Key Points
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Rates of infectious complications after transrectal prostate biopsies have increased over the past 15 years
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The predominant risk factor for postbiopsy infection seems to be exposure to faecal fluoroquinolone-resistant bacteria
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Every patient should undergo a preoperative assessment, including history of fluoroquinolone intake over the past 6 months, and a urine culture
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Choice of empirical antibiotic prophylaxis should take regional resistance rates into consideration, as well as the pharmacokinetic and pharmacodynamic characteristics of each antibiotic
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Novel strategies to reduce rates of infectious complications after transrectal prostate biopsies include targeted prophylaxis after sampling of the rectal flora, bowel preparation, and perineal prostate biopsy
Abstract
Over the years, prostate biopsy has become the gold-standard technique for diagnosing prostate carcinoma. Worldwide, several million prostate biopsies are performed every year, most commonly using the transrectal approach. Preoperative antibiotic prophylaxis with fluoroquinolones has been shown to be effective for reducing infection rates. However, in recent years, an increase in febrile infection rates after transrectal prostate biopsy (from 1% to 4%) has been reported in retrospective and prospective studies. The predominant risk factor for infection seems to be the presence of fluoroquinolone-resistant bacteria in faeces. Patients at risk of fluoroquinolone resistance should receive carefully selected antibiotics at sufficient concentrations to be effective. Targeted prophylaxis after rectal flora swabbing has been shown to be efficacious compared with empirical antibiotic prophylaxis. Several forms of bowel preparations are under investigation, although none have yet been shown to significantly reduce infection rates. Perineal prostate biopsy is currently being evaluated as a strategy for preventing the inoculation of rectal flora, but limited data support this approach at present.
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F. M. E. Wagenlehner researched, wrote, edited, and discussed this article with colleagues. A. Pilatz researched the literature and reviewed the manuscript before submission. P. Waliszewski, W. Weidner, and T. E. Bjerklund Johansen reviewed the article and made substantial contributions towards discussions of content.
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F. M. E. Wagenlehner has served as a paid consultant for Astellas, AstraZeneca, Bionorica, Cernelle, Cubist, OM-Pharma, Lilly Pharma, Pierre Fabre, and Rosen-Pharma. He has received lecture honoraria from AstraZeneca, Bionorica, OM-Pharma, Pierre Fabre, Rosen Pharma, and Serag Wiessner. He has been paid for performing clinical trials on behalf of Astellas, AstraZeneca, Calixa, Cerexa, Cernelle, Cubist, GSK, Merlion, OM-Pharma, Janssen-Cilag, Johnson & Johnson, Lilly Pharma, Pharmacia, Pierre-Fabre, Rosen Pharma, Sanofi-Aventis, Strathmann, and Zambon. The other authors declare no competing interests.
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Wagenlehner, F., Pilatz, A., Waliszewski, P. et al. Reducing infection rates after prostate biopsy. Nat Rev Urol 11, 80–86 (2014). https://doi.org/10.1038/nrurol.2013.322
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DOI: https://doi.org/10.1038/nrurol.2013.322
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