Comparative Effectiveness of Targeted vs Empirical Antibiotic Prophylaxis to Prevent Sepsis from Transrectal Prostate Biopsy: A Retrospective Analysis

Purpose We compared the effectiveness of targeted prophylaxis to the effectiveness of empirical prophylaxis for preventing sepsis after transrectal prostate biopsy using a retrospective multicenter quality improvement study. Materials and Methods A total of 13 Kaiser Permanente urology departments participated in a 1-year retrospective analysis of a quality improvement study. In the targeted prophylaxis group rectal cultures were performed before transrectal prostate biopsy and antibiotic sensitivities of Escherichia coli were used to guide the selection of a single agent antibiotic for prophylaxis. Cultures were plated on 10 μg/ml ciprofloxacin infused MacConkey agar at a central laboratory. Urologists using empirical prophylaxis continued the usual regimen of ciprofloxacin monotherapy prophylaxis but sometimes added an additional prophylactic antibiotic. The primary outcome of post-biopsy sepsis was compiled by a search of the electronic medical record for the appropriate ICD-9 codes. Results A total of 5,355 prostate biopsy procedures were performed between May 1, 2013 and April 30, 2014. Targeted prophylaxis was used in 1,802 procedures (34%) and empirical prophylaxis was used in 3,553 (66%). The overall incidence of post-biopsy sepsis was 0.52% (28 of 5,355 cases). The incidence of sepsis was 0.44% (8 of 1,802 cases) in the targeted prophylaxis group and 0.56% (20 of 3,553) in the empirical prophylaxis group (p = 0.568). The prevalence of ciprofloxacin resistant E. coli on rectal culture was 25% (444 of 1,802 cases). Seven of the 8 patients (88%) on targeted prophylaxis in whom sepsis developed used a prophylactic antibiotic to which the bacteria causing post-biopsy sepsis were sensitive. Conclusions The targeted prophylaxis protocol enabled physicians to avoid using more than 1 broad-spectrum empirical antibiotic while simultaneously achieving an overall rate of sepsis similar to the rate seen with empirical prophylaxis.