study. Blinded pathologic analysis of the specimens retrieved revealed that cores obtained using the powered system were longer and wider than those obtained using the manual technique (25.4±12.3 mm² vs 11.9±5.6 mm², p=0.001). For marrow aspiration, no difference was seen between groups for clot/particle spicules or smear spicules. Operator assessment favoured the use of the powered device. CONCLUSIONS: Results of this trial suggest that the use of a powered bone marrow biopsy device significantly reduces needle insertion pain and procedural time when compared to a manual technique. The superior size and overall quality of core specimens retrieved by the powered device provides more material for pathologic evaluation, thereby increasing diagnostic yield and reducing the need for repeat procedures.