Fosfomycin vs. quinolone-based antibiotic prophylaxis for transrectal ultrasound-guided biopsy of the prostate: A systematic review and meta-analysis

Background: Infection-related complications secondary to quinolone resistance have been on the rise following transrectal ultrasound-guided biopsy of the prostate (TRUSBP). The aim of this review was to compare the efficacy of fosfomycin with quinolone-based antibiotic prophylaxis for TRUSBP. Methods: A systematic review in line with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and Cochrane guidelines was conducted. All studies comparing fosfomycin vs. non-fosfomycin antimicrobial prophylaxis for TRUSBP were considered. The main outcomes were number of urinary tract infections (UTIs) (overall, afebrile, febrile, and urosepsis) and fluoroqinolone resistance. Secondary outcomes were positive urine and blood cultures, and adverse effects of drugs. Results: Five studies comparing fosfomycin and non-fosfomycin antimicrobials were included in the review. In all, 1447 and 1665 patients were included in the fosfomycin and non-fosfomycin cohorts, respectively. The systematic review report significantly lower UTIs in the fosfomycin cohort (M-H, Fixed, 95% CI), 0.20 (0.13, 0.30), p < 0.00001. Urine cultures from patients given fosfomycin showed significantly lower resistance rates (M-H, Fixed, 95% CI) 0.27 (0.15, 0.50), p < 0.0001. The adverse effect profile between the two cohorts were similar (M-H, Fixed, 95% CI) 1.13 (0.51, 2.50), p = 0.33. On Grade Pro evaluation, overall UTI, afebrile UTI, febrile UTI, and urosepsis were rates as moderate, low, very low, and moderate quality evidence, respectively. Positive blood and urine culture were rated as moderate and very low-quality evidence, respectively. Fluoroquinolone resistance was rated as low-quality evidence. Adverse effects was rated as very low-quality evidence. Conclusions: This review suggests that fosfomycin has significantly lower septic complications with an equivalent side effect profile in comparison with quinolone-based prophylaxis regimen for TRUSBP. There is an urgent need for appropriate antibiotic stewardship and it is paramount that studies with robust methodology are developed to establish the role of fosfomycin over existing antibiotic regimens for TRUSBP.