A Comprehensive Systematic Review of Comparison of Antibiotic Prophylaxis in Prostate Cancer Patient Biopsy Cases
Keywords:
Prostate Biopsy, Antibiotic Prophylaxis, Infectious Complications, Fosfomycin, Fluoroquinolone Resistance, Transperineal Biopsy, Targeted Prophylaxis, Systematic ReviewAbstract
Introduction: Prostate biopsy is a crucial diagnostic procedure for prostate cancer but carries a risk of infectious complications, including urinary tract infections, bacteremia, and sepsis. The rising global prevalence of antibiotic resistance, particularly to fluoroquinolones, has complicated traditional empirical prophylaxis, necessitating a thorough reevaluation of optimal prevention strategies (Pilatz et al., 2020).
Methods: This comprehensive systematic review synthesized evidence from 80 sources, including randomized controlled trials (RCTs), meta-analyses, and cohort studies. The review compared antibiotic prophylaxis versus no prophylaxis, different antibiotic regimens (e.g., fosfomycin vs. fluoroquinolones), prophylaxis durations, empirical versus targeted approaches, augmented prophylaxis, and the impact of biopsy approach (transrectal vs. transperineal). Data on infection outcomes, resistance patterns, and non-infectious complications were extracted and analyzed.
Results: Antibiotic prophylaxis significantly reduces infectious complications for transrectal prostate biopsy compared to no prophylaxis (RR 0.56) (Pilatz et al., 2020). For transperineal biopsy, evidence shows no significant benefit of prophylaxis, with pooled infection rates of 0.50% with vs. 0.37% without antibiotics (Castellani et al., 2021; Wolff et al., 2024). Fosfomycin demonstrated superior or equivalent efficacy to fluoroquinolones, particularly in reducing febrile UTIs (Freitas & Moreira, 2019; Şen et al., 2015). Augmented (combination) prophylaxis and targeted prophylaxis based on rectal swab cultures were more effective than single-agent empirical regimens in high-resistance settings (Elshal et al., 2018; Yang et al., 2016; Doherty et al., 2019). Rectal cleansing with povidone-iodine provided additive protection (Pu et al., 2014).
Discussion: The findings highlight a paradigm shift. The transperineal approach inherently lowers infection risk, potentially obviating the need for routine antibiotics and aligning with antimicrobial stewardship. For transrectal biopsies, a one-size-fits-all empirical approach is obsolete. Strategy must be tailored based on local resistance patterns, favoring augmented or targeted prophylaxis when fluoroquinolone resistance exceeds 20%. Fosfomycin emerges as a key agent, though its use in combination may be required in high-burden settings.
Conclusion: The optimal strategy for preventing post-prostate biopsy infections is multifaceted. For transperineal biopsy, omitting routine antibiotic prophylaxis is safe and recommended. For transrectal biopsy, a tailored approach incorporating local resistance data, augmented or targeted antibiotic prophylaxis, and rectal disinfection is essential. Future research should focus on cost-effectiveness analyses and standardized protocols for targeted prophylaxis implementation.
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