DISCUSSION
postbiopsy, infections, infection, postbiopsy infection, coronavirus disease 2019
CORONAVIRUS DISEASE 2019, STILL, ADVERSE EVENTS, CNS INFECTIONS, EVENT, INFECTIONS, INFECTION, COMPLICATIONS
This multicenter trial supports the use of rectal culture-based prophylaxis to reduce early infectious complications after transrectal PB. Even though the absolute reduction of infections is small because of the small event rate, the effect is clinically relevant because PBs are performed frequently, leading to >40 000 postbiopsy infections in the United States yearly. Importantly, culture-based prophylaxis also reduced severe infections (ie, bacteremia).Our study is the first RCT with sufficient power on this topic, adding substantial high-quality evidence. The multicenter trial design increases the robustness of our data. Considerable variation, however, exists in the number of included patients per hospital (Ninety-one patients (5.9%) dropped out after randomization and before PB, 56 (3.6%) of which because PB was cancelled for various reasons. This dropout was largely unforeseen and related to the start of the coronavirus disease 2019 pandemic in March 2020. Importantly, reasons and patient numbers for dropout after randomization were comparable for both groups. Because randomization results were not blinded, some selection bias could have occurred. Two patients in the CG dropped out because of a high risk of postbiopsy infection. For 12 patients in the CG (1.9%), the exact reason for canceling PB or withdrawing informed consent could not be ascertained. If this had any impact on our results, it would have underestimated our results. Two patients in the IG withdrew informed consent because of the prescribed prophylaxis regimen.Our results are in line with 3 meta-analyses [When interpreting our results, some factors must be taken into account. Because of the nature of our (phenotypic) culture technique, the susceptibility of Gram-positive bacteria, particularly In general, infection rates should be interpreted in the context of the level of ciprofloxacin resistance, which is subject to geographical differences. Given the relatively low resistance for ciprofloxacin in the Netherlands (15.2%), our study is not necessarily representative for geographic regions with higher rates of resistance where the impact of culture-based prophylaxis will likely be higher.Still, 2.5% of patients developed an early postbiopsy infection despite culture-based prophylaxis. Therefore, alternative strategies to reduce postbiopsy infections needs consideration as well (ie, transperineal PB for which previous studies reported comparable postbiopsy infection rates as our study and antibiotic prophylaxis might be omitted) [The choice and uptake of any strategy does not depend solely on the effectiveness. In our setting, the additional costs of culture-based prophylaxis were estimated to be €79. The efficiency will be higher in geographic regions with higher rates of ciprofloxacin resistance because of an increased event rate, which is generally the case outside The Netherlands [Several aspects about the culture-based prophylaxis strategy need to be considered. First, the optimal timing of swab collection must be established. Liss et al showed that screening approximately 2 weeks and immediately before PB provided concordant results in 93% of all patients [Second, recently, in Europe, attention has been paid to the adverse events of FQ [Third, the optimal culture strategy needs to be determined taking into account local antimicrobial resistance patterns and cost efficiency. Perhaps screening with other antibiotics is more sensible in other settings.Last, 24 hours of prophylaxis is recommendable. Prolonged prophylaxis has disadvantages (adverse events and selection of resistant bacteria). Evidence that supports long-course prophylactic regimens is lacking, except for pivmecillinam/amoxicillin/clavulanic acid [