Targeted Antimicrobial Prophylaxis with Cefmetazole Based on Presence of Fluoroquinolone-Resistant Isolates to Prevent Post-Prostate Biopsy Infectious Complications

Round 1

Reviewer 1 Report

 

The authors should always finish the sections on informed consent, funding and data availibility with the uttermost carefulness and preciseness as this is of the biggest importance to the reviewer. For the lack of these qualities, I recommend staight-forward rejection. The main text is promising although would also require major revisions.

The main concern is that how can be a written consent to participate be obtained in a retrospective study? Did the authors send letters to the patients whose records they wanted to examine or how can this be possible? However, as the informed consent statement is not mentioned in the main text but only in the end (row 190), and as the rows 176-193 look unfinished, I think it may be an involuntary error, and in truth no consent was obtained and not necessarily required for a retrospective study.

Also I would hope that I would not have access to the "all data generated or analyzed during this study" as this would probably include identifiable information that would be in contradiction with laws and decralation of Helsinki. Of course the is no supplementary material provided, so I don't have access to the metadata.

Supplementary material section row 176-177 is unfinished and the file does not include supplementary material. Rows 183-184 include instructions on credit taxonomy. Funding (row 184) includes a sentence "please add".

Further notes:

- There are indentations in the first paragraphs which is not according to the journal style

- Introduction should refer the literature more. What kind of antibiotic regimens have previously been experimented on? Easily, I found similar articles such as Singh et al. that used tinidazole. The reader is interested in the existing literature

- Inclusion and exclusion criteria are not provided. I doubt that patients allergic to cephalosporins were included

- Figure legends and Tables should include all the abbreviations used

- Are the diagnostic criteria for acute prostatitis determined according to some existing guideline or why the current ones are used? It seems that post-biopsy prostatitis was only defined occuring within 14 days since the biopsy but this is not stated in rows 81-83, although in row 100 it is stated that fever occuring 15 days after biopsy was not counted as a post-operative prostatitis

- P-values for the differences between the main study question (difference between the groups is not cited (although it is stated it was not significant)

- Why the present study focused only on E. coli and not other ESBL-organisms such as Enterobacter? The actual proportions of post-biopsy prostatitises where ESBL E. coli is the culprit should be referred if such exist

- Both groups received cefmetazole, even if they did not have ESBL E. coli? Why? No explanation is given

- It is not clarified in the discussion that since the incidence of post-operative prostatitis is so low, this study lacks the statistical power (with 3 vs 2 cases) to make any strong arguments although the perceived incidences seem similar. Also, since the patients that did not have ESBL E. coli had much larger prostate volumes (over 10 ml), this could favour the group that did have ESBL E. coli and this could lead to misleading results. This is not discussed.

The need for minor edits:

- webpage should be cited as any other reference in row 32

- comma should be added after 20% in row 41

- complication to complications in row 44

- Institution capitalized although shouldn't be in rows 46, 108

- Deoxycholate capitalized although shouldn't be in row 62

- analysis should be analyses in row 87

- tilde instead of hyphen in row 110

- multiple times E coli where should E. coli in rows 140-142

- ESBL producing should be ESBL-producing in row 137

- In anyway in row 171 should be rephrased. I would not recommend "in any case" either since this is a new paragraph and should not be linked to the previous one. "Albeit the limitations" or something similar should be used.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments:

This retrospective study assessed the prevalence of fluoroquinolone-resistant E. coli in patients undergoing prostate biopsy and evaluated the efficacy of targeted prophylaxis in reducing post-biopsy infections. Rectal swabs were collected pre-procedure, and patients were given cefmetazole or levofloxacin prophylaxis based on the presence or absence of fluoroquinolone-resistant organisms. The study reported a low infectious complication rate and suggests that rectal swabs and targeted antibiotic prophylaxis could reduce post-biopsy infections common in patients that have undergone prostate biopsy.

 

Suggestions:

While the authors have acknowledged some of the study design limitations and offered recommendations for future research, I have a few suggestions for improvement.

 

Firstly, I recommend rephrasing the title to make it less wordy, for instance "Reducing Postoperative Acute Prostatitis by Identifying Fluoroquinolone-Resistant Isolates with Pre-Procedure Rectal Swab and Targeted Antimicrobial Prophylaxis for Transrectal Ultrasound-Guided Prostate Biopsy."

 

Secondly, Figure 1's legibility could be improved by either enlarging it or bolding the fonts.

 

Overall, with these minor corrections, I believe the manuscript is ready for publication.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

the authors are presenting interesting study on one of the most serious problem with performing TR prostate biopsy - infectious complications. They represent their results with targeted antibiotic prophylaxis according to pre-procedure rectal swab, focused on FQ-resistant E.coli

Abstract - clearly and clearly written paragraph - no remarks

Introduction - comprehensive description on the rationale and soundness of the study - no remarks

Material and methods - will recommend a comment on anesthesia used in TR and TR+TP in the study - in the last decade the ambulatory performance of TR biopsy is its only advantage, bearing in mind that TP route virtually eliminates infectious complications - major

Results - nicely presented, the two groups (FQ-resistant and non-FQ-resistant) are nicely matched. Significant statistical significance on the variables, researched by the authors - frequency of FQ-resistant flora in the rectal swabs, and influence of targeted peri-operative antibiotic prophylaxis on infectious complications.

discussion - two main issues need additional comments

- first is the usage of control groups with empirical antibiotic prophylaxis - the cited in this research is 15 years old - should be expanded significantly as the study lacks a control group with non-targeted antibiotic group - newest study from the same healthcare systems, usage of results from systematic reviews and  meta-analyses to compare the results achieved with rectal-swab guided targeted antibiotic  prophylaxis - major      

- second is discussion on the the reason/s for performing prostate biopsies through TR route instead of TP - such as healthcare policy and logistics, performing as an ambulatory procedure and others. This is only briefly mentioned as a non-antibiotic strategy - major

- the finding of difference in prostate volume between the two groups should be discussed as it is being mentioned as a variable correlating with FQ-resistance - could be just a selection bias, could be age-related (both prostate volume and chance of FQ-resistance increase with age) - minor  

the references should be updated on a subject such dynamic with antibiotic policy changing constantly and especially with the TP route implementation as a major way to evade post-biopsy infections - major

Regarding all the aforementioned, my recommendation is to re-assess this manuscript for publication after satisfactory comments and appropriate modification by the authors on the abovementioned issues.

Author Response

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Author Response File: Author Response.docx

Reviewer 4 Report

General comment

The manuscript entitled “Identification of fluoroquinolone-resistant isolates by rectal swab before transrectal ultrasound-guided prostate biopsy and targeted antimicrobial prophylaxis use the reduced incidence of postoperative acute prostatitis” aims to evaluate the prevalence of FQ-resistant organism and infective complications after transrectal biopsy and the role of the preprocedural rectal swab in decreasing this risk. Although the manuscript deals with an interesting and always contemporary topic, the paper has to be improved in terms of quality and clarity. In particular, the aim of the study and the role of acute prostatitis are not well reported in the text. Additionally, the lack of limitations also represents another issue to be solved. Other suggestions are reported followingly.

TITLE

As it is written, is too long and not clear.

ABSTRACT

Bear in mind that the abstract represents the business card of your study. It should be clear, concise and briefly report the conclusion of the manuscript.

INTRODUCTION

30-39: this should be better explained. The misuse of FQs in the past has led to the emergence of e.coli multiresistant. Currently, urological guidelines do not advise the use of FQs for prophylaxis before a transrectal biopsy.

47-50: before stating the aim of your study, you should conclude the premises and then report why you conceived this study.

MATERIALS AND METHODS

80-83: placed like this, the paragraph is quite strange. provide a brief explanation of prostatitis in the introduction. Regarding the role of prostatitis, transrectal biopsy and prostate cancer also see DOI: 10.2217/fon-2020-0185

85-86: did you obtain descriptive statistics? did you assess the normality of the data? please report.

RESULTS

results could be aided by a figure also.

DISCUSSION

107-109: avoid the repetition of your findings and discuss critically your results according to current literature.

161-163: the use of nutraceutical products has also been proposed in order to decrease the needing for antibiotics. Please see DOI: 10.3390/jcm12082784

171-173: add the limitations of your study.

English is overall fine. Minor typos and errors to be checked.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

After a thorough reading with thought, I think the article is acceptable after changes to the title and the conclusions which to my opinion do not reflect the findings of the article. The revised text has a plenty of grammar errors, for which I've given my own suggestions for corrections. PDF-document with comments attached.

Comments for author File: Comments.pdf

After a thorough reading with thought, I think the article is acceptable after changes to the title and the conclusions which to my opinion do not reflect the findings of the article. The revised text has a plenty of grammar errors, for which I've given my own suggestions for corrections. PDF-document with comments attached.

Author Response

Thank you for your kind and thoughtful suggestions provided for our article.  We have revised our article according to the suggestions and we think that our article has improved and met the quality of the journal.  We have added our comments to your suggestions. Please see the attached PDF document.  

Author Response File: Author Response.pdf

Reviewer 3 Report

the authors has sufficiently addressed the issues put forward by the reviewers.

Few minor remarks:

row 140 - maybe a text left from the previous version

Author Response

Thank you for your suggestion. We deleted the line.

Reviewer 4 Report

Implement suggested references in the manuscript

none

Author Response

Thank you for reviewing our article.  According to your suggestions, we think that our article has improved and met the quality of the journal.  However, we think that the references (DOI:10.2217/fon-2020-0185 and 10.3390/jcm12082784) suggested by the Reviewer are not appropriate to cite in each part, since they do not deal with acute prostatitis following prostate biopsy.