prostate cancer is the most prevalent cancer and the third most common cause of mortality in men in western countries .
transrectal ultrasonography - guided prostate biopsy ( trus - bx ) is an essential procedure for diagnosing prostate cancer but may cause variable complications , including pain , hematuria , hemospermia , urethral injury , and urinary tract infection . among the complications , infective complications are clinically important because these can cause prostatitis or urosepsis , which are sometimes fatal to patients .
the incidence rate of infective complications after trus - bx was reported to range from 0.1% to 7% and has increased during the past 10 years .
for example , the american urological association ( aua ) guideline recommends antibiotic prophylaxis with fluoroquinolone for less than 24 hours as the first - line therapy and aminoglycoside combined with metronidazole or clindamycin for less than 24 hours as the second - line therapy .
the european association of urology ( eau ) guideline also recommends oral or intravenous antibiotic prophylaxis before biopsy , and quinolone is recommended as the drug of choice .
however , these recommendations would not be appropriate in a region where the prevalence of quinolone - resistant escherichia coli is high .
the recent increase in infective complications is possibly due to an increase in quinolone - resistant e. coli prevalence in the community . because overuse of antibiotics has not been strictly controlled in korea ,
a recent epidemiology study reported that the resistance rate to ciprofloxacin was over 24% in cystitis patients .
for this reason , korean urologists hardly follow the aua or eau guideline and instead use various combinations of antibiotics to prevent infective complications . considering the increase in quinolone - resistant pathogens worldwide , it is clinically significant to know the pattern of antibiotic prophylaxis in korea , where the prevalence of quinolone - resistant e. coli is already high
. such data would give insight into the future of antibiotic prophylaxis in other countries where the quinolone resistance rate is still low but increasing .
therefore , we investigated the real practice of antibiotic prophylaxis to prevent infective complications of trus - bx in korea .
we sent an e - mail to the urology departments of 77 hospitals in korea .
these hospitals were secondary or tertiary referral hospitals and covered most prostate biopsy cases in korea .
the contents of the e - mail included questions about the real practice of trus - bx as follows : ( 1 ) which department has performed trus - bx ? ( department of radiology or urology ) , ( 2 ) how has biopsy been performed ?
( inpatient or outpatient setting ) , ( 3 ) which type of enema has been performed ? ( 4 ) has betadine enema been performed ? ( 5 ) which kinds of antibiotics have been used prior to biopsy ? ( 6 ) which kinds of antibiotics have been used after the procedure ? ( 7 ) how long did the patients take the medicine after prostate biopsy ? we analyzed the contents of the returned e - mails . according to the responses received , the prophylactic drugs in practice before and after trus - bx were classified according to the type of antibiotic ( quinolone , cephalosporin , aminoglycoside , and metronidazole ) , and we investigated the prevalence of each antibiotic regimen .
in addition , duration of postbiopsy medication and the identity of the antibiotics used before and after biopsy were evaluated .
all statistical analyses were performed by using spss ver . 17.0 ( spss inc . , chicago , il , usa ) , and the prevalence was presented as the number of hospitals with percentages .
a total of 54 hospitals replied to our e - mail ; the response rate was 70.1% .
two thirds of the responding hospitals indicated that the department of urology performed the prostate biopsy procedures ( 37 hospitals , 68.5% ) , and patients were admitted for trus - bx in 33 hospitals ( 61.1% ; fig .
, various types of enema or suppositories were used in 48 hospitals ( 88.8% ) , and disinfection with povidone - iodine was used in 29 hospitals ( 53.7% ; fig .
2 ) . various types of prophylactic antibiotics prior to prostate biopsy were used in each hospital ( table 1 ) .
a quinolone alone regimen was the most common ( 26 hospitals , 48.1% ) , followed by cephalosporin alone ( 11 hospitals , 20.4% ) , and aminoglycoside alone ( 5 hospitals , 9.3% ) .
a combination of two or more antibiotics was used in 12 hospitals ( 22.2% ) .
the doctors of all hospitals that participated in this study prescribed oral antibiotics after trus - bx ( table 2 ) .
the most common type of postbiopsy medication was quinolone alone ( 42 hospitals , 77.8% ) .
a cephalosporin alone regimen was used in 11 hospitals ( 20.4% ) , and only 1 hospital answered that oral quinolone and cephalosporin were routinely prescribed simultaneously .
the treatment duration of postbiopsy antibiotics also varied among the hospitals ( table 2 ) .
routine protocols of most hospital ( 43 hospitals , 79.6% ) were treatment for 4 or more days with oral antibiotics after trus - bx . among the 26 hospitals that chose quinolone alone before biopsy , 1 hospital ( 3.8% ) changed the type of antibiotic to cephalosporin after biopsy .
the other hospitals maintained an identical type of antibiotic during the post - biopsy period . among the 11 hospitals using cephalosporin alone prior to trus - bx
in contrast , the other 8 hospitals adhered to the same type of antibiotic used for the initial prophylaxis .
postbiopsy quinolone was used in all 3 hospitals that administrated aminoglycoside alone before trus - bx .
overall , the proportion of hospitals using prophylaxis with a single type of antimicrobial agent before and after prostate biopsy was 61.1% ( 33 hospitals ) . on the other hand ,
various types of prophylactic antibiotics prior to prostate biopsy were used in each hospital ( table 1 ) . a quinolone alone
regimen was the most common ( 26 hospitals , 48.1% ) , followed by cephalosporin alone ( 11 hospitals , 20.4% ) , and aminoglycoside alone ( 5 hospitals , 9.3% ) .
a combination of two or more antibiotics was used in 12 hospitals ( 22.2% ) .
the doctors of all hospitals that participated in this study prescribed oral antibiotics after trus - bx ( table 2 ) .
the most common type of postbiopsy medication was quinolone alone ( 42 hospitals , 77.8% ) .
a cephalosporin alone regimen was used in 11 hospitals ( 20.4% ) , and only 1 hospital answered that oral quinolone and cephalosporin were routinely prescribed simultaneously .
the treatment duration of postbiopsy antibiotics also varied among the hospitals ( table 2 ) .
routine protocols of most hospital ( 43 hospitals , 79.6% ) were treatment for 4 or more days with oral antibiotics after trus - bx .
among the 26 hospitals that chose quinolone alone before biopsy , 1 hospital ( 3.8% ) changed the type of antibiotic to cephalosporin after biopsy .
the other hospitals maintained an identical type of antibiotic during the post - biopsy period . among the 11 hospitals using cephalosporin alone prior to trus - bx
in contrast , the other 8 hospitals adhered to the same type of antibiotic used for the initial prophylaxis .
postbiopsy quinolone was used in all 3 hospitals that administrated aminoglycoside alone before trus - bx .
overall , the proportion of hospitals using prophylaxis with a single type of antimicrobial agent before and after prostate biopsy was 61.1% ( 33 hospitals ) . on the other hand , various combinations of drugs were used in 21 hospitals ( 38.9% ) .
the incidence of acute prostatitis related to trus - bx has been reported to range from 0.1% to 7% . in korea ,
the incidence of biopsy - related prostatitis was reported to range from 1.4% to 1.9% .
various studies have been undertaken to reduce the incidence of acute prostatitis after trus - bx .
one study reported that rectal preparation prior to biopsy with bisacodyl decreased biopsy - induced infectious complications significantly compared with a non - rectal - preparation group .
an intrarectal mixture of povidone - iodine and lidocaine gel also significantly decreased infectious complications in another study .
recently , issa et al .   described that formalin disinfection of a biopsy needle after each core reduces the incidence of urinary tract infection and sepsis . among these prophylactic methods ,
antibiotic prophylaxis has been the standard method of preventing infectious complications . in particular , fluoroquinolones have traditionally been used as the primary prophylactic agent owing to their excellent prostatic penetration . in the past , these agents also provided good coverage against the key pathogens implicated in infections after prostate biopsy .
analyzed a total of 1,994 strains from patients with community - acquired urinary tract infection from 34 hospitals in korea from january 2008 to june 2009 . in that study , the resistance rate to ciprofloxacin
was reported to range from 20% to 38% in community - acquired uncomplicated cystitis and showed a tendency to increase .
the overall resistance rate to ciprofloxacin rapidly increased from 15.2% in 2002 to 24.8% in 2009 .
furthermore , ciprofloxacin - resistant e. coli has been shown to be more prevalent in complicated urinary tract infection ( 40.9% ) than in uncomplicated urinary tract infection ( 24.8% ) in korea .
recent studies have reported that the prevalence of quinolone - resistant e. coli has also increased in western countries . however , the rate of quinolone resistance is lower than in korea . in the united states ,
fluoroquinolone - resistant bacteria were identified in 22% of samples from rectal swab cultures before trus - bx . in that study ,
asian men had a higher risk of resistant rectal flora colonization ( odds ratio , 2.8 ) .
in american men who developed acute prostatitis after trus - bx , the fluoroquinolone - resistant rate was reported to be 57.1% . in korea ,
a study reported that 2.0% of patients who underwent trus - bx developed acute prostatitis , and nearly all culture - positive specimens ( 96.3% ) were identified as ciprofloxacin - resistant pathogens . in that study , most quinolone - resistant pathogens were sensitive to cephalosporin and aminoglycoside .
therefore , several studies have evaluated the effect of cephalosporin combined with quinolone on the prevention of infectious complications after trus - bx .
some reports have suggested that adding aminoglycoside is helpful for preventing infectious complications in areas with a high antibiotic resistance rate .
the aua guideline does not recommend using multiple antibiotics during prostate biopsy . in our study , 21 hospitals ( 38.9% ) used two or more antimicrobial agents during trus - bx .
cephalosporin alone or combined with other antibiotics was used in 19 hospitals ( 35.2% ) , and aminoglycoside alone or combined with other antibiotics was used in 13 hospitals ( 24.1% ) .
only 25 hospitals ( 46.2% ) followed the aua guideline recommending fluoroquinolone alone before and after trus - bx .
no hospitals used alternative antimicrobials ( aminoglycoside with metronidazole or clindamycin ) . regarding the duration of antibiotic treatment , fewer hospitals adhered to aua guidelines .
prophylactic antibiotic use of less than 24 hours was used by only 7.4% of the hospitals in our study , although several studies have suggested that there are no significant benefits of long - term use .
a recent cochrane review revealed that there was no clinically nor statistically significant difference between a short course or a single - dose regimen compared with a longer course .
our study revealed that a quinolone only regimen was the single most common method for prophylaxis , but less than half of hospitals used a quinolone only regimen for prophylaxis .
these results showed that most hospitals did not follow the aua or eau guidelines for various reasons .
first , we could not evaluate the incidence of infectious complications nor the changes in complications after modifying the antibiotic regimen at each hospital because this study was a cross - sectional observational study .
furthermore , we could not assess why the current practice was selected in each hospital . because there are no randomized controlled trials comparing the effectiveness of antibiotics for trus - bx in korean populations , and because current recommendations for antibiotic prophylaxis for trus - bx are derived from studies performed in western countries
, we can assume that the current prophylactic antibiotic regimens are based on clinical experience .
therefore , the results of this study do not mean that other antibiotic regimens are more effective for preventing acute prostatitis after trus - bx than the quinolone - alone regimen .
nonetheless , this is still the first study that has reported the practical use of antibiotics during trus - bx . as such
, the results of this study could be helpful for establishing a health policy in countries with increasing antibiotic resistance .
the aua recommendation was not followed by most hospitals and a combination regimen was used by nearly half of the responding hospitals in korea .
this clinical practice pattern might be a result of the struggle to reduce infective complications after trus - bx in a country where the quinolone resistance rate is high . to justify this empirical use of antibiotics ,
 purposetransrectal ultrasonography - guided prostate biopsy ( trus - bx ) is an essential procedure for diagnosing prostate cancer . 
 the american urological association ( aua ) guideline recommends fluoroquinolone alone for 1 day during trus - bx . 
 however , this recommendation may not be appropriate in regions where the prevalence of quinolone - resistant escherichia coli is high . 
 we investigated the real practice of antibiotic prophylaxis for trus - bx in korea.materials and methodsa total of 77 hospitals performing trus - bx were identified and an e - mail was sent to the urology department of those hospitals . 
 the questions in the e - mail included the choice of antibiotics before and after the procedure and the duration of antibiotic therapy after trus-bx.resultsa total of 54 hospitals ( 70.0% ) responded to the e - mail . before trus - bx , all hospitals administered intravenous antibiotic prophylaxis . 
 the percentage of hospitals that used quinolone , cephalosporin , and aminoglycoside alone was 48.1% , 20.4% , and 9.3% , respectively . 
 the percentage of hospitals that used two or more antibiotics was 22.2% . 
 after biopsy , all 54 hospitals prescribed oral antibiotics . 
 the percentage of hospitals that prescribed quinolone alone , cephalosporin alone , or a combination of two or more antibiotics was 77.8% , 20.4% , and 1.8% , respectively . 
 the duration of antibiotic use was more than 3 days in most hospitals ( 79.6% ) . 
 only four hospitals ( 7.4% ) followed the aua recommendation of a 1-day regimen.conclusionsthe aua recommendation was not followed by most hospitals in korea . 
 this clinical behavior might reflect the high quinolone resistance rate in korea , and further studies on the most efficient prophylactic antibiotics after trus - bx in korea are warranted . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
1. Antibiotics used before prostate biopsy
2. Antibiotics used after prostate biopsy
3. Overall type of antibiotics used around prostate biopsy
DISCUSSION
CONCLUSIONS