Transrectal biopsy and the increasing risk for procedure-related infection

According to a paper presented at the recent meeting of the European Association of Urology in Madrid, Spain, there seems to be a significant and ongoing rise in the global risk for infections associated with prostate biopsy (and particularly with the transrectal prostate biopsy).

Wagenlehner et al. conducted their research between 2010 and 2013 as a stsudy associated with the Global Prevalence of Infections in Urology initiative. The study enrolled 1,214 patients from 136 countries in Africa, Asia, Europe, and South America. To be eligible for enrollment in the project, patients had to be biopsied within a predetermined 2-week window in each of the 3 years of the study.

Here are the study findings, which are discussed in more detail in a report on the Medscape web site:

  • Outcome data at 2 weeks post-biopsy were available for 876/1,214 patients (72.2 percent).
  • Among the 876 patients for whom such outcome data were available
    • 97 percent had had a transrectal biopsy.
    • 98 percent had been treated with prophylactic antibiotic therapy of any type.
    • 82 percent had been treated with prohylactic antibiotic therapy using a fluoroquinolone.
    • 50 percent developed symptomatic urinary tract infections (UTIs) of any type.
    • 3 percent developed febrile UTIs (i.e., UTIs serious enough to cause a fever).
    • 4 percent were hospitalized for their infections.
    • 0.1 percent (i.e., 1 patient) died as a consequence of infection.
  • Risk factors for infection were not significantly different between patients who developed infection after biopsy and those who did not.

Dr. Wagenlehner is quoted by Medscape as saying that:

These rates are significantly higher than results published in the 1990s, which showed febrile urinary tract infections around 1 percent, so there’s definitely a higher rate now.

Commenting on this study. Dr. Michael Liss of the University of Texas Southwestern Medical Center in San Antonio indicated that:

  • He uses this type of infection in counseling his patients about their need for and the value of prostate biopsy.
  • He recommends against prostate biopsy if a patient’s “risk of infection or hospitalization is higher than the chances of high-grade prostate cancer.”

We already know that transperineal biopsy is less likely to lead to post-biopsy infection than a trans-rectal biopsy, but a transperienal biopsy has to be carried out under general anesthesia. This cannot be done as an office procedure, and general anesthesia itself come with a small but known risk for  very serious complications (including death).

We also know that the use of rectal swabs prior to biopsy can be used to target antibiotic prophylaxis based on fecal flora analysis and that this can result in lower infection rates. However, antibiotic resistance to relatively common organisms continues to rise, and so there is little doubt that the risks associated with biopsy (and multiple biopsies over time) are increasing the risk for hospitalizations associated with this procedure — particularly for men with low-risk disease and men on active surveillance protocols.

6 Responses

  1. Curious whether results on hospitalizations were consistent for all continents.

    The link did not work for me, and perhaps this question was answered in the linked article. I’m wondering whether the higher results might be due to inclusion of many countries in Africa, where the health systems are often substandard, and perhaps in Latin America, as compared to Europe. I’m specifically wondering about the frequency of prophylaxis and about the frequency of hospitalization for each continent.

    Also, that high rate of symptomatic UTIs — 50% — was surprising.

    Thanks for posting this important study.

  2. Jim:

    The link will work now. Sorry about that. However, there is no information currently available about exactly how many patients were enrolled by country in the Medscape article, and I haven’t seen the actual poster that presumably does include that information.

    The Medscape article does seem to imply that most of the patients enrolled were in Europe, however, and I don’t think that “most” European health systems would regard themselves as “substandard”.

  3. Thanks for this excellent article! The rising risk of infection and the very high incidence of UTI are disturbing. I wonder to what extent UTI leads to prostatitis … which leads to higher PSA … and more biopsies?

    I believe these findings will accelerate the demand for mpMRIs and, only if needed, MRI-guided biopsies in lieu of TRUS-guided systematic biopsies.

    In addition, we need to be aware of other risks. For example, how serious is the risk of an having an allergic reaction to the antibiotic? And what are the cumulative risks over time for men with previous biopsies and repeated use of antibiotics?

  4. Possible typo in cited article — 5% vs. 50%? (and an aside re TV tonight)

    Thanks for fixing the link. I could not find the abstract at the EAU site, but I did find a 2013 article by the same lead author. In that paper, as stated in the conclusion to the abstract, “Despite antibiotic prophylaxis, 5% of men will experience an infective complication, ….” While 5% is not as good as we would like, it is a whole lot better than 50%. Either we have a typo by the Medscape group or transmitting author or a whopping big increase in infection. I’m suspecting a typo.

    In my earlier comment I did not mean to imply that European practice was not advanced. What I was and am thinking is that substandard practice in Africa in particular, but possibly also in South America, might have contributed to higher infection numbers.

    TV tonight (and last night and tomorrow night: Last night I watched the two hour PBS program about cancer, “The Emperor of All Maladies.” There was nothing about prostate cancer in particular, but this first episode of the Ken Burns miniseries is outstanding. It especially resonated with me as combined therapy has been key in my own case and the development of combined therapy is highlighted in the first episode. Also, who would have thought that money Mr. Lasker earned as an advertiser for the L&M tobacco company would have been vital in creating the American Cancer Society.

  5. A doctor friend of mine said one of his partners was hospitalized for 5 days for a post-prostate biopsy infection. I don’t know whether the biopsy was positive or not.

  6. I’m part of these statistics; 5 days of high fever and a lot of antibiotic shots to control it.

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