Infectious Complications after Prostate Biopsy: A Prospective Multicenter Prostate Biopsy Study

Eu Chang Hwang; Ho Song Yu; Seung Il Jung; Dong Deuk Kwon; Sun Ju Lee; Tae-Hyoung Kim; In Ho Chang; Hana Yoon; Bongsuk Shim; Kwang Hyun Kim; Donghyun Lee; Jung-Sik Huh; Dong Hoon Lim; Won Jin Jo; Seung Ki Min; Gilho Lee; Ki Ho Kim; Tae Hwan Kim; Seo Yeon Lee; Seung Ok Yang; Sang Don Lee; Chang Hee Han; Sang Rak Bae; Hyun Sop Choe; Seung-Ju Lee; Hong Chung; Yong Gil Na; Seung Woo Yang; Sung Woon Park; Young Ho Kim; Tae Hyo Kim; Won Yeol Cho; June Hyun Han; Yong-Hyun Cho; U-Syn Ha; Heung Jae Park

doi:10.14777/uti.2016.11.1.17

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Hwang, Yu, Jung, Kwon, Lee, Kim, Chang, Yoon, Shim, Kim, Lee, Huh, Lim, Jo, Min, Lee, Kim, Kim, Lee, Yang, Lee, Han, Bae, Choe, Lee, Chung, Na, Yang, Park, Kim, Kim, Cho, Han, Cho, Ha, and Park: Infectious Complications after Prostate Biopsy: A Prospective Multicenter Prostate Biopsy Study

Original Article

Urogenit Tract Infect 2016;11(1):17-24.

Published online: 20 April 2016

DOI: https://doi.org/10.14777/uti.2016.11.1.17

Infectious Complications after Prostate Biopsy: A Prospective Multicenter Prostate Biopsy Study

Eu Chang Hwang, Ho Song Yu, Seung Il Jung, Dong Deuk Kwon, Sun Ju Lee¹, Tae-Hyoung Kim², In Ho Chang², Hana Yoon³, Bongsuk Shim³, Kwang Hyun Kim³, Donghyun Lee³, Jung-Sik Huh⁴, Dong Hoon Lim⁵, Won Jin Jo⁵, Seung Ki Min⁶, Gilho Lee⁷, Ki Ho Kim⁸, Tae Hwan Kim⁹, Seo Yeon Lee¹⁰, Seung Ok Yang¹¹, Sang Don Lee¹², Chang Hee Han¹³, Sang Rak Bae¹³, Hyun Sop Choe¹⁴, Seung-Ju Lee¹⁴, Hong Chung¹⁵, Yong Gil Na¹⁶, Seung Woo Yang¹⁶, Sung Woon Park¹⁷, Young Ho Kim¹⁸, Tae Hyo Kim¹⁹, Won Yeol Cho¹⁹, June Hyun Han²⁰, Yong-Hyun Cho²¹, U-Syn Ha²², Heung Jae Park²³

Department of Urology, Chonnam National University Medical School, Gwangju, Korea

¹Kyung Hee University School of Medicine, Seoul, Korea

²Chung-Ang University School of Medicine, Seoul, Korea

³Ewha Womans University School of Medicine, Seoul, Korea

⁴Jeju National University School of Medicine, Jeju, Korea

⁵Chosun University School of Medicine, Gwangju, Korea

⁶National Police Hospital, Seoul, Korea

⁷Dankook University Medical College, Cheonan, Korea

⁸Dongguk University School of Medicine, Gyeongju, Korea

⁹Kyungpook National University School of Medicine, Daegu, Korea

¹⁰0Myongji Hospital, Seonam University, Goyang, Korea

¹¹Veterans Health Service Medical Center, Seoul, Korea

¹²Pusan National University Yangsan Hospital, Yangsan, Korea

¹³The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea

¹⁴The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea

¹⁵Konkuk University School of Medicine, Chungju, Korea

¹⁶Chungnam National University School of Medicine, Daejeon, Korea

¹⁷Kwangju Christian Hospital, Gwangju, Korea

¹⁸Soon Chun Hyang University Bucheon Hospital, Bucheon, Korea

¹⁹Dong-A University College of Medicine, Busan, Korea

²⁰Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea

²¹The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea

²²The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea

²³Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Seung Il Jung http://orcid.org/0000-0003-4864-8175 Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, 322 Seoyang-ro, Hwasun-eup, Hwasun 58128, Korea Tel: +82-61-379-8160, Fax: +82-61-379-7750 E-mail: drjsi@yahoo.co.kr

Received 10 March 2016 Revised 27 March 2016 Accepted 28 March 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Recent studies have highlighted an increasing trend of infectious complications due to fluoroquinolone-resistant organisms among men undergoing transrectal prostate biopsy. This study evaluated the current incidence of infective complications after trans-rectal prostate biopsy for identification of risk factors in Korean men who received fluoroquinolone prophylaxis.

Materials and Methods

A prospective, multicenter study was conducted in Korea from January to December 2015. Prostate biopsies performed with fluoroquinolone prophylaxis during 3 months in each center were included. A pre-biopsy questionnaire was used for identification of patient characteristics. Clinical variables including underlying disease, antibiotic prophylaxis, enema, povidone-iodine cleansing of the rectum, and infectious complications were evaluated. The primary outcome was the post-biopsy infection rate after fluoroquinolone prophylaxis. Univariable and multivariable analyses were used for identification of risk factors for infectious complications.

Results

The study included 827 patients, of whom 93 patients (11.2%) reported receiving antibiotics in the previous 6 months and 2.5% had a history of prostatitis. The infectious complication rate was 2.2%. Post-biopsy sepsis was reported in 2 patients (0.2%). In multivariable analysis predictors of post-biopsy sepsis included person performing biopsy (adjusted odds ratio [OR], 4.05; 95% confidence interval [CI], 1.31–12.5; p=0.015) and operation history within 6 months (adjusted OR, 5.65; 95% CI, 1.74–18.2; p=0.004).

Conclusions

The post-prostate biopsy infectious complication rate in this study was 2.2%. Person performing biopsy (non-urologists) and recent operation history were independent risk factors for infectious complications after trans-rectal prostate biopsy.

Keywords: Biopsy, Escherichia coli, Fluoroquinolones, Infection, Prostate

References

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Table 1.

Baseline characteristics of enrolled patients

Variable	Value (n=827)
Age (y)	69 (63–74)
PSA^a) (ng/dl)	1.87 (1.51–2.43)
Prostate volume (ml)	37.2 (27.0–51.7)
Biopsy operators
Urologist	423 (51.1)
Non-urologists	404 (48.9)
Biopsy results
BPH	512 (61.9)
Prostate cancer	313 (37.8)
ASAP	2 (0.2)
Number of biopsy cores
＜12	345 (41.7)
≥12	482 (58.3)
Health care-associated patients	98 (11.9)
Health care workers
Non-medical	806 (97.5)
Medical service provider	20 (2.4)
Medical service provider's family	1 (0.1)
Travel history within 4 wk	20 (2.4)
Diabetes mellitus	122 (14.8)
Operation history within 6 mo	48 (5.8)
Prostatitis history within 6 mo	21 (2.5)
UTI history within 6 mo	12 (1.5)
Prior prostate biopsy
No	794 (96.0)
＜12 mo	23 (2.8)
≥12 mo	10 (1.2)
Antibiotics exposure history	93 (11.2)
Duration of Antibiotics
＜3 d	104 (12.6)
≥3 d	723 (87.4)
Local anesthesia used	252 (30.5)
Povidone iodine used	827 (100)
Enema
No	21 (2.5)
Rectal	789 (95.4)
Oral	17 (2.1)
Infectious complication	18 (2.2)
Hospitalization due to infectious complications	16 (1.9)
Fever	17 (2.1)
UTI, acute prostatitis	15 (1.8)
Bacteremia	8 (1.0)
Sepsis	2 (0.2)

Values are presented as median (interquartile range) or number (%). PSA: prostate specific antigen, BPH: benign prostate hyperplasia, ASAP: atypical small acinar proliferation, UTI: urinary tract infection.

^a )Logarithmically adjusted.

Table 2.

Univariable and multivariable analysis of clinical parameters affecting infectious complications after prostate biopsy

Variable	Odds ratio	p-value	Adjusted odds ratio	p-value
Age	0.96 (0.91–1.01)	0.088
Person performing biopsy (non-urologists vs. urologists)	3.76 (1.22–11.5)	0.020	4.05 (1.31–12.5)	0.015
Number of biopsy cores (vs. ＜12)	2.85 (1.06–7.69)	0.038
Health care-associated	2.96 (1.03–8.49)	0.043
Health care workers
Medical service provider	NA	0.998
Medical service provider's family	NA	1
Travel history within 4 wk	NA	0.998
Diabetes mellitus	1.67 (0.54–5.17)	0.371
Operation history within 6 mo	4.96 (1.57–15.7)	0.006	5.65 (1.74–18.2)	0.004
Prostatitis history within 6 mo	2.32 (0.29–18.2)	0.424
UTI history within 6 mo	4.26 (0.52–34.9)	0.176
Prior prostate biopsy (vs. no)
＜12 mo	NA	0.998
≥12 mo	NA	0.999
Antibiotics exposure history	4.14 (1.51–11.3)	0.006
Duration of antibiotic use (vs. ≥3 d)	2.48 (0.32–18.8)	0.380
Local anesthesia used	0.28 (0.06–1.22)	0.091
Enema
Rectal	NA	0.998
Oral	NA	1

UTI: urinary tract infection, NA: not available.

Table 3.

Culture results

Culture	Pathogens	ESBL positivity	Fluoroquinolone resistance
Urine (n=2)	E. coli	–	+
Urine (n=2)	E. coli	–	+
Blood (n=3)	E. coli	+	+
	E. coli	–	+
	Staphylococcus aureus	–	–
Blood and urine (n=5)	E. coli	+	+
	E. coli	+	+
	Citrobacter freundii	–	–
	E. coli	+	+
	E. coli	–	+

ESBL: extended-spectrum beta lactamase, E. coli: Escherichia coli.

Table 4.

Escherichia coli resistance patterns

Antibiotics	Urine (n=2)		Blood (n=2)		Blood and urine (n=4)
Amoxicillin/clavulanate	Resistance	Sensitive	Sensitive	Sensitive	Intermediatte	Resistance	Resistance	Sensitive
Piperacillin/tazobactam	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive
Trimethoprim-sulfamethoxazole	Resistance	Sensitive	Sensitive	Resistance	Sensitive	Resistance	Resistance	Resistance
Levofloxacin	Not tested	Intermediatte	Not tested	Not tested	Not tested	Resistance	Not tested	Not tested
Ciprofloxacin	Resistance	Resistance	Intermediate	Resistance	Resistance	Resistance	Resistance	Resistance
Gentamicin	Resistance	Resistance	Sensitive	Not tested	Resistance	Sensitive	Sensitive	Sensitive
Amikacin	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive
Imipenem	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive	Sensitive
Meropenem	Not tested	Sensitive	Sensitive	Sensitive	Not tested	Sensitive	Not tested	Not tested

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