World J Urol DOI 10.1007/s00345-014-1291-8
Original Article
Peri‑procedural povidone‑iodine rectal preparation reduces microorganism counts and infectious complications following ultrasound‑guided needle biopsy of the prostate Justin R. Gyorfi · Christopher Otteni · Kevin Brown · Amar Patel · Kathleen Lehman · Brett E. Phillips · Kalyan Dewan · Girish Kirimanjeswara · Jay D. Raman
Received: 27 February 2014 / Accepted: 21 March 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of the study was to evaluate whether a peri-procedural povidone-iodine rectal preparation (PIRP) prior to transrectal ultrasound-guided prostate needle biopsy (TRUS PNB) can reduce microorganism colony counts and infectious complications. Methods Our institutional TRUS PNB database was reviewed to identify infectious post-biopsy complications (defined as fever >38.5 °C with positive culture). The last 570 biopsy patients were divided into those administered only preoperative oral and/or parenteral antibiotics (n = 456; chronologically cohorts A–D) versus men receiving peri-procedural PIRP in conjunction with standard preoperative antibiotics (n = 114; cohort E). Rectal cultures were obtained in the PIRP cohort to quantify changes in microorganism colony counts. Results Mean baseline PSA for patients was 11.6 ng/ ml, 63 % were undergoing an initial biopsy, and 17 % had documented use of antibiotic therapy within the previous 6 months. A reduction in infectious complications was observed when comparing the conventional antibiotic (cohorts A–D) versus PIRP (cohort E) group (1.8 vs. J. R. Gyorfi · C. Otteni · K. Brown · A. Patel · K. Lehman · J. D. Raman (*) Division of Urology, Penn State Milton S. Hershey Medical Center, 500 University Drive, H055, Hershey, PA 17033‑0850, USA e-mail: [email protected] B. E. Phillips Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA K. Dewan · G. Kirimanjeswara Department of Veterinary and Biomedical Science, Penn State University, University Park, PA, USA
0 %), with the largest magnitude of decline occurring in the concurrent contemporary cohorts (cohort D—5.3 % vs. cohort E—0 %, p = 0.03). Rectal cultures obtained in 92 men before and after PIRP administration noted a 97 % reduction in microorganism colonies (2.1 × 105 vs. 6.3 × 103 CFU/ml, p 38.5 °C with a positive blood and/or urine culture. Of these men, 456 received only preoperative oral and/ or parenteral antibiotics and were divided chronologically into 4 equal groups (cohorts A, B, C, and D) of 114 patients each to determine changes in incidence of infectious complications over time. Cohort A included men biopsied from March 2010 to November 2010, cohort B from December 2010 to May 2011, cohort C from June 2011 to December 2011, and cohort D from January 2012 to May 2013. Oral antibiotic regimens used in these patients include 3 days of ciprofloxacin 500 mg bid (n = 414) or Bactrim DS
13
World J Urol
800/160 mg bid (n = 42). Adjunctive intravenous antibiotics at time of TRUS PNB were utilized in 137 (30 %) with the most common regimens being aminoglycosides [i.e., gentamicin (80 mg) or amikacin (1 g)] and 3rd generation cephalosporins [i.e., ceftriaxone (1 g)]. Cohort E included 114 men also biopsied between January 2012 and May 2013 who received a peri-procedural PIRP in addition to standard of care preoperative antibiotics. These patients received 3 days of oral antibiotics (ciprofloxacin; n = 108 and Bactrim; n = 6) while only 18 % were dosed with adjunctive perioperative intravenous antibiotics. As indicated above, cohorts D and E accrued over the same time period with use of PIRP at the discretion of the individual attending urologist. Variables of interest collected in the database included age, baseline PSA, DRE status, history of prior biopsy, immunosuppression, antibiotic use or hospitalization within the previous 6 months, use of preoperative enema, prostate volume, number of biopsy cores obtained, and presence of cancer on pathology. For patients treated with PIRP, a commercially available 10 % povidone-iodine solution was mixed with lidocaine jelly to create slurry. Immediately prior to insertion of the transrectal probe, a gynecologic swab was used to first paint a 2-cm diameter in the perianal area. Thereafter, the rectal vault was swabbed with the povidone-iodine solution. The biopsy then proceeded in the standard manner after waiting 2 min for the povidone-iodine to dry. Adverse reactions to the PIRP were recorded via direct patient query 7-day following the biopsy. All patients included in the study had follow-up recorded in our database for 30 days post-procedure. Rectal cultures were obtained immediately before and after in 92 patients treated with PIRP to quantify changes in microorganism colony counts. Briefly, cultures were obtained by use of sterile culture swabs. The swabs were then immersed in PBS, vortexed to release the bacteria, and serially diluted on Mueller–Hinton agar plates. Bacteria were allowed to grow for 36–48 h and counted. All morphological varieties of bacterial colonies arising on the plate were included to provide a total count. Statistical analysis was performed with S-Plus Professional version 4.5 (MathSoft Inc., Seattle, Washington). All p values ≤0.05 were considered significant.
Results A total of 570 men with a mean age of 63.6 years and baseline PSA of 11.6 ng/ml were included. Approximately two-thirds were undergoing an initial biopsy, 17 % had received antibiotic therapy within the previous 6 months, 8 % had been hospitalized for at least 23 h in this same
World J Urol Table 1 Baseline and biopsy characteristics for patients included undergoing TRUS PNB Variable (No., %)
Cohort A
Cohort B
Cohort C
Cohort D
Cohort E (PIRP)
p value
Patients Mean baseline PSA (ng/ml) Mean age (range) Caucasian race Antibiotic use past 6 months Hospitalization in past 6 months Immunosuppression Initial biopsy Median biopsy cores (range) Parenteral ABx at biopsy PCa at biopsy
114 15.0 (0.5–745) 63.6 (40–82) 101 (89) 24 (21) 22 (19) 1 (1) 67 (59) 14.5 (10–32) 25 (22) 38 (33)
114 16.1 (0.4 –882) 64.1 (36–93) 99 (87) 17 (15) 8 (7) 1 (1) 84 (74) 14.0 (6–75) 25 (22) 56 (49)
114 9.8 (0.9–205) 63.0 (42–90) 101 (89) 13 (11) 1 (1) 2 (2) 81 (71) 14.0 (12–35) 45 (39) 48 (42)
114 7.3 (0.2–42) 63.9 (42–83) 104 (91) 20 (18) 7 (6) 4 (4) 62 (54) 14.0 (6–30) 45 (39) 46 (40)
114 9.7 (0.3–150) 63.5 (41–81) 102 (89) 25 (22) 10 (9) 4 (4) 67 (59) 14.0 (6–26) 20 (18) 45 (39)
0.02 0.88 0.28 0.01
Original Article
Peri‑procedural povidone‑iodine rectal preparation reduces microorganism counts and infectious complications following ultrasound‑guided needle biopsy of the prostate Justin R. Gyorfi · Christopher Otteni · Kevin Brown · Amar Patel · Kathleen Lehman · Brett E. Phillips · Kalyan Dewan · Girish Kirimanjeswara · Jay D. Raman
Received: 27 February 2014 / Accepted: 21 March 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of the study was to evaluate whether a peri-procedural povidone-iodine rectal preparation (PIRP) prior to transrectal ultrasound-guided prostate needle biopsy (TRUS PNB) can reduce microorganism colony counts and infectious complications. Methods Our institutional TRUS PNB database was reviewed to identify infectious post-biopsy complications (defined as fever >38.5 °C with positive culture). The last 570 biopsy patients were divided into those administered only preoperative oral and/or parenteral antibiotics (n = 456; chronologically cohorts A–D) versus men receiving peri-procedural PIRP in conjunction with standard preoperative antibiotics (n = 114; cohort E). Rectal cultures were obtained in the PIRP cohort to quantify changes in microorganism colony counts. Results Mean baseline PSA for patients was 11.6 ng/ ml, 63 % were undergoing an initial biopsy, and 17 % had documented use of antibiotic therapy within the previous 6 months. A reduction in infectious complications was observed when comparing the conventional antibiotic (cohorts A–D) versus PIRP (cohort E) group (1.8 vs. J. R. Gyorfi · C. Otteni · K. Brown · A. Patel · K. Lehman · J. D. Raman (*) Division of Urology, Penn State Milton S. Hershey Medical Center, 500 University Drive, H055, Hershey, PA 17033‑0850, USA e-mail: [email protected] B. E. Phillips Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA K. Dewan · G. Kirimanjeswara Department of Veterinary and Biomedical Science, Penn State University, University Park, PA, USA
0 %), with the largest magnitude of decline occurring in the concurrent contemporary cohorts (cohort D—5.3 % vs. cohort E—0 %, p = 0.03). Rectal cultures obtained in 92 men before and after PIRP administration noted a 97 % reduction in microorganism colonies (2.1 × 105 vs. 6.3 × 103 CFU/ml, p 38.5 °C with a positive blood and/or urine culture. Of these men, 456 received only preoperative oral and/ or parenteral antibiotics and were divided chronologically into 4 equal groups (cohorts A, B, C, and D) of 114 patients each to determine changes in incidence of infectious complications over time. Cohort A included men biopsied from March 2010 to November 2010, cohort B from December 2010 to May 2011, cohort C from June 2011 to December 2011, and cohort D from January 2012 to May 2013. Oral antibiotic regimens used in these patients include 3 days of ciprofloxacin 500 mg bid (n = 414) or Bactrim DS
13
World J Urol
800/160 mg bid (n = 42). Adjunctive intravenous antibiotics at time of TRUS PNB were utilized in 137 (30 %) with the most common regimens being aminoglycosides [i.e., gentamicin (80 mg) or amikacin (1 g)] and 3rd generation cephalosporins [i.e., ceftriaxone (1 g)]. Cohort E included 114 men also biopsied between January 2012 and May 2013 who received a peri-procedural PIRP in addition to standard of care preoperative antibiotics. These patients received 3 days of oral antibiotics (ciprofloxacin; n = 108 and Bactrim; n = 6) while only 18 % were dosed with adjunctive perioperative intravenous antibiotics. As indicated above, cohorts D and E accrued over the same time period with use of PIRP at the discretion of the individual attending urologist. Variables of interest collected in the database included age, baseline PSA, DRE status, history of prior biopsy, immunosuppression, antibiotic use or hospitalization within the previous 6 months, use of preoperative enema, prostate volume, number of biopsy cores obtained, and presence of cancer on pathology. For patients treated with PIRP, a commercially available 10 % povidone-iodine solution was mixed with lidocaine jelly to create slurry. Immediately prior to insertion of the transrectal probe, a gynecologic swab was used to first paint a 2-cm diameter in the perianal area. Thereafter, the rectal vault was swabbed with the povidone-iodine solution. The biopsy then proceeded in the standard manner after waiting 2 min for the povidone-iodine to dry. Adverse reactions to the PIRP were recorded via direct patient query 7-day following the biopsy. All patients included in the study had follow-up recorded in our database for 30 days post-procedure. Rectal cultures were obtained immediately before and after in 92 patients treated with PIRP to quantify changes in microorganism colony counts. Briefly, cultures were obtained by use of sterile culture swabs. The swabs were then immersed in PBS, vortexed to release the bacteria, and serially diluted on Mueller–Hinton agar plates. Bacteria were allowed to grow for 36–48 h and counted. All morphological varieties of bacterial colonies arising on the plate were included to provide a total count. Statistical analysis was performed with S-Plus Professional version 4.5 (MathSoft Inc., Seattle, Washington). All p values ≤0.05 were considered significant.
Results A total of 570 men with a mean age of 63.6 years and baseline PSA of 11.6 ng/ml were included. Approximately two-thirds were undergoing an initial biopsy, 17 % had received antibiotic therapy within the previous 6 months, 8 % had been hospitalized for at least 23 h in this same
World J Urol Table 1 Baseline and biopsy characteristics for patients included undergoing TRUS PNB Variable (No., %)
Cohort A
Cohort B
Cohort C
Cohort D
Cohort E (PIRP)
p value
Patients Mean baseline PSA (ng/ml) Mean age (range) Caucasian race Antibiotic use past 6 months Hospitalization in past 6 months Immunosuppression Initial biopsy Median biopsy cores (range) Parenteral ABx at biopsy PCa at biopsy
114 15.0 (0.5–745) 63.6 (40–82) 101 (89) 24 (21) 22 (19) 1 (1) 67 (59) 14.5 (10–32) 25 (22) 38 (33)
114 16.1 (0.4 –882) 64.1 (36–93) 99 (87) 17 (15) 8 (7) 1 (1) 84 (74) 14.0 (6–75) 25 (22) 56 (49)
114 9.8 (0.9–205) 63.0 (42–90) 101 (89) 13 (11) 1 (1) 2 (2) 81 (71) 14.0 (12–35) 45 (39) 48 (42)
114 7.3 (0.2–42) 63.9 (42–83) 104 (91) 20 (18) 7 (6) 4 (4) 62 (54) 14.0 (6–30) 45 (39) 46 (40)
114 9.7 (0.3–150) 63.5 (41–81) 102 (89) 25 (22) 10 (9) 4 (4) 67 (59) 14.0 (6–26) 20 (18) 45 (39)
0.02 0.88 0.28 0.01
