Infection on the Rise After Transrectal Prostate Biopsy

Kate Johnson

March 27, 2015

MADRID — Infection rates after transrectal prostate biopsy are on the rise, and are "considerably higher" than they were a decade ago, a worldwide prevalence study suggests.

"We initiated this study in 2010 because of more and more evidence that infections after transrectal biopsy were a problem," said study investigator Florian Wagenlehner, MD, from the Justus-Liebig University in Giessen, Germany.

Among the prostate biopsies performed around the world — and approximately 1 million are performed in Europe alone each year — there is a "significant level of infectious complications," he said here at the European Association of Urology 30th Annual Congress.

The research, conducted from 2010 and 2013 as a side study of the Global Prevalence of Infections in Urology study, involved 1214 patients from 136 countries in Africa, Asia, Europe, and South America.

Patients biopsied during a 2-week window each year were eligible for the study.

Outcome data 2 weeks after biopsy were available for 876 patients. Of this cohort, 97% had undergone transrectal biopsy and 98% had received prophylactic antibiotics (82% with fluoroquinolone-based agents).

Of these patients, 50% developed symptomatic urinary tract infections, 3% developed febrile urinary tract infections, and 4% were hospitalized for these infections. One patient died as a result.

 
I use this information in counseling patients.
 

"These rates are significantly higher than results published in the 1990s, which showed febrile urinary tract infections around 1%, so there's definitely a higher rate now," Dr Wagenlehner told Medscape Medical News.

This infection prevalence information is very valuable for clinicians, said Michael Liss, MD, from the University of Texas Health Science Center in San Antonio, who was approached for comment.

"I use this information in counseling patients," said Dr Liss "If their risk of infection or hospitalization is higher than the chances of high-grade prostate cancer, I would recommend against prostate biopsy."

Risk Factors

Risk factors for infection — such as preoperative bacteriuria, bowel preparation, antibiotic prophylaxis for more than 1 day, fluoroquinolone-based prophylaxis, repeat biopsy, local anesthesia, and histopathologic inflammation — were not significantly different between patients who developed infection after biopsy and those who did not.

"Our study did not find any risk factors, but we know from other studies that a major risk factor is fluoroquinolone resistance," Dr Wagenlehner said.

Dr Liss pointed out that in this study, the researchers "could not control for the antibiotics given by the physicians. Therefore, the physicians most likely selected the men at highest risk for infection and gave them alternative or additional antibiotics to prevent infection."

Although studies have shown that targeted antibiotic prophylaxis based on fecal flora analysis can reduce infection rates, one expert not involved in the study expressed reservations.

"The idea of using antibiotics to try to avert fluoroquinolone resistance is nice," said Karan Wahda, MD, from the University of Cambridge in the United Kingdom. "Unfortunately, we're going to run out of antibiotics soon and, despite our best efforts, we're really not going to have anything in terms of prophylaxis," he told Medscape Medical News. Transperineal prostate biopsy provides an alternative because it allows us to avoid the fecal route, he added.

However, despite evidence that transperineal biopsies pose significantly less infection risk than the transrectal approach, this worldwide study shows that 97% of clinicians still use the transrectal route.

"For the general practitioner urologist, the transperineal biopsy is not the first choice," Dr Wahda explained, because the procedure requires that the patient be under general anesthesia.

Dr Wagenlehner, Dr Liss, and Dr Wahda have disclosed no relevant financial relationships.

European Association of Urology (EAU) 30th Annual Congress: Abstract 255. Presented March 21, 2015.

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