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    Updated prostate Bx paper outlines preventive strategies

    Risk assessment, directed or augmented prophylaxis among recommendations

    Badar M. Mian, MDBadar M. Mian, MD

     

    “Journal Article of the Month” is a new Urology Times section in which Badar M. Mian, MD, in which Badar M. Mian, MD (left), offers perspective on noteworthy research in the peer-reviewed literature.  Dr. Mian is associate professor of surgery in the division of urology at Albany Medical College, Albany, NY.


    Despite a recent decline in the number of prostate biopsies performed each year, it remains one of the most common urologic procedures in the United States (also see “Major decline in prostate Bx rates follows PSA publications"). According to a recent white paper published by the AUA and the Society of Urologic Nurses and Associates, risk assessment should be performed in all men undergoing prostate biopsy to determine their risk of complications and alternative strategies should be utilized to prevent such complications.

    Lead author Michael Liss, MD, assistant professor of urology the University of Texas Health Science Center in San Antonio, and co-authors have updated the previous white paper from 2012 to include new data on the prevalence of prostate biopsy-related complications and outline the current preventive strategies. This white paper, which is meant to serve as “a more concise reference document for the more common complications,” is focused primarily on the infectious complications. The report is based on the data compiled from 119 manuscripts on this subject between January 2010 and June 2015 and was published online in the Journal of Urology (March 28, 2017).

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    Bleeding complications are the most prevalent complications after prostate biopsy and are reported in 10%-95% of patients. These complications include hematospermia, hematuria, and rectal bleeding. While these side effects can be troublesome and anxiety provoking for patients, these are almost always self-limited. Active intervention for hematuria or rectal bleeding, such as cauterization, hospitalization, endoscopy, etc. are required in 1%-2.5% of men.

    The biopsy-related infectious complications, which are less frequent but potentially more serious, have been on the rise over the last 10 years. This is in large part due to the presence of fluoroquinolone (FQ)-resistant gram negative bacterial colonization of the rectum. The authors noted that the risk of FQ-resistance in the rectal cultures to be over 20%. They reported the rate of infectious complications to be from 0.1% to 7.0%, and the risk of sepsis from 0.3% to 3.1%.

    Post-Bx infection: Factors to consider

    There are a couple of considerations regarding the risk of post-biopsy infections. First, the reported range is quite wide, which raises questions about the definitions and data collection in those studies. Second, the rate of FQ resistance in most communities is 20%-25%, yet the FQ-resistant bacterial infections occur in only a fraction of those patients. Clearly, there is more to the risk of post-biopsy infections than just the prophylactic antibiotics. There are certainly some other factors that influence the risk of infection such as bacterial load, host immunity, timing, and serum levels of antibiotics, and require further study.

    A number of preventive strategies are catalogued in this white paper, including risk assessment through history taking and directed or augmented antibiotic prophylaxis. Pre-biopsy rectal culture-guided antibiotics are reported by several authors to lower infection rate. Others have reported a similar reduction in infections through augmented or adjusted antibiotics based on clinical risk factors such as FQ use in the previous 6 months, previous infections, overseas travel, and working in a health care setting. Other useful measures that have reportedly reduced the infection rate include povidone-iodine rectal prep and needle wipes, and adherence of general principles to prevent cross contamination or use of disposable needle guides.

    Also see:

    While it’s extremely important to learn and understand the extent of the infectious issues following prostate biopsy, there is a risk in overstating the problem as well. For example, raising undue alarm about the risk of sepsis may dissuade some patients and urologists from adopting active surveillance strategies for low-risk prostate cancer.

    Trying to identify the single best method of infection prevention is less important than being aware of the risk in one’s own practice or center. For every patient, risk assessment through history taking, adjusting the antibiotic regimen, and knowledge of local antibiograms will go a long way to keep the problem of post-biopsy infections under control.

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