Prevention & Management of Infection post Trans Rectal Ultrasound (TRUS) biopsy Dr. Fidelma Fitzpatrick Consultant Microbiologist, Co-chair, NCCP Prostate Bx Infection Project Board Fidelma.fitzpatrick@hse.ie @ffitzp
Outline 1. What s the issue post TRUS prostate biopsy? 2. Why national guidelines? 3. Sneak preview of the guidelines!
Complications post TRUS Generally safe & well-tolerated Post biopsy complications may include Pain Rectal bleeding, Haematuria, Haematospermia Urinary retention Infection Clin Infect Dis. (2013) 57 (2): 267-274
What type of infectious complications can present post TRUS? Direct inoculation of bacteria from rectal mucosa into prostate, blood vessels, or urinary tract Urinary tract infection Prostatitis Bloodstream infection (+ secondary spread!) Severe sepsis
Infections post TRUS? Underreported most managed in community 4.2% had fever in the 2 weeks post TRUS 0.8% hospitalised UTI: 2% -6% 30% 50% also have bloodstream infection Severe sepsis 0.1% 2.2% Clin Infect Dis. (2013) 57 (2): 267-274
SO WHY IS A MICROBIOLOGIST CHAIRING A NCCP COMMITTEE ON TRUS COMPLICATIONS??
The issue = ANTIMICROBIAL RESISTANCE
What is the most common bug?
WHY NATIONAL GUIDELINES? REPORTS OF ANTIBIOTIC RESISTANT INFECTIONS & NEED FOR STANDARDISATION OF PRACTICE
National Survey 10 centres Procedure Type n = 10 TRUS 10 Transperineal 4 Other* 1 *radical prostatectomy, brachytherapy Where? n = 9 Interventional radiology Rapid Access Clinic Urology OPD 2 Endoscopy 1 5 3
Antibiotic prophylaxis pre biopsy (n=10) Different regimens All = oral quinolone ciprofloxacin or ofloxacin 5 also use second antibiotic Different dosing schedules & doses Single dose (n=2) X 24 hr (n=4) X 48 hr (n=1) X 72 (n=2) X 5 days (n=1)
Risk Assessment for Antibiotic Resistance to Alter Antibiotic Prophylaxis 1 centre piloting ESBL screening (rectal swab) 3/10 (30%) used formal risk assessment tool
Risk factors assessed included... History antibiotic resistant bug (n=3) Immunocompromise (n=3) Previous antibiotic use & specifically previous quinolone (n=2) Previous urological procedures (n=2) Previous post biopsy sepsis (n= 1) Indwelling material, abnormality of the renal tract, diabetes, age and recent hospitalisation (n=1)
Prevention of Infection post TRUS
Prevention Screening versus Risk Assessment 1. Screen ALL patients pre-biopsy 3. Risk factor assessment only & adjust antibiotic prophylaxis accordingly 2. Screen only those with risk factors for antibiotic resistance
SO WHAT ARE WE RECOMMENDING? Pre-biopsy screening only if patient requires CRE screening Everybody else Check if risk factors for resistant Enterobacteriaceae
SO WHAT ARE WE RECOMMENDING? Pre-biopsy screening only if patient requires CRE screening Everybody else Check if risk factors for resistant Enterobacteriaceae
THE ULTIMATE SUPERBUG
CRE in Ireland
CRE in Ireland colonisations & infections Source: HPSC * Data for 2013 are provisional to the end of Q3
WHY IS THIS SUCH A BIG DEAL?
Carbapenem-resistant Klebsiella (CRE) in Greece Vatopoulos et al Eurosurveillance 2008
Carbapenem-resistant Klebsiella (CRE) in Italy Data source: GM Rossolini, ARHAI Network Meeting, Berlin, Dec 2012
CRE - Who should be screened? 1. Previous CRE 2. Transfer from a healthcare facility abroad 3. Admitted to healthcare facility abroad for > 48 hours in the last 12 months 4. Admitted to Irish healthcare facility* for > 48 hours with CRE outbreak in last 12 months www.hpsc.ie
Where can you get further information? Type a quote here. Johnny Appleseed
CRE risk factors 1. CRE Rectal swab 2. Do not list for biopsy pending swab results 3. MDT discussion if positive
SO WHAT ARE WE RECOMMENDING? Pre-biopsy screening only if patient requires CRE screening Everybody else Check if risk factors for resistant Enterobacteriaceae
1. CRE risk factors 2. Other Antibiotic Resistance Risk Factors Recent quinolone Patient is healthcare worker Travel abroad last year Previous post Bx infection Past Hx ESBL 3. No Antibiotic Resistance Risk Factors
Prevention Antimicrobial Prophylaxis CRE risk factors Other Antibiotic Resistance Risk Factors PO Ciprofloxacin plus Aminoglycoside History AMR/ESBL: check susceptibilities History post-biopsy infection: check old microbiology No Antibiotic Resistance Risk Factors PO Ciprofloxacin 750mg 1 hour pre biopsy
Management of Infection
Before the patient leaves... Clear WRITTEN information How to recognise infection post biopsy Who to contact if have symptoms of an infection (including out of hours) Letter for GP/ED/Urology in case of infection 1. Antimicrobial prophylaxis used 2. Algorithm for the treatment of potential infection post-trus prostate biopsy
Patient follow up post biopsy Units performing TRUS Contact patients within 48 hours by phone & record Record absence/presence of infection at OPD Develop an infection surveillance system Promote awareness of TRUS prostate biopsy Hospital / referring Institutions/GP Circulate management guidelines
Management of sepsis post biopsy HISTORY 1. Interval between biopsy & symptom onset. 2. Antibiotics. - TRUS biopsy & current 3.Antibiotic allergies? - document what happened 4. Previous resistant Enterobacteriaceae? 5. Renal function. - what is the baseline creatinine? EXAMINATION 1.Early Warning Score 2. Signs of systemic inflammation 3. Infections other than UTI, especially if >10d post biopsy KEY DECISIONS 1. Is hospital admission required? 2. Are criteria for sepsis/severe sepsis/septic shock evident? 3. Is there history/risk factors for antibiotic resistant Enterobacteriaceae?
What investigations should be performed? 1. Blood cultures BEFORE antibiotics 2. Urine culture 3. Bloods: FBC, U&E, CRP. If Sepsis - Add lactate, LFTs, coag screen if patient meets sepsis criteria
SEPSIS HOW TO RECOGNISE? Resp > 20 PATIENT HAS 2 OR MORE OF... Temp<36 or >38.3 ( o C) Heart Rate > 90 Acutely altered mental status WCC < 4 or > 12 Bedside glucose >7.7 (no diabetes) PLUS Infection is suspected Ensure Doctor present within 30 mins This patient has SEPSIS COMPLETE SEPSIS SIX WITHIN 1 HOUR
Sepsis 6 3 to take Blood cultures before antibiotics Lactate & FBC Urine output measurement 3 to give O 2 IV fluid resuscitation IV antibiotics
A: PATIENT REQUIRES ADMISSION 1. FOLLOW SEPSIS PROTOCOL 2. Antibiotics after taking blood cultures INVESTIGATIONS A: TWO ANTIBIOTICS B: DON T GIVE SAME ANTIBIOTIC AS USED FOR BIOPSY PROPHYLAXIS. 3. ALWAYS discuss further antimicrobial therapy decisions once additional microbiology results are back
INVESTIGATIONS B: PATIENT DOES NOT REQUIRE ADMISSION 1. If patient has suspected lower UTI WITHOUT signs of systemic inflammation or suspected sepsis: PO nitrofurantoin 100mg qds or PO coamoxiclav 625mg TDS PO or PO fosfomycin 3gm sachet stat only 2. Follow-up MSU results at 48 hours to ensure empiric therapy appropriate
Summary Antibiotic resistance in infections post TRUS = on the rise Pre Biopsy 1.? CRE risk factors screen + don t list 2.? Other antibiotic resistant risk factors antibiotic prophylaxis needs to be changed
Summary - 2 After biopsy verbal + written patient information If you see a patient unwell after TRUS 1. Think sepsis & act FAST 2. Check what antibiotic prophylaxis they got 3. Give 2 different antibiotics
Acknowledgements 10 units for completing the national survey Ms. Eileen Nolan, NCCP NCCP Prostate Bx Infection Project Board
Questions? Fidelma.fitzpatrick@hse.ie @ffitzp