Antibiotic-resistant infections associated with prostate biopsy

There is a long report today on about the risks from infection associated with prostate biopsy. This is a topic that The “New” Prostate Cancer InfoLink has cautioned about previously, and it is increasingly a risk that needs to be taken seriously.

As we are seeing an increasing incidence and prevalence of infections involving drug-resistant bacteria of many types (bacteria like methicillin-resistant Staphylococcus aureus or MRSA being among the more common), there is also an increasing risk that such bacteria may infect patients undergoing prostate biopsies — particularly when those biopsies are carried out in institutions know to already have a high incidence of hospital-acquired infection.

The Bloomberg article notes that there is a significant death rate associated with infections caused by antibiotic-resistant bacteria, as pointed out in February 2010 in commentary on a report by Nam et al. about biopsy-related infections in Canada. The careful reader will note that leading urologists from a series of centers around the world are becoming increasingly concerned about this problem, and rightly. No one is going to want to have a biopsy to assess their real risk for prostate cancer if the real risk of the biopsy is a potentially lethal infection.

The key message here is the importance of sterile procedure in the conduct of prostate biopsies. Additional efforts will need to be made to ensure a sterile field in the conduct of prostate biopsy, and one has to question whether the conduct of prostate biopsies at facilities known to have a significant incidence antibiotic-resistant, hospital acquired infections is in the best interests of patients.

According to Dr. David Bell, a urologist practicing in Halifax, Nova Scotia, the men who appear to be most susceptible to risk of serious, antibiotic-resistant infections associated with prostate biopsy include those who have taken antibiotics in the year before the procedure; those who have recently visited countries where antibiotic resistance is common in the community; and those who work in a hospital or who live with someone who works in a hospital. In other words, the greatest risk is not that you will actually acquire the infection as a consequence of the biopsy. It is that you might already have the infection, but that the biopsy gives the bacteria an opportunity to spread rapidly through the bloodstream, leading to sepsis.

19 Responses

  1. What I found particularly interesting about the Bloomberg article was how it concentrate on prostate biopsy procedures.

    Surely, if as the article finally mentions

    [i]This is a major international public health problem –not just in prostate biopsies,” said Collignon, who also teaches at the Australian National University. “We are all seeing so many difficult or impossible to treat Gram-negative bacteria infections, and there’s nothing in the pipeline capable of fighting the most resistant of them.” [/i]

    then the same issues must apply to other treatments and especially surgery? If men are indeed dying in worrying numbers following biopsy, surely even more would be at a greater risk from greater invasive therapies.

    Is the risk of infection by these drug-resistant bacteria greater or less in surgery v external radiation therapy v brachytherapy v cryotherapy v HIFU?

    I think we should be told. Maybe surgery isn’t the best bet in the face of this dire warning?

  2. Any surgical procedure today (including brachytherapy, cryotherapy, and surgical impantation of gold seeds to track accuracy of radiation therapy) comes with risk for antibiotic-resistant infection. However, the risk is still small. It becomes more of a problem with volume. Remember that there are hundreds of thousands of prostate biopsies done each year, but “only” tens of thousands of radical prostatectomies.

    The bottom line today is that, particularly for anyone with a less than outstanding immune system, spending time in a hospital is a risky business … but it is still a lot less risky than in was in the 1920s!

  3. I must have misunderstood this para:

    Studies emerging during the past year have uncovered that a small, yet growing percentage of those undergoing routine needle biopsy tests are becoming critically ill and dying from bacterial infections. Infectious complications including sepsis, the condition Greenstein had, from prostate biopsies have more than doubled in less than a decade, studies from three countries show. Nine out of 10,000 men whose tests were negative died within a month, researchers in Toronto reported in the Journal of Urology in March last year.

    I thought it reasonable to expect similar infection rates from “penetrative” therapies such as brachytherapy, cryotherapy and HIFU, with a slightly lower rate for EBRT associated with the placement of target beads and a higher rate from surgery because of the greater exposure.

    Given that the majority of the men diagnosed with prostate cancer will have some form of therapy — and the majority will have surgery, then the numbers exposed are not in the tens of thousands but the hundreds of thousands, given the ACS projections used in media releases of over 200,000 men being diagnosed each year?

    Or perhaps it is just alarmist spin?

  4. Terry:

    I think it is important to clearly differentiate between “awareness” and “alarmism.”

    There absolutely is an increasing risk for biopsy-related mortality subsequent to antibiotioc-resistant infection (“nine out of 10,000 men whose tests were negative died within one month” in Canada), but that is still a risk of < 0.1 percent. It is likely that if one dug hard enough, one might find an analogous infection-related mortality rate in men actually being treated for prostate cancer. However, the quality of sterile procedure is probably better in a surgical operating room than it is in an office-based biopsy procedure. Trying to make any sort of direct comparison is simply not reasonable.

    The message for patients here is the one that I have always, always pointed out. … A biopsy is not a procedure that is without risk. Neither is any sort of treatment. One of the possible risks associated with both biopsy and treatment is death. However, the treatment-related mortality rates associated with EBRT and HIFU are extremely low … to the point of invisibility … and the mortality rates associated with surgery have been falling steadily since the late 1980s. An increasing prevalence of antibiotic-resistant infections as a consequence of biopsy could quickly become a real problem because there are at least 1-2 million biopsies carried out in the USA every year. A 2% rate of mortality from antibiotic-resistant infections resulting from prostate biopsies would be 20,000 to 40,000 deaths each year, and in men a lot younger than a median of 80 years of age!

  5. Total sterility isn’t really an option, it seems like to me, with this test because the needle goes through bowel too — and repeatedly.

    Its an inherently dangerous and non-sterile procedure that should no longer be done on healthy younger men (in my opinion).

    Seems like bad medical advice by doctors to recommend the test, especially on those who die or get seriously ill from the test. They and/or their families deserve compensation and there ought to be a fund or insurance to help them I hope.

  6. Dear Fabrice:

    (1) Prophylactic antibiotic therapy prior to biopsy is customary to prevent the vast majority of potential bacterial infections, and so is topical sterile procedure. These are actually very effective techniques, but you are right, total sterility with 100% certainly is no longer an option.

    (2) Please tell us what procedure — other than biopsy — that you know of that would permit early diagnosis of potentially high-risk prostate cancer. I do not know of any other. If we don’t diagnose aggressive prostate cancer early, then relatively young men will die of metastatic prostate cancer (which is currently still incurable).

    The idea that medical care can be designed to be risk free is simply unrealistic. There is always risk. The question is only how well we can manage it. We are all responsible for the development of drug-resistant bacteria over the past 100 years — as a direct consequence of our over-use of prescription antibiotics to treat and prevent a wide variety of infections. This is a societal problem.

  7. Hmmmmm … so, we get, from another recent study that compares WW (a term indistinguishable from AS to most or many)

    “However, our findings show that some tumors that are considered to be low-risk at diagnosis do pose a threat to life, especially if they are not surgically removed.”

    That’s an endorsement for surgery — who’d want to take a chance even on low-risk tumors?

    And now … well, the biopsy procedures that are part and parcel of AS protocols turn out to be more deadly than surgery.

    Hmmmm …. that’s a couple more nails in the AS coffin.

  8. Terry: You are over-analyzing this. The lead author of the paper on infectious complications of biopsy is actually a close colleague of Dr. Klotz and very much in favor of wider use of active surveillance.

  9. As my son used to say after his closed brain injury when we challenged his view of the past, Perception is reality.

    So from your side of the fence my post may be seen as “over-analyzing”; from my side it is typical of the kind of “evidence” that will be quoted to men contemplating active surveillance to emphasis the danger of that path.

    I have seen many arguments against active surveillance (AS) or watchful waiting over the years. Some of these have been dealt with by the good studies that have been running for years now, but like a many headed Hydra, no sooner is one dealt with than two more grow.

    To quote Stamey, I believe that when the final chapter of this disease is written, which is unlikely to be in my lifetime, never in the history of oncology will so many men have been so overtreated for one disease, and it is that overtreatment that will oil the wheels of the prostate cancer industry despite weak efforts to demonstrate that AS generates a greater cash flow than other options.

  10. Hi,

    I’m the journalist who wrote the article mentioned here. I’m glad it’s prompted this discussion and thought. The feedback from dozens of patients and doctors the story received has made me even more convinced that this a problem that needs attention and solutions. I’m planning a follow-up story looking at some alternatives. I would be grateful for any suggestions and comments. Click here to send me an e-mail.


  11. What is not mentioned in this article, is the risk of 10 biopsies, increasing the risk of cancer spreading within the prostate. Besides mild or dangerous infection being pushed well into the centre of the prostate, cancer cells on its surface might easily be pushed further in. Ten needle biopsies will multiply the risks by 90% (correct? unless a mathematician will correct this figure).

    When people die, as a result of these biopsies, it will sometimes be diagnosed as such, but how often will this be overlooked, or even covered up? Remember that the prostate treatment industry will clearly minimize criticism whenever possible.

    Even bacteria that are beneficial within the gut will clearly be pushed into the centre of the prostate. Although it may not kill the patient immediately, surely the same procedure being repeated every few years, as is common, provides serious risk, which will certainly strain the healing powers of even the healthiest patient. I would guess that most prostate biopsies are not done on the healthiest people anyway, otherwise their system would be coping and killing cancer cells regularly.

  12. Dear Mr. Maybury:

    If your hypothesis was correct, then in the 20 years since the introduction of the PSA test (which has resulted in a massive increase in the number and frequency of prostate biopsies in the Western world), there would have been an associated massive increase in the number of deaths caused by urological infections and their sequelae among men of 50 years of age and older. We have seen no sign of any such massive increase.

    Men who are given prostate biopsies are given a short course of prophylactic antibiotic therapy prior to biopsy in order to prevent risk of associated infeection. The infections mentioned in the above article are resulting from bacteria that are resistant to the majority of currently available antibiotics.

  13. This has just happened to my 53-year-old husband. He had the procedure done 8 days ago, and has now been in the hospital for 6 days. I am furious about this. I think the test was unnecessary. We had to cancel a 2-week trip abroad for a family wedding, but most importantly, my husband’s health has been compromised. I told his doctor that medical care in this country should be better than this

  14. Doctor wanted to give me a biopsy before going on a long vacation and cruise. I told them to stuff it. That was 5 years ago. The procedure to me seems archaic, brutal and defies my common sense. If this is the best test the medical system can come up with then I have little faith. It is too easy to spread E. coli, Staph. germs, etc. … and perhaps cancer cells.

  15. Sitemaster kindly added an observation above. I may well be out of my depth arguing with a scientist or qualified doctor. However, I understand that a typical course of antibiotics only destroys some of the trillions of bacteria within the intestines. Those that are left normally multiply quickly enough, with most people, not to cause severe digestive upset.

    If only some bacteria are killed in the gut, surely one is being optimistic to expect all bacteria, right inside the prostate, to be killed by the course of antibiotics. If, as you say, infections have not increased, it is possibly down to the natural resistance in our bodies.

    On the matter of MRSA and other super-infections. It is generally considered that the low-dose antibiotics fed regularly to food animals is the main cause of these superbugs. The only way to reduce or eliminate them is surely to stop this very expensive and regular dosing of animals.

  16. Dear Mr. Maybury:

    Respectfully, I don’t think that the appearance of bacteria such as MRSA or VRSA has ever been tied to the use of low-dose antibiotics in food animals (see, for example, this paper by Enright et al.). As far as I am aware, it has never even been suggested that drugs like methicillin or vancomycin are antibiotics one would use in food animals at any dose level. (There are, however, many very good reasons for minimizing the use of low-dose antibiotics in food animals.)

    With respect to the prophylactic use of antibiotic therapy prior to surgery in general and prostate biopsy in particular, I would refer you to any number of standard textbooks on the prophylactic use of antibiotics to prevent specific disorders in specific organs. This is by no means a “one size fits all” concept. The right antibiotic needs to be used to prevent the highest risk infections in the specific organ, and most certainly the “natural resistance” of each individual’s immune system is relevant … but it is clearly not sufficient given the thousands of people who used to die daily in hospitals around the world from antibiotic infections contracted during surgery. Even in the 1930s and early 1940s, surgical treatment of appendicitis was a very common cause of death because bacteria would escape into other parts of the body, but since that would happen anyway if one did not try to remove the appendix before it ruptured, surgery was the only curative treatment.

  17. The [U.S. Preventive Services Task Force] said recently that PSA tests were not necessary; urologists around country were outraged, now the majority back up the findings of the government panel.

    My brother and i went to the doctor today. My brother has an enlarged prostate, and probably prostatitis, with BPH for sure. A DRE revealed no nodules or hard mass on rectal examination, and this ******* money greedy ********** of a doctor wants him to have biopsy. He didn’t even know my brother has had open heart surgery, nor did he know he has a mechanical valve.

    It’s all about money, people. American doctors, for the most part, are greedy ****** *******. Don’t ever allow any biopsy. The majority of men who have prostate cancer have slow-growing tumors. **** the surgery and these immoral men who seek the almighty dollar; they don’t give a ****** **** about any of you.

    As a former RN with a masters degree, I said, “What about a course of antibiotics if you are going to do biopsy?” He didn’t know I was a nurse. His answer: “It isn’t needed.” I am angry as hell. We are brothers, and if we get prostate cancer, and it progresses, we will die not from prostate cancer, but from other ailments. … I am suing this ********* for malpractice. …

    Viet Nam Vet, RN with Masters degree

    PS: I have seen too many die at Trinity Hospital in Minot, ND. … In town, this hospital is referred to as “the widow maker.” Angry as a hornet.

    [Editorial comment: Since this is a “family friendly” web site, we have removed some of the commentator’s racier expressions … but we hope his sense of outrage is still clear and apparent.]

  18. I had a biopsy early last fall of 2013, 12 total punctures, and soon after contracted MRSA. I went back to my urologist and explained the bumps and open wounds. These were presented around my prostate area. I did not know what it was at the time. He told me that wasn’t his problem and that I should go to my primary care doctor. I did and they cultured it as MRSA. I have since had it five times, currently experiencing the fifth. My primary said that it was probably due to the biopsy. I have never had health issues before this and no one told me this was a possible outcome. I am very upset, but probably have no recourse. My primary now tells me the recurrences are something that I will just need to get used to having. B***s**. No one seems interested in helping me understand what is happening. I do understand that things happen. But to contract MRSA every 3 months after never being sick in my life? And doctors tell me “live with it”? There is a problem somewhere.

  19. This is a very sad tale, and for your urologist to even suggest that this “wasn’t his problem” is unconscionable. Has anyone referred you to a specialist in infectious diseases?

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