British Journalof Urology (1979, 41, 679-681 0
Urinary Tract Infection following Trans-rectal Biopsy of the Prostate D. P. FAWCETT, SUSANNAH EYKYN, M. I. BULTITUDE
Departments of Urology and Microbiology, St Thomas’s Hospital, London
Trans-rectal prostatic biopsy has been used for some years as a method of obtaining tissue for histology and reported complications of the procedure are uncommon. Wendel and Evans (1 967) in a review of over 4,300 cases of punch biopsy of the prostate by both trans-rectal and transperineal routes found an overall incidence of complications of 3.7 % with one case of “pyelonephritis”. In their own series of 250 cases the incidence was 7-2% with one case of “cystitis”. In a later study, Davison and Malament (1971) found that of 50 patients with negative urine cultures before trans-rectal biopsy 17.7% developed a urinary tract infection following the procedure, on one occasion associated with a fatal septicaemia with E. coli. This paper compares the incidence of urinary infection following trans-rectal biopsy with that following simple endoscopy.
Patients and Methods All trans-rectal biopsies in this department are preceded by bladder endoscopy which in itself carries a risk of urinary infection. Two surveys were therefore undertaken: 1. A retrospective survey of all cases of trans-rectal biopsy of the prostate performed between 1968 and 1973 for whom detailed records of pre- and postoperative urine cultures and antibiotic therapy were available. Urine was considered infected if a mid-stream specimen contained 105 or more bacteria per ml. 2. A prospective survey of urinary tract infection following bladder endoscopy to establish the incidence of urinary infection attributable solely to the biopsy procedure. We studied male patients who were having simple diagnostic urethral and bladder endoscopy under general anaesthesia either as in-patients or out-patients. Preoperative urine specimens were collected after the passage of the cystoscope and postoperative cultures were obtained on the fourth day following the procedure using the ‘Dipinoc’ type of dip inoculum which was sent to the Microbiology Department. In both groups of patients the urine was known to be sterile at the time of the biopsy. Any patient with infected urine at the time was automatically excluded from the study, and any patient for whom the bacteriological state of the preoperative urine was not known was also excluded.
Results 1. Retrospective survey: a total of 56 trans-rectal biopsies had been performed but in only 44 were sufficient bacteriological data available for analysis. Of these 44 cases, 17 had received antibiotic therapy which had begun the day after the procedure. Table I shows the incidence of urinary tract infection and the organisms isolated in these patients. 2. Prospective survey: a total of 137 cystoscopies were performed but 14 of the patients failed to return the dipslides to the laboratory. The incidence of infection for the 123 patients whose dipslides were returned and the organisms cultured from their urine are shown in Table 11. 619
680
BRITISH JOURNAL OF UnoLoCjY
Table I Incidence of Urinary Tract Infection following Trans-rectal Biopsy No. patients
lnfected post-op.
Uninfected post-op.
N o systemic antibiotics Systemic antibiotics
27 17
12 (44.5 %) 5 (30.0%)
15 (55.5 %) 12 (70.0%)
Total
44
17 ( 3 8 3 %)
27 (61.5 %)
___
Organisms isolated: E. coli, 10 (2 positive blood cultures); S. faecalis, 5; E. coli S. faecalis, 1 ; P. mirabilis, I .
+
Table II Incidence of Urinary Tract Infection following Cystoscopy No. patients
Post-op infection
123
9 (7.6 %)
Organisms isolated: E. coli, 6; S. faecalis, 2; Klebsiella, 1.
Discussion Our retrospective survey of patients undergoing trans-rectal biopsy of the prostate showed that 38.5% of the 44 patients developed urinary tract infection, on at least 2 occasions with accompanying bacteraemia. This rate is twice that quoted by Davis and Malament (1971) and is unacceptably high. The postoperative “prophylactic” systemic antibiotics which I7 of the patients received reduced their infection rate to 30% compared with an incidence of 44.5% in the 27 patients who did not receive antibiotics. A course of “prophylactic” systemic antibiotics given after the operation would seem to have achieved only a minor reduction in the infection rate (from 44.5% to 30%). It is possible that if an adequate concentration of a suitable antimicrobial had been present in both blood and urine at the time of the trans-rectal biopsy the results niight have been different. Since in all the patients undergoing prostatic biopsy the procedure was preceded by endoscopy the object of the prospective survey was to assess how often urinary infection was likely to occur from this alone. The incidence of 7.6% was considerably lower than that following prostatic biopsy though the bacteria isolated were similar. We conclude that trans-rectal prostatic biopsy results in an increased incidence of postoperative urinary infection. It seems likely that this arises either from perforation of the bladder base or direct implantation of faecal bacteria into the prostatic ducts. It might be possible to prevent such infections by administering a systemic antibiotic hefbre the procedure thereby ensuring maximum blood and urine concentrations of the drug at the time of the biopsy.
URINARY TRACT INFECTION FOLLOWING TRANS-RECTAL BIOPSY OF THE PROSTATE
681
Summary An unacceptably high incidence of urinary tract infection was found in a retrospective survey of patients undergoing trans-rectal biopsy of the prostate. The incidence was considerably greater than that found in a prospective survey of bladder endoscopy alone. It is suggested that preoperative antibiotic prophylaxis might be worthwhile in this situation.
References DAVISON, P. and MALAMENT, M. (1971). Urinary contamination as a result of transrectal biopsy of the prostate. Journal of Urology, 105, 545-546. WENDEL, R. G. and EVANS,A. T. (1967). Complications of punch biopsy of the prostate gland. Journal of Urology, 97, 122-126.
The Authors Derek Fawcett, MB, BS, Senior House Officer, Department of Urology. Susannah Eykyn, MB, BS, MRC Path, Senior Lecturer, Department of Microbiology. M. I. Bultitude, FRCS, Senior Registrar, Department of Urology.
47/64
Urinary Tract Infection following Trans-rectal Biopsy of the Prostate D. P. FAWCETT, SUSANNAH EYKYN, M. I. BULTITUDE
Departments of Urology and Microbiology, St Thomas’s Hospital, London
Trans-rectal prostatic biopsy has been used for some years as a method of obtaining tissue for histology and reported complications of the procedure are uncommon. Wendel and Evans (1 967) in a review of over 4,300 cases of punch biopsy of the prostate by both trans-rectal and transperineal routes found an overall incidence of complications of 3.7 % with one case of “pyelonephritis”. In their own series of 250 cases the incidence was 7-2% with one case of “cystitis”. In a later study, Davison and Malament (1971) found that of 50 patients with negative urine cultures before trans-rectal biopsy 17.7% developed a urinary tract infection following the procedure, on one occasion associated with a fatal septicaemia with E. coli. This paper compares the incidence of urinary infection following trans-rectal biopsy with that following simple endoscopy.
Patients and Methods All trans-rectal biopsies in this department are preceded by bladder endoscopy which in itself carries a risk of urinary infection. Two surveys were therefore undertaken: 1. A retrospective survey of all cases of trans-rectal biopsy of the prostate performed between 1968 and 1973 for whom detailed records of pre- and postoperative urine cultures and antibiotic therapy were available. Urine was considered infected if a mid-stream specimen contained 105 or more bacteria per ml. 2. A prospective survey of urinary tract infection following bladder endoscopy to establish the incidence of urinary infection attributable solely to the biopsy procedure. We studied male patients who were having simple diagnostic urethral and bladder endoscopy under general anaesthesia either as in-patients or out-patients. Preoperative urine specimens were collected after the passage of the cystoscope and postoperative cultures were obtained on the fourth day following the procedure using the ‘Dipinoc’ type of dip inoculum which was sent to the Microbiology Department. In both groups of patients the urine was known to be sterile at the time of the biopsy. Any patient with infected urine at the time was automatically excluded from the study, and any patient for whom the bacteriological state of the preoperative urine was not known was also excluded.
Results 1. Retrospective survey: a total of 56 trans-rectal biopsies had been performed but in only 44 were sufficient bacteriological data available for analysis. Of these 44 cases, 17 had received antibiotic therapy which had begun the day after the procedure. Table I shows the incidence of urinary tract infection and the organisms isolated in these patients. 2. Prospective survey: a total of 137 cystoscopies were performed but 14 of the patients failed to return the dipslides to the laboratory. The incidence of infection for the 123 patients whose dipslides were returned and the organisms cultured from their urine are shown in Table 11. 619
680
BRITISH JOURNAL OF UnoLoCjY
Table I Incidence of Urinary Tract Infection following Trans-rectal Biopsy No. patients
lnfected post-op.
Uninfected post-op.
N o systemic antibiotics Systemic antibiotics
27 17
12 (44.5 %) 5 (30.0%)
15 (55.5 %) 12 (70.0%)
Total
44
17 ( 3 8 3 %)
27 (61.5 %)
___
Organisms isolated: E. coli, 10 (2 positive blood cultures); S. faecalis, 5; E. coli S. faecalis, 1 ; P. mirabilis, I .
+
Table II Incidence of Urinary Tract Infection following Cystoscopy No. patients
Post-op infection
123
9 (7.6 %)
Organisms isolated: E. coli, 6; S. faecalis, 2; Klebsiella, 1.
Discussion Our retrospective survey of patients undergoing trans-rectal biopsy of the prostate showed that 38.5% of the 44 patients developed urinary tract infection, on at least 2 occasions with accompanying bacteraemia. This rate is twice that quoted by Davis and Malament (1971) and is unacceptably high. The postoperative “prophylactic” systemic antibiotics which I7 of the patients received reduced their infection rate to 30% compared with an incidence of 44.5% in the 27 patients who did not receive antibiotics. A course of “prophylactic” systemic antibiotics given after the operation would seem to have achieved only a minor reduction in the infection rate (from 44.5% to 30%). It is possible that if an adequate concentration of a suitable antimicrobial had been present in both blood and urine at the time of the trans-rectal biopsy the results niight have been different. Since in all the patients undergoing prostatic biopsy the procedure was preceded by endoscopy the object of the prospective survey was to assess how often urinary infection was likely to occur from this alone. The incidence of 7.6% was considerably lower than that following prostatic biopsy though the bacteria isolated were similar. We conclude that trans-rectal prostatic biopsy results in an increased incidence of postoperative urinary infection. It seems likely that this arises either from perforation of the bladder base or direct implantation of faecal bacteria into the prostatic ducts. It might be possible to prevent such infections by administering a systemic antibiotic hefbre the procedure thereby ensuring maximum blood and urine concentrations of the drug at the time of the biopsy.
URINARY TRACT INFECTION FOLLOWING TRANS-RECTAL BIOPSY OF THE PROSTATE
681
Summary An unacceptably high incidence of urinary tract infection was found in a retrospective survey of patients undergoing trans-rectal biopsy of the prostate. The incidence was considerably greater than that found in a prospective survey of bladder endoscopy alone. It is suggested that preoperative antibiotic prophylaxis might be worthwhile in this situation.
References DAVISON, P. and MALAMENT, M. (1971). Urinary contamination as a result of transrectal biopsy of the prostate. Journal of Urology, 105, 545-546. WENDEL, R. G. and EVANS,A. T. (1967). Complications of punch biopsy of the prostate gland. Journal of Urology, 97, 122-126.
The Authors Derek Fawcett, MB, BS, Senior House Officer, Department of Urology. Susannah Eykyn, MB, BS, MRC Path, Senior Lecturer, Department of Microbiology. M. I. Bultitude, FRCS, Senior Registrar, Department of Urology.
47/64
