Post-TRUS sepsis: Targeted use of prophylactic ertapenem for high-risk patients

Introduction Consistent with international trends, Wellington Regional

Hospital has experienced an increasing rate of sepsis following transrectal ultrasound-guided prostate biopsy (TRUS).

In this study, we prospectively trialled ertapenem prophylaxis in patients with known risk factors for post TRUS sepsis.

Conclusions Ertapenem prophylaxis is effective at reducing sepsis post-prostate

biopsy.

The post TRUS sepsis rate amongst low risk patients receiving standard prophylaxis remains high.

Ertapenem prophylaxis for all patients is likely to be the least morbid and most cost-effective strategy.

Results From January to December 2011, 281 biopsies were performed: 5

patients developed post TRUS sepsis (1.8%)

From January to March 2012, 52 biopsies were performed: 6 patients developed post TRUS sepsis (11.5%).

Ertapenem prophylaxis was used from March to October 2012.

6 of 170 patients developed sepsis (3.5%): 6 of 90 in the low risk group (6.7%) and 0 from 80 in the high risk group (p = 0.03).

Of the 6 patients that had post TRUS sepsis, 3 grew ciprofloxacin-resistant organisms, 2 had no growth and 1 grew a ciprofloxacin-sensitive organism.

Per episode cost of routine ertapenem prophylaxis is $161.53 compared to $249.77 using a rectal-swab targeted protocol.

Methods Prospective comparative cohort study.

High risk identification based on known risk factors: previous TRUS prostate biopsy previous urosepsis immunocompromise, ciprofloxacin use within 12 months overseas travel to South-east Asia or South America

within 6 months.

All patients received oral ciprofloxacin and amoxicillin.

High risk patients additionally received ertapenem 1 g intramuscularly one hour before biopsy.

Sepsis requiring hospital admission was recorded.

Culture/sensitivities for those with sepsis recorded.

Powered to calculate a 12% difference in sepsis rate with a beta error of 80%.

Data analysed using a 2-tailed Fisher’s exact test.

Cost-effectiveness model was developed to compare routine ertapenem prophylaxis with targeted use by rectal swab culture.

AcknowledgementsMany thanks to Shelley de Boer for assistance with data collection and Dalice Sim for statistical analysis.

Aims To determine if the targeted use of prophylactic ertapenem

for patients with risk factors for sepsis reduced the rate of sepsis after TRUS prostate biopsy.

To perform a cost-effectiveness analysis comparing this approach to a rectal-swab targeted protocol.

ReferencesKehinde EO, Al-Maghrebi M, Sheikh M, Anim JT. Combined ciprofloxacin and amikacin prophylaxis in the prevention of septicemia after transrectal ultrasound guided biopsy of the prostate. J Urol 2013: 189; 911-5.

Graph shows rates of sepsis before (first column) and after the introduction of ertapenem (last three columns). The lack of sepsis in the ertapenem group is easily demonstrated.

Giovanni Losco, Rod StuddDepartment of Urology, Wellington Regional Hospital, Wellington, New Zealand

No. 078

Posters Proudly Supported by:

Pre-ertapenem Post-ertapenem No ertapenem Ertapenem

0%

2%

4%

6%

8%

10%

12%

14%11.5%

3.5%

6.7%

0.0%

Sepsis No Sepsis

No Ertapenem 6 84 90

Ertapenem 0 80 80

6 164 170

Table shows the number of patients in each group after the introduction of the ertapenem regimen. The zero-sepsis rate with ertapenem is statistically significant p = 0.03)