Name: Povidone Iodine Rectal Preparation at Time of Prostate Needle Biopsy is a Simple and Reproducible Means to Reduce Risk of Procedural Infection (Video) | JoVE Journal
Uploaded: 2015-09-21T14:00:00.000+00:00
Duration: 5 min 32 s
Description: Learn how to reduce infections after prostate needle biopsy using povidone iodine rectal preparation. This simple technique significantly lowers bacterial counts without requiring tailored antibiotic regimens.

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5 minutes

The authors acknowledge the Carefusion Foundation for support via a clinical excellence grant of this work titled &#8220;Prospective evaluation of procedural povidone iodine rectal preparation to reduce infectious complications following ultrasound guided prostate needle biopsy.&#8221;

This patient related study was approved by the institutional review board (IRB) for human research.
1. Patient Preparation and Positioning
<ol>
	<li>Bring the patient to the procedure suite and place them on their right or left side with knees flexed to the chest.</li>
	<li>Perform a surgical timeout whereby the patient, surgical procedure, and indication are reviewed and confirmed.</li>
	<li>When indicated, administer intravenous sedation via the anesthesia service.</li>
</ol>
2. Perform a Digital Rectal Examination (DRE)
<ol>
	<li>Place size appropriate gloves onto both hands.</li>
	<li>Insert gloved finger after lubrication into rectal vault and examine prostate to feel for potential suspicious areas in need of focused attention during transrectal ultrasonography.10</li>
</ol>
3. Creation of Povidone Iodine Rectal Preparation (PIRP)
<ol>
	<li>Pour 15 ml&#160;of a 10% commercially available povidone iodine solution into a sterile basin.</li>
	<li>Add 5 ml&#160;of a commercially available 1% lidocaine gel to this basin.</li>
	<li>Mix the contents for 15 sec&#160;to create a povidone iodine slurry.</li>
</ol>
4. Primary Administration of PIRP
<ol>
	<li>Use a sterile rectal swab to culture the rectal vault.</li>
	<li>Open up a 4 cm x 4 cm sterile gauze, soak in the povidone iodine slurry, and then insert into the rectal vault. Only a small tail of gauze is left emanating from the anus.</li>
	<li>Leave the gauze in place for 2 min&#160;after which it is removed and discarded.</li>
</ol>
5. Secondary Administration of PIRP
<ol>
	<li>Use a disposable gynecologic swab to paint the perianal area with the PIRP solution.</li>
	<li>Insert this gynecologic swab into the rectal vault to a distance of 3 cm from the anus.</li>
	<li>To further maximize the exposure of the rectal mucosa to PIRP, swab the rectal vault in a similar manner at least three times.</li>
	<li>Allow the povidone iodine solution to dry for 2 - 3 min&#160;prior to proceeding with standard transrectal ultrasonography and subsequent biopsy.11 This is essential as the bactericidal effects of the PIRP require the solution to dry on the exposed mucosa.</li>
	<li>Use a sterile rectal swab to culture the rectal vault.</li>
</ol>
6. Transrectal Ultrasonography and Biopsy
<ol>
	<li>Insert the ultrasound probe via the rectum.</li>
	<li>Perform measurements of the prostate and subsequent biopsy in the standard manner consistent with all urologic practices.11,12</li>
</ol>

<ol><li>American Cancer Society. , Available from: <a target="_blank" href="http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-key-statistics">http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-key-statistics</a> (2015).</li>
<li>Nam, R. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Increasing+hospital+admission+rates+for+complications+after+transrectal+ultrasound+guided+prostate+biopsy%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Increasing hospital admission rates for complications after transrectal ultrasound guided prostate biopsy.</a> J Urol. 189, Suppl 1. S12-S17 (2013).</li>
<li>Feliciano, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+incidence+of+fluoroquinolone+resistant+infections+after+prostate+biopsy+are+fluoroquinolones+still+effective+prophylaxis%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">The incidence of fluoroquinolone resistant infections after prostate biopsy are fluoroquinolones still effective prophylaxis.</a> J Urol. 179 (3), 952-955 (2008).</li>
<li>Kehinde, O., Al-Maghrebi, M., Sheikh, M., Anim, J. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Combined+ciprofloxacin+and+amikacin+prophylaxis+in+the+prevention+of+septicemia+after+transrectal+ultrasound+guided+biopsy+of+the+prostate%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Combined ciprofloxacin and amikacin prophylaxis in the prevention of septicemia after transrectal ultrasound guided biopsy of the prostate.</a> J Urol. 189 (3), 911-915 (2013).</li>
<li>Taylor, A. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Targeted+antimicrobial+prophylaxis+using+rectal+swab+cultures+in+men+undergoing+transrectal+ultrasound+guided+prostate+biopsy+is+associated+with+reduced+incidence+of+postoperative+infectious+complications+and+cost+of+care%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care.</a> J Urol. 187 (4), 1275-1279 (2012).</li>
<li>Gyorfi, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Peri+procedural+povidone+iodine+rectal+preparation+reduces+microorganism+counts+and+infectious+complications+following+ultrasound-guided+needle+biopsy+of+the+prostate%5BTitle%5D)+AND+%22World+J+Urol%22%5BJournal%5D)">Peri procedural povidone iodine rectal preparation reduces microorganism counts and infectious complications following ultrasound-guided needle biopsy of the prostate.</a> World J Urol. 32 (4), 905-909 (2014).</li>
<li>Park, D. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Control+of+infective+complications+of+transrectal+prostate+biopsy%5BTitle%5D)+AND+%22Surg+Infect+Larchmt%22%5BJournal%5D)">Control of infective complications of transrectal prostate biopsy.</a> Surg Infect Larchmt. 15 (4), 431-436 (2014).</li>
<li>Park, D. S., Oh, J. J., Lee, J. H., Jang, W. K., Hong, Y. K., Hong, S. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simple+use+of+the+suppository+type+povidone+iodine+can+prevent+infectious+complications+in+transrectal+ultrasound+guided+prostate+biopsy%5BTitle%5D)+AND+%22Adv+Urol%22%5BJournal%5D)">Simple use of the suppository type povidone iodine can prevent infectious complications in transrectal ultrasound guided prostate biopsy.</a> Adv Urol. , (2009).</li>
<li>AbuGhosh, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+prospective+randomized+trial+of+povidone+iodine+prophylactic+cleansing+of+the+rectum+before+transrectal+ultrasound+guided+prostate+biopsy%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">A prospective randomized trial of povidone iodine prophylactic cleansing of the rectum before transrectal ultrasound guided prostate biopsy.</a> J Urol. 189 (4), 1326-1331 (2013).</li>
<li>Gerber, G. S., Brendler, C. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+the+Urological+Patient%3A+History%2C+Physical+Exam%2C+and+Urinalysis%5BTitle%5D)+AND+%22Campbell+Walsh+Urology%22%5BJournal%5D)">Evaluation of the Urological Patient: History, Physical Exam, and Urinalysis.</a> Campbell Walsh Urology. , 10th ed, Available from: 
 <a target="_blank" href="http://www.campbellsurology.com">http://www.campbellsurology.com</a> (2015).</li>
<li>Hodge, K. K., McNeal, J. E., Terris, M. K., Stamey, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Random+systematic+versus+directed+ultrasound+guided+transrectal+core+biopsies+of+the+prostate%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate.</a> J Urol. 142 (1), 71-74 (1989).</li>
<li>Donoghue, P. M., McSweeney, S. E., Jhaveri, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Genitourinary+imaging%3A+current+and+emerging+applications%5BTitle%5D)+AND+%22J+Postgrad+Med%22%5BJournal%5D)">Genitourinary imaging: current and emerging applications.</a> J Postgrad Med. 56 (2), 131-139 (2010).</li>
</ol>

The authors have nothing to disclose.

Infections following TRUS PNB are secondary to translocation of rectal vault bacteria into the highly vascular prostate. Based on this principle, we have explored the simple method of using a topic antiseptic such as povidone iodine to reduce microorganism colony counts prior to prostate needle biopsy. Our experience highlights a reduction from 4.3% to 0.6% (p=0.02) with use of this PIRP regimen at time of biopsy. Furthermore, we hypothesize that the 97% reduction in rectal vault microorganisms is the principle factor un...

Prostate cancer is the most common cancer in men and the second leading cause of cancer-related mortality. In 2014, approximately 233,000 cases will be diagnosed in the United States with almost 30,000 men succumbing to this malignancy.1 While the prostate specific antigen (PSA) blood test and digital rectal examination (DRE) play an essential role in prostate cancer screening, transrectal ultrasound guided prostate needle biopsy (TRUS PNB) is the most common means to obtain a histologic tissue diagnosis.
TRUS PNB involves inserting an ultrasound probe into the patient&#8217;s rectum and then generally obtaining 12-14 biopsies of the peripheral zone of the prostate located just anteriorly. Each needle biopsy requires passage of an 18 G needle through the rectal wall into the highly vascular prostate. Therefore, the theoretical risk of bleeding and infection due to bacterial translocation exists following the procedure. Nonetheless, the actuarial complication rate post-procedure has historically remained low.
Antibiotic prophylaxis prior to TRUS PNB is routinely prescribed with quinolone-based antibiotics being the most frequently used agents. Despite adequate prophylaxis, contemporary research implicates an increase in infectious complications post-biopsy.2 Furthermore, studies have attributed this rise in infectious complications following TRUS PNB to the emergence of quinolone resistant microorganisms particularly E. coli.3
This rising rate of quinolone resistance suggests the need for alternate prophylaxis regimens for TRUS PNB procedures. To this end, several different avenues are under investigation. One approach involves administration of an intravenous or intramuscular antibiotic at time of biopsy in conjunction with an oral quinolone.4 While this strategy can reduce sepsis events following TRUS PNB, a principal limitation of this approach is the potential for further developing resistant organisms to this antibiotic family. Another recently investigated methodology incorporates use of a pre-biopsy rectal swab to screen patients colonized with quinolone-resistant rectal flora.5 If such organisms are detected, a &#8220;targeted&#8221; antibiotic regimen could be employed based on the sensitivity profile of the identified resistant bacterial strain. While the methodology is elegant, the actual process of obtaining such swabs, selectively culturing on a quinolone selective medium, and tailoring antibiotics thereafter requires a clinical and laboratory infrastructure that may be lacking in many clinical practices.
Administration of a topic antiseptic to reduce rectal vault microorganism colony counts prior to biopsy may present an alternative strategy to limit TRUS PNB infections. Povidone iodone is an inexpensive, readily available agent that is documented to reduced bacterial counts when applied to surgical sites. Applications in both colorectal and gynecologic surgeries are well known. Therefore, use of povidine iodine as a rectal preparation would present a producible, simple, and cost-effective method to reduced TRUS PNB infections without need for additional preparation prior to biopsy. With respect to the urologic literature, previously work has noted a reduction in clinical infections following TRUS PNB.6-9 This video demonstrates the technique of PIRP to highlight the ease and simplicity to integrate into clinical practices.
All patients undergoing TRUS PNB were initially seen in a specialty urology clinic for referral or initial evaluation for prostate cancer screening. This evaluation entailed a review of the patient&#8217;s serum prostate specific antigen (PSA) and performance of a digital rectal examination (DRE). Abnormality of either the PSA or DRE prompted recommendation of a TRUS PNB.
The TRUS PNB procedure was discussed with all patients and associated risks including infection, bleeding, and urinary retention were clarified. All patients received three days of oral antibiotic prophylaxis with either a quinolone-based medication (i.e., Ciprofloxacin) or trimethoprim-sulfamethoxazole (Bactrim) prior to biopsy.

<table><tbody><tr><td>Povidone Iodine Solution, 10% Topical Microbicide Antiseptic, 8 fl oz.</td><td>Equate</td><td>4067979</td><td></td></tr><tr><td>4 x 4 sterile gauze pads, white</td><td>Dukal Corporation</td><td>DKL1412</td><td></td></tr><tr><td>disposable gynecologic swab&amp;nbsp;</td><td>numerous vendors</td><td></td><td></td></tr><tr><td>1% lidocaine gel&amp;nbsp;</td><td>numerous vendors</td><td></td><td></td></tr></tbody></table>

povidone iodine rectal preparation at time of prostate needle biopsy is a simple and reproducible means to reduce risk of procedural infection

Povidone Iodine Rectal Preparation at Time of Prostate Needle Biopsy is a Simple and Reproducible Means to Reduce Risk of Procedural Infection

Single institution and population-based studies highlight that infectious complications following transrectal ultrasound guided prostate needle biopsy (TRUS PNB) are increasing. Such infections are largely attributable to quinolone resistant microorganisms which colonize the rectal vault and are translocated into the bloodstream during the biopsy procedure. A povidone iodine rectal preparation (PIRP) at time of biopsy is a simple, reproducible method to reduce rectal microorganism colony counts and therefore resultant infections following TRUS PNB.
All patients are administered three days of oral antibiotic therapy prior to biopsy. The PIRP technique involves initially positioning the patient in the standard manner for a TRUS PNB. Following digital rectal examination, 15 ml&#160;of a 10% solution of commercially available povidone iodine is mixed with 5 ml&#160;of 1% lidocaine jelly to create slurry. A 4 cm x 4 cm sterile gauze is soaked in this slurry and then inserted into the rectal vault for 2 min after which it is removed. Thereafter, a disposable cotton gynecologic swab is used to paint both the perianal area and the rectal vault to a distance of 3 cm from the anus. The povidone iodine solution is then allowed to dry for 2 - 3 min prior to proceeding with standard transrectal ultrasonography and subsequent biopsy.
This PIRP technique has been in practice at our institution since March of 2012 with an associated reduction of post-biopsy infections from 4.3% to 0.6% (p = 0.02). The principal advantage of this prophylaxis regimen is its simplicity and reproducibility with use of an easily available, inexpensive agent to reduce infections. Furthermore, the technique avoids exposing patients to additional systemic antibiotics with potential further propagation of multi-drug resistant organisms. Usage of PIRP at TRUS PNB, however, is not applicable for patients with iodine or shellfish allergies.

This PIRP technique has been in practice since January of 2012 (until present) with 165 patients having been enrolled in this quality improvement measure. In this time, only one patient (0.6%) has experienced an infectious complication in the form of systemic sepsis. This patient was colonized with a multi-drug resistant E. coli strain. Rectal swabs following administration of PIRP in this patient noted that the rectal vault was still colonized with 2.1 x 105 CFU/ml bacteria thereby questioning whethe...

Here, we present a protocol for use at the time of transrectal ultrasound guided prostate needle biopsy (TRUS PNB) that is a simple and cost-effective means to reduce infections following the procedure.

Single institution and population-based studies highlight that infectious complications following transrectal ultrasound guided prostate needle biopsy ...

The overall goal of this procedure is to reduce infectious complications following prostate needle biopsy by pretreating the rectal vault and perianal area using a povidone iodine slurry. Ultimately, microbial culture data from the rectal vault and monitoring of clinical infections demonstrates that the preparation reduces bacterial counts and infections following prostate biopsy. We first came up with the idea for this method based upon observations that infectious complications following prostate needle biopsy we're increasing despite patients taking adequate antibiotic prophylaxis.The main advantage of our technique versus other methods, such as targeted antibiotic prophylaxis, is that our method can be used in every biopsy patient without the need of culture processes and adjustment of antibiotic regimens. To prepare the patient, ask him to lie down on the examination table on his side with his knees flexed to his chest before proceeding. Take a moment to review the documentation on the patient, the procedure, and the indication once everything is confirmed.If the patient has elected for anesthesia, proceed by having the anesthesia service. Give the patient an intravenous injection of sedative. Next, prepare for the examination by putting on examination gloves.Now lubricate the rectal vault and perform a rectal examination to investigate the areas of the prostate, which will be focused on by the trans rectal ultrasonography. To make the working povidone iodine solution first, pour 15 milliliters of stock, 10%povidone iodine solution into a sterile container. Then add five milliliters of 1%lidocaine gel to this basin, and mix them together with a cotton applicator for 15 seconds to create a slurry, thus completing the PIRP.Next, open up a four centimeter square sterile gauze and soak it in the povidone iodine slurry. Then insert the gauze into the rectal vault. Only a small tail of gauze should be left emanating from the anus.After two minutes, remove and discard the gauze. Next, use a disposable gynecologic swab to paint the perianal area with A-P-I-R-P solution. Once finished, dispose of this swab, then soak a fresh gynecologic swab in the povidone iodine slurry and insert it into the rectal vault approximately three centimeters into the anus.Paint the anterior rectal wall with this swab. An essential component of this operation is painting the anterior rectal vault with the povidone iodine preparation, because this is the mucosal surface that's penetrated by the needle biopsy probe. To maximize the exposure of the rectal mucosa to the PIRP, repeat this process at least three times.Keep using the same swab to paint the back wall of the rectal vault repeatedly. Very importantly, proceed with letting the PIRP solution dry for two to three minutes so its spec to recital effects, can have their full effect. Then proceed with the standard TRANSRECTAL ultra sonography and biopsy.This PIRP technique has been in practice since January of 2012 on 165 patients. Thus far, only one patient has experienced an infectious complication in the form of systemic sepsis. A patient population undergoing T-R-U-S-P-M-B, which only received oral antibiotic therapy serves as a control population.22 of the 515 patients in this cohort experienced an infection. 17 of the infections were in the urinary tract, and five experienced clinical sepsis defined by a fever with a positive blood culture.Overall. Integration of the PIRP technique into clinical practice was associated with a significant reduction in post biopsy infections.Rectal cultures were performed in the 165 patients before and after PIRP to document changes in rectal vault microorganism colony count attributable to the treatment overall, a very significant 97.2%reduction in microorganism colonies was noted after PIRP administration. After watching this video, you should have a good understanding of the optimal means to prepare the rectal vault with the povidone iodine preparation prior to biopsy. Don't forget that povidone iodine can elicit an allergic reaction in patients with shellfish or iodine allergies, and should be avoided in use in these patients.

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Learn how to reduce infections after prostate needle biopsy using povidone iodine rectal preparation. This simple technique significantly lowers bacterial counts without requiring tailored antibiotic regimens.

Povidone Iodine Rectal Preparation at Time of Prostate Needle Biopsy is a Simple and Reproducible Means to Reduce Risk of Procedural Infection (Video) | JoVE Journal

Povidone Iodine Rectal Preparation at Time of Prostate Needle Biopsy is a Simple and Reproducible Means to Reduce Risk of Procedural Infection

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