Int Urol Nephrol (2007) 39:897–903
DOI 10.1007/s11255-006-9112-7
ORIGINAL PAPER
Time of administration of a single dose of oral levofloxacin
and its effect in infectious complications from transrectal
prostate biopsy
Athanasios N. Argyropoulos Æ Konstantinos Doumas Æ Antonios Farmakis Æ
Ioannis Liakatas Æ Ioannis Gkialas Æ Michael Lykourinas
Received: 12 May 2006 / Accepted: 13 September 2006 / Published online: 4 January 2007
Ó Springer Science+Business Media B.V. 2006
Abstract
Objective To evaluate the efficacy of two pro-
phylactic schemes for prostate biopsy using a
single dose of oral levofloxacin given either
before, or immediately after transrectal ultra-
sound-guided prostate biopsy.
Material and methods A total of 300 men
formed two groups of 150 patients each: the first
group received one dose of 500 mg of levofloxa-
cin 30 min to an hour before, and the second
group the same antibiotic immediately after
prostate biopsy. No pre-biopsy enema was used.
Side effects after prostate biopsy were recorded,
and the two groups were compared.
Results Only one patient from the first group
developed a urinary tract infection after biopsy. A
mean number of more than 10 cores per patient
were taken. Haematuria was the most common
complaint, followed by haemospermia. Haemat-
uria and rectal bleeding were more common in
patients where more than 8 cores were taken from
the prostate (P = 0.005 and P = 0.017, respec-
tively). Prostate cancer was detected in 34.3% of
patients in total.
A. N. Argyropoulos (&) Æ K. Doumas Æ
A. Farmakis Æ I. Liakatas Æ I. Gkialas Æ M. Lykourinas
Department of Urology, Athens General Hospital
‘‘G. GENNIMATAS’’, Mesogion avenue, 11527
Athens, Greece
e-mail: thanarg@yahoo.gr
Conclusion The use of a single dose of 500 mg
levofloxacin given immediately after prostate
biopsy proved to be quite effective for the
prevention of infectious complications, even in
the setting of an extensive biopsy protocol.
Keywords Prostate biopsy Æ Complications Æ
Infection Æ Levofloxacin Æ Prophylaxis Æ Effective
1 Introduction
Prostate cancer is currently the most common
malignant tumour and the second cause of cancer-
specific death in European and American men.
The widespread use of PSA testing and increased
patient awareness of prostate cancer has led to a
dramatic increase in the incidence of prostate
cancer. The result is a shift towards detection of
early stage disease, i.e. when it is still local or
regional, and of a 5-year (relative) disease-specific
survival that approaches 100% [1].
Transrectal prostate biopsy is a procedure
dating back to 1937, considered as the method
of choice to diagnose prostate cancer [2]. A
number of usually minor and rarely major com-
plications, including urinary tract infections
(UTIs), urosepsis, and less common like abscesses
and meningitis, have been reported as a conse-
quence of prostate biopsy [3–5]. Most urologists
agree that some preparation or prophylactic
123
898
scheme in terms of antibiotic coverage is neces-
sary. The role of a cleansing enema in the
prevention the infectious complications of trans-
rectal ultrasound-guided biopsy of the prostate
(TRUSB) is still a matter of debate [6–9].
Fluoroquinolones have been used in studies as
prophylaxis before prostate biopsy with excellent
results, and are currently considered as the
antibiotic of choice. Two earlier studies, using a
scheme with one dose of ofloxacin plus a fleet
enema or levofloxacin only, provided satisfactory
results [10, 11]. Others have shown that even the
administration of antibiotics post-biopsy was fol-
lowed by a relatively low rate of infection,
suggesting this as an interesting alternative
scheme [12].
In this prospective study, the goal was to
evaluate the efficacy and effectiveness of a
prophylactic scheme with a single dose of oral
levofloxacin in an extensive biopsy protocol, and
to investigate whether the time of levofloxacin
administration has any influence on the rate of
infectious complications.
2 Materials and methods
2.1 Patient selection
A prospective randomised study of consecutive
men subjected to transrectal ultrasound guided
biopsy of the prostate (TRUSB) was performed
in our clinic from May 2003 to December 2004.
The indications for biopsy were an elevated PSA
level (>4 ng/ml) and/or an abnormal digital
rectal examination (DRE). Each patient
received a single dose of oral levofloxacin
(500 mg), and two groups were formed: the first
group consisted of patients who received levo-
floxacin before 30 min to an hour before biopsy,
and the second group included those who
took the antibiotic immediately after the proce-
dure. No enema was routinely used before the
examination.
Patients with a UTI, an indwelling urethral
catheter or an artificial heart valve, and those who
reported an allergy to fluoroquinolones, were
excluded from the protocol. Those on aspirin, or
other non-steroidal anti-inflammatory drugs
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Int Urol Nephrol (2007) 39:897–903
(NSAIDS), were instructed to discontinue their
medication at least 7 days before biopsy. All
patients provided informed consent, after receiv-
ing adequate information about the procedure
and the prophylactic scheme. Patients were
excluded from the study due to failure of
compliance (in case they received additional
antibiotics on their own) or loss of follow up.
2.2 TRUSB procedure
The examination was performed in an outpatient
setting; all men came to the hospital the morning
prostate biopsy was scheduled. They were ran-
domly separated in two groups in a 1:1 ratio.
Those in the first group received a dose of
antibiotic 30 min to an hour before prostate
biopsy. Patients were placed in the left decubitus
position, and 10 ml of 2% lidocaine jelly were
placed intrarectally 5 min before biopsy for local
anaesthesia. The prostate gland was imaged at the
transverse and sagittal planes with a 7.5-MHz
transrectal multi-planar probe (type 8551, B&K
Medical AS, Glostrup, Denmark); its dimensions
were recorded, and the prostate volume was
calculated. Extensive sampling of the prostate,
with a mean number of more than 10 cores, was
then performed with a Bard biopsy gun, using an
18G needle. The presence of severe pain, haem-
orrhage, vasovagal episode or any other side
effect was recorded.
After biopsy, patients in the second group
received a tablet of 500 mg of levofloxacin, a
member of the medical staff (AA) being
responsible for its administration. All patients
were given additional information about the
post-procedure follow-up. They were instructed
to drink a lot of fluids, check their body
temperature frequently, and also the colour of
their urine, stools and sperm. Specific instruc-
tions were given so as to communicate by
telephone or return to the clinic/emergency
department in case of high fever, chills, urinary
symptoms or any other sign of infection. In case
of fever and symptoms of UTI, urine testing
(microscopy and culture) was performed to-
gether with any other necessary examinations,
and patients were placed in a close follow-up, or
hospitalised if necessary.
Int Urol Nephrol (2007) 39:897–903 899

2.3 Patient follow-up
The usual follow-up consisted by a second visit (in
87% of the total group) 2–3 weeks after biopsy: in
the remaining 13% follow-up was completed by
telephone, in case they had not returned to the
hospital for the biopsy results after this time. A
brief questionnaire for each patient was com-
pleted. All complications were recorded, such as
the presence and duration of haematuria, hae-
matospermia, rectal bleeding, urinary retention,
fever >38.5°C with or without chills, and the
results of urine culture were recorded.
2.4 Statistical analysis
Statistical analysis was performed using the chi-
square test to detect differences in complications
in the two groups, and also the difference in
complication rates between other groups formed
based on the number of cores taken during
biopsy. The Student t-test was used in order to
compare the characteristics of the two groups
(age, PSA levels etc.).
3 Results
A total of 300 patients were analysed for the
protocol; 150 patients were placed in each group.
Nine more patients were excluded from the study:
five from the first group, due to failure of
compliance (received additional antibiotics on
their own) or loss of follow up, and four from the
second group (one lost to follow up, and three
received additional antibiotics). Table 1 shows
the demographic characteristics in the whole
group and the two subgroups. The mean age of
the study group was 69.4 years (±12.3); mean
PSA level 22.8 ng/ml (±67.6), and the mean
prostate volume 53.9 cc (±25.7). Prostate cancer
was detected in 103 men (34.3%) in total. In 36
out of 300 patients, the pre-biopsy PSA level was
more than 20 ng/ml. A mean number of more
than 10 cores per patient were taken. No statis-
tical differences were identified regarding char-
acteristics like age, PSA level, prostate volume or
number of cores between the two groups, using
the Student t-test (P > 0.1 in every category).
The complications reported by patients have
been summarised in Table 2; haematuria was the
most common complaint in more than half of the
patients, followed by haemospermia. In the vast
majority of cases haematuria was mild, lasting
more than 4 days in only 18 patients (6%), and no
patient required any kind of treatment. Vasovagal
episodes during biopsy occurred in nine men. No
patient required admission to the hospital for
infectious or other reasons. Comparing the two
groups of patients, no statistically significant

Table 1 Patient characteristics in the total and two subgroups

Variable Total group Group 1 (levofloxacin Group 2 (levofloxacin Stat. Difference Group
500 mg 30 minutes–1 h 500 mg after biopsy) 1 versus Group 2
before biopsy)

Number of patients (n) 300 150 150

Age, mean 69.4 (±12. 3) 69.2 (±10.1) 69.6 (±14.4) P = 0.55
Median 69.0 69.0 70.0
(Range, in years) (43–87) (43–86) (53–87)
PSA, mean 22.8 (±67.6) 25.9 (±82.6) 19.1 (±44.3) P = 0.17
Median 9.0 8.7 9.5
(Range, in ng/ml) (1.6–582) (1.6–582) (3.6–400)
Prostate volume, mean 53.9 (±25. 7) 54.7 (±26.9) 52.9 (±24.3) P = 0.56
Median 47.7 47.3 48.5
(Range, in cc) (18.3–164) (20.5–164) (18.3–135)
Number of cores, mean 10.3 (±2.3) 10.1(±2.2) 10.6(±2.4) P = 0.10
Median 10.0 9.5 10.5
(Range) (6–17) (6–16) (6–17)
Positive biopsies (%) 103 (34.3%) 49 (32.7%) 54 (36%)

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900 Int Urol Nephrol (2007) 39:897–903

Table 2 Complication rates after TRUSB

Total group (%) Group 1 (%) (levofloxacin Group 2 (%) (levofloxacin Stat.
500 mg 30 min–1 h 500 mg after biopsy) difference
before biopsy)

Number of patients 300 150 150

Minor complications
Haematuria (>1 day) 152 (50.7) 80 (53.3) 72 (48) P = 0.35
Haematospermiaa 88 (32.4)a 43 (32.3)a 45 (32.6)a P = 0.96
Rectal bleeding 63 (21) 30 (20) 33 (22) P = 0.67
Vasovagal episodes 9 (3) 5 (3.3) 4 (2.7) P = 0.73
Major complications
Retention 2 (0.7) 1 (0.7) 1 (0.7) P = 1.00
Allergy 0 (0) 0 (0) 0 (0) NDb
Fever (±chills) 1 (0.3) 1 (0.7) 0 (0) P = 0.31
Sepsis 0 (0) 0 (0) 0 (0) NDb
Hospitalisation 0 (0) 0 (0) 0 (0) NDb
a
Percent of patients who reported ejaculation
b
No difference

differences were found in the rate of haematuria, (P = 0.005) and rectal bleeding (P = 0.017), but
haemospermia or rectal bleeding (P > 0.1 in all not in haemospermia, when more or less than 8
parameters). cores were used as a cut-off point. No difference
Only one patient presented with a UTI after was found when the analysis used as cut-off points
biopsy in the first group: he was a 78-year-old man, less or more than 8 cores between groups A and B.
with a prostate volume of 43 cc. Two days after The results of the analysis are presented in Table 3.
biopsy he presented to the clinic suffering from
urgency, painful urination, and a fever of 38.5°C,
without chills. The examinations (urine analysis 4 Discussion
and culture) showed that the patient was suffering
from a UTI (E. coli); he required antibiotic Transrectal biopsy of the prostate is perhaps the
therapy for 2 weeks, being under surveillance in most common procedure performed in a urolog-
our outpatient clinic. It was the first biopsy ical department nowadays. As in almost every
performed on this patient: he had received one other surgical procedure, the issue of antimicro-
tablet of levofloxacin before biopsy, and 8 cores bial prophylaxis is of major importance. Most
were taken. No patient in the protocol suffered urologists agree that some kind of prophylaxis is
from urosepsis or required hospitalisation. necessary before this procedure, though wide
We also analysed the results of complications, discordance has been reported with the use of
using different numbers of cores as cut-off values various substances, from different routes, and for
between the two groups. A statistically significant quite different periods of time [13, 14]. Since the
difference was discovered in the rate of haematuria rate of infection appears to be low, whatever
prophylactic strategy used, the issue of cost-
benefit ratio must always be kept in mind when
Table 3 Comparison of side-effects between groups of the choice of antibiotics and the duration of
patients with less (group A) or more (group B) than eight
cores in TRUSB
treatment are discussed. Clinical infection rates
vary between 0.1 and 5% in past series, though
Side-effect Group A Group B P value others have reported rates of up to 20%. [6, 7, 13–
Yes No Yes No 20] Furthermore, since a single patients’ hospi-
talisation for sepsis costs thousands of euros and
Haematuria 34 55 118 93 P = 0.005 poses a serious threat for his health and even his
Rectal bleeding 11 78 52 159 P = 0.017
Haemospermia 30 49 58 135 P = 0.205 life, any proposed regimen must provide ade-
quate proof of safety and effectiveness.

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The literature over the past 10 years shows a
wide variation between the different schemes
used. An early study of Shandera et al. [21] in
the 1990s showed that in the United States the pre-
biopsy regimen included prophylactic antibiotics
in 98.6%, and a cleansing enema in 81%. In total,
11 different antibiotics were used in 20 dosing
schemes, and 23 different timing-duration
schemes. In a similar survey, Davis et al. [22] in
2002 found that 81% of urologists prescribed an
oral fluoroquinolone, and 79% suggested an
enema before biopsy. The same conclusion was
the result of a study in the UK: Taylor and
Bingham reported that thirteen antibiotics were in
use as prophylaxis, in 48 different regimens [23].
Bearing these facts in mind, the current trend
and evidence provided from the literature sug-
gests that fluoroquinolones have already become
the prophylactic treatment of choice. Neverthe-
less, it is well known that drugs in this category
have different qualities and spectrum of antimi-
crobial activity. The urologist should select an
antibiotic possessing the following characteristics:
(a) ability to rapidly achieve its peak serum
concentration, (b) providing high concentration
inside the prostatic tissue, and (c) having a half-
life of such duration to enable easy dosing.
Levofloxacin was selected from the whole spec-
trum of fluoroquinolones for this study because of
these qualities. High levels of the drug are
detected in plasma in less than an hour, and the
prostatic concentrations are more than enough to
kill the most common pathogens [24]. The half-
life of 6 h permits once daily dosing, and the drug
is effective both in complicated and uncom-
plicated UTIs from Gram-negative micro-
organisms, and also in infections from most
Gram-positive pathogens. The dose selected was
the maximum daily dose of 500 mg.
This study has recorded one of the lowest rates
of clinical infection in a significant number of
patients. In the first group where the antibiotic
was given prior to the procedure the rate of
clinical infection was 0.66%, while in the whole
group of 300 patients with levofloxacin the rate
was 0.33%. Kapoor et al. [25] in a randomised,
double blind, placebo-controlled trial, were able
to demonstrate benefit from the use of oral
ciprofloxacin 500 mg, reporting clinical failure in
901
2% versus 5% of patients, in favour of antibiotic
use. Shandera et al. [10] reported an infection rate
of 0.75% with ofloxacin. In a study from Griffith
et al. [11] using one tablet of 500 mg of levoflox-
acin in 400 low-risk patients, the rate was 0.25%,
which is in line with our results. Others have
reported higher rates of up to 7.5% [26, 27]. The
results from these studies are summarised in
Table 4. In contrary to these facts, Enlund et al.
[18] reported an infection rate of 2.9% without
the use of prophylactic antibiotics.
These low infection rates with a single dose of
levofloxacin document the safety with this antibi-
otic, even in the current trend of extended biopsy
protocols. Most of these biopsies were taken from
the lateral regions of the gland, as proposed by
Stamey, compared to the standard sextant proto-
col [28, 29]. Since contemporary studies support
the use of such protocols of up to 21 cores, as de
la Taille et al. [30] suggested, the conclusion that
the use of only one tablet of levofloxacin was
effective in the prevention of infectious compli-
cations is extremely important, as such protocols
are nowadays becoming standard practice.
An interesting observation derived from this
study is that the rate of infectious complications
was low in both groups. It is, to our knowledge,
the first one comparing the same antibiotic
scheme in pre- and post-biopsy administration.
Since other authors have studied the effectiveness
of different dosing schemes of the same antibiotic
given after TRUSB, our effort was to examine if
levofloxacin can achieve the same, or perhaps
even better, results. Aus et al. [12] in a study of
491 patients receiving norfloxacin 400 mg per os
immediately after biopsy, for 1 or 7 days, showed
that the 7-day regimen was better, but included
patients with risk factors, such as the presence of
an indwelling catheter or prostatitis. Such patients
were excluded from our study, by a complete
history for prostatitis (acute or chronic), DRE,
and urinalysis plus urine culture in case of
evidence of UTI. Furthermore, the time to peak
serum concentration for levofloxacin is 60 min in
maximum, compared to 60–120 min for norflox-
acin. The above differences and the improved
spectrum of levofloxacin for Gram-positive and
atypical pathogens versus most of the other
fluoroquinolones can account for our improved
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902 Int Urol Nephrol (2007) 39:897–903

Table 4 Results from

Author Year Patients Antibiotic (dose) Enema Infection
studies with a single dose
(n) rate (%)
of antibiotic prophylaxis
for TRUSB Kapoor et al. [25] 1998 269 Ciprofloxacin Yes 2
(500 mg)
Shandera et al. [10] 1998 150 Ofloxacin Yes 0.67
(300 mg)
Isen et al. [19] 1999 42 Ofloxacin Yes 4.76
(300 mg)
Isen et al. [19] 1999 45 TMP-SMX Yes 6.66
(800 + 160 mg)
Aron et al. [27] 2000 79 Ciprofloxacin Yes 7.5
(500 mg)
Peyromaure et al. [26] 2002 289 Fluoroquinolone Yes 4.9
Griffith et al. [11] 2002 400 Levofloxacin No 0.25
(500 mg)

results in the second group, compared to the
previous study.
It is of importance to point out the 0% rate of
infection in the second group. Though the sample
is limited—150 patients—it is a result that
deserves further examination in future studies.
Since transrectal ultrasound is rapidly becoming
an essential part of the evaluation in many
prostate-related symptoms and diseases, the need
for biopsy may become evident only after com-
pletion of the examination. Such a scheme, if
proven effective, has the advantage of being used
only when a prostate biopsy is performed after a
transrectal ultrasound. The way to discover such
potential, if present, is if a double-blind, rando-
mised study is undertaken, with a group of
patients not receiving any antibiotics. Still, such
a study would probably never be accepted by an
ethics committee, considering the amount of
scientific evidence in favour of antibiotic use as
prophylaxis in TRUSB.
Care must also be taken when trying to
evaluate these data with the traditional time-
honoured prophylactic schemes of antibiotic use
prior to a surgical intervention, based in a large
number of studies. Currently, the majority of
urologists have identified the favourable results of
earlier fluoroquinolones, like norfloxacin and
ciprofloxacin, as prophylaxis in prostate biopsy.
Nevertheless, the results of levofloxacin adminis-
tered pre-operatively in our study, together with
those of Griffith et al. [11] also suggest that it may
be one of the best candidates among this group of
antibiotics for prophylaxis in TRUSB.
Data from the literature about the use of a pre-
biopsy preparation of the bowel are conflicting.
Most urologists suggest a cleansing enema or
other preparation, as it was thought to decrease
the infectious complications in some studies [9,
31, 32]. Nonetheless, in a retrospective study of
410 patients, Carey and Korman [8] showed that
those who received an enema before biopsy did
not show a clinically significant outcome advan-
tage. Sieber et al. have also recorded infection
rates similar to previous studies when no enema
was used, in a large series of more than 4,000
biopsies, and the same results were observed in
the study of Raaijmakers et al. with 5,802 biopsies
[6, 7]. No enema was used in the pre-biopsy
preparation scheme used in the current study. We
believe that the standard use of enemas in a
prophylactic scheme only increases the cost and
discomfort for patients, without providing solid
evidence of benefit.
Summarising the above-presented data, it is
safe to say that most complications regarding
TRUSB are minor. It is common practice to
use antibiotics prophylactically in order to
reduce the, potentially dangerous, infectious
complications. The ideal scheme should be
easy to use, cost-effective and safe, especially
in the setting of nowadays extended biopsy
protocols. Fluoroquinolones are considered as
the prophylactic treatment of choice. A single
tablet of 500 mg of levofloxacin, in accordance
to previous reports, seems to offer excellent
results, even when administered immediately
after biopsy.

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References
1. Schmid HP, Prikler L, Sturgeon CM et al (2003)
Diagnosis of prostate cancer—the clinical use of
prostate specific antigen. EAU Update Series 1:3–8
2. Astraldi A (1937) Diagnosis of cancer of the prostate;
biopsy by rectal route. Urol Cutan Rev 41:421–427
3. Binsaleh S, Al-Assiri M, Aronson S et al (2004) Septic
shock after transrectal ultrasound guided prostate
biopsy. Is ciprofloxacin prophylaxis always
protecting? Can J Urol 11(4):2352–2353
4. Borer A, Gilad J, Sikuler E et al (1999) Fatal
Clostridium sordellii ischio-rectal abscess with
septicaemia complicating ultrasound-guided
transrectal prostate biopsy. J Infect 38(2):128–129
5. Meisel F, Jacobi C, Kollamr R et al (2003) Acute
meningitis after transrectal prostate biopsy. Urologe A
42(12):1611–1615
6. Raaijmakers R, Kirkels WJ, Roobol MJ et al (2002)
Complication rates and risk factors of 5,802 transrectal
ultrasound-guided sextant biopsies of the prostate
within a population-based screening program.
Urology 60:826–830
7. Sieber PR, Rommel FM, Agusta VE et al (1997)
Antibiotic prophylaxis in ultrasound guide transrectal
prostate biopsy. J Urol 157:2197–2200
8. Carey JM, Korman HJ (2001) Transrectal ultrasound
guided biopsy of the prostate. Do enemas decrease
clinically significant complications? J Urol 66:82–85
9. Jeon SS, Woo SH, Hyun JH et al (2003) Bisacodyl can
decrease infectious complications of transrectal
ultrasound-guided prostate biopsy. Urology
62(3):461–466
10. Shandera KC, Thibault GP, Deshon GE Jr (1998)
Efficacy of one dose fluoroquinolone before prostate
biopsy. Urology 52:641–643
11. Griffith BC, Morey AF, Ali-Khan MM (2002) Single
dose levofloxacin prophylaxis for prostate biopsy in
patients at low risk. J Urol 168:1021–1023
12. Aus G, Ahlgren G, Bergdahl S et al (1996) Infection
after transrectal core biopsies of the prostate-risk
factors and antibiotic prophylaxis. Br J Urol 77:851–855
13. Cooner WH, Mosley BR, Rutherford CL Jr et al
(1990) Prostate cancer detection in a clinical urological
practice by ultrasonography, digital rectal exam and
prostate specific antigen. J Urol 143:1146–1154
14. Rodriguez LV, Terris MK (1998) Risks and
complications of transrectal ultrasound guided
prostate needle biopsy: a prospective study and
review of the literature. J Urol 160:2115–2120
15. Desmond PM, Clark J, Thompson IM et al (1993)
Morbidity with contemporary prostate biopsy. J Urol
150:1425–1426
16. Brewster SF, Macgowan AP, Gingell JC (1994)
Antimicrobial prophylaxis for transrectal prostatic
biopsy: a prospective randomized trial of cefuroxime
versus piperacillin/tazobactam. Br J Urol 76:351–354
17. Vallancien G, Prapotnich D, Veillon B et al (1991)
Systematic prostatic biopsies in 100 men with no
903
suspicion of cancer on digital rectal examination. J
Urol 146:1308–1312
18. Enlund AL, Varenhorst E (1997) Morbidity of
ultrasound-guided transrectal core biopsy of the
prostate without prophylactic antibiotic therapy. A
prospective study in 415 cases. Br J Urol 79:777–780
19. Isen K, Kupeli B, Sinik Z et al (1999) Antibiotic
prophylaxis for transrectal biopsy of the prostate: a
prospective randomised study of the prophylactic use
of single dose oral fluoroquinolone versus
trimethoprim-sulfamethoxazole. Int Urol Nephrol
31:491–495
20. Cormio L, Berardi B, Callea A et al (2002)
Antimicrobial prophylaxis for transrectal prostatic
biopsy: a prospective study of ciprofloxacin vs.
piperacillin/tazobactam. BJU Int 90:700–702
21. Shandera KC, Thibault GP, Deshon Jr GE (1998)
Variability in patient preparation for prostate biopsy
among American urologists. Urology 52:644–646
22. Davis M, Sofer M, Kim SS et al (2002) The procedure
of transrectal ultrasound guided biopsy of the prostate:
a survey of patient preparation and biopsy technique. J
Urol 167:566–570
23. Taylor HM, Bingham JB (1997) The use of
prophylactic antibiotics in ultrasound-guided
transrectal prostate biopsy. Clin Radiol 52:787–790
24. Drusano GL, Preston SL, Van Guilder M et al (2000)
A population pharmakokinetic analysis of the
penetration of the prostate by levofloxacin.
Antimicrob Agents Chemother 44:2046–2051
25. Kapoor DA, Klimberg IW, Malek GH et al (1998)
Single-dose oral ciprofloxacin versus placebo for
prophylaxis during transrectal prostate biopsy.
Urology 52:552–558
26. Peyromaure M, Ravery V, Messas S (2002) Pain and
morbidity of an extensive prostate 10-biopsy protocol:
a prospective study in 289 patients. J Urol 167:218–221
27. Aron M, Rajeev J, Gupta NP (2000) Antibiotic
prophylaxis for transrectal needle biopsy of the
prostate: a randomized controlled study. BJU Int
85:682–685
28. Stamey TA (1995) Making the most out of six
systematic sextant biopsies. Urology 45:2–12
29. Hodge KK, McNeal JE, Terris MK (1989) Random
systematic versus directed ultrasound guided
transrectal core biopsies of the prostate. J Urol
142:71–74
30. de la Taille A, Antiphon P, Salomon L et al (2003)
Prospective evaluation of a 21-sample needle biopsy
procedure designed to improve the prostate cancer
detection rate. Urology 61:1181–1186
31. Brown RW, Warner JJ, Turner BI et al (1981)
Bacteremia and bacteriuria after transrectal prostatic
biopsy. Urology 18:145–148
32. Lindert KA, Kabalin JN Terris MK (2000) Bacteremia
and bacteriuria after transrectal ultrasound guided
prostate biopsy. J Urol 164:76–80
123