Transrectal urological procedures: prostate biopsy or fiducial marker insertion

Antibiotic regimens

Consider the principles for appropriate prescribing of surgical antibiotic prophylaxis (see Principles for appropriate prescribing of surgical antibiotic prophylaxis) and the general principles of surgical antibiotic prophylaxis for urological surgery. Surgical antibiotic prophylaxis is indicated for transrectal prostate biopsy or fiducial marker insertion.

Patients undergoing transrectal prostate biopsy or fiducial marker insertion should be screened for bacteriuria preoperatively (see Screening for preoperative bacteriuria). For patients treated for bacteriuria preoperatively, modify the choice of surgical antibiotic prophylaxis based on the results of culture and susceptibility testing.

Postoperative infection following transrectal urological procedures is increasingly caused by resistant bacteria. There may be a role for preprocedural screening for ciprofloxacin-resistant Enterobacteriaceae—see Ciprofloxacin-resistant Enterobacteriaceae (below) and seek expert advice.

For prophylaxis for transrectal prostate biopsy or fiducial marker insertion, in the absence of culture and susceptibility test results, use:

Randomised controlled trials have not shown that multiple-dose prophylaxis is superior to single-dose prophylaxis. However, repeat doses are required in limited circumstances (see here).

Some centres use a higher dose of ciprofloxacin (750 mg or 1 g), but clinical studies have not compared this approach to the standard regimen.

Ciprofloxacin-resistant Enterobacteriaceae

In some studies, prebiopsy screening for ciprofloxacin-resistant Enterobacteriaceae (with faecal samples or rectal swabs), with prophylaxis guided by the results of susceptibility testing, reduced the incidence of infective complications, as well as the overall cost of care. Consider this approach for transrectal urological procedures, particularly for patients at high risk of carriage of ciprofloxacin-resistant Enterobacteriaceae (eg quinolone therapy within the preceding 3 months, risk factors for infection with a multidrug-resistant Gram-negative bacterium [see Risk factors for infection with methicillin-resistant Staphylococcus aureus]).

There is currently little consensus on the most effective prophylaxis for patients who are colonised with ciprofloxacin-resistant Enterobacteriaceae. Ciprofloxacin-resistant strains may also be resistant to gentamicin, trimethoprim+sulfamethoxazole and ceftriaxone. Fosfomycin may be an option for prophylaxis for transrectal urological procedures in patients colonised with ciprofloxacin-resistant Enterobacteriaceae—seek expert advice.

If screening is not possible, seek expert advice for alternative prophylactic antibiotic regimens for patients at high risk.

A transperineal urological procedure may be an alternative approach in high-risk patients.

Nonantibiotic measures

Due to insufficient data, a recommendation cannot currently be made about the practice of adjunctive intrarectal disinfection (eg with povidone-iodine).

The efficacy of disinfecting the biopsy needle with formalin or alcohol between multiple biopsy passes in an individual patient is uncertain.