Highly effective prophylaxis with ertapenem for transrectal ultrasound-guided prostate biopsy: effects on overall antibiotic use and inpatient hospital exposure.

BACKGROUND: Ertapenem prophylaxis for transrectal ultrasound-guided prostate biopsy (TRUS-PB) has proven highly effective at our institution. A subsequent study showed no selection for carbapenem resistance, but antimicrobial stewardship concerns remained. AIM: To assess the effects of this prophylaxis on overall antibiotic consumption and exposure to the hospital environment. METHODS: All men undergoing TRUS-PB from November 2006 to July 2019 were included. Hospital records of men presenting within 30 days of biopsy were searched to determine whether post-biopsy infection (PBI) occurred, antibiotic usage, and duration of hospitalization. Prophylaxis during the pre-ertapenem period (period 1: 2006 to 2012) was oral ciprofloxacin for three days, with oral amoxicillin-clavulanate added in 2009. During the subsequent period (period 2: 2012 to 2019) a single intramuscular dose of ertapenem was used. FINDINGS: From periods 1 and 2, 1663 and 2357 men, respectively, were included. Median age was 65 years for both groups. Between periods 1 and 2, PBI incidence decreased from 2.65% to 0.34% (risk ratio: 0.13; 95% confidence interval (CI): 0.06, 0.27), and PBI-related bacteraemia from 1.14% to 0.04% (0.04; 0.01, 0.22), with a single bacteraemia during period 2. PBI treatment antibiotic consumption decreased from 57.6 to 4.3 defined daily doses (DDDs) per 100 biopsies (mean difference: -53.3; 95% CI: -73.1, -33.5) and overall consumption (treatment plus prophylaxis) decreased from 580.8 to 104.3 DDDs per 100 biopsies (mean difference: -476.5). PBI-related hospitalized bed-days per 100 biopsies decreased from 9.44 to 0.89 (mean difference: -8.55; 95% CI: -12.31, -4.79). CONCLUSION: Ertapenem prophylaxis was highly effective and resulted in marked reductions in overall antibiotic consumption and inpatient bed-days. Effective prophylaxis has advantages from an antimicrobial stewardship perspective.

The best local therapy for unfavorable risk prostate cancer: the role of surgery.

High-risk prostate cancer has an increased rate of local and systemic recurrence after locally definitive therapy. High-risk prostate cancer is defined by using a combination of pretreatment tumor related factors (prostatic specific antigen [PSA] level, stage, Gleason score, and extent of involved biopsy cores) and by pathological findings. Pretreatment PSA kinetics may allow the identification of more patients at high risk of treatment failure who otherwise would have been included in lower risk groups according to conventional risk assignment systems. Eight months of neoadjuvant androgen deprivation therapy prior to radical prostatectomy has been shown in a randomized trial to significantly reduce rates of positive margins compared to 3 months of therapy; however, no significant difference in PSA recurrence rates is apparent 5 years postsurgery. The use of early chemotherapy in prostate cancer has until recently been limited by lack of evidence of an effective chemotherapeutic agent for more advanced disease. Recent data, confirming a survival advantage of docetaxel based regimes in metastatic disease, has focused attention on the use of early chemotherapy in these men with high-risk disease. The technical requirements of surgery on high-risk patients are now better defined and one challenge for the specialty is to take this knowledge and apply it successfully in the laparoscopic setting. However, the limit of surgery alone in reducing recurrence in high-risk disease from technical advancements has plateaued. In order to take the field forward, successful multimodal treatment strategies are needed to improve the outcomes over surgical monotherapy for high-risk disease. Novel nucleotide therapy targeting the production of cell survival proteins has provided promising phase 1 data in prostate cancer. This experimental therapy has been built on an understanding of the observed effects that androgen deprivation therapy has on cancer cell survival proteins produced during periods of cellular stress.