prostate cancer is the most prevalent cancer and the third most common cause of mortality in men in western countries . transrectal ultrasonography - guided prostate biopsy ( trus - bx ) is an essential procedure for diagnosing prostate cancer but may cause variable complications , including pain , hematuria , hemospermia , urethral injury , and urinary tract infection . among the complications , infective complications are clinically important because these can cause prostatitis or urosepsis , which are sometimes fatal to patients . the incidence rate of infective complications after trus - bx was reported to range from 0.1% to 7% and has increased during the past 10 years . for example , the american urological association ( aua ) guideline recommends antibiotic prophylaxis with fluoroquinolone for less than 24 hours as the first - line therapy and aminoglycoside combined with metronidazole or clindamycin for less than 24 hours as the second - line therapy . the european association of urology ( eau ) guideline also recommends oral or intravenous antibiotic prophylaxis before biopsy , and quinolone is recommended as the drug of choice . however , these recommendations would not be appropriate in a region where the prevalence of quinolone - resistant escherichia coli is high . the recent increase in infective complications is possibly due to an increase in quinolone - resistant e. coli prevalence in the community . because overuse of antibiotics has not been strictly controlled in korea , a recent epidemiology study reported that the resistance rate to ciprofloxacin was over 24% in cystitis patients . for this reason , korean urologists hardly follow the aua or eau guideline and instead use various combinations of antibiotics to prevent infective complications . considering the increase in quinolone - resistant pathogens worldwide , it is clinically significant to know the pattern of antibiotic prophylaxis in korea , where the prevalence of quinolone - resistant e. coli is already high . such data would give insight into the future of antibiotic prophylaxis in other countries where the quinolone resistance rate is still low but increasing . therefore , we investigated the real practice of antibiotic prophylaxis to prevent infective complications of trus - bx in korea . we sent an e - mail to the urology departments of 77 hospitals in korea . these hospitals were secondary or tertiary referral hospitals and covered most prostate biopsy cases in korea . the contents of the e - mail included questions about the real practice of trus - bx as follows : ( 1 ) which department has performed trus - bx ? ( department of radiology or urology ) , ( 2 ) how has biopsy been performed ? ( inpatient or outpatient setting ) , ( 3 ) which type of enema has been performed ? ( 4 ) has betadine enema been performed ? ( 5 ) which kinds of antibiotics have been used prior to biopsy ? ( 6 ) which kinds of antibiotics have been used after the procedure ? ( 7 ) how long did the patients take the medicine after prostate biopsy ? we analyzed the contents of the returned e - mails . according to the responses received , the prophylactic drugs in practice before and after trus - bx were classified according to the type of antibiotic ( quinolone , cephalosporin , aminoglycoside , and metronidazole ) , and we investigated the prevalence of each antibiotic regimen . in addition , duration of postbiopsy medication and the identity of the antibiotics used before and after biopsy were evaluated . all statistical analyses were performed by using spss ver . 17.0 ( spss inc . , chicago , il , usa ) , and the prevalence was presented as the number of hospitals with percentages . a total of 54 hospitals replied to our e - mail ; the response rate was 70.1% . two thirds of the responding hospitals indicated that the department of urology performed the prostate biopsy procedures ( 37 hospitals , 68.5% ) , and patients were admitted for trus - bx in 33 hospitals ( 61.1% ; fig . , various types of enema or suppositories were used in 48 hospitals ( 88.8% ) , and disinfection with povidone - iodine was used in 29 hospitals ( 53.7% ; fig . 2 ) . various types of prophylactic antibiotics prior to prostate biopsy were used in each hospital ( table 1 ) . a quinolone alone regimen was the most common ( 26 hospitals , 48.1% ) , followed by cephalosporin alone ( 11 hospitals , 20.4% ) , and aminoglycoside alone ( 5 hospitals , 9.3% ) . a combination of two or more antibiotics was used in 12 hospitals ( 22.2% ) . the doctors of all hospitals that participated in this study prescribed oral antibiotics after trus - bx ( table 2 ) . the most common type of postbiopsy medication was quinolone alone ( 42 hospitals , 77.8% ) . a cephalosporin alone regimen was used in 11 hospitals ( 20.4% ) , and only 1 hospital answered that oral quinolone and cephalosporin were routinely prescribed simultaneously . the treatment duration of postbiopsy antibiotics also varied among the hospitals ( table 2 ) . routine protocols of most hospital ( 43 hospitals , 79.6% ) were treatment for 4 or more days with oral antibiotics after trus - bx . among the 26 hospitals that chose quinolone alone before biopsy , 1 hospital ( 3.8% ) changed the type of antibiotic to cephalosporin after biopsy . the other hospitals maintained an identical type of antibiotic during the post - biopsy period . among the 11 hospitals using cephalosporin alone prior to trus - bx in contrast , the other 8 hospitals adhered to the same type of antibiotic used for the initial prophylaxis . postbiopsy quinolone was used in all 3 hospitals that administrated aminoglycoside alone before trus - bx . overall , the proportion of hospitals using prophylaxis with a single type of antimicrobial agent before and after prostate biopsy was 61.1% ( 33 hospitals ) . on the other hand , various types of prophylactic antibiotics prior to prostate biopsy were used in each hospital ( table 1 ) . a quinolone alone regimen was the most common ( 26 hospitals , 48.1% ) , followed by cephalosporin alone ( 11 hospitals , 20.4% ) , and aminoglycoside alone ( 5 hospitals , 9.3% ) . a combination of two or more antibiotics was used in 12 hospitals ( 22.2% ) . the doctors of all hospitals that participated in this study prescribed oral antibiotics after trus - bx ( table 2 ) . the most common type of postbiopsy medication was quinolone alone ( 42 hospitals , 77.8% ) . a cephalosporin alone regimen was used in 11 hospitals ( 20.4% ) , and only 1 hospital answered that oral quinolone and cephalosporin were routinely prescribed simultaneously . the treatment duration of postbiopsy antibiotics also varied among the hospitals ( table 2 ) . routine protocols of most hospital ( 43 hospitals , 79.6% ) were treatment for 4 or more days with oral antibiotics after trus - bx . among the 26 hospitals that chose quinolone alone before biopsy , 1 hospital ( 3.8% ) changed the type of antibiotic to cephalosporin after biopsy . the other hospitals maintained an identical type of antibiotic during the post - biopsy period . among the 11 hospitals using cephalosporin alone prior to trus - bx in contrast , the other 8 hospitals adhered to the same type of antibiotic used for the initial prophylaxis . postbiopsy quinolone was used in all 3 hospitals that administrated aminoglycoside alone before trus - bx . overall , the proportion of hospitals using prophylaxis with a single type of antimicrobial agent before and after prostate biopsy was 61.1% ( 33 hospitals ) . on the other hand , various combinations of drugs were used in 21 hospitals ( 38.9% ) . the incidence of acute prostatitis related to trus - bx has been reported to range from 0.1% to 7% . in korea , the incidence of biopsy - related prostatitis was reported to range from 1.4% to 1.9% . various studies have been undertaken to reduce the incidence of acute prostatitis after trus - bx . one study reported that rectal preparation prior to biopsy with bisacodyl decreased biopsy - induced infectious complications significantly compared with a non - rectal - preparation group . an intrarectal mixture of povidone - iodine and lidocaine gel also significantly decreased infectious complications in another study . recently , issa et al .   described that formalin disinfection of a biopsy needle after each core reduces the incidence of urinary tract infection and sepsis . among these prophylactic methods , antibiotic prophylaxis has been the standard method of preventing infectious complications . in particular , fluoroquinolones have traditionally been used as the primary prophylactic agent owing to their excellent prostatic penetration . in the past , these agents also provided good coverage against the key pathogens implicated in infections after prostate biopsy . analyzed a total of 1,994 strains from patients with community - acquired urinary tract infection from 34 hospitals in korea from january 2008 to june 2009 . in that study , the resistance rate to ciprofloxacin was reported to range from 20% to 38% in community - acquired uncomplicated cystitis and showed a tendency to increase . the overall resistance rate to ciprofloxacin rapidly increased from 15.2% in 2002 to 24.8% in 2009 . furthermore , ciprofloxacin - resistant e. coli has been shown to be more prevalent in complicated urinary tract infection ( 40.9% ) than in uncomplicated urinary tract infection ( 24.8% ) in korea . recent studies have reported that the prevalence of quinolone - resistant e. coli has also increased in western countries . however , the rate of quinolone resistance is lower than in korea . in the united states , fluoroquinolone - resistant bacteria were identified in 22% of samples from rectal swab cultures before trus - bx . in that study , asian men had a higher risk of resistant rectal flora colonization ( odds ratio , 2.8 ) . in american men who developed acute prostatitis after trus - bx , the fluoroquinolone - resistant rate was reported to be 57.1% . in korea , a study reported that 2.0% of patients who underwent trus - bx developed acute prostatitis , and nearly all culture - positive specimens ( 96.3% ) were identified as ciprofloxacin - resistant pathogens . in that study , most quinolone - resistant pathogens were sensitive to cephalosporin and aminoglycoside . therefore , several studies have evaluated the effect of cephalosporin combined with quinolone on the prevention of infectious complications after trus - bx . some reports have suggested that adding aminoglycoside is helpful for preventing infectious complications in areas with a high antibiotic resistance rate . the aua guideline does not recommend using multiple antibiotics during prostate biopsy . in our study , 21 hospitals ( 38.9% ) used two or more antimicrobial agents during trus - bx . cephalosporin alone or combined with other antibiotics was used in 19 hospitals ( 35.2% ) , and aminoglycoside alone or combined with other antibiotics was used in 13 hospitals ( 24.1% ) . only 25 hospitals ( 46.2% ) followed the aua guideline recommending fluoroquinolone alone before and after trus - bx . no hospitals used alternative antimicrobials ( aminoglycoside with metronidazole or clindamycin ) . regarding the duration of antibiotic treatment , fewer hospitals adhered to aua guidelines . prophylactic antibiotic use of less than 24 hours was used by only 7.4% of the hospitals in our study , although several studies have suggested that there are no significant benefits of long - term use . a recent cochrane review revealed that there was no clinically nor statistically significant difference between a short course or a single - dose regimen compared with a longer course . our study revealed that a quinolone only regimen was the single most common method for prophylaxis , but less than half of hospitals used a quinolone only regimen for prophylaxis . these results showed that most hospitals did not follow the aua or eau guidelines for various reasons . first , we could not evaluate the incidence of infectious complications nor the changes in complications after modifying the antibiotic regimen at each hospital because this study was a cross - sectional observational study . furthermore , we could not assess why the current practice was selected in each hospital . because there are no randomized controlled trials comparing the effectiveness of antibiotics for trus - bx in korean populations , and because current recommendations for antibiotic prophylaxis for trus - bx are derived from studies performed in western countries , we can assume that the current prophylactic antibiotic regimens are based on clinical experience . therefore , the results of this study do not mean that other antibiotic regimens are more effective for preventing acute prostatitis after trus - bx than the quinolone - alone regimen . nonetheless , this is still the first study that has reported the practical use of antibiotics during trus - bx . as such , the results of this study could be helpful for establishing a health policy in countries with increasing antibiotic resistance . the aua recommendation was not followed by most hospitals and a combination regimen was used by nearly half of the responding hospitals in korea . this clinical practice pattern might be a result of the struggle to reduce infective complications after trus - bx in a country where the quinolone resistance rate is high . to justify this empirical use of antibiotics ,