Fluoroquinolone-Resistant Escherichia coli Infections after Transrectal Biopsy of the Prostate in the Veterans Affairs Healthcare System

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Elie Antoun Saade
Nuntra Suwantara
Trina F. Zabarsky
Brigid Wilson
Curtis J. Donskey


Background: Recent reports suggest that infections due to fluoroquinolone-resistant Escherichia coli (E. coli) are an increasingly common complication of transrectal biopsy of the prostate (TBP) in the United States. A better understanding of the magnitude and scope of these infections is needed to guide prevention efforts. Our objective is to determine whether the incidence of infections due to fluoroquinolone-resistant E. coli after TBP has increased nationwide in the Veterans Affairs Health Care System and to identify risk factors for infection.

Methods: We performed a retrospective, observational cohort study and a nested case-control study within the US Deparment of Veterans Affairs Healthcare System. The primary outcomes were the incidence of urinary tract infection (UTI) and bacteremia with E. coli and with fluoroquinolone-resistant E. coli strains within 30 days after TBP. Secondary endpoints focused on the correlation between fluoroquinolone-resistance in all urinary E. coli isolates and post-TBP infection and risk factors for infection due to fluoroquinolone-resistant E. coli infection.

Results: 245 618 patients undergoing 302 168 TBP procedures from 2000 through 2013 were included in the cohort study, and 59 469 patients undergoing TBP from 2011 through 2013 were included in the nested case-control study. Between 2000 and 2013, there was a 5-fold increase in the incidence of E. coli UTI (0.18%–0.93%) and a 4-fold increase in the incidence of E. coli bacteremia (0.04%–0.18%) after TBP that was attributable to an increase in the incidence of fluoroquinolone-resistant E. coli UTI (0.03%–0.75%) and bacteremia (0.01%–0.14%). The increasing incidence of fluoroquinolone-resistant E. coli infections after TBP occurred in parallel with increasing rates of fluoroquinolone-resistance in all urinary E. coli isolates. By multivariable logistic regression analysis, independent risk factors for fluoroquinolone-resistant E. coli UTI after TBP included diabetes mellitus, fluoroquinolone exposure, prior hospitalization, and prior cultures with fluoroquinolone-resistant gram-negative bacilli.

Conclusion: In the Veterans Affairs Healthcare System, the incidence of E. coli infection after TBP has increased significantly since 2000 due to a dramatic rise in infections with fluoroquinolone-resistant E. coli.

Keywords: bacteremia; case-control studies; cohort studies; early detection of cancer; Escherichia coliinfections; microbial drug resistance; postoperative complications; prostate; retrospective studies; United States Department of Veterans Affairs; urinary tract infections.


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Author Biography

Elie Antoun Saade, Infectious Diseases Division, University Hospitals, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH

Assistant Professor of Medicine; Department of Internal Medicine; Divisions of Geriatric Medicine and Infectious Diseases; University Hospitals of Cleveland, Case Medical Center.


1. Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011;186(5):1830-4. PubMed PMID: 21944136. doi: 10.1016/j.juro.2011.06.057

2. Liss MA, Johnson JR, Porter SB, Johnston B, Clabots C, Gillis K, Nseyo U, Holden M, Sakamoto K, Fierer J. Clinical and microbiological determinants of infection after transrectal prostate biopsy. Clin Infect Dis. 2015;60(7):979-87. PubMed PMID: 25516194. doi: 10.1093/cid/ciu1129

3. Rietbergen JB, Kruger AE, Kranse R, Schroder FH. Complications of transrectal ultrasound-guided systematic sextant biopsies of the prostate: evaluation of complication rates and risk factors within a population-based screening program. Urology. 1997;49(6):875-80. PubMed PMID: 9187694.

4. Otrock ZK, Oghlakian GO, Salamoun MM, Haddad M, Bizri ARN. Incidence of urinary tract infection following transrectal ultrasound guided prostate biopsy at a tertiary-care medical center in Lebanon. Infect Control Hosp Epidemiol. 2004;25(10):873-7. PubMed PMID: 15518032. doi: 10.1086/502312

5. Shigehara K, Miyagi T, Nakashima T, Shimamura M. Acute bacterial prostatitis after transrectal prostate needle biopsy: clinical analysis. J Infect Chemother Off J Japan Soc Chemother. 2008;14(1):40-3. PubMed PMID: 18297448. doi: 10.1007/s10156-007-0570-3

6. Kim SJ, Kim S Il, Ahn HS, Choi JB, Kim YS, Kim SJ. Risk factors for acute prostatitis after transrectal biopsy of the prostate. Korean J Urol. 2010;51(6):426-30. PubMed PMID: 20577611. Pubmed Central PMCID: 2890061. doi: 10.4111/kju.2010.51.6.426

7. Hadway P, Barrett LK, Waghorn DJ, Hasan K, Bdesha A, Haldar N, Kelleher J. Urosepsis and bacteraemia caused by antibiotic-resistant organisms after transrectal ultrasonography-guided prostate biopsy. BJU Int. 2009;104(11):1556-8. PubMed PMID: 20053186. doi: 10.1111/j.1464-410X.2009.08959.x

8. 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(5):1035-41. PubMed PMID: 21420152. doi: 10.1016/j.urology.2010.12.067

9. 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(3):511-4. PubMed PMID: 21782225. doi: 10.1016/j.urology.2011.04.064

10. Hedelin H, Claesson BEB, Wilpart A. Febrile reactions after transrectal ultrasound-guided prostatic biopsy: a retrospective study. Scand J Urol Nephrol. 2011;45(6):393-6. PubMed PMID: 21679017. doi: 10.3109/00365599.2011.590996

11. Zani EL, Clark OAC, Rodrigues Netto NJ. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev. 2011;(5):CD006576. PubMed PMID: 21563156. doi: 10.1002/14651858.CD006576.pub2

12. Wolf JSJ, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179(4):1379-90. PubMed PMID: 18280509. doi: 10.1016/j.juro.2008.01.068

13. Johnson L, Sabel A, Burman WJ, Everhart RM, Rome M, MacKenzie TD, Rozwadowski J, Mehler PS, Price CS. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med. 2008;121(10):876-84. PubMed PMID: 18823859. doi: 10.1016/j.amjmed.2008.04.039

14. Neuhauser MM, Weinstein RA, Rydman R, Danziger LH, Karam G, Quinn JP. Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for fluoroquinolone use. JAMA. 2003;289(7):885-8. PubMed PMID: 12588273.

15. Feliciano J, Teper E, Ferrandino M, Macchia RJ, Blank W, Grunberger I, Colon I. The incidence of fluoroquinolone resistant infections after prostate biopsy--are fluoroquinolones still effective prophylaxis? J Urol. 2008;179(3):952-5; discussion 955. PubMed PMID: 18207185. doi: 10.1016/j.juro.2007.10.071

16. Young JL, Liss MA, Szabo RJ. Sepsis due to fluoroquinolone-resistant Escherichia coli after transrectal ultrasound-guided prostate needle biopsy. Urology. 2009;74(2):332-8. PubMed PMID: 19464041. doi: 10.1016/j.urology.2008.12.078

17. Liss MA, Chang A, Santos R, Nakama-Peeples A, Peterson EM, Osann K, Billimek J, Szabo RJ, Dash A. Prevalence and significance of fluoroquinolone resistant Escherichia coli in patients undergoing transrectal ultrasound guided prostate needle biopsy. J Urol. 2011;185(4):1283-8. PubMed PMID: 21334021. Pubmed Central PMCID: 4063558. doi: 10.1016/j.juro.2010.11.088

18. Dumford D 3rd, Suwantarat N, Bhasker V, Kundrapu S, Zabarsky TF, Drawz P, Zhu H, Donskey CJ. Outbreak of fluoroquinolone-resistant Escherichia coli infections after transrectal ultrasound-guided biopsy of the prostate. Infect Control Hosp Epidemiol. 2013;34(3):269-73. PubMed PMID: 23388361. doi:10.1086/669512

19. 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. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol. 2010;183(3):963-8. PubMed PMID: 20089283. doi:10.1016/j.juro.2009.11.043

20. Taylor AK, Zembower TR, Nadler RB, Scheetz MH, Cashy JP, Bowen D, Murphy AB, Dielubanza E, Schaeffer AJ. 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(4):1275-9. PubMed PMID: 22341272. doi: 10.1016/j.juro.2011.11.115

21. Duplessis CA, Bavaro M, Simons MP, Marguet C, Santomauro M, Auge B, Collard DA, Fierer J, Lesperance J. Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates. Urology. 2012;79(3):556-61. PubMed PMID: 22386395. doi: 10.1016/j.urology.2011.09.057

22. Suwantarat N, Dumford DM 3rd, Ponce-Terashima R, Kundrapu S, Zabarsky TF, Zhu H, Donskey CJ. Modification of antimicrobial prophylaxis based on rectal culture results to prevent fluoroquinolone-resistant Escherichia coli infections after prostate biopsy. Infect Control Hosp Epidemiol. 2013;34(9):973-6. PubMed PMID: 23917913. doi: 10.1086/671734

23. Ho HSS, Ng LG, Tan YH, Yeo M, Cheng CWS. Intramuscular gentamicin improves the efficacy of ciprofloxacin as an antibiotic prophylaxis for transrectal prostate biopsy. Ann Acad Med Singapore. 2009;38(3):212-6. PubMed PMID: 19347074. Available from:http://www.annals.edu.sg/pdf/38VolNo3Mar2009/V38N3p212.pdf

24. Madden T, Doble A, Aliyu SH, Neal DE. Infective complications after transrectal ultrasound-guided prostate biopsy following a new protocol for antibiotic prophylaxis aimed at reducing hospital-acquired infections. BJU Int. 2011;108(10):1597-602. PubMed PMID: 21592292. doi: 10.1111/j.1464-410X.2011.10160.x

25. Batura D, Rao GG, Bo Nielsen P, Charlett A. Adding amikacin to fluoroquinolone-based antimicrobial prophylaxis reduces prostate biopsy infection rates. BJU Int. 2011;107(5):760-4. PubMed PMID: 21029317. doi: 10.1111/j.1464-410X.2010.09715.x

26. Hori S, Sengupta A, Joannides A, Balogun-Ojuri B, Tilley R, McLoughlin J. Changing antibiotic prophylaxis for transrectal ultrasound-guided prostate biopsies: are we putting our patients at risk? BJU Int. 2010;106(9):1298-302; discussion 1302. PubMed PMID: 20518764. doi: 10.1111/j.1464-410X.2010.09416.x

27. Colpan A, Johnston B, Porter S, Clabots C, Anway R, Thao L, Kuskowski MA, Tchesnokova V, Sokurenko EV, Johnson JR, Investigators V. Escherichia coli sequence type 131 (ST131) subclone H30 as an emergent multidrug-resistant pathogen among US veterans. Clin Infect Dis. 2013;57(9):1256-65. PubMed PMID: 23926176. Pubmed Central PMCID: 3792724. doi: 10.1093/cid/cit503

28. Butt AA, McGinnis K, Rodriguez-Barradas MC, Crystal S, Simberkoff M, Goetz MB, Leaf D, Justice AC, Veterans Aging Cohort S. HIV infection and the risk of diabetes mellitus. AIDS. 2009;23(10):1227-34. PubMed PMID: 19444074. Pubmed Central PMCID: 2752953. doi: 10.1097/QAD.0b013e32832bd7af

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