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Clinical Microbiology and Infection :... Jan 2023Bacterial prostatitis is a highly prevalent infection responsible for significant morbidity among men. The diagnosis and treatment for bacterial prostatitis remains... (Review)
Review
BACKGROUND
Bacterial prostatitis is a highly prevalent infection responsible for significant morbidity among men. The diagnosis and treatment for bacterial prostatitis remains complicated. The difficulty in diagnosis is in part owing to the paucity of high-quality evidence that guides a clinician's interpretation of patients' history, physical examination, and laboratory findings. Treatment is challenging because of the few antimicrobials capable of prostate penetration, growing antimicrobial resistance limiting effective treatment options, and the high risk of recurrence.
OBJECTIVES
We aimed to provide a useful resource for clinicians in effectively diagnosing and managing acute bacterial prostatitis (ABP) and chronic bacterial prostatitis (CBP).
SOURCES
A PubMed literature search on prostatitis was performed with no restrictions on publication date.
CONTENT
The epidemiology, pathophysiology, diagnosis, and treatment for ABP and CBP are explored using a clinical vignette as relevant context.
IMPLICATIONS
Bacterial prostatitis can be diagnosed through a focused history and microbiological investigations. The Meares-Stamey 4-glass test or modified 2-glass test can help confirm the diagnosis if uncertainty exists. Typical uropathogens are common contributors to bacterial prostatitis but there is growing interest in exploring the role atypical and traditional non-pathogenic organisms may have. Fluoroquinolones remain first-line therapy, followed by trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline if the pathogen is susceptible. Fosfomycin has emerged as a repurposed and useful agent because of the increasing incidence of multidrug-resistant pathogens. Selection of appropriate antimicrobial regimens can be challenging and is dependent on the host, chronicity of symptoms, uropathogens' susceptibilities, antimicrobials' side effect profile, and the presence of prostatic abscesses or calcifications. ABP can typically be treated similar to other complicated urinary tract infections. However, CBP requires prolonged therapy, with a minimum of 4 weeks and up to 12 weeks of therapy.
Topics: Male; Humans; Prostatitis; Anti-Bacterial Agents; Chronic Disease; Bacterial Infections; Anti-Infective Agents
PubMed: 35709903
DOI: 10.1016/j.cmi.2022.05.035 -
Current Urology Reports Jun 2020We conducted a review of the literature describing the most up-to-date diagnosis and treatment options of chronic bacterial prostatitis. (Review)
Review
PURPOSE OF REVIEW
We conducted a review of the literature describing the most up-to-date diagnosis and treatment options of chronic bacterial prostatitis.
RECENT FINDINGS
Recurrence after oral antimicrobial therapy is common, due in part to the rising rates of antimicrobial resistance and inability to completely clear the offending bacteria from the prostate following prostatitis. Recent literature has described various treatment options for chronic bacterial prostatitis refractory to conventional antimicrobial agents, including the use of alternative agents such as fosfomycin, direct antimicrobial injections into the prostate, surgical removal of infected prostatic tissue, chronic oral antibiotic suppression, and an emerging novel therapy utilizing bacteriophages to target antibiotic resistant bacteria. Management of chronic bacterial prostatitis, especially recurrence after oral antimicrobial treatment, remains challenging. This review highlights an urgent need for further evidence assessing the efficacy and safety of treatment modalities for chronic bacterial prostatitis refractory to conventional oral antimicrobials.
Topics: Anti-Bacterial Agents; Bacterial Infections; Bacteriophages; Chronic Disease; Drug Resistance, Bacterial; Humans; Male; Prostatectomy; Prostatitis; Recurrence
PubMed: 32488742
DOI: 10.1007/s11934-020-00978-z -
Progres En Urologie : Journal de... Nov 2022The objective of the French Urology Association Cancer Committee is to propose an update of the recommendations for the diagnosis and management of prostate cancer (PC). (Review)
Review
OBJECTIVE
The objective of the French Urology Association Cancer Committee is to propose an update of the recommendations for the diagnosis and management of prostate cancer (PC).
METHODS
A systematic review of the literature from 2020 to 2022 was conducted by the CCAFU on the diagnosis and therapeutic management of localised PC, while evaluating the references and their levels of evidence.
RESULTS
The recommendations specify the genetics, epidemiology and means of diagnosing prostate cancer, as well as the notions of screening and early detection. MRI, the gold standard imaging examination for localised cancer, is recommended before prostate biopsies are performed. The transperineal approach reduces the risks of infection. The therapeutic methods are described and recommended according to the clinical context. Active surveillance is the gold standard of treatment for tumours with a low risk for progression. Early salvage radiotherapy is recommended in case of biochemical recurrence after radical prostatectomy. Imaging, particularly molecular imaging, helps to guide the decision-making in the event of biochemical recurrence after local treatment, but should not delay early salvage radiotherapy in the event of biological recurrence after radical prostatectomy.
CONCLUSION
This update of the French recommendations should help to improve the management of patients with PC.
Topics: Humans; Male; Prostate; Prostatic Neoplasms; Prostatectomy; Prostate-Specific Antigen; Magnetic Resonance Imaging
PubMed: 36400483
DOI: 10.1016/j.purol.2022.07.148 -
International Journal of Antimicrobial... Oct 2020There has been growing interest in fosfomycin for the treatment of bacterial prostatitis due to evidence suggesting that it achieves adequate prostatic concentrations... (Review)
Review
There has been growing interest in fosfomycin for the treatment of bacterial prostatitis due to evidence suggesting that it achieves adequate prostatic concentrations for antimicrobial effect, has activity against resistant micro-organisms, and has a low-toxicity profile. This review evaluated the current clinical evidence for fosfomycin in acute and chronic bacterial prostatitis to elucidate the clinical implications of fosfomycin in an era of increasing antimicrobial resistance. PubMed, Scopus, EMBASE, Web of Science, Google Scholar and ClinicalTrials.gov were searched for studies published in the English language from January 1984 to November 2019. The inclusion criteria were met if the study reported the use of fosfomycin (more than one dose) to treat bacterial prostatitis. Ten observational studies were identified that met the inclusion criteria. The evidence for the use of fosfomycin in acute bacterial prostatitis is sparse. The majority of the available evidence is for chronic bacterial prostatitis caused by Escherichia coli. Despite the implementation of variable dosing regimens, extended courses of fosfomycin appear to be safe and effective in achieving clinical and microbiological cure. In these studies, the use of fosfomycin was restricted to cases of treatment failure, intolerance to first-line therapy, or multi-resistant organisms. However, given the development of resistant organisms and the undesirable adverse effects of many first-line therapeutic options, fosfomycin has the potential to be considered as an effective first-line alternative for acute and chronic bacterial prostatitis in the future. Further studies, including randomized controlled trials, would be helpful to firmly establish its optimal dosing regimen, efficacy and place in therapy.
Topics: Anti-Bacterial Agents; Antimicrobial Stewardship; Bacterial Infections; Enterobacteriaceae; Enterococcus faecium; Escherichia coli; Fosfomycin; Humans; Male; Prostate; Prostatitis; Pseudomonas aeruginosa; Treatment Outcome
PubMed: 32721595
DOI: 10.1016/j.ijantimicag.2020.106106 -
BMJ Open Nov 2022Our objective was to compare prostate cancer detection rates between patients undergoing serum prostate-specific antigen (PSA) vs magnetic resonance imaging (MRI) for... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
Our objective was to compare prostate cancer detection rates between patients undergoing serum prostate-specific antigen (PSA) vs magnetic resonance imaging (MRI) for prostate cancer screening.
DESIGN
Phase III open-label randomised controlled trial.
SETTING
Single tertiary cancer centre in Toronto, Canada.
PARTICIPANTS
Men 50 years of age and older with no history of PSA screening for ≥3 years, a negative digital rectal exam and no prior prostate biopsy.
INTERVENTIONS
Patients were recommended to undergo a prostate biopsy if their PSA was ≥2.6 ng/mL (PSA arm) or if they had a PIRADS score of 4 or 5 (MRI arm). Patients underwent an end-of-study PSA in the MRI arm.
PRIMARY AND SECONDARY OUTCOME MEASURES
Adenocarcinoma on prostate biopsy. Prostate biopsy rates and the presence of clinically significant prostate cancer were also compared.
RESULTS
A total of 525 patients were randomised, with 266 in the PSA arm and 248 in the MRI arm. Due to challenges with accrual and study execution during the COVID-19 pandemic, the study was terminated early. In the PSA arm, 48 patients had an abnormal PSA and 28 (58%) agreed to undergo a prostate biopsy. In the MRI arm, 25 patients had a PIRADS score of 4 or 5 and 24 (96%) agreed to undergo a biopsy. The relative risk for MRI to recommend a prostate biopsy was 0.52 (95% CI 0.33 to 0.82, p=0.005), compared with PSA. The cancer detection rate for patients in the PSA arm was 29% (8 of 28) vs 63% (15 of 24, p=0.019) in the MRI arm, with a higher proportion of clinically significant cancer detected in the MRI arm (73% vs 50%). The relative risk for detecting cancer and clinically significant with MRI compared with PSA was 1.89 (95% CI 0.82 to 4.38, p=0.14) and 2.77 (95% CI 0.89 to 8.59, p=0.07), respectively.
CONCLUSIONS
Prostate MRI as a stand-alone screening test reduced the rate of prostate biopsy. The number of clinically significant cancers detected was higher in the MRI arm, but this did not reach statistical significance. Due to early termination, the study was underpowered. More patients were willing to follow recommendations for prostate biopsy based on MRI results.
TRIAL REGISTRATION NUMBER
NCT02799303.
Topics: Male; Humans; Prostatic Neoplasms; Prostate-Specific Antigen; Prostate; Early Detection of Cancer; Pandemics; COVID-19; Magnetic Resonance Imaging
PubMed: 36351725
DOI: 10.1136/bmjopen-2021-059482 -
Topics in Magnetic Resonance Imaging :... Feb 2020Magnetic resonance imaging (MRI) has been increasingly used in the detection, localization, and staging of prostate cancer. Because of its excellent soft tissue contrast... (Review)
Review
Magnetic resonance imaging (MRI) has been increasingly used in the detection, localization, and staging of prostate cancer. Because of its excellent soft tissue contrast and multiplane imaging, it can be also very useful in the evaluation of benign prostate diseases. Prostatic benign disorders have a high prevalence, vastly represented by benign prostatic hyperplasia and prostatitis. On the contrary, benign prostatic neoplasms are extremely rare, represented by multilocular cystadenoma, leiomyomas, hemangioma, and granular cell tumor, although these uncommon tumors have been most encountered due to widespread use of MRI. Congenital prostatic anomalies are associated with defects in the development of the prostate embryology, including hypoplasia, ectopia, and vascular malformations, abnormalities rarely seen on cross-sectional imaging. Prostatic cysts are the most common development abnormalities and occasionally are related to clinical symptoms, mainly due to infection and hemorrhage. As with prostate cancer, multiparametric MRI is a reliable tool for the diagnosis and management of benign prostatic diseases as well, providing additional information such morphological changes of the prostate, more accurate prostatic measurements, and functional characteristics of nonmalignant prostatic lesions. In this review, we discuss MRI findings of these benign prostatic diseases.
Topics: Humans; Magnetic Resonance Imaging; Male; Prostate; Prostatic Diseases
PubMed: 32015291
DOI: 10.1097/RMR.0000000000000227 -
The Lancet. Oncology Sep 2021Screening for prostate cancer using prostate-specific antigen (PSA) reduces prostate cancer mortality but can lead to adverse outcomes. We aimed to compare a traditional...
Prostate cancer screening using a combination of risk-prediction, MRI, and targeted prostate biopsies (STHLM3-MRI): a prospective, population-based, randomised, open-label, non-inferiority trial.
BACKGROUND
Screening for prostate cancer using prostate-specific antigen (PSA) reduces prostate cancer mortality but can lead to adverse outcomes. We aimed to compare a traditional screening approach with a diagnostic strategy of blood-based risk prediction combined with MRI-targeted biopsies.
METHODS
We did a prospective, population-based, randomised, open-label, non-inferiority trial (STHLM3-MRI) in Stockholm county, Sweden. Men aged 50-74 years were randomly selected by Statistics Sweden and invited by mail to participate in screening; those with an elevated risk of prostate cancer, defined as either a PSA of 3 ng/mL or higher or a Stockholm3 score of 0·11 or higher were eligible for randomisation. Men with a previous prostate cancer diagnosis, who had undergone a prostate biopsy within 60 days before the invitation to participate, with a contraindication for MRI, or with severe illness were excluded. Eligible participants were randomly assigned (2:3) using computer-generated blocks of five, stratified by clinically significant prostate cancer risk, to receive either systematic prostate biopsies (standard group) or biparametric MRI followed by MRI-targeted and systematic biopsy in MRI-positive participants (experimental group). The primary outcome was the detection of clinically significant prostate cancer at prostate biopsy, defined as a Gleason score of 3 + 4 or higher. We used a margin of 0·78 to assess non-inferiority for the primary outcome. Key secondary outcome measures included the proportion of men with clinically insignificant prostate cancer (defined as a Gleason score of 3 + 3), and the number of any prostate MRI and biopsy procedures done. We did two comparisons: Stockholm3 (using scores of 0·11 and 0·15 as cutoffs) versus PSA in the experimental group (paired analyses) and PSA plus standard biopsy versus Stockholm3 plus MRI-targeted and systematic biopsy (unpaired, randomised analyses). All analyses were intention to treat. This study is registered with ClinicalTrials.gov, NCT03377881.
FINDINGS
Between Feb 5, 2018, and March 4, 2020, 49 118 men were invited to participate, of whom 12 750 were enrolled and provided blood specimens, and 2293 with elevated risk were randomly assigned to the experimental group (n=1372) or the standard group (n=921). The area under the receiver-operating characteristic curve for detection of clinically significant prostate cancer was 0·76 (95% CI 0·72-0·80) for Stockholm3 and 0·60 (0·54-0·65) for PSA. In the experimental group, a Stockholm3 of 0·11 or higher was non-inferior to a PSA of 3 ng/mL or higher for detection of clinically significant prostate cancer (227 vs 192; relative proportion [RP] 1·18 [95% CI 1·09-1·28], p<0·0001 for non-inferiority), and also detected a similar number of low-grade prostate cancers (50 vs 41; 1·22 [0·96-1·55], p=0·053 for superiority) and was associated with more MRIs and biopsies. Compared with PSA of 3 ng/mL or higher, a Stockholm3 of 0·15 or higher provided identical sensitivity to detect clinically significant cancer, and led to fewer MRI procedures (545 vs 846; 0·64 [0·55-0·82]) and fewer biopsy procedures (311 vs 338; 0·92 (0·86-1·03). Compared with screening using PSA and systematic biopsies, a Stockholm3 of 0·11 or higher combined with MRI-targeted and systematic biopsies was associated with higher detection of clinically significant cancers (227 [3·0%] men tested vs 106 [2·1%] men tested; RP 1·44 [95% CI 1·15-1·81]), lower detection of low-grade cancers (50 [0·7%] vs 73 [1·4%]; 0·46 [0·32-0·66]), and led to fewer biopsy procedures. Patients randomly assigned to the experimental group had a lower incidence of prescription of antibiotics for infection (25 [1·8%] of 1372 vs 41 [4·4%] of 921; p=0·0002) and a lower incidence of admission to hospital (16 [1·2%] vs 31 [3·4%]; p=0·0003) than those in the standard group.
INTERPRETATION
The Stockholm3 test can inform risk stratification before MRI and targeted biopsies in prostate cancer screening. Combining the Stockholm3 test with an MRI-targeted biopsy approach for prostate cancer screening decreases overdetection while maintaining the ability to detect clinically significant cancer.
FUNDING
The Swedish Cancer Society, the Swedish Research Council, and Stockholm City Council.
Topics: Aged; Biomarkers, Tumor; Early Detection of Cancer; Humans; Image-Guided Biopsy; Intention to Treat Analysis; Magnetic Resonance Imaging; Male; Middle Aged; Neoplasm Grading; Prospective Studies; Prostate; Prostate-Specific Antigen; Prostatic Neoplasms; ROC Curve; Random Allocation; Risk Assessment; Sweden
PubMed: 34391509
DOI: 10.1016/S1470-2045(21)00348-X -
Australian Veterinary Journal Jun 2022To describe clinical signs, diagnostics, treatments and outcomes of prostatitis and prostatic abscesses of dogs in a referral population.
OBJECTIVES
To describe clinical signs, diagnostics, treatments and outcomes of prostatitis and prostatic abscesses of dogs in a referral population.
ANIMALS
Eighty-two dogs diagnosed with prostatitis and/or prostatic abscesses from three referral hospitals.
PROCEDURES
Retrospective case series.
RESULTS
A total of 82 dogs were included, and the median age was nine years. Acute prostatitis was diagnosed in 63% of cases, chronic prostatitis in 37% of cases and 40% of cases had prostatic abscessation. Prostatomegaly was the most common ultrasonographic finding. Mineralisation was identified in 20% of cases. The results of urine and prostatic bacterial culture were concordant in only 50% of cases. Antimicrobial resistance was encountered commonly, with 29% of cultures resistant to one antimicrobial and 52% resistant to two or more antimicrobials. Abscesses were treated with either antimicrobials alone, ultrasound-guided needle drainage or surgical drainage.
CONCLUSIONS AND CLINICAL RELEVANCE
With antimicrobial treatment and castration, the prognosis for canine prostatitis appears good. Prostatic abscessation is commonly encountered and does not appear to infer a worse prognosis and antimicrobials alone, ultrasound-guided needle drainage and surgical drainage all appear to be reasonable treatment options. Antimicrobial resistance is commonly encountered, and the results of urine culture and susceptibility testing are frequently discordant with those from samples from the prostate. Sampling of the prostate is required to confirm a diagnosis and exclude other pathologies such as neoplasia, particularly as mineralisation is seen in a reasonable number of cases of dogs with prostatitis.
Topics: Abscess; Animals; Anti-Bacterial Agents; Anti-Infective Agents; Dog Diseases; Dogs; Male; Orchiectomy; Prostatitis; Retrospective Studies
PubMed: 35176814
DOI: 10.1111/avj.13150 -
Drugs Mar 2022Urinary tract infections, including cystitis, acute pyelonephritis, and prostatitis, are among the most common diagnoses prompting antibiotic prescribing. The rise in... (Review)
Review
Urinary tract infections, including cystitis, acute pyelonephritis, and prostatitis, are among the most common diagnoses prompting antibiotic prescribing. The rise in antimicrobial resistance over the past decades has led to the increasing challenge of urinary tract infections because of multidrug-resistant and "difficult-to-treat resistance" among Gram-negative bacteria. Recent advances in pharmacotherapy and medical microbiology are modernizing how these urinary tract infections are treated. Advances in pharmacotherapy have included not only the development and approval of novel antibiotics, such as ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam, ceftolozane/tazobactam, cefiderocol, plazomicin, and glycylcyclines, but also the re-examination of the potential role of legacy antibiotics, including older aminoglycosides and tetracyclines. Recent advances in medical microbiology allow phenotypic and molecular mechanism of resistance testing, and thus antibiotic prescribing can be tailored to the mechanism of resistance in the infecting pathogen. Here, we provide a narrative review on the clinical and pre-clinical studies of drugs that can be used for difficult-to-treat resistant Gram-negative bacteria, with a particular focus on data relevant to the urinary tract. We also offer a pragmatic framework for antibiotic selection when encountering urinary tract infections due to difficult-to-treat resistant Gram-negative bacteria based on the organism and its mechanism of resistance.
Topics: Anti-Bacterial Agents; Cystitis; Drug Resistance, Multiple, Bacterial; Gram-Negative Bacteria; Gram-Negative Bacterial Infections; Humans; Male; Prostatitis; Pyelonephritis
PubMed: 35286622
DOI: 10.1007/s40265-022-01676-5 -
The Journal of Urology Feb 2024Transrectal prostate biopsy has come under scrutiny due to potential for postbiopsy infections and transperineal prostate biopsy is being offered as the safer... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Transrectal prostate biopsy has come under scrutiny due to potential for postbiopsy infections and transperineal prostate biopsy is being offered as the safer alternative. However, there is a lack of randomized comparative studies. Our goal was to directly evaluate infectious and noninfectious complications following the 2 biopsy procedures.
MATERIALS AND METHODS
We conducted a prospective, pragmatic, randomized clinical study in men undergoing prostate biopsy. The participants underwent either transrectal or transperineal prostate biopsy in the office under local anesthesia. The primary outcome was a 30-day composite infectious complication rate, comprising of 1 or more components including fever, genitourinary infection, antibiotic prescriptions, office or emergency visits, hospitalization, or sepsis. Secondary outcomes included 30-day composite noninfectious complications (urinary or hemorrhagic).
RESULTS
Of the 763 randomized participants, 718 underwent either transrectal (351) or transperineal (367) prostate biopsy. A composite infectious complication event occurred in 9 participants (2.6%) in the transrectal and 10 participants (2.7%) in the transperineal group (odds ratio, 1.06; 95% CI, 0.43 to 2.65; = .99). None of the participants developed sepsis in either group. There were no between-group differences in any of the individual component infectious events. A composite noninfectious complication occurred in 6 (1.7%) and 8 (2.2%) participants in the transrectal and transperineal groups, respectively (odds ratio, 1.28; 95% CI, 0.44 to 3.73; = .79). No participants required hospitalization or other interventions.
CONCLUSIONS
Among men undergoing transperineal or transrectal prostate biopsy, we could not demonstrate any difference in the infectious or noninfectious complications. Both biopsy approaches remain clinically viable and safe.
Topics: Humans; Male; Biopsy; Image-Guided Biopsy; Prospective Studies; Prostate; Prostatic Neoplasms; Rectum; Sepsis
PubMed: 37976319
DOI: 10.1097/JU.0000000000003788