Antibiotic Prophylaxis for Transrectal Prostate Biopsy: Systematic Review of Targeted vs. Empirical Therapy

Abstract

Introduction: Transrectal ultrasound-guided prostate biopsy (TRUSB) carries a 2–5% risk of infectious complications. Rising fluoroquinolone resistance has shifted practice toward targeted prophylaxis based on rectal swab cultures. This review compares targeted versus empirical prophylaxis.

Methods: PubMed, Cochrane, and clinicaltrials.gov were searched (2010–2023) for RCTs and quasi-experimental studies. Inclusion: adult men undergoing TRUSB, comparison of pre-procedural rectal swab culture-guided antibiotics vs. standard empirical regimen. Primary outcome: post-biopsy infection (fever, urinary tract infection, or sepsis within 30 days). Random-effects meta-analysis was performed.

Results: Nine studies (n=5,672) met inclusion. Targeted prophylaxis reduced infectious complications from 5.1% to 1.8% (RR 0.35, 95%CI 0.24–0.51). Sepsis risk decreased from 1.2% to 0.3% (RR 0.25, p<0.01). Fluoroquinolone resistance was detected in 38% of rectal cultures. Number needed to treat to prevent one infection was 30. No differences in minor bleeding or pain.

Discussion: Targeted prophylaxis significantly lowers infection rates, driven by avoidance of ineffective fluoroquinolones. Barriers include added cost of culture and delays. Most studies excluded men with recent antibiotics, limiting generalizability. Duration of targeted therapy varied widely.

Conclusions: Rectal swab culture-guided targeted prophylaxis should be standard for TRUSB where fluoroquinolone resistance exceeds 10%. Implementation requires workflow integration but is cost-effective.