Occurrence of infections and hospitalizations in men having prostate biopsy (in Europe)

There has been increased discussion in the past couple of years related to the risk of infection in men undergoing prostate biopsy after initial testing for risk of prostate cancer (based on results of PSA test data and/or a digital rectal examination). Studies based on data from the United States and Canada have previously reported a rising number of hospitalizations for infectious complications after prostate biopsy.

Loeb et al. have now published an analysis of data on infectious complications and hospitalizations after prostate biopsy among patients enrolled in the the Dutch component (Rotterdam section) of the European Randomized Study of Screening for Prostate Cancer (ERSPC).

Between 1993 and 2011, a total of 10,474 prostate biopsies were carried out among patients in the Rotterdam section of the ERSPC. All patients in this study who were given a prostate biopsy also received prophylactic antibiotic therapy prior to their biopsy. From 1993 to 2007, the recommended antibiotic was trimethoprim-sulfamethoxazole; in 2008, the antibiotic was changed to ciprofloxacin.

All patients in the Rotterdam section of the study were asked to complete a questionnaire 2 weeks after their biopsy that included questions about fever (“febrile complications” to be strictly accurate) and hospital admissions.

Here are the results reported by Loeb and her colleagues:

  • Fevers were reported by 392 patients in 9,241 questionnaires received (4.2 percent).
  • Hospital admissions were reported by 78 patients in 9,198 questionnaires received (0.8 percent).
  • Most fevers were effectively managed on an outpatient basis.
  • 63/78 hospital admissions (81 percent) were for infection.
  • Blood culture results from 34/56 patients hospitalized for infection were positive and Escherichia coli was the organism most commonly identified as the cause of infection.
  • Men with prostate enlargement and diabetes appeared to be at highest risk for fever after a prostate biopsy.
  • Later year of biopsy was the only factor significantly associated with an increased risk of hospital admission.

Clearly, in this analysis, the risk of hospitalization after a prostate biopsy was low overall (at < 1 percent), and most infectious complications could be effectively dealt with on an outpatient basis. However, it is notable that, “Consistent with prior international reports, the frequency of hospital admissions after [prostate biopsy] significantly increased over time.” This finding is consistent with the idea that there is an increased incidence of biopsy-induced infections caused by bacteria that are resistant to commonly used antibiotics like trimethoprim-sulfamethoxazole and ciprofloxacin.

The authors state their opinion that, “the absolute frequency of hospital admissions related to [prosate biopsy] was low” in this study “and should not dissuade healthy men who would benefit from early prostate cancer diagnosis from undergoing biopsy when clinically indicated.”

7 Responses

  1. Regarding “the absolute frequency of hospital admissions related to [prosate biopsy] was low and should not dissuade healthy men who would benefit from early prostate cancer diagnosis from undergoing biopsy when clinically indicated.” How would one know that one was such a man? It appears that the data say that there is no one who would benefit from early prostate cancer diagnosis.

  2. Dear John:

    Quite separately, in a variety of publications since 2009, the European Randomized Screening study has consistently shown that early detection of prostate cancer can, on average, extend prostate cancer-specific mortality.

    Whether the risks (including the risks associated with biopsy and with treatment) are worth the benefit is a much debated topic. Furthermore, it is widely accepted that until we can come up with tests that can accurately differentiate between clinically significant and clinically insignificant and indolent forms of prostate cancer, it will continue to be a much debated topic.

    The study described above deals only with an analysis of the risks associated with infections subsequent to actual prostate biopsy, and was never intended to address the issue you are raising. The authors’ concluding comment is an opinion, not a statement of fact.

  3. I have not had a biopsy at all but waited until other signs showed up to verify I had an aggressive prostate cancer. I did not like the idea at all and as the above states I reckon I did the right thing not to mention the untold risk of making it easier for the prostate to leak its dirty cancer cells to god knows where.

  4. Dear Barry:

    (1) The article referred to above says absolutely nothing whatsoever about the (utterly unproven) concept that prostate biopsy increases the risk of prostate cancer cells being disseminated outside the prostate.

    (2) Your decision to not have a biopsy “until other signs showed up to verify I had an aggressive prostate cancer” may well have contributed significantly to the risk that your cancer is now incurable.

    Naturally, you have a complete right to make your own decisions about how you manage your health care. However, your decisions appear to be based on a very limited understanding of medical and scientific risk related to the diagnosis of prostate cancer (as opposed to the risks for bacterial infection associated with any form of biopsy today).

  5. After watching one of my long-time acquaintances nearly die after having a prostate biopsy without any prophylactic antibiotic medication, I think it critical that physicians make sure their patients get an appropriate antibiotic regimen and refuse to perform biopsies unless the antibiotics are actually taken.

    My friend said his urologist didn’t even prescribe such and he ended up losing over 30 lb after a 2-week stay in the hospital dealing with a massive E. coli infection. Of course, the doctor refutes his claim. I wonder if doctors in Europe with their socialized medical care are more inclined to get these crucial drugs into their biopsy patients than they are likely to here in the U.S.?

  6. What was the procedural protocol for preparation of the rectum, the guidance device/digit, and number of biopsy cores? The current standard seems to be TRUS-guided 12 cores, an enema, and IV antibiotic before and after. My urologist used finger-directed, 4-core, no cleanout, and ciprofloxin, which resulted in a septic infection in my case. After speaking with other patients of my urologist at a prostate cancer support meeting it seems clear that his stats for infection are significantly worse than 1%. Apparently there is no mandated minimum standard (at least in Canada).

  7. Dear Terry:

    As far as I am aware, there are no “mandated” prostate biopsy protocols anywhere in the world. There are guidelines, however. Most guidelines today appear to include recommendations for an enema, a brief oral (as opposed to intravenous) antibiotic regimen that is effective against Gram-negative bacteria such as E. coli, TRUS-guided biopsy using a biopsy “gun,” and removal of between 6 and 18 biopsy cores depending on the expertise of the urologist and the precise clinical risk/presentation of the patient.

    As far as I am aware, biopsies conducted within the Rotterdam section of the ERSCP trial would have conformed to the above criteria.

    The risk for infection associated with biopsy seems to be particularly high in Canada, although it is not clear exactly why this is the case.

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