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    Post-prostate biopsy infection: Incidence and preventive steps

    New prophylactic measures address problems of drug resistance, infectious complications


    Dr. Casey
    Transrectal ultrasound (TRUS)-guided prostate needle biopsy is a procedure performed frequently in response to an elevated PSA level or abnormal digital rectal exam in order to diagnose prostate cancer. Recently, with studies promoting prostate biopsy at lower PSA cut-offs, such as 2.5 ng/mL or above age-specific medians (Urology 2006; 67:316-20) and the increased need for repeat prostate biopsies in men with low-risk prostate cancer undergoing active surveillance protocols, the number of prostate biopsies performed in the future is likely to increase.

    Dr. Schaeffer
    Prostate biopsy is generally considered a safe procedure, although beset by frequent minor complications such as hematuria, hematospermia, rectal bleeding, and voiding symptoms in about half of patients (Urology 2000; 60:826-30). Major complications such as infections, significant bleeding, and urinary retention are rare. The reported incidences of asymptomatic bacteriuria and bacteremia following prostate biopsy are 20% to 53% and 16% to 73%, respectively (J Urol 2000; 164:76-80). Symptomatic infectious complications are lower, with published rates of febrile urinary tract infection after prostate biopsy of 0.8% to 4.5% and rates of sepsis of 0.05% to 1.7% (Urology 2000; 60:826-30; J Urol 2001; 166:856-60; J Urol 2004; 171:1478-81; Sao Paulo Med J 2006; 124:198-202; J Formos Med Assoc 2007; 106:929-34).

    This article discusses the rising incidence of both fluoroquinolone resistance and serious post-biopsy infectious complications, and offers recommended preventive measures, including a new algorithm incorporating targeted antimicrobial prophylaxis based on rectal swab cultures.

    Infections and antimicrobial resistance

    Although the use of prophylactic peri-procedural antimicrobials has reduced the incidence of symptomatic infectious complications, the specific antimicrobial to be used and the duration of treatment are not uniformly agreed upon. Fluoroquinolones are widely used due to their oral administration, minimal side effect profile, broad-spectrum coverage of both colorectal and urinary flora, high concentration within prostatic tissue, and long-lasting urinary bactericidal activity. Additionally, there is controversy in the literature regarding the use of pre-procedure bowel preps to prevent infectious complications.

    Given their wide usage as prophylaxis during urologic procedures and as treatment for urologic infections, resistance to fluoroquinolones is beginning to emerge. Recent reports have demonstrated increasing rates of fluoroquinolone-resistant symptomatic urinary tract infections following prostate biopsy (J Urol 2008; 179:952-5; J Urol 2011; 185[suppl]:e574, abs. 1434). Additionally, there have been numerous case reports of extended-spectrum beta-lactamase (ESBL)-producing bacteria causing post-prostate biopsy febrile urinary tract infections and sepsis. ESBL are enzymes that mediate resistance to extended-spectrum (third-generation) cephalosporins (eg, ceftazidime [Fortaz, Tazicef], cefotaxime [Claforan], and ceftriaxone [Rocephin]) and monobactams (eg, aztreonam [Azactam]) but do not affect cephamycins (eg, cefoxitin [Mefoxin] and cefotetan) or carbapenems (eg, meropenem [Merrem], imipenem/cilastatin [Primaxin] and ertapenem [INVanz]) (Urology 2006; 68:1169-74).

    ESBL resistance is usually encoded on large plasmids that often carry genes conferring resistance to other nonrelated antimicrobials (including fluoroquinolones, trimethoprim-sulfamethoxazole [Bactrim, Septra DS], penicillins, and aminoglycosides), leaving few therapeutic options. Ena et al demonstrated a significant increase in the proportion of ESBL-producing Escherichia coli isolates from urine samples collected in their hospital, from 0.2% to 5.52% between 1999 and 2004 (Urology 2006; 68:1169-74). Risk factors for the development of fluoroquinolone-resistant or ESBL-associated sepsis include recent use of third-generation cephalosporins, fluoroquinolones, or aminoglycosides; relationships to health care workers; indwelling catheters; and history of urinary tract disorders (eg, retention, nephrolithiasis, etc.) (Am J Infect Control 2005; 33:326-32; Urology 2006; 68:1169-74).

    Table: Hospital admission rates for complications following TRUS biopsy
    Finally, a recent study by Nam et al has demonstrated an increasing hospital admission rate after prostate biopsy, from 1.0% in 1996 to 4.1% in 2005 (J Urol 2010; 183:963-9) (table). The majority (71.6%) of admissions were for infectious complications, with the rate of such admissions increasing from 0.6% in 1996 to 2.6% in 2005. In a complementary U.S. study performed in the Medicare population, Johns Hopkins researchers found rising rates of biopsy-related infectious complications, particularly in more recent years (J Urol 2010; 183[suppl]:e815, abs. 2096). The recent rise in hospital admissions for infectious complications following prostate biopsy and increased rates of fluoroquinolone resistance are cause for concern. Therefore, urologists must be proactive in preventing complications.


    Anthony J. Schaeffer, MD
    Dr. Schaeffer, a member of the Urology Times Editorial Council, is professor and chairman, department of urology, Feinberg School of ...


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