Infectious complications following prostate biopsy (PB) are increasing and fluoroquinolone (FQ) prophylaxis has recently been banned by the European Commission. In this systematic review, we have summarized the evidence for different antibiotic prophylaxis regimens.
We searched MEDLINE, Embase, and Cochrane Database for randomized controlled trials (RCTs) (Inception to Oct. 2019) assessing antimicrobial interventions in PB. Primary outcome was infectious complications. Exclusion criteria were simultaneous interfering interventions. GRADE was used to assess the certainty of evidence. Protocol was registered with PROSPERO (CRD42015026354).
59 RCTs (14.153 participants) and 7 different antimicrobial interventions were included. Antibiotic prophylaxis reduced infectious complications compared to no prophylaxis (RR 0·56, 95% CI 0·40-0·77, p=0·0005, I=15%, participants=1753, studies=11). A short-term prophylaxis (single shot to 3 days) was inferior to a long-term prophylaxis (1 to 7 days) with FQ (RR 1·89, 95% CI 1·37-2·61, p=0·0001, I=0%, participants=3999; studies=17). Fosfomycin trometamol was an alternative to FQ with reduced rates of infectious complications (RR 0·49, 95 CI 0·27-0·87; p=0·02, I=54%, participants=1239, studies=3). Empiric prophylaxis was inferior to targeted prophylaxis (RR 1·81, 95% CI 1·28-2·55, p=0·0008, I=48%, participants=1511, studies=6). Standard prophylaxis was inferior to augmented prophylaxis (using multiple rather than single agent) using a fixed model (RR 2·10, 95% CI 1.53-2.88, p<0·0001, I=71%, participants=2597, studies=9), but not using a random model (p=0·07). No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. The certainty of evidence was rated as low/very low.
In countries where fluoroquinolones are allowed as antibiotic prophylaxis, a minimum of a full 1-day administration as well as targeted therapy in case of fluoroquinolone resistance is recommended. In countries with a ban on fluoroquinolones, fosfomycin is a good alternative, as is augmented prophylaxis, although no established standard combination exists to date.