Howard Wolinsky a journalist based in the Chicago area, was diagnosed with early prostate cancer in 2010. In an ongoing series of articles for 鶹ý, he describes his journey from diagnosis to the decision to chose active surveillance. In this latest installment, he explains how a change in protocol turned up an unexpected finding.
A funny thing happened on the way to my latest prostate biopsy.
For the first time, I underwent a rectal swab in an exam room at , about 50 miles from my home in Chicago's southern suburbs. The test had to be at least 2 weeks before I was scheduled to have the biopsy in July.
It seemed strange. It got stranger.
The results from the rectal culture revealed fluoroquinolone-resistant E. coli in my digestive tract. Only weeks earlier, I had had a bout of diverticulitis. My internist prescribed ciprofloxacin (Cipro), which must have altered the bugs in my gut and given a boost to antibiotic-resistant bugs.
I've had five previous biopsies. Each time, I was prescribed antibiotics. I took them for a few days. I never had an infection. But no one ever looked to see if I was carrying antibiotic resistant bugs.
We've heard a lot in recent years about antibiotic resistance.
At least 2 million Americans per year become infected with antibiotic-resistant bacteria, and at least 23,000 people die as a result of these infections, according to the Centers for Disease Control and Prevention.
Now I found myself right in the middle of the issue.
I was advised to come to the oncology department at NorthShore to receive an intravenous infusion of two grams of ceftriaxone an hour before the biopsy.
I wondered why NorthShore was taking these precautions and how successful they had been.
I asked , an infectious diseases attending and the chief hospital epidemiologist at NorthShore about my concerns.
There's Something Happening Here
She said national infection rates with transrectal ultrasound prostate biopsies range from 2% to 6%.
The worst type of post-prostate biopsy infectious complication is bacteremia, which affects 0.1% to 2.2% of cases.
Smith said that around 2005, ID experts began to observe that some patients who had undergone prostate biopsies were developing E. coli infections resistant to fluoroquinolone, just the sort of situation in which I found myself.
Ciprofloxacin or levofloxacin were the most commonly prescribed because they reach high levels in the prostate.
Smith stressed that NorthShore never had "a problem" with these infections – meaning that their rate of infections was within the expected rate in the literature. But to stay ahead of the problem with increasing rates of fluorquinolone resistance in 2006, infectious disease specialists at NorthShore recommended a different approach.
"Instead of just giving levofloxacin, which was traditionally prescribed, patients received two antibiotics to cover (with the second antibiotic) for the 20% chance that the patient was carrying fluoroquinolone-resistant bacteria," she said.
Smith said the bacteria kept fighting back, introducing plasmids to bacterial DNA that made the "little bad guys" even more resistant to cephalosporins and penicillins. She said about 8% of the population has extended spectrum beta-lactamase producing (ESBL) bacteria, adding that most oral antibiotics do not cover ESBLs.
In 2012, Smith said she looked at the data from NorthShore. "Our infection rate was less than 1%. But that's still one out of 100 people who might have to come back to the hospital after a prostate biopsy. That's bad for them, and if there was a way to reduce that number, we needed to do it," she said.
Fighting Back
As a result, NorthShore in 2012 launched a quality-improvement project to introduce rectal swabbing for patients who are undergoing prostate biopsies. "This way we could not only detect whether a patient was carrying fluoroquinolone-resistant E. coli, but also avoid giving two antibiotics to patients who did not need them and therefore improve antimicrobial stewardship," Smith said.
Since the implementation of the screening protocol, NorthShore has noted ongoing improvement in their already low rates of post-prostate biopsy infectious complications, virtually eliminating complications that would result in ER visits or re-hospitalization.
Smith said this review is retrospective and that a randomized controlled study is needs to be done to determine if screening and modification of periprocedure, antibiotic prophylaxis results in fewer post-biopsy infectious complications. "We've seen an already good infection rate go to almost nothing," she said. "But, not everyone will buy into this until prospective research is done."
Outside the procedure suite, is this information useful to someone like me with fluoroquinolone-resistant E. coli?
Smith said that over time, my status could change. If I have another biopsy at NorthShore, I would be screened again. She advised me to inform my internist, which I did via his group's portal. "It's good knowledge to have, and you're not branded for life," she said.
Smith added: "If you had a serious infection and did not have culture results to guide antibiotic therapy (that is, you did not know if the bacteria were susceptible) doctors would likely avoid giving you empiric antibiotic therapy with a fluoroquinolone antibiotic in case of resistance."