World Journal of Urology

, Volume 36, Issue 7, pp 1007–1017 | Cite as

The effectiveness of targeted relative to empiric prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy: a meta-analysis

  • Susan Scott
  • Patrick N. Harris
  • Deborah A. Williamson
  • Michael A. Liss
  • Suhail A. R. Doi
  • Matthew J. Roberts
Invited Review



Rectal culture screening for fluoroquinolone (FQ)-resistant Enterobacteriaceae before transrectal ultrasound guided prostate (TRUSPB) biopsy and targeted antibiotic prophylaxis (TAP) may decrease post-TRUSPB infection rates compared to empiric (EAP) regimens. The objective of this study was to evaluate the effectiveness of targeted relative to empiric prophylaxis regimens on rates of infectious complications after TRUSPB and to determine the baseline prevalence of FQ resistance based on prior rectal swabs.


An electronic search within literature databases including EMBASE and Web of Science (all databases) for articles assessing TAP as an approach to TRUSPB prophylaxis was conducted. Quality assessment was performed using the Hoy instrument. Meta-analysis was performed using MetaXL 5.3.


From 15 studies (eight retrospective and seven prospective) representing 12,320 participants, infectious complication incidence was 3.4% in EAP and 0.8% in TAP patients. The number needed to treat with TAP to avoid one more infection when compared to the EAP group was 39. Effect sizes were homogeneous. Prevalence of FQ resistance showed low (15%) and high (28%) subgroups, likely due to region of origin (within and outside USA, respectively).


Rectal culture prior to TRUSPB and use of TAP adjusts for endemic FQ resistance and is associated with less infectious complications and resulting morbidity when compared to EAP. Overtreatment associated with augmented prophylaxis approaches may be reduced as a result. Further prospective assessment and cost–benefit analyses are required before widespread implementation can be recommended.


Fluoroquinolone resistance Prophylaxis Prostate biopsy Rectal culture Symptomatic infection 


Author contributions

SE Scott: data collection, manuscript writing, and editing. PN Harris: manuscript editing and critical revisions & guidance. D Williamson: project development, manuscript editing, and critical revisions & guidance. MA Liss: manuscript editing and critical revisions & guidance. S.A.R Doi: project development, data analysis, and manuscript editing. MJ Roberts: project development, data collection and management, and manuscript writing and editing.



Compliance with ethical standards

Conflict of interest

All authors have no conflicts of interest to report.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors. Included studies report institutional ethical approval.

Informed consent

Informed consent was obtained where appropriate within the included manuscripts included in this study.

Supplementary material

345_2018_2217_MOESM1_ESM.doc (252 kb)
Supplementary material 1 (DOC 252 kb)


  1. 1.
    Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM (2011) Complications after prostate biopsy: data from SEER-medicare. J Urol 186:1830–1834CrossRefPubMedGoogle Scholar
  2. 2.
    Wolf JS, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ (2008) Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 179:1379–1390CrossRefPubMedGoogle Scholar
  3. 3.
    Grabe M, Bartoletti R, Bjerklund-Johansen TE et al (2014) Guidelines on urological infections. European Association of Urology (EAU), Arnhem. Accessed 10 June 2017
  4. 4.
    Yamamoto S, Shigemura K, Kiyota H, Wada K, Hayami H, Yasuda M, Takahashi S, Ishikawa K, Hamasuna R, Arakawa S, Matsumoto T (2016) Essential Japanese guidelines for the prevention of perioperative infections in the urological field: 2015 edition. Int J Urol 23:814–824CrossRefPubMedGoogle Scholar
  5. 5.
    El-Hakim A, Moussa S (2010) CUA guidelines on prostate biopsy methodology. Can Urol Assoc J 4:89CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Zani EL, Clark OA, Rodrigues Netto N Jr (2011) Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev. PubMedCrossRefGoogle Scholar
  7. 7.
    Halpern JA, Sedrakyan A, Dinerman B, Hsu W-C, Mao J, Hu JC (2016) Indications, utilization and complications following prostate biopsy: a New York state analysis. J Urol 197:1020–1025CrossRefPubMedGoogle Scholar
  8. 8.
    Lahdensuo K, Rannikko A, Anttila VJ, Erickson A, Patari-Sampo A, Rautio M, Santti H, Tarkka E, Vaara M, Huotari K (2016) Increase of prostate biopsy-related bacteremic complications in southern Finland, 2005-2013: a population-based analysis. Prostate Cancer Prostatic Dis 19:417–422CrossRefPubMedGoogle Scholar
  9. 9.
    Aly M, Dyrdak R, Nordstrom T, Jalal S, Weibull CE, Giske CG, Gronberg H (2015) Rapid increase in multidrug-resistant enteric bacilli blood stream infection after prostate biopsy-a 10-year population-based cohort study. Prostate 75:947–956CrossRefPubMedGoogle Scholar
  10. 10.
    Wagenlehner FM, van Oostrum E, Tenke P, Tandogdu Z, Çek M, Grabe M, Wullt B, Pickard R, Naber KG, Pilatz A, Weidner W, Bjerklund-Johansen TE (2013) 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 63:521–527CrossRefPubMedGoogle Scholar
  11. 11.
    Wagenlehner FME, Pilatz A, Waliszewski P, Weidner W, Johansen TEB (2014) Reducing infection rates after prostate biopsy. Nat Rev Urol 11:80–86CrossRefPubMedGoogle Scholar
  12. 12.
    Carignan A, Roussy J-F, Lapointe V, Valiquette L, Sabbagh R, Pépin J (2012) Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: time to reassess antimicrobial prophylaxis? Eur Urol 62:453–459CrossRefPubMedGoogle Scholar
  13. 13.
    Roberts MJ, Williamson DA, Hadway P, Doi SAR, Gardiner RA, Paterson DL (2014) Baseline prevalence of antimicrobial resistance and subsequent infection following prostate biopsy using empirical or altered prophylaxis: a bias-adjusted meta-analysis. Int J Antimicrob Agents 43:301–309CrossRefPubMedGoogle Scholar
  14. 14.
    Liss MA, Johnson JR, Porter SB, Johnston B, Clabots C, Gillis K, Nseyo U, Holden M, Sakamoto K, Fierer J (2015) Clinical and microbiological determinants of infection after transrectal prostate biopsy. Clin Infect Dis 60:979–987CrossRefPubMedGoogle Scholar
  15. 15.
    Roberts MJ, Bennett HY, Harris PN, Holmes M, Grummet J, Naber K, Wagenlehner FME (2017) Prostate biopsy-related infection: a systematic review of risk factors, prevention strategies, and management approaches. Urology 104:11–21CrossRefPubMedGoogle Scholar
  16. 16.
    Womble PR, Dixon MW, Linsell SM, Ye Z, Montie JE, Lane BR, Miller DC, Burks FN (2014) Infection related hospitalizations after prostate biopsy in a statewide quality improvement collaborative. J Urol 191:1787–1792CrossRefPubMedGoogle Scholar
  17. 17.
    Roberts MJ, Doi SA (2016) Prostate biopsy, targeted prophylaxis and infectious complications: a critique of methods used. BJU Int 117:719–721CrossRefPubMedGoogle Scholar
  18. 18.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. BMJ. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Higgins JPT, Green, S (2011) Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration Version 5.1.0Google Scholar
  20. 20.
    Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, Baker P, Smith E, Buchbinder R (2012) Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol 65:934–939CrossRefPubMedGoogle Scholar
  21. 21.
    Takkouche B, Cadarso-Suarez C, Spielgelman D (1999) Evaluation of old and new tests of heterogeneity in epidemiologic meta-analysis. Am J Epidemiol 150:206CrossRefPubMedGoogle Scholar
  22. 22.
    Onitilo AA, Doi SAR, Barendregt JJ (2013) Meta-analysis II. In: Williams G, Doi SAR (eds) Methods of clinical epidemiology. Series on epidemiology and public health. Springer, Berlin, pp 253–266CrossRefGoogle Scholar
  23. 23.
    Bennett HY, Roberts MJ, Doi SAR, Gardiner RA (2016) The global burden of major infectious complications following prostate biopsy. Epidemiol Infect 144:1784–1791CrossRefPubMedGoogle Scholar
  24. 24.
    Doi SAR, Barendregt JJ, Khan S, Thalib L, Williams GM (2015) Advances in the meta-analysis of heterogeneous clinical trials I: the inverse variance heterogeneity model. Contemp Clin Trials 45:130–138CrossRefPubMedGoogle Scholar
  25. 25.
    Doi SAR, Furuya-Kanamori L, Thalib L, Barendregt JJ (2017) Meta-analysis in evidence-based healthcare: a paradigm shift away from random effects is overdue. Int J Evid Based Healthc 15(4):152–160Google Scholar
  26. 26.
    Fahmy A, Rhashad H, Mohi M, Elabbadie A, Kotb A (2016) Optimizing prophylactic antibiotic regimen in patients admitted for transrectal ultrasound-guided prostate biopsies: a prospective randomized study. Prostate Int 4:113–117CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Zembower TR, Maxwell KM, Nadler RB, Cashy J, Scheetz MH, Qi C, Schaeffer AJ (2017) Evaluation of targeted antimicrobial prophylaxis for transrectal ultrasound guided prostate biopsy: a prospective cohort trial. BMC Infect Dis 17:401CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Summers SJ, Patel DP, Hamilton BD, Presson AP, Fisher MA, Lowrance WT, Southwick AW (2015) An antimicrobial prophylaxis protocol using rectal swab cultures for transrectal prostate biopsy. World J Urol 33:2001–2007CrossRefPubMedGoogle Scholar
  29. 29.
    Duplessis CA, Bavaro M, Simons MP, Marguet C, Santomauro M, Auge B, Collard DA, Fierer J, Lesperance J (2012) Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates. Urology 79:556–563CrossRefPubMedGoogle Scholar
  30. 30.
    Liss MA, Nakamura KK, Peterson EM (2013) Comparison of broth enhancement to direct plating for screening of rectal cultures for ciprofloxacin-resistant Escherichia coli. J Clin Microbiol 51:249–252CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Budak S, Karakece E, Budak GG, Aydemir H, Kumsar S, Kose O, Sencelikel T, Ciftci IH, Saglam HS, Adsan O (2015) Detection of fluoroquinolone-resistant bacteria prior to transrectal prostate biopsy: analysis of stool samples facilitates targeted prophylaxis. Acta Medica Mediterranea 31:275–279Google Scholar
  32. 32.
    Liss MA, Kim W, Moskowitz D, Szabo RJ (2015) Comparative effectiveness of targeted vs empirical antibiotic prophylaxis to prevent sepsis from transrectal prostate biopsy: a retrospective analysis. J Urol 194:397–402CrossRefPubMedGoogle Scholar
  33. 33.
    Boeri L, Fontana M, Gallioli A, Zanetti SP, Catellani M, Longo F, Mangiarotti B, Montanari E (2017) Rectal culture-guided targeted antimicrobial prophylaxis reduces the incidence of post-operative infectious complications in men at high risk for infections submitted to transrectal ultrasound prostate biopsy -results of a cross-sectional study. PLoS ONE 12:e0170319CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Trujillo CG, Plata M, Caicedo JI, Cataño Cataño JG, Mariño Alvarez AM, Castelblanco D, Robledo D (2016) Impact of rectal swabs on infectious complications after transrectal prostate biopsy. Urol Int 97:340–346CrossRefPubMedGoogle Scholar
  35. 35.
    Taylor AK, Zembower TR, Nadler RB, Scheetz MH, Cashy JP, Bowen D, Murphy AB, Dielubanza E, Schaeffer AJ (2012) 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 187:1275–1279CrossRefPubMedGoogle Scholar
  36. 36.
    Nam RK, Saskin R, Lee Y, Liu Y, Law C, Klotz LH, Loblaw DA, Trachtenberg J, Stanimirovic A, Simor AE, Seth A, Urbach DR, Narod SA (2013) Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 189:S12–S18CrossRefPubMedGoogle Scholar
  37. 37.
    Losco G, Studd R (2013) Post-TRUS sepsis: targeted use of prophylactic ertapenem for high-risk patients. BJU Int 112:7CrossRefGoogle Scholar
  38. 38.
    Pruthi DK, Liss MA (2017) Sepsis: prophylactic antibiotic for prostate biopsy: the carbapenem gamble. Nat Rev Urol 14:394–396CrossRefPubMedGoogle Scholar
  39. 39.
    Zowawi HM, Harris PN, Roberts MJ, Tambyah PA, Schembri MA, Pezzani MD, Williamson DA, Paterson DL (2015) The emerging threat of multidrug-resistant Gram-negative bacteria in urology. Nat Rev Urol 12:570–584CrossRefPubMedGoogle Scholar
  40. 40.
    Liss MA, Ehdaie B, Loeb S, Meng MV, Raman JD, Spears V, Stroup SP (2017) An update of the American Urological Association white paper on the prevention and treatment of the more common complications related to prostate biopsy. J Urol 198:329–334CrossRefPubMedGoogle Scholar
  41. 41.
    Grummet JP, Weerakoon M, Huang S, Lawrentschuk N, Frydenberg M, Moon DA, O’Reilly M, Murphy D (2014) Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy? BJU Int 114:384–388PubMedGoogle Scholar
  42. 42.
    Bonkat G, Pickard R, Bartoletti R, Bruyere F, Geerlings S, Wagenlehner F, Wullt B (2017) EAU guidelines. Urological infections. Accessed 21 Sept 2017
  43. 43.
    Roberts MJ, Scott S, Harris PN, Naber K, Wagenlehner FME, Doi SAR (2017) Comparison of fosfomycin against fluoroquinolones for transrectal prostate biopsy prophylaxis: an individual patient-data meta-analysis. World J Urol (in press)Google Scholar
  44. 44.
    Adibi M, Hornberger B, Bhat D, Raj G, Roehrborn CG, Lotan Y (2013) Reduction in hospital admission rates due to post-prostate biopsy infections after augmenting standard antibiotic prophylaxis. J Urol 189:535–540CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  2. 2.Department of UrologySunshine Coast University HospitalBirtinyaAustralia
  3. 3.The University of Queensland, Centre for Clinical ResearchBrisbaneAustralia
  4. 4.Central Laboratory, Department of Microbiology, Pathology QueenslandRoyal Brisbane and Women’s HospitalBrisbaneAustralia
  5. 5.Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology & ImmunologyThe University of Melbourne at The Doherty Institute for Infection and ImmunityMelbourneAustralia
  6. 6.Department of UrologyUniversity of Texas Health Science Center at San AntonioSan AntonioUSA
  7. 7.Department of Population Medicine, College of MedicineQatar UniversityDohaQatar

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