Background: Culture-based antibiotic prophylaxis is a plausible strategy to reduce infections after transrectal prostate biopsy (PB) related to fluoroquinolone-resistant pathogens.Objective: To assess the cost effectiveness of rectal culture-based prophylaxis com-pared with empirical ciprofloxacin prophylaxis. Design, setting, and participants: The study was performed alongside a trial in 11 Dutch hospitals investigating the effectiveness of culture-based prophylaxis in transrectal PB between April 2018 and July 2021 (trial registration number: NCT03228108).Intervention: Patients were 1:1 randomized for empirical ciprofloxacin prophylaxis (oral) or culture-based prophylaxis. Costs for both prophylactic strategies were determined for two scenarios: (1) all infectious complications within 7 d after biopsy and (2) culture-proven Gram-negative infections within 30 d after biopsy.Outcome measurements and statistical analysis: Differences in costs and effects (quality-adjusted life-years [QALYs]) were analyzed from a healthcare and societal perspective (including productivity losses, and travel and parking costs) using a bootstrap procedure presenting uncertainty surrounding the incremental cost-effectiveness ratio in a cost-effectiveness plane and acceptability curve.Results and limitations: For the 7-d follow-up period, culture-based prophylaxis (n = 636) was euro51.57 (95% confidence interval [CI] 6.52-96.63) more expensive from a healthcare perspective and euro16.95 (95% CI -54.29 to 88.18) from a societal perspective than empirical ciprofloxacin prophylaxis (n = 652). Ciprofloxacin-resistant bacteria were detected in 15.4%. Extrapolating our data, from a healthcare perspective, 40% ciprofloxacin resistance would lead to equal cost for both strate-gies. Results were similar for the 30-d follow-up period. No significant differences in QALYs were observed.Conclusions: Our results should be interpreted in the context of local ciprofloxacin resistance rates. In our setting, from a healthcare perspective, culture-based pro-phylaxis was significantly more expensive than empirical ciprofloxacin prophy-laxis. From a societal perspective, culture-based prophylaxis was somewhat more cost effective against the threshold value customary for the Netherlands (euro80.000).Patient summary: Culture-based prophylaxis in transrectal prostate biopsy was not associated with reduced costs compared with empirical ciprofloxacin prophylaxis.(c) 2023 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons. org/licenses/by/4.0/).

ABSTRACT The emerging prevalence of extended-spectrum beta-lactamase (ESBL) producing Enterobacterales has implications for the empirical treatment of common infections, such as complicated urinary tract infections. To provide adequate treatment, while avoiding empirical therapy with last resort carbapenems, rapid identification of ESBL-containing pathogens is desirable. Routine urine samples were collected between February and July 2021 in two Dutch clinical medical microbiology laboratories according to a predefined list containing certain culture characteristics. All urine samples were screened for the presence of ESBL genes (bla CTX-M2, bla CTX-M14, and bla CTX-M15) with random-access quantitative PCR (qPCR) using the Cepheid GeneXpert ESBL-ampC prototype assay. The qPCR and microbiological culture results were compared. After the calculation of the sensitivity and specificity, discrepancies were investigated by whole-genome sequencing. In total, 276 urine samples were available for ESBL analysis (94 ESBL culture positive and 182 ESBL culture negative). The sensitivity and specificity for detection of ESBL genes were 90.4% and 98.4%, respectively. In nine samples (9.6%), no ESBL genes were detected with GeneXpert, while in the microbiological culture, an ESBL-positive organism was isolated. This was mainly explained by non-GeneXpert ESBL genes: bla SHV-family (n = 6; 75.0%), bla TEM-family (n = 1; 12.5%), and bla SRT-family (n = 1; 12.5%). The positive and negative predictive values in a hypothetical clinical scenario with a 15% ESBL prevalence were 0.91 and 0.98, respectively. Regarding ampC, the specificity appears to be satisfactory, but the sensitivity is low. The Cepheid GeneXpert ESBL assay could be beneficial for the fast and accurate detection of ESBL genes in regions where the epidemiology of ESBL genes coincides with the targets in the panel. IMPORTANCE Early identification of complicated urinary tract infections caused by ESBL-producing Enterobacterales has the potential to limit the use of carbapenems to those patients without alternative antibiotic options and avoid the empirical use of carbapenems in patients without ESBL-producing bacteria. The purpose for such a test will differ by setting and ESBL prevalence rates. Countries with low ESBL rates and cephalosporins as empiric treatment (e.g., The Netherlands) will need a rule-in test to decide to use carbapenems, while countries with high ESBL rates and empiric carbapenem treatment will need a rule-out test for ESBLs to de-escalate therapy early. Anyway, such as a test would—at least theoretically—improve patient care and reduce selective pressure for the emergence of carbapenem resistance.

PURPOSE:The aim of our study was to compare infectious complication rates between different prostate biopsy techniques with various number of biopsy cores. MATERIALS AND METHODS:In this retrospective study, all patients from 2 hospitals who underwent prostate biopsy between 2012 and 2019 were identified. Cohorts with different types of prostate biopsies were compiled within these hospitals. Primary outcome measure was any registered infectious complication within 7 days post-biopsy. Secondary outcomes were infectious complications within 30 days, hospitalization and bacteremia. To compare the risk of infection following different prostate biopsy techniques, data was fitted into a logistic regression model adjusting for potential confounders. RESULTS:In total, 4,233 prostate biopsies in 3,707 patients were included. After systematic transrectal ultrasound-guided prostate biopsy (TRUSPB; 12±1.4 biopsy cores), 4.0% (2,607) of all patients had infectious complications within 7 days post-biopsy. Transperineal magnetic resonance imaging (MRI)-ultrasound fusion guided prostate biopsy (16±3.7 biopsy cores) was associated with significantly lower infection rates than systematic TRUSPB (adjusted OR: 0.29 [0.09-0.73] 95% confidence interval [CI]). Transrectal targeted MRI-ultrasound fusion guided prostate biopsy (3.1±0.8 biopsy cores) and transrectal targeted in-bore MRI guided prostate biopsy (2.8±0.8 biopsy cores) also showed fewer infectious complications than systematic TRUSPB (adjusted OR: 0.41 [0.12-1.12] 95% CI and 0.68 [0.37-1.20] 95% CI, respectively). CONCLUSIONS:Transperineal prostate biopsy, or transrectal prostate biopsy with reduced number of biopsy cores, could lower the risk of infectious complications.

Abstract Background An increase in infections after transrectal prostate biopsy (PB), related to an increasing number of patients with ciprofloxacin-resistant rectal flora, necessitates the exploration of alternatives for the traditionally used empirical prophylaxis of ciprofloxacin. We compared infectious complication rates after transrectal PB using empirical ciprofloxacin prophylaxis versus culture-based prophylaxis. Methods In this nonblinded, randomized trial, between 4 April 2018 and 30 July 2021, we enrolled 1538 patients from 11 Dutch hospitals undergoing transrectal PB. After rectal swab collection, patients were randomized 1:1 to receive empirical prophylaxis with oral ciprofloxacin (control group [CG]) or culture-based prophylaxis (intervention group [IG]). Primary outcome was any infectious complication within 7 days after biopsy. Secondary outcomes were infectious complications within 30 days, and bacteremia and bacteriuria within 7 and 30 days postbiopsy. For primary outcome analysis, the χ2 test stratified for hospitals was used. Trial registration number: NCT03228108. Results Data from 1288 patients (83.7%) were available for analysis (CG, 652; IG, 636). Infection rates within 7 days postbiopsy were 4.3% (n = 28) (CG) and 2.5% (n = 16) (IG) (P value = .08; reduction: −1.8%; 95% confidence interval, −.004 to .040). Ciprofloxacin-resistant bacteria were detected in 15.2% (n = 1288). In the CG, the presence of ciprofloxacin-resistant rectal flora resulted in a 6.2-fold higher risk of early postbiopsy infection. Conclusions Our study supports the use of culture-based prophylaxis to reduce infectious complications after transrectal PB. Despite adequate prophylaxis, postbiopsy infections can still occur. Therefore, culture-based prophylaxis must be weighed against other strategies that could reduce postbiopsy infections. Clinical Trials Registration. NCT03228108.

Background The acceptability of innovative medical strategies among healthcare providers and patients affects their uptake in daily clinical practice. Objectives To explore experiences of healthcare providers and patients with culture-based antibiotic prophylaxis in transrectal prostate biopsy with three swab-screening scenarios: self-sampling at home, self-sampling in the hospital and sampling by a healthcare provider. Methods We performed focus group interviews with urologists and medical microbiologists from 11 hospitals and six connected clinical microbiological laboratories. We used Flottorp's comprehensive checklist for identifying determinants of practice to guide data collection and analysis. The experiences of 10 laboratory technicians from five laboratories and 452 patients from nine hospitals were assessed using a questionnaire. Results Overall, culture-based prophylaxis strategies were experienced as feasible in daily clinical practice. None of the three swab-screening scenarios performed better. For urologists (n = 5), implementation depended on the effectiveness of the strategy. In addition, it was important to them that the speed of existing oncology care pathways is preserved. Medical microbiologists (n = 5) and laboratory technicians (n = 8) expected the strategy to be fairly easy to implement. Patients (n = 430; response rate 95.1%) were generally satisfied with the screening scenario presented to them. To meet the various patients' needs and preferences, multiple scenarios within a hospital are probably needed. Conclusions This multi-method study has increased our understanding of the acceptability of culture-based prophylaxis strategies in prostate biopsy, which can help healthcare providers to offer high-quality patient-centred care. The strategy seems relatively straightforward to implement as overall acceptance appears to be high.

BACKGROUND:The clinical landscape of prostate biopsy (PB) is evolving with changes in procedures and techniques. Moreover, antibiotic resistance is increasing and influences the efficacy of pre-biopsy prophylactic regimens. Therefore, increasing antibiotic resistance may impact on clinical care, which probably results in differences between hospitals. The objective of our study is to determine the (variability in) current practices of PB in the Netherlands and to gain insight into Dutch urologists' perceptions of fluoroquinolone resistance and biopsy related infections.METHODS:An online questionnaire was prepared using SurveyMonkey® platform and distributed to all 420 members of the Dutch Association of Urology, who work in 81 Dutch hospitals. Information about PB techniques and periprocedural antimicrobial prophylaxis was collected. Urologists' perceptions regarding pre-biopsy antibiotic prophylaxis in an era of antibiotic resistance was assessed. Descriptive statistical analysis was performed.RESULTS:One hundred sixty-one responses (38.3%) were analyzed representing 65 (80.3%) of all Dutch hospitals performing PB. Transrectal ultrasound guided prostate biopsy (TRUSPB) was performed in 64 (98.5%) hospitals. 43.1% of the hospitals (also) used other image-guided biopsy techniques. Twenty-three different empirical prophylactic regimens were reported among the hospitals. Ciprofloxacin was most commonly prescribed (84.4%). The duration ranged from one pre-biopsy dose (59.4%) to 5 days extended prophylaxis. 25.2% of the urologists experienced ciprofloxacin resistance as a current problem in the prevention of biopsy related infections and 73.6% as a future problem.CONCLUSIONS:There is a wide variation in practice patterns among Dutch urologists. TRUSPB is the most commonly used biopsy technique, but other image-guided biopsy techniques are increasingly used. Antimicrobial prophylaxis is not standardized and prolonged prophylaxis is common. The wide variation in practice patterns and lack of standardization underlines the need for evidence-based recommendations to guide urologists in choosing appropriate antimicrobial prophylaxis for PB in the context of increasing antibiotic resistance.

We evaluated the Copan Eswab transport system for the quantitative recovery of Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa after 1, 2, 3, 5, and 7 days of storage at room and refrigerator temperatures, and 7 and 30 days of storage at -80 degrees C and -20 degrees C using mono- and polymicrobial samples. The study was based on Clinical and Laboratory Standards Institute (CLSI) M40-A2 standard procedures on the quality control of microbiological transport systems. Eswab met the CLSI standards at room and refrigerator temperatures for all (combinations of) bacterial strains tested. At room temperature, after 24 h, bacterial growth was observed. At -80 degrees C, bacterial viability was maintained in monomicrobial samples; however, in polymicrobial samples, P. aeruginosa recovery was compromised. Storage at -20 degrees C was unsuitable. We conclude that specimens collected using Eswab should be transported to the laboratory as soon as possible. If transport or processing is delayed, specimens should preferably be stored at refrigerator temperatures. (C) 2020 The Author(s). Published by Elsevier Inc.

A rectal culture-guided antimicrobial prophylaxis strategy may prevent infections after transrectal ultrasound-guided prostate biopsy (TRUSP). The use of selective culture media could assist the choice of appropriate antibiotic prophylaxis. The objective of our study was to evaluate the performance of four selective media used for guidance of oral antibiotic prophylaxis in TRUSP. In this prospective validation study, we used MacConkey media with vancomycin plus one of the following antibiotics: ciprofloxacin (McC3+CIP/V), trimethoprim (McC3+TMP/V), fosfomycin (McC3+FOF/V), and amdinocillin-amoxicillin-clavulanic acid (McC3+MEC/V). First, clinical strains of Gram-negative bacilli (GNB) (n = 33) were evaluated for growth on the selective media. Thereafter, rectal swabs (n = 97) were randomly collected from residual material of fresh stool samples and plated on a growth control and the four selective media. Levels of recovery of GNB on the growth control and selective media were compared, and the MICs of the antibiotics used in this study were determined. The sensitivity and specificity of the four selective media amounted, respectively, to 90.0% (55.5 to 99.8%) and 98.7% (93.1 to 100.0%) for McC3+CIP/V, 95.7% (85.2 to 99.5%) and 100.0% (91.6 to 100.0%) for McC3+TMP/V, 95.5% (84.5 to 99.4%) and 97.8% (88.2 to 99.9%) for McC3 + FOF/V, and 100.0% (76.8 to 100.0%) and 97.6% (87.4 to 99.9%) for McC3+MEC/V. In conclusion, the four selective media were sufficiently sensitive and specific for the identification of rectal GNB resistant to ciprofloxacin, trimethoprim, fosfomycin, or amdinocillin-amoxicillin-clavulanic acid. These media can have added value in streamlining the optimal culture based antibiotic prophylaxis in TRUSP in a non-labor-intensive manner.

A reduction in nephron number results in compensatory glomerular hyperfiltration. This initiates a vicious circle of glomerular hypertrophy and sclerosis, continued nephron loss and worsening hyperfiltration, clinically characterized by proteinuria and progressive renal function loss.1,2 Glomerular hyperfiltration may be particularly important in kidney transplantation. Indeed, it has been suggested that posttransplant graft function and long-term outcome can be improved by matching nephron supply and recipient needs.1,2 In humans, nephron number cannot be measured noninvasively. It is suggested that donor kidney weight provides a suitable estimate of the number of nephrons.3-5 Several studies have reported on a positive association between donor kidney weight and glomerular filtration rate after transplantation.3-5 We regularly measured weights of living and postmortal donor kidneys between 1997 and 2001. Kidneys of living donors were weighed after donor nephrectomy, perfusion with cold preservation solution, and preparation by the surgeon. Postmortal donor kidney weight was determined after cold storage, immediately before implantation into the recipient. The average living donor kidney weight (n = 85) amounted to 167 g (Table 1). However, mean kidney weights of postmortal donors were clearly higher: +32 g (+19%) and +71 g (+43%) for donor kidneys after brain death (DKBD) (n = 95) and donor kidneys after cardiac death (DKCD) (n = 35), respectively. The higher weight of postmortal donor kidneys could not be explained by a higher donor body length, donor body weight, or donor body mass index (Table 1). There was a moderate correlation between donor kidney weight and donor body mass index in postmortal kidney donation (r = 0.465 [DKBD] and r = 0.391 [DKCD]).TABLE 1: Donor characteristicsCold ischemia time and type of preservation fluid are given in Table 1. There was only a weak correlation between cold ischemia time and kidney weight in DKBD and DKCD (r = 0.26). Unfortunately, the type of preservation solution differed between the 3 donor populations. However, the differences in kidney weight remained when limiting the analysis to donor kidneys perfused with the same (HTK) preservation solution (Table S2, SDC, https://links.lww.com/TP/B207). We also evaluated the possible role of perfusate pressure. Kidneys of brain death donors were perfused with higher perfusate pressures (300 mm Hg) than kidneys of cardiac death donors or kidneys of living donors (both 110 mmHg). These differences are not associated with the observed differences in kidney weight. We hypothesize that in postmortal kidney transplants prolonged ischemia will cause tubular necrosis and edema formation resulting in increased kidney weights. In this case, a relatively high kidney weight does not reflect a high number of functional nephrons but rather represents more severe kidney damage. Our findings indicate that measurement of kidney weight in postmortal kidney transplantation is unreliable, thus invalidating reliable conclusions. We observed no association between donor kidney weight and renal allograft function at 2 years after transplantation.