Evaluation of targeted antimicrobial prophylaxis for transrectal ultrasound guided prostate biopsy: a prospective cohort trial.

BACKGROUND: We evaluated the effectiveness of targeted antimicrobial prophylaxis in transrectal ultrasound guided prostate biopsy (TRUSP). METHODS: A prospective, non-randomized cohort study was conducted. Rectal swab cultures plated on non-selective blood agar and on selective MacConkey agar supplemented with ciprofloxacin identified ciprofloxacin-susceptible and -resistant gram-negative bacteria (CS-GNB and CR-GNB). Patients with CS-GNB received ciprofloxacin while those with CR-GNB received directed prophylaxis. Infectious complications were defined clinically and microbiologically within 30 days after TRUSP. Data were derived at 7 and 30 days post procedure by questionnaires and electronic medical records. We hypothesized that there would be no difference in the infectious outcomes among the CS and CR groups. RESULTS: From November 1, 2012 to March 31, 2015, 510 men completed the study; 430 (84.3%) had CS-GNB and 80 (15.7%) had CR-GNB. 484 (94.9%) completed the study per protocol, while 26 (5.1%) had an intention-to-treat (ITT) analysis. Of the 484, 475 (98.1%) had no infections, nine (1.9%) had infections, six of which (1.2%) were culture-proven (CP). The nine infections were as follows: five (1.0%) uncomplicated UTIs, one (0.2%) complicated UTI, and three (0.6%) urosepsis. One case of uncomplicated UTI and two cases of urosepsis were not CP, but were diagnosed clinically. ITT outcomes were similar. The infection rates were not statistically different between the CS-and CR-GNB patients (p-value = 0.314; 95% CI 0.8-3.3). The four patients with complicated UTIs or sepsis were hospitalized for a mean of 2.6 days and discharged without sequelae. Of the nine infections, three were antimicrobial prophylaxis failures (two ciprofloxacin and one amikacin); three were likely due to failure of the collection or processing of the rectal swab or increasing bacterial resistance between the time of swab collection and biopsy, and three developed clinical infections with no isolate recovered. CONCLUSIONS: Targeted antimicrobial prophylaxis follows the principles of antimicrobial stewardship and achieved a low rate of infectious complications with limited morbidity and no sequelae. This individualized method of prophylaxis may be widely applied. Further studies are needed to explore reasons for targeted prophylaxis failure and to determine comparative efficacy of non-ciprofloxacin-containing targeted prophylaxis regimens. TRIAL REGISTRATION: ClinicalTrials.gov. NCT01659866 . Registered 9 July 2012. First patient enrolled 1 November 2012.

Optimal timing of oral fosfomycin administration for pre-prostate biopsy prophylaxis.

OBJECTIVES: As the optimal administration time for fosfomycin peri-procedural prophylaxis is unclear, we sought to determine optimal administration times for fosfomycin peri-procedural prophylaxis. METHODS: Plasma, peripheral zone and transition zone fosfomycin concentrations were obtained from 26 subjects undergoing transurethral resection of the prostate (TURP), following a single oral dose of 3 g of fosfomycin. Population pharmacokinetic modelling was completed with the Nonparametric Adaptive Grid (NPAG) algorithm (Pmetrics package for R), with a four-compartment model. Plasma and tissue concentrations were simulated during the first 24 h post-dose, comparing these with EUCAST susceptibility breakpoints for Escherichia coli, a common uropathogen. RESULTS: Non-compartmental-determined pharmacokinetic values in our population were similar to those reported in the package insert. Predicted plasma concentrations rapidly increased after the first hour, giving more than 90% population coverage for organisms with an MIC ≤4 mg/L over the first 12 h post-dose. Organisms with higher MICs fared much worse, with organisms at the EUCAST breakpoint being covered for <10% of the population at any time. Transitional zone prostate concentrations exceeded 4 mg/L for 90% of the population between hours 1 and 9. Peripheral zone prostate concentrations were much lower and only exceeded 4 mg/L for 70% of the population between hours 1 and 4. CONCLUSIONS: Until more precise plasma and tissue data are available, we recommend that fosfomycin prophylaxis be given 1-4 h prior to prostate biopsy. We do not recommend fosfomycin prophylaxis for subjects with known organisms with MICs >4 mg/L.

Reprogramming requirements after sacral nerve stimulator implantation: correlation with preoperative indication.

PURPOSE: Recent publications support sacral nerve stimulator implantation in patients with interstitial cystitis. To our knowledge the reprogramming requirements for all patients following stimulator implantation has not been described and it is unknown whether the number of sessions required vary by pre-implantation diagnosis. We determined overall reprogramming requirements following nerve stimulator implantation and whether requirements vary based on preoperative indication. MATERIALS AND METHODS: After obtaining institutional review board approval we retrospectively reviewed the records of all patients who underwent sacral nerve stimulator implantation at our institution between June 2002 and October 2004. The preoperative indication and number of reprogramming sessions during the initial test period (stage 1) and following permanent implantation (stage 2) were compared. RESULTS: The 17 patients proceeding to stage 2 with a minimum 12-month followup during the study period were included. Mean age was 43 years (range 26 to 78) and all patients except 1 were female. Patients were separated by diagnosis for evaluation purposes, including urgency/frequency/incontinence in 8, urinary retention in 2 and interstitial cystitis in 7. The average number of reprogramming sessions during stage 1 was 0.9, 3.5 and 2.3 for urgency/frequency/incontinence, urinary retention and interstitial cystitis, respectively. The average number of reprogramming sessions after stage 2 was 2.8, 3.0 and 6.9 at 12-month followup for urgency/frequency/incontinence, urinary retention and interstitial cystitis, respectively. No patient had the stimulator removed for reprogramming failure. CONCLUSIONS: Patients in urinary retention appear to require more frequent reprogramming during stage 1, while patients with interstitial cystitis require more sessions after stage 2 implantation.

A case of systemic polyarteritis nodosa with spermatic cord involvement.

BACKGROUND: A 50-year-old man with a history of hyperlipidemia and hypertension presented to an emergency department after 10 days of fevers (temperature 40 degrees C), headache, malaise, myalgia, poor appetite, diarrhea, and weight loss of 6.35 kg. He would subsequently develop bilateral scrotal swelling and pain during his evaluation. INVESTIGATIONS: Physical examination, CBC, blood chemistry panel, measurement of erythrocyte sedimentation rate and C-reactive protein level, liver function profile, urinalysis, lumbar puncture, blood cultures, urine cultures, cerebrospinal fluid culture, stool analysis and cultures, multiple viral studies including hepatitis serologies, measurement of antineutrophil cytoplasmic autoantibody levels, urine protein electrophoresis, serum protein electrophoresis, CT of the head, chest, abdomen and pelvis, MRI of the brain, temporal artery biopsy and pathologic analysis, scrotal ultrasonography, right spermatic cord biopsy and pathologic analysis. DIAGNOSIS: Polyarteritis nodosa with involvement of both spermatic cords. MANAGEMENT: Prednisone 60 mg daily was started for presumed temporal arteritis, but was discontinued when no evidence of arteritis was found in the temporal artery biopsy specimen. When pathologic analysis of the spermatic cord biopsy tissue confirmed polyarteritis nodosa, prednisone 40 mg twice daily was administered and the patient's scrotal pain and swelling resolved quickly. Steroids were slowly tapered and discontinued over the next 18 months. He remained free of systemic symptoms, with normal results on physical examination and laboratory evaluation, including urinalysis, CBC, erythrocyte sedimentation rate and C-reactive protein level, 5.5 months after discontinuation of glucocorticoid therapy.