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  • How to find biopsy without fluoroquinolones

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    Old 02-10-2019, 08:39 AM   #1
    ymot
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    How to find biopsy without fluoroquinolones

    I need to have a prostate biopsy, basic TRUS PNB, but I don't want any fluoroquinolones (e.g., Ciprofloxacin) administered for antibacterial prophylaxis. In recent years, those drugs have acquired enough FDA boxed warnings that they should be used only when there are no alternatives. And they are anyhow increasingly less effective. Other options for AB prophylaxis are coming into use, like the cephalosporins.

    The urology practice within my health group uses Ciprofloxacin. And worse yet, they prescribe a four-day course when current literature says a single pre-operative administration should suffice.

    How should I approach finding a practice that doesn't use fluoroquinolones?

    Do you think practices would respond to a phone or email query? I don't want to start making appointments with different urologists just to pose this question.

    Thanks so much! - Tom

    Last edited by ymot; 02-15-2019 at 12:12 PM. Reason: Edited to change "10-day course" to "four-day"

     
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    Old 02-10-2019, 09:56 AM   #2
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    Re: How to find biopsy without fluoroquinolones

    Have you asked about other options? Like what do they use for someone who is allergic to cipro?They do have an alternative.

     
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    Old 02-10-2019, 10:01 AM   #3
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    Re: How to find biopsy without fluoroquinolones

    Quote:
    Originally Posted by Titchou View Post
    Have you asked about other options?
    I'm afraid they were quite definitive about not altering their protocol.

    Thanks! - Tom

     
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    Old 02-10-2019, 12:12 PM   #4
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    Re: How to find biopsy without fluoroquinolones

    So they send you to someone else if you are allergic to cipro...good,ask them who that is.

     
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    Old 02-10-2019, 12:37 PM   #5
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    Re: How to find biopsy without fluoroquinolones

    Great idea! I'll give it a try, though they were pretty dismissive of my concerns and simply said I could go elsewhere because it was "just" a biopsy.

    Thanks again. - Tom

     
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    Old 02-10-2019, 05:34 PM   #6
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    Re: How to find biopsy without fluoroquinolones

    I'm allergic to so many antibiotics my doctors won't give me any. So any time I have a surgery or procedure, I have to go thru this issue with the provider/surgeon. I've even had to show the picture of my arm when I had the penicillin allergy challenge to convince one that I am REALLY allergic to it and any derivatives. No, my allergy to it isn't a rash -it's anaphalaxis. They can be stubborn.

    And if it is "just a biopsy", then why are they so intractable? Should be simple to switch to another.

     
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    Old 02-10-2019, 06:40 PM   #7
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    Re: How to find biopsy without fluoroquinolones

    I'll see what the urologist has to say, if anything, about alternatives when I write to cancel the procedure. And I'll check with my PCP, who is great.

    I respect why there are set protocols. I figure I've just run up against an unfortunate limitation of this practice. I don't want to make any huge fuss. I like and trust the medical group I use. Heck, seven or eight years back I let them pull half a lung out of me .

    I am just concerned about what it will take to find a practice that does what I want (or rather doesn't do what I don't want). So I really like your idea of putting these people on the spot for what they do when cipro isn't an option.

     
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    Old 02-10-2019, 07:38 PM   #8
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    Re: How to find biopsy without fluoroquinolones

    Thanks! I'll post back when/if I get anywhere with this.

     
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    Old 02-15-2019, 10:40 AM   #9
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    Re: How to find biopsy without fluoroquinolones

    Hi Tom,


    I had one biopsy in December 1999 with several days dosing of Cipro before, on the day, and after; my recollection is that I had 3 or 4 doses, but certainly not 10, probably not even 6. I experienced no problems of any kind that I could associate with the drug, but I had a much bigger problem - almost certain and dangerous prostate cancer - on my mind and probably would not have noticed a side effect of Cipro.


    Having followed prostate cancer discussions and issues for nearly 20 years now, I don't recall this issue having come up before, except for very real concerns that Cipro was not enough in the face of some bacteria, harbored by a small but meaningful proportion of patients, bacteria that were transferred from the bowel during the biopsy procedure, causing infection. There are effective ways of minimizing that risk, as you probably know. I was not aware of a risk of side effects, but, because of your post, I am now looking into this. I was surprised that tendonitis is one of the concerns.


    Regarding effectiveness of Cipro, I just found this study, available online in full, published in 2017. It involved more than 500 men, and the results for efficacy are encouraging. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5463462/ A very low percentage of side effects is reported, with good management results for those that did occur. However, the researchers appear to have limited their view basically to infections associated with Cipro, and not to issues like tendonitis and other non-UTI issues. As so often happens in research, you don't see what you are not looking for.


    Over the years I've learned that key questions regarding issues involve considerations such as the proportion of patients involved, the seriousness of the issue, the manageability of the issue, the availability and quality of research about the issue, burdens versus benefits, and alternatives. At the moment I feel you have spotlighted a legitimate issue, but I am unclear about the status of these considerations. It is clear that there has been a lot of research, including clinical trials, involving Cipro and related drugs, but I am a long way from having studied much of it.


    Thanks for raising this issue, and welcome to the Board!

     
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    Old 02-15-2019, 01:09 PM   #10
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    Re: How to find biopsy without fluoroquinolones

    The Larger Question - Do You Need a Biopsy, or Would A Less Invasive Alternative Be Appropriate At This Time?

    Hi again Tom,


    It's always good to get a view of the forest before examining the trees in detail, and the "forest" here is the question whether you need to move to a biopsy now or try an alternative, while the "tree" is the biopsy protocol, including measures to prevent infection. Biopsies give key information and have a key role, but now may or may not be the best time for one.


    The main alternatives would be a multiparametric MRI (mpMRI, giving separate but co-registered images of anatomy clues, water flow clues and blood vascularity clues that are considered as a combined picture of what's happening) or one (or more) of the tests now often used before biopsy to sort those who really need a biopsy from those who can safely defer one or flat out don't need one. mpMRI is growing in popularity in the US and is apparently commonplace in the UK.


    Are you aware of these alternatives and their role for someone who is considering a biopsy?

     
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    Old 02-15-2019, 01:35 PM   #11
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    Re: How to find biopsy without fluoroquinolones

    In follow-up to your first post...

    I first saw mention of the FDA warnings for fluoroquinolones in the NCCN clinician guidelines for early detection of prostate cancer. So then I read everything I could find.

    As far as I can tell, the urologic community is aware of the FDA warnings but more concerned around issues of antibacterial resistance. See, for example, the American Urological Association guidelines, which predate some additional FDA warnings.

    There are alternatives to the fluoroquinolones. Unless other risks are present, a single or one-day pre-/peri-operative administration of the antibacterial is now preferred over a full course of several days. My health group is thus far firm on four days of Cipro (not ten as I originally said).

    I assume the really nasty side effects of Cipro are rare, but I see this as an avoidable risk. I might feel different if the application was curative, to combat an actual case of acute bacterial prostatitis, rather than prophylactic. Or if there was no alternative to the fluoroquinolones.

    Last edited by Administrator; 02-15-2019 at 01:55 PM.

     
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    Old 02-15-2019, 04:49 PM   #12
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    Re: How to find biopsy without fluoroquinolones

    Quote:
    Originally Posted by IADT3since2000 View Post
    Do You Need a Biopsy...
    I could check, and maybe I will, but I suspect insurance won't cover mpMRI as an additional screening measure prior to an initial TRUS PNB. Nor do I think any of the more exotic biomarkers would change my story. I know the limitations of a prostate biopsy but at this point, alas, I believe it's the right thing.

    Nonetheless, many thanks! You inspired me to again review all the options. And maybe I'll wind up working with a doctor who feels something other than a TRUS biopsy should be the next step.

     
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    Old 02-16-2019, 11:56 AM   #13
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    Re: How to find biopsy without fluoroquinolones

    Poking needles from the colon into organs is a very messy procedure. I couldn't believe this should be the best way to get tissue samples from the prostate, but it's what all the experts say. In my opinion one should weigh the probability of finding cancer against the risks of the biopsy.

    If a decision to go forward with the biopsy is taken I think Cipro or similar quinolones are the antibiotic of choice. Even with Cipro the biopsy has about a 1% risk of causing serious infections, and moreover alternative prescriptions aren't risk-free either.

    Most importantly, do not defer the biopsy because of fears of taking Cipro if your PSA scores or other diagnostic criteria indicate a high risk of cancer.

     
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    Old 02-16-2019, 02:09 PM   #14
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    Re: How to find biopsy without fluoroquinolones

    (Re: the biopsy procedure and risk of serious infections)

    I too feel a biopsy should not be deferred out of fear of Cipro, or complementary or alternative medications intended to prevent infection caused by the biopsy procedure.

    On the other hand, it is a much different matter if case characteristics, perhaps bolstered by a multiparametric MRI and/or tests like SELECT MDx, 4K, or PHI – the more likely tests out of the gate – suggest a low probability of clinically significant prostate cancer, meaning the kind that could make a difference in quality of life or even survival over the patient’s lifetime. In these situation, deferring a biopsy, perhaps forever if surveillance warrants, is often the best course.

    Regarding details of the procedure, technically speaking the trans-rectal biopsy is done through the rectum, the lower extremity of the colon, rather than through what is commonly considered the colon.

    However, highly relevant here is another kind of biopsy technique with a far lower infection risk (1-2% versus 10-20%, with much smaller rates for serious infections for both, as previously indicated), the trans-perineal biopsy. The ultrasound probe is inserted the same way for both types and in neither case penetrates the rectum, but in the transperineal biopsy the needles go through a space between the scrotum and anus, thus avoiding the rectum (therefore no possibility of risky rectal bacteria), and also gaining much better access to the whole prostate, especially the anterior area that is not probed in trans-rectal biopsies. The downsides to the transperineal approach are that many doctors do not do it, it requires a general rather than a local anaesthetic (but therefore no pain due to the needles – not usually a major matter anyway), and it requires about a day’s hospital stay instead of an outpatient visit of perhaps 2 to 4 hours, including recovery.

    Regarding serious infections, such as can result from Cipro-type medication resistant bacteria, these days this risk has been much reduced at modern facilities and up-to-speed doctors who use rectal swabs to detect the presence of resistant bacteria prior to the procedure, provided the patient’s circumstances, especially location, suggest elevated risk . If a resistant Escherichia coli (E. coli) bacterium is detected, a different, culture-directed preventive medication, such as cephalosporin or aminoglycoside can be used.

     
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    Old 02-16-2019, 09:18 PM   #15
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    Re: How to find biopsy without fluoroquinolones

    Quote:
    Originally Posted by KarlE View Post
    fears of taking Cipro
    Everything you say here makes sense, and I sincerely appreciate your concern.

    It would be prudent of me to get a prostate biopsy. Nothing is saying high risk of high-grade, but we have enough indicators for some concern. I'm not looking forward to this. And I'd like to get it over with.

    But over the past ten years the fluoroquinolones, and specifically the fluoroquinolones, have accumulated a half-dozen FDA boxed warnings, with side effects that can lead to permanent damage even after a single dose. Other drugs are in use to provide antibacterial prophylaxis for a prostate biopsy, with cephalosporin an antibacterial of choice alongside fluoroquinolone. So, I see no reason to take even a slender risk here, when I might rue the decision for the rest of my days.

    Last edited by Administrator; 02-16-2019 at 09:26 PM.

     
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