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July/August 2011
Patient Care and Science
EIN Update: GNR Bacteremia Following Urologic Surgery

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds EIN. The reader assumes all risks in using this information.

EIN members recently discussed cases of Gram-negative rod (GNR) bacteremia following urologic surgery and infection control steps for prevention.

A member in Florida shared a recent statement from the American Urology Association (AUA) noting that “the rates of infectious complications, including sepsis, after transrectal prostate needle biopsy may be increasing” and that urologists should be aware of the issue.

The notice also referenced AUA’s best practice statement for antimicrobial prophylaxis. The antimicrobial of choice before a prostate needle biopsy is a fluoroquinolone or a second- or third-generation cephalosporin, according to AUA. Alternative agents include an aminoglycoside plus metronidazole or clindamycin. Oral fluoroquinolones are the most commonly used agents in clinical practice, AUA says.

“We have seen a few cases of GNR bacteremia with sepsis after prostate biopsy or external radiation therapy (XRT) brachytherapy implants despite quinolone prophylaxis and plan on publishing our experience of several cases with a literature review,” an EIN member in Florida wrote. “Has anyone in our ID community seen similar cases?”

Seven EIN members from five different states (California, New York, Ohio, Pennsylvania, and Texas) reported seeing such cases.

A respondent in Texas described a recent patient with a fever and chills 48 hours after a prostate biopsy, despite being given levofloxacin, cefixime, and metronidazole prophylaxis by a urologist. The patient’s blood and urine culture grew extended-spectrum beta-lactamase (ESBL) E. coli. “The patient did well on ertapenem,” the member wrote, “and I am treating as possible prostatitis.”

An EIN member in California also reported seeing higher rates of these cases than usual, “usually ciprofloxacin-resistant E. coli,” the member noted. “We are working with our urologists on prophylaxis modification.”

It is important to ensure that urologists are using a single-use, sterile needle guide, or following meticulous cleaning and disinfection methods for re-processing, a respondent with the Centers for Disease Control and Prevention (CDC) wrote. “These procedures are often done in an outpatient setting where rigorous infection control oversight may be lacking.”

The CDC respondent cited a May 2007 study in the journal Urology describing an outbreak of Pseudomonas aeruginosa infections after transrectal ultrasound-guided prostate biopsies. The outbreak resulted from a contaminated needle guide.

Emphasizing the importance of infection control, an EIN member from Missouri recalled a series of three patients who were admitted “with very peculiar multi-drug resistant GNR (E. coli, I believe) symptomatic and clinically significant urinary tract infections immediately (within days) following outpatient transrectal prostate biopsies.” All of the cases came from the same urologist, had had biopsies taken at the same outpatient office, and presented within 30 to 90 days of each other.

Hospital infection control (IC) staff visited the urologist’s office. The IC team “felt that there were significant irregularities in the sterilization practices used by this specific busy urologist’s office, and they reviewed basic standard sterile procedure with the doctor and the doctor’s staff,” the Missouri member wrote. “We immediately saw a complete disappearance of these types of cases after the IC team visit.”

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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