Infectious complications after transrectal ultrasound-guided prostate biopsy remain a significant clinical concern amid rising antibiotic resistance. Recent clinical investigations, including a 209-patient retrospective study and prospective data covering 544 patients, evaluate alternative prophylactic regimens such as ertapenem, amikacin, and fosfomycin trometamol to reduce post-biopsy infections safely and effectively.
Prostate cancer stands as the second most commonly diagnosed cancer among men worldwide and holds the position of the most common cancer in males in Lebanon, accounting for 16.4 percent of all diagnosed male cancers, according to research published in Cureus. Early detection strategies have evolved substantially over time. While digital rectal examination served as the primary clinical tool historically, the widespread adoption of prostate-specific antigen testing has dramatically increased early-stage detection rates.
Additional diagnostic investigations are typically triggered when serum PSA levels reach or exceed 4 ng/mL, with patients showing PSA levels between 4 and 10 ng/mL facing an estimated prostate cancer detection risk of 20 to 30 percent. Despite these screening advances, prostate biopsy remains the gold standard for a definitive diagnosis. Over the decades, techniques have progressed from finger-guided transrectal procedures to transrectal ultrasound-guided biopsy, which provides enhanced anatomical guidance and accuracy.
Infectious Risks and the Decline of Fluoroquinolone Efficacy
Transrectal ultrasound-guided prostate biopsy is widely performed globally, yet the procedure carries an inherent infectious complication rate of approximately 3 percent, with potential risks extending to life-threatening sepsis. To mitigate these risks, antibiotic prophylaxis is an essential component of patient management prior to the procedure. Historically, fluoroquinolones served as the standard prophylactic agents due to their proven effectiveness in suppressing post-biopsy infections.
However, escalating microbial resistance has severely diminished their efficacy. This resistance surge has forced clinicians to investigate alternative prophylactic approaches, such as fosfomycin trometamol and single-dose intramuscular regimens, to protect patients undergoing transrectal ultrasound-guided procedures.
Comparative Findings From Recent Prophylaxis Studies
Recent clinical evaluations provide concrete data on alternative regimens designed to circumvent fluoroquinolone resistance. A retrospective observational study conducted across two hospitals in Lebanon between January 2015 and June 2025 encompassed 209 patients with an average age of 66.7 years and a mean prostate-specific antigen level of 18.2 ng/mL. The findings revealed an overall post-biopsy infection rate of 12.9 percent.
Patients who received a single dose of intramuscular ertapenem, administered either alone or combined with fluoroquinolones, experienced zero infections. Meanwhile, the infection rate for patients receiving a single dose of intramuscular amikacin stood at 3.8 percent, contrasted against a 26 percent infection rate for those treated with fluoroquinolone monotherapy. Statistical analysis demonstrated that single-dose intramuscular ertapenem or amikacin was linked to a lower risk of infection than fluoroquinolone-based prophylaxis.
In a separate prospective randomized study evaluating short-term prophylactic regimens between January 2021 and December 2022, researchers assessed 544 patients who met inclusion criteria out of 605 performed biopsies. Patients were divided into three prophylactic groups: fosfomycin trometamol combined with ciprofloxacin, a two-dose fosfomycin trometamol regimen, and a short-term ciprofloxacin schedule. Infectious complications emerged in just 10 cases, representing 1.83 percent of the cohort, with no statistically significant differences between the individual patient groups. None of those patients required hospitalization, and all remained free of sepsis symptoms.
Clinical Preparation Protocols and Patient Management
Urological centers implement pre-procedural protocols to safeguard patients. Guidance from Dr. Rose Private Hospital outlines patient preparation, which includes dietary restrictions the evening before the biopsy, the application of Betadine rectal suppositories, and the administration of prescribed antibiotics. Following the procedure, patients typically leave the hospital within four to five hours, maintain adequate fluid intake, and avoid physical exertion for a four-week period while continuing necessary antibiotic therapy.
While temporary urinary symptoms such as irritative complaints, frequent urination urge, or urinary retention can occur alongside blood in the urine or semen, these effects generally resolve spontaneously within days or weeks. Inflammatory complications like urinary tract infections or prostatitis remain less common, and hospital-acquired infections or deep vein thrombosis are characterized as extremely rare when correct clinical protocols are strictly followed.
