Reminder of important clinical lesson
CASE REPORT
Radical prostatectomy in the presence of ongoing refractory ESBL Escherichia coli bacterial prostatitis Louise Catherine McLoughlin, T E D McDermott, John Alan Thornhill Tallaght Hospital, Dublin, Ireland Correspondence to John Alan Thornhill, marjorie.whitefl[email protected] Accepted 28 September 2014
SUMMARY A 44-year-old Indian national with a prostate-specific antigen of 5.4 ng/mL underwent 12-core transrectal ultrasound-guided prostate biopsies. Following this, he had three hospital admissions with severe urosepsis secondary to extended spectrum β lactamase (ESBL) producing Escherichia coli. He had recurrent sepsis immediately after discontinuation of intravenous meropenem to which the ESBL was sensitive. He proceeded to radical prostatectomy for intermediate-high risk Gleason 7 prostate cancer, while still on intravenous meropenem, 2 months after his biopsy. His prostatectomy involved a difficult dissection due to inflammatory changes and fibrosis after multiple septic episodes. He had complete resolution of infection after surgery with discontinuation of antibiotics on the third postoperative day, without any recurrence of sepsis.
BACKGROUND This case demonstrates the significant challenge presented by the emergence of multiantibiotic resistant organisms in the setting of extended spectrum β lactamase (ESBL) producing organisms causing severe urosepsis after transrectal ultrasound (TRUS) biopsy. There is a lack of consensus in the literature about the most appropriate prophylactic antibiotic to administer prior to TRUS biopsy. This case also highlights the difficulties in treating ESBL sepsis. We were unable to discontinue intravenous antibiotics. Removing the source of sepsis, the prostate, was the only cure for ESBL urosepsis.
CASE PRESENTATION
To cite: McLoughlin LC, McDermott TED, Thornhill JA. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014206291
A 44-year-old Indian man with a screening prostate-specific antigen of 5.4, no symptoms, no family history and no signs on examination underwent standard 12-core TRUS biopsy of prostate. Pathology, subsequent MRI and isotope bone scintigraphy confirmed Gleason score 7 (3+4) adenocarcinoma in moderate to high volume in 8 of 12 cores. Three of six right-sided cores had 60%, 5% and 1100 men. Sci World J 2012;2012:650858. Zani EL, Clark OA, Rodrigues Netto N Jr. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev 2011;(5):CD006576. Park SC, Lee JW, Rim JS. Robot-assisted laparoscopic radical prostatectomy after fluoroquinolone resistant Escherichia coli sepsis following a transrectal ultrasonography-guided prostate biopsy. Can Urol Assoc J 2011;5:E56–9.
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Williamson DA, Roberts SA, Paterson DL, et al. Escherichia coli bloodstream infection after transrectal ultrasound-guided prostate biopsy: implications of fluoroquinolone-resistant sequence type 131 as a major causative pathogen. Clin Infect Dis 2012;54:1406–12. Williamson DA, Masters J, Freeman J, et al. Travel-associated extended-spectrum beta-lactamase-producing Escherichia coli bloodstream infection following transrectal ultrasound-guided prostate biopsy. BJU Int 2012;109:E21–2. Cullen IM, Manecksha RP, McCullagh E, et al. The changing pattern of antimicrobial resistance within 42,033 Escherichia coli isolates from nosocomial, community and urology patient-specific urinary tract infections, Dublin, 1999–2009. BJU Int 2012;109:1198–206.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
McLoughlin LC, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-206291
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CASE REPORT
Radical prostatectomy in the presence of ongoing refractory ESBL Escherichia coli bacterial prostatitis Louise Catherine McLoughlin, T E D McDermott, John Alan Thornhill Tallaght Hospital, Dublin, Ireland Correspondence to John Alan Thornhill, marjorie.whitefl[email protected] Accepted 28 September 2014
SUMMARY A 44-year-old Indian national with a prostate-specific antigen of 5.4 ng/mL underwent 12-core transrectal ultrasound-guided prostate biopsies. Following this, he had three hospital admissions with severe urosepsis secondary to extended spectrum β lactamase (ESBL) producing Escherichia coli. He had recurrent sepsis immediately after discontinuation of intravenous meropenem to which the ESBL was sensitive. He proceeded to radical prostatectomy for intermediate-high risk Gleason 7 prostate cancer, while still on intravenous meropenem, 2 months after his biopsy. His prostatectomy involved a difficult dissection due to inflammatory changes and fibrosis after multiple septic episodes. He had complete resolution of infection after surgery with discontinuation of antibiotics on the third postoperative day, without any recurrence of sepsis.
BACKGROUND This case demonstrates the significant challenge presented by the emergence of multiantibiotic resistant organisms in the setting of extended spectrum β lactamase (ESBL) producing organisms causing severe urosepsis after transrectal ultrasound (TRUS) biopsy. There is a lack of consensus in the literature about the most appropriate prophylactic antibiotic to administer prior to TRUS biopsy. This case also highlights the difficulties in treating ESBL sepsis. We were unable to discontinue intravenous antibiotics. Removing the source of sepsis, the prostate, was the only cure for ESBL urosepsis.
CASE PRESENTATION
To cite: McLoughlin LC, McDermott TED, Thornhill JA. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014206291
A 44-year-old Indian man with a screening prostate-specific antigen of 5.4, no symptoms, no family history and no signs on examination underwent standard 12-core TRUS biopsy of prostate. Pathology, subsequent MRI and isotope bone scintigraphy confirmed Gleason score 7 (3+4) adenocarcinoma in moderate to high volume in 8 of 12 cores. Three of six right-sided cores had 60%, 5% and 1100 men. Sci World J 2012;2012:650858. Zani EL, Clark OA, Rodrigues Netto N Jr. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev 2011;(5):CD006576. Park SC, Lee JW, Rim JS. Robot-assisted laparoscopic radical prostatectomy after fluoroquinolone resistant Escherichia coli sepsis following a transrectal ultrasonography-guided prostate biopsy. Can Urol Assoc J 2011;5:E56–9.
12
13
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Williamson DA, Roberts SA, Paterson DL, et al. Escherichia coli bloodstream infection after transrectal ultrasound-guided prostate biopsy: implications of fluoroquinolone-resistant sequence type 131 as a major causative pathogen. Clin Infect Dis 2012;54:1406–12. Williamson DA, Masters J, Freeman J, et al. Travel-associated extended-spectrum beta-lactamase-producing Escherichia coli bloodstream infection following transrectal ultrasound-guided prostate biopsy. BJU Int 2012;109:E21–2. Cullen IM, Manecksha RP, McCullagh E, et al. The changing pattern of antimicrobial resistance within 42,033 Escherichia coli isolates from nosocomial, community and urology patient-specific urinary tract infections, Dublin, 1999–2009. BJU Int 2012;109:1198–206.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
McLoughlin LC, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-206291
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