Original Paper

Urologia

Received: January 6, 2015 Accepted after revision: February 20, 2015 Published online: April 11, 2015

Urol Int DOI: 10.1159/000381271

Internationalis

The Value of Rectal Cultures in Treatment of Sepsis Following Post-Transrectal Ultrasound-Guided Prostate Biopsy Tamar Gottesman a Orit Yossepowich a Orna Harari-Schwartz c Alexander Tsivian d Jay Idler e Michael Dan a, b  

 

a

 

 

 

 

Infectious Diseases Unit, E. Wolfson Hospital, Holon, b Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Microbiology Laboratory, E. Wolfson Hospital, Holon, d Department of Urology, E. Wolfson Hospital, Holon, e Student, School of Medicine, Tel Aviv University, Tel-Aviv, Israel c

 

 

 

 

 

Abstract Background: Cases with sepsis after transrectal ultrasoundguided prostate biopsy (TRUSPB) were documented, with special focus on cultures and susceptibility of isolates. We also evaluated the contribution of concomitant rectal cultures to the treatment of selective cases. Materials and Methods: Patients with sepsis after TRUSPB were followed prospectively. Manifestations and risk factors for antimicrobial resistance were documented. Results of urine and blood cultures and antimicrobial susceptibility were recorded for all participating patients. In 40 patients, rectal swab cultures were obtained concomitantly. Results: Ninety-five patients were consecutively studied. Sepsis symptoms started showing up within 48 h after biopsy in 93% of patients. At least one of the cultures was positive in 72 patients. E. coli grew in 70 cases; isolates were highly resistant: 67% displayed multidrug-resistance. Rectal cultures grew E. coli in 38 cases. In patients with positive E. coli in rectum and in at least one additional culture (blood and/or urine), the antibiogram was identical in all cases but one. Eight cases had negative cultures. Conclusion: The prevalence of antimicrobial resis-

© 2015 S. Karger AG, Basel 0042–1138/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin

tance among E. coli isolates from patients with TRUSPB sepsis was alarming. Susceptibilities of rectal E. coli isolates used for deescalation of initial empiric treatment in culture-negative TRUSPB sepsis can contribute to the reduction of broadspectrum antibiotics exposure. © 2015 S. Karger AG, Basel

Introduction

Transrectal ultrasound-guided prostate biopsy (TRUSPB) is in use since the early 1980s and is one of the most commonly performed procedures in urology. Although generally considered to be a relatively safe outpatient procedure, severe sepsis has been described in up to 3.5% of cases after TRUSPB, with Escherichia coli being the most commonly involved pathogen [1–3]. Recently there has been an apparent increase in hospitalization for infectious complications after TRUSPB [1, 4, 5]. Although the role of antimicrobial prophylaxis in reducing infectious complications after biopsy is now well established [6–8], life-threatening infection still occurs despite prophylaxis [9]. Recently, one of the main issues of concern has been the increasing resistance to antimicrobials of isolates from patients with sepsis following TRUSPB. Several publications have documented an alarming inMichael Dan, MD 30 Ben Yossef St. Tel Aviv 69125 (Israel) E-Mail midan @ post.tau.ac.il

Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 7/3/2015 10:47:26 AM

Key Words Antibacterial resistance · E. coli · Rectal cultures · Sepsis · Transrectal ultrasound-guided prostate biopsy

crease in resistance to fluoroquinolone among E. coli in post-TRUSPB infections [10, 11], as well as to other antimicrobial agents such as ampicillin, ampicillin/sulbactam, trimethoprim/sulfamethoxazole and gentamicin [9, 11]; extended spectrum β-lactamase (ESBL)-producing isolates have been increasingly recovered [12]. Over the years, there has been an increase of E. coli resistance to ciprofloxacin (up to 90%) accompanied by a concomitant increase in the rate of post-TRUSPB infectious complications [9, 11]. If this trend continues, the resistance will spread to other antimicrobial agents at alarming rates. Because of this rise in resistance to antibacterial agents, it is increasingly becoming complicated to formulate a judicious empiric therapy for post-TRUSPB infections, especially if both urine and blood cultures show no growth. The aim of this study was to present our clinical experience with post-TRUSPB infections, and to propose a practical approach to circumvent the problem of negative urine and blood cultures. Material and Methods

2

 

Urol Int DOI: 10.1159/000381271

 

Patients were treated on an inpatient basis. The initial empiric treatment protocol consisted of intravenous amikacin; this was adjusted according to bacterial susceptibility results, when available. Intravenous drugs were replaced by oral preparations, when possible, as patients became afebrile. Patients were discharged after at least a week of antibiotic treatment. Statistical analysis was performed using commercially available software.

Results

A total of 95 patients with sepsis following transrectal ultrasound-guided prostate biopsy were recruited between February 2006 and April 2014. There was conformity among all patients in terms of the definition of sepsis. Almost all of them had received antibiotic prophylaxis periprocedure that included a 7-day regimen of a fluoroquinolone and a single intramuscular dose of 80 mg gentamicin immediately before the biopsy. Patients usually underwent biopsy for elevated serum prostate specific biopsy (PSA) and/or abnormal digital rectal examination. The procedure was performed in 9 different out-patient clinics, most of which were not located within hospitals. Patient characteristics and clinical manifestations are presented in table 1. No patient died as a result of sepsis. Gottesman/Yossepowich/ Harari-Schwartz/Tsivian/Idler/Dan

Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 7/3/2015 10:47:26 AM

 

 

 

Age, years, mean (range) 64.3 (51–78) Fever ± SD, °C 39.6±0.548 Chills, n (%) 79 (83) Urinary tract symptoms, n (%) 37 (39) Start of clinical symptoms following biopsy, n (%) ≤24 h 61 (64) ≤48 h 28 (29) ≥48 h 6 (6) Leukocytosis Patients with abnormal count, n (%) 70 (73) Patients with leukocytosis, ×109/l, mean ± SD 14.006±2.948 Underlying conditions, n (%) Diabetes mellitus 20/95* (21) Corticosteroids 4/93* (4) Predisposing factors for antimicrobial resistance, n (%) Exposure to antibiotics in previous 6 months 15/41* (36.5) Hospitalizations in previous 6 months 7/37* (19) Being a health care worker 2/31* (6) Complications, n Hypotension 4 Shock 2 Epididymitis 2 * n of patients with positive response/n of patients questioned.

Patients admitted to the urology department at Wolfson Hospital, Holon, Israel in 2006 to April 2014 with documentation or history of fever (temp >38 ° C) with or without urinary tract symptoms and chills, within 10 days after TRUSPB, were prospectively enrolled in the study. Sepsis was defined as at least two of the following symptoms: body temperature above 101 F (38.3 ° C) or below 96.8 F (36 ° C); heart rate higher than 90 beats a minute; respiratory rate higher than 20 breaths a minute; probable or confirmed infection. Patients with documented alternative origin of fever were excluded. A history was obtained, including demographic details, history of diabetes mellitus, steroid use, risk factors for antibiotic resistance (antibiotic administration, other than prophylaxis before the TRUSPB in the previous 6 months; previous admission to hospital in the past 6 months, being a health care worker); name of the institution where the biopsy was done, interval from biopsy to the appearance of symptoms, whether prophylactic antibiotic treatment was administered and the type of antibiotics. Physical examination included, among others, body temperature, blood pressure, signs of orchiepididymitis and prostatitis, and exclusion of non-urinary tract infection. Complications during hospitalization and outcome were noted. Laboratory evaluation included complete blood count, urine culture and blood cultures. Patients admitted from January 2010 onward, had rectal cultures obtained on admission after signing an informed consent. All organisms isolated in urine, blood and rectal cultures were tested for antibiotic susceptibility. Resistance to antibiotics was defined as MDR (multidrug-resistant) when the isolate was non-susceptible to ≥1 agent in ≥3 antimicrobial categories; XDR (extensively drugresistant) when the isolate was non-susceptible to ≥1 agent in all but ≤2 categories; and PDR (pandrug-resistant) when the isolate was non-susceptible to all antimicrobial agents listed [13]. Isolates were categorized by the use of the multi-locus sequence typing method (MLST).  

Table 1. Patients’ characteristics

Patients with concomitant rectal swab cultures 40

Patients with E. coli in rectal swab cultures 38

Sterile urine and blood 8/38 (21%)

Patients with no E. coli in rectal swab cultures 2

Sterile urine and blood 1

Klebsiella in urine and blood 1

Identical antibiogram in all same patient’s samples 29/30 (96.6%)

Fig. 1. Patients with concomitant rectal swab cultures.

In all 95 patients, blood and/or urine cultures were obtained. At least one of the cultures was positive in 72 patients. E. coli grew in 70 (97%) of the cases; in the remaining two cases Klebsiella spp. was isolated. In 34 (48.5%) patients both urine and blood cultures grew E. coli. In 29 cases, all of which grew E. coli, either blood or urine cultures were positive. In 23 (24%) patients, both urine and blood cultures were sterile. In another 7 cases, one of the samples was sterile, while the other was not obtained. Susceptibility testing of E. coli isolates revealed the following patterns: all isolates from blood and/or urine were resistant to at least one of the antimicrobial agents tested. The antibiotics to which the isolates were mostly resistant were ciprofloxacin (91%), ampicillin (84%) and trimethoprim-sulfamethoxazole (55%) (table 2). Twenty-five patients (34%) grew E. coli which was ESBL-positive; the strains were equally distributed over the study period. Forty-eight patients (67%) had isolates that were MDR. There were no isolates with XDR. All isolates were susceptible amikacin, ertapenem, meropenem and colistin. Patients with MDR isolates had more often risk factors for antimicrobial resistance than did patients with nonMDR isolates (30 and 17%, respectively), although the difference did not reach statistical significance. Concomitant stool cultures were obtained in 40 patients (fig. 1). In all cases, with the exception of two patients, E. coli was grown. In the two patients with negative

Table 2. Rate of E. coli resistance* to tested antimicrobial agents

Post-TRUS-Guided Prostate Biopsy Sepsis

Urol Int DOI: 10.1159/000381271

Agent

Resistant, n/ tested, n

Resistant, %

Ampicillin Amoxacillin-clavulanate Ampicillin-sulbactam Cefazolin Cefuroxime Ceftriaxone Ceftazidime Astreonam Piperacillin-tazobactam Ertapenem Meropenem Gentamicin Amikacin Colistin (polymyxin E) Ciprofloxacin Trimethoprim-sulfamethoxazole Nitrofuratoin ESBL+

59/70 14/54 26/42 23/70 26/70 22/70 22/70 22/70 3/70 0/70 0/37 20/70 0/70 0/44 64/70 39/70 3/61 24/70

84 26 62 33 37 31 31 31 4 0 0 29 0 0 91 55 5 34

* Isolates of intermediate susceptibility (non-susceptible) were counted as resistant.

3

Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 7/3/2015 10:47:26 AM

E. coli stool cultures, urine and blood cultures were sterile in one and grew Klebsiella spp. in the other. Of the 38 patients with positive E. coli in the stool, 18 had negative urine cultures, 12 had negative blood cultures and 8 (21%) had both urine and blood negative cultures. In patients

Discussion

This is one of the biggest series of patients with sepsis following transrectal ultrasound-guided prostate biopsy that was documented prospectively. The most impressive finding was the extent of antimicrobial resistance among the vastly predominant isolate, namely E. coli. Although patients with MDR isolates had more often risk factors for antimicrobial resistance, with the difference not being statistically significant, this cannot be the only explanation for the remarkable phenomenon observed. Another possible risk factor that has to be considered is the exposure to prophylactic antimicrobials given prior to the procedure. It is a common practice among urologists to recommend a course of 7 days of antibiotic (starting 2 days before TRUS biopsy and continuing for 5 days afterwards) or any other variation of multiple dosing, consisting most often of a fluoroquinolone with or without an additional agent [14]. All the patients in our series received the 7-day prophylactic regimen. This long prophylactic regimen is not in accordance with the Surgical Infection Prevention Guidelines [15]. According to these guidelines, the administration of the first IV fluoroquinolone dose should begin within 120 min before procedure, and prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. A more prolonged administration of prophylactic antimicrobials is associated with the risk of emergence of resistant bacterial strains [16]. One of the two major factors contributing to the emergence and spread of antimicrobial resistance in hospitals is the high rate of antimicrobial drug use. An example for inappropriate antimicrobial drug use in hospitals is the continuation of perioperative prophylaxis beyond 24 to 48 h [17]. This principle is relevant for outpatient settings as well. Several randomized controlled trials have documented the equivalence of single-dose or one-day regimens compared to three-day regimens for TRUSPB [6, 18, 19]. 4

Urol Int DOI: 10.1159/000381271

Indeed, in a preliminary study comprising 10 patients, all E. coli isolates that were recovered from rectal specimen before administration of a prophylactic fluoroquinolone for TRUSPB showed no resistance to this agent. However, one of the patients developed post-TRUSPB sepsis that was caused by ciprofloxacin-resistant E. coli despite harboring a ciprofloxacin-susceptible organism pre-TRUSPB [M. Dan, A. Striker, unpublished data]. In a study investigating the prevalence of antimicrobial resistance in intestinal flora of patients undergoing prostate biopsy who received ciprofloxacin prophylaxis, 10% of rectal coliforms pre-TRUSPB were ciprofloxacin-resistant compared to 100% (7/7) of coliforms isolated from patients who developed post-TRUSPB infection; the resistance rate of pre-TRUSPB rectal coliforms in these patients was 71.4% (5/7) [14]. Although a selection phenomenon certainly plays a role, namely, in a patient harboring a fluoroquinolone-resistant organism in the rectum, fluoroquinolone prophylaxis is destined to fail and the patient will develop an infection with fluoroquinolone-resistant pathogen. But this is apparently not the only mechanism since fluoroquinolone-resistance can appear to be the novo probably through the transfer of resistance genes from other enterobacteriaceae [20]. Any attempt to use another approach based on administrating antimicrobials for prophylaxis will eventually lead to the development of resistance. A novel approach consisting of the use of non-antibiotic prophylactic techniques is the only way to tackle the problem of expanding antimicrobial resistance. Our finding of E. coli as the predominant pathogen in post-TRUSPB sepsis and its extensive resistance to antimicrobial agents is not exceptional and has been documented by studies from other centers (table 3). In most studies, E. coli represented almost 90% and more of recovered isolates and more than 80% were resistant to fluoroquinolones [3, 10, 14, 21–24]. Another consequence of the extensive multidrug resistance documented in this study as well as in others, is the difficulty to formulate an empirical antibiotic treatment with commonplace antibacterial agents. This is particularly troublesome in cases with negative cultures (approximately 20% of cases) when one is compelled to use broad spectrum agents for the whole period of treatment, and to expose unnecessarily the patient’s flora to powerful antibiotics. We tried to circumvent this problem by using the susceptibility results of the rectal E. coli isolate of the same patient to tailor the antibacterial regimen for postTRUSPB sepsis. The basis for relaying on rectal isolates Gottesman/Yossepowich/ Harari-Schwartz/Tsivian/Idler/Dan

Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 7/3/2015 10:47:26 AM

with positive E. coli in stool and at least one additional culture with E. coli (blood and/or urine), the antibiogram was identical in all cases but one (stool isolate but not the one from blood was ESBL+). In 21 patients with positive E. coli in stool and at least one additional culture (blood and/or urine), the strains underwent genotypic analysis; strains belonging to the same patient were found to be genotypically identical [M. Dan manuscript in preparation].

Table 3. Literature report of E. coli rate and resistance to ciprofloxacin in relation to TRUSPB

[Ref.]/year

[3]/2003 [14]/2009 [22]/2011 [10]/2011 [23]/2011 [24]/2011 [21]/2012 [25]/2014 Present study/2014

Country

Israel UK Japan USA Egypt Turkey USA Korea Israel

Pre-TRUSPB cultures

Post TRUSPB infection

E. coli/ total isolates (%)

cipro-resistant E. coli (%)

E. coli/ total isolates (%)

cipro-resistant E. coli (%)

ND ND 100/100 (100) ND ND ND ND 76 ND

ND 10.6 13 ND ND ND ND 26/7 ND

13/14 (93) 7/8 (87.5) 4/4 (100) 20/31 (64.5) 6/8 (75) 10/10 (100) 8/9 (89) ND 70/72 (97)

80 100 100 55 85.7 100 87.5 ND 94

TRUSPB = Trans rectal ultrasound-guided prostate biopsy; year = year of publication; cipro = ciprofloxacin; ND = not done or no data.

was the finding that the yield of rectal cultures was much higher than that of blood and/or urine cultures. In patients with positive E. coli cultures in the three sites, the isolates were genetically identical [M. Dan manuscript in preparation] and showed the same susceptibility pattern. Therefore, we permitted ourselves to conclude that the E. coli isolates from the rectum represent with very high probability the pathogens responsible for the postTRUSPB sepsis that failed to grow in blood and/or urine. Others have already used the results of pre-TRUSPB rectal cultures to guide the antibacterial prophylaxis [14, 21]. To the best of our knowledge, this study is the first one that examines the idea of using rectal culture results to tailor the antimicrobial therapy in culture-negative post-TRUSPB sepsis. Our study has a few limitations: It is a single-center series so it is unclear whether the findings can be generalized to other settings, although E. coli, as the predominant pathogen in post-TRUSPB sepsis and its extensive resistance to antimicrobial agents has been documented by others (table 3). This is only an observational study. The next step would be to conduct an interventional trial demonstrating equivalent outcomes between empirical treatment versus treatment guided by the results of rectal cultures in post-TRUSPB sepsis that failed to grow pathogen in blood and/or urine. In order to limit the alarming increase in antibiotic resistance [26], urologists are urged to reduce the duration of pri-procedure antibiotic prophylaxis and to conform to Surgical Infection Prevention Guidelines [15]. The ultimate solution to reduce post-procedure infection would be

to use non-antibiotic prophylactic techniques. The use of information from rectal isolates of E. coli and their susceptibilities for deescalation of initial empiric treatment in culture-negative post-TRUSPB sepsis can also contribute to the reduction of exposure to broad-spectrum antimicrobial agents. These steps should be part of the global struggle against the spread of antimicrobial resistance [26].

Post-TRUS-Guided Prostate Biopsy Sepsis

Urol Int DOI: 10.1159/000381271

Disclosure Statement No conflict of interest for all authors. Informed consent: Informed consent was obtained from all individual participants from whom rectal cultures were obtained.

1 Nam RK, Saskin R, Lee Y, Liu Y, Law C, Klotz LH, et al: Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010;183:963–968. 2 Raaijmakers R, Kirkels WJ, Roobol MJ, Wildhagen MF, Schrder FH: Complication rates and risk factors of 5802 transrectal ultrasound-guided sextant biopsies of the prostate within a population-based screening program. Urology 2002;60:826–830. 3 Tal R, Livne PM, Lask DM, Baniel J: Empirical management of urinary tract infections complicating transrectal ultrasound guided  prostate biopsy. J Urol 2003; 169: 1762– 1765. 4 Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM: Complications after prostate biopsy: data from SEER-Medicare. J Urol 2011;186:1830–1834.

5

Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 7/3/2015 10:47:26 AM

References

6

Urol Int DOI: 10.1159/000381271

13

14

15

16

17 18

19

randomized against 3-day antibiotic prophylaxis for transrectal ultrasonography-guided prostate biopsy. BJU Int 2009;103:1069–1073; discussion 1073. Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al: Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268–281. Batura D, Rao GG, Nielsen PB: Prevalence of antimicrobial resistance in intestinal flora of patients undergoing prostatic biopsy: implications for prophylaxis and treatment of infections after biopsy. BJU Int 2010;106:1017– 1020. Bratzler DW, Houck PM: Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38: 1706– 1715. Harbarth S, Samore MH, Lichtenberg D, Carmeli Y: Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation 2000;101:2916–2921. Bell D: Controversies in the prevention and control of antimicrobial drug resistance. Emerg Infect Dis 1998;4:473–474. Sabbagh R, McCormack M, Péloquin F, Faucher R, Perreault JP, Perrotte P, et al: A prospective randomized trial of 1-day versus 3-day antibiotic prophylaxis for transrectal ultrasound guided prostate biopsy. Can J Urol 2004;11:2216–2219. Shigemura K, Tanaka K, Yasuda M, Ishihara S, Muratani T, Deguchi T, et al: Efficacy of 1-day prophylaxis medication with fluoroqui-

20

21

22

23

24

25

26

nolone for prostate biopsy. World J Urol 2005;23:356–360. Schjørring S, Struve C, Krogfelt KA: Transfer of antimicrobial resistance plasmids from Klebsiella pneumoniae to Escherichia coli in the mouse intestine. J Antimicrob Chemother 2008;62:1086–1093. Taylor AK, Zembower TR, Nadler RB, Scheetz MH, Cashy JP, Bowen D, et al: Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care. J Urol 2012;187:1275–1279. Minamida S, Satoh T, Tabata K, Kimura M, Tsumura H, Kurosaka S, et al: Prevalence of fluoroquinolone-resistant Escherichia coli before and incidence of acute bacterial prostatitis after prostate biopsy. Urology 2011;78:1235–1239. Mosharafa AA, Torky MH, El Said WM, Meshref A: Rising incidence of acute prostatitis following prostate biopsy: fluoroquinolone resistance and exposure is a significant risk factor. Urology 2011;78:511–514. Akduman B, Akduman D, Tokgöz H, Erol B, Türker T, Ayoğlu F, et al: Long-term fluoroquinolone use before the prostate biopsy may increase the risk of sepsis caused by resistant microorganisms. Urology 2011;78:250–255. Lee JW, Park SC, Kim MK, Cheon MW, Kim GY, Cho JH: Prevalence of antimicrobial resistance in normal rectal flora of patients undergoing transrectal ultrasonography-guided prostate biopsy in Korea. Int J Urol 2014; 21: 811–814. World Health Organization (WHO). Antimicrobial Resistance: Global Report on Surveillance, 2014. Geneva: WHO 2014.

Gottesman/Yossepowich/ Harari-Schwartz/Tsivian/Idler/Dan

Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 7/3/2015 10:47:26 AM

5 Wagenlehner FM, van Oostrum E, Tenke P, Tandogdu Z, Çek M, Grabe M, et al: Infective complications after prostate biopsy: outcome of the Global Prevalence Study of Infections in Urology (GPIU) 2010 and 2011, a prospective multinational multicentre prostate biopsy study. Eur Urol 2013;63:521–527. 6 Aron M, Rajeev TP, Gupta NP: Antibiotic prophylaxis for transrectal needle biopsy of the prostate: a randomized controlled study. BJU Int 2000;85:682–685. 7 Zani EL, Clark OA, Rodrigues Netto N Jr: Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev 2011; 5:CD006576. 8 Shandera KC, Thibault GP, Deshon GE Jr: Variability in patient preparation for prostate biopsy among American urologists. Urology 1998;52:644–646. 9 Carignan A, Roussy JF, Lapointe V, Valiquette L, Sabbagh R, Pépin J: Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: time to reassess antimicrobial prophylaxis? Eur Urol 2012;62:453–459. 10 Zaytoun OM, Vargo EH, Rajan R, Berglund R, Gordon S, Jones JS: Emergence of fluoroquinolone-resistant Escherichia coli as cause of postprostate biopsy infection: implications for prophylaxis and treatment. Urology 2011; 77:1035–1041. 11 Feliciano J, Teper E, Ferrandino M, Macchia RJ, Blank W, Grunberger I, et al: The incidence of fluoroquinolone resistant infections after prostate biopsy – are fluoroquinolones still effective prophylaxis? J Urol 2008; 179: 952–955; discussion 955. 12 Briffaux R, Coloby P, Bruyere F, Ouaki F, Pires C, Doré B, et al: One preoperative dose

The Value of Rectal Cultures in Treatment of Sepsis Following Post-Transrectal Ultrasound-Guided Prostate Biopsy.

Cases with sepsis after transrectal ultrasound-guided prostate biopsy (TRUSPB) were documented, with special focus on cultures and susceptibility of i...
133KB Sizes 0 Downloads 15 Views