title: Infections after fiducial marker implantation for prostate radiotherapy: are we underestimating the risks?
abstract: BACKGROUND
  The use of gold fiducial markers (FM) for prostate image-guided radiotherapy (IGRT) is standard practice. Published literature suggests low rates of serious infection following this procedure of 0-1.3%, but this may be an underestimate. We aim to report on the infection incidence and severity associated with the use of transrectally implanted intraprostatic gold FM.
  
  
  METHODS
  Three hundred and fifty-nine patients who underwent transrectal FM insertion between January 2012 and December 2013 were assessed retrospectively via a self-reported questionnaire. All had standard oral fluoroquinolone antibiotic prophylaxis. The patients were asked about infective symptoms and the treatment received including antibiotics and/or related hospital admissions. Potential infective events were confirmed through medical records.
  
  
  RESULTS
  285 patients (79.4%) completed the questionnaire. 77 (27.0%) patients experienced increased urinary frequency and dysuria, and 33 patients (11.6%) reported episodes of chills and fevers after the procedure. 22 patients (7.7%) reported receiving antibiotics for urinary infection and eight patients (2.8%) reported hospital admission for urosepsis related to the procedure.
  
  
  CONCLUSIONS
  The overall rate of symptomatic infection with FM implantation in this study is 7.7%, with one third requiring hospital admission. This exceeds the reported rates in other FM implantation series, but is in keeping with the larger prostate biopsy literature. Given the higher than expected complication rate, a risk-adaptive approach may be helpful. Where higher accuracy is important such as stereotactic prostate radiotherapy, the benefits of FM may still outweigh the risks. For others, a non-invasive approach for prostate IGRT such as cone-beam CT could be considered.
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. jyuin@yahoo.com.
authors.forename: Jasmin
authors.initials: J
authors.lastname: Loh
authors.affiliation: Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia. katieandmitchell@bigpond.com.
authors.forename: Katie
authors.initials: K
authors.lastname: Baker
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. Swetha.Sridharan@calvarymater.org.au.
authors.forename: Swetha
authors.initials: S
authors.lastname: Sridharan
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. Peter.Greer@calvarymater.org.au.|Medical Physics Research Group, School of Mathematical and Physical Sciences, Faculty of Science & IT, The University of Newcastle & Centre for Clinical Radiation Research, Calvary Mater Newcastle, Waratah, NSW, Australia. Peter.Greer@calvarymater.org.au.
authors.forename: Peter
authors.initials: P
authors.lastname: Greer
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. Chris.wratten@calvarymater.org.au.
authors.forename: Chris
authors.initials: C
authors.lastname: Wratten
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. Anne.capp@calvarymater.org.au.
authors.forename: Anne
authors.initials: A
authors.lastname: Capp
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. Sarah.gallagher@calvarymater.org.au.
authors.forename: Sarah
authors.initials: S
authors.lastname: Gallagher
authors.affiliation: Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Edith St, Waratah, NSW, 2298, Australia. Jarad.Martin@calvarymater.org.au.
authors.forename: Jarad
authors.initials: J
authors.lastname: Martin
mesh_terms: D057918:Fiducial Markers / Q000009:adverse effects*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011471:Prostatic Neoplasms / Q000150:complications / Q000473:pathology / Q000532:radiotherapy*; D019919:Prosthesis Implantation / Q000009:adverse effects*; D061089:Radiotherapy, Image-Guided / Q000009:adverse effects*; D012189:Retrospective Studies; D018570:Risk Assessment; D011795:Surveys and Questionnaires; D018084:Ultrasonography, Interventional / Q000009:adverse effects*; D014552:Urinary Tract Infections / Q000209:etiology* / Q000473:pathology