How to reduce prostate biopsy complications

Each year more than 1 million men in the U.S. have a prostate biopsy, an invasive procedure to discover whether the prostate gland is cancerous. While most prostate biopsies turn out to be negative, the rate of cancer detection as a result of biopsies ranges from 17 to 44 percent in recent studies. But an alarming number of the men who undergo the procedure are also getting infections that are resistant to antibiotics. The problem is so serious that our medical consultants say men should be cautious about prostate-cancer screening.

A biopsy is the usual follow-up procedure if a man’s prostate-specific anti­gen level is consistently elevated, as shown by a blood test. In a standard biopsy, a urologist uses an ultrasound probe to guide a needle through the wall of the rectum and into the prostate gland, taking multiple tissue samples to examine for cancerous cells. Since the rectum is full of bacteria, doctors should prescribe antibiotics before and after the procedure to thwart infection.

The latest research suggests that between 1 percent and 4 percent of men who have a prostate biopsy will develop an infection requiring hospital care. The 30-day hospital admission rate for infections increased from 0.6 percent in 1996 to 3.6 percent in 2005, according to a study of 75,190 Canadian men published in January 2013 in the Journal of Urology. A U.S. study of 17,472 men enrolled in Medicare covering a 16-year span found an increased rate of infections requiring hospitalization. The bump was seen toward the end of the study.

For more information read "Evaluating drugs used to treat enlarged prostate."

In the last decade, some bacterial strains have become resistant to the class of antibiotics that were once highly effective: fluoroquinolones such as ciprofloxacin (Cipro and generic). Studies suggest that about one in five men undergoing biopsies harbor E. coli bacteria that are resistant to fluoroquinolones. They are more likely to develop infections of the urinary tract or bloodstream and land in a hospital’s intensive-care unit.

With proper precautions, prostate biopsies can be done with a lower risk of infection. It’s worth noting that complications beyond infections have become less common, so the overall rate of hospitalizations after biopsies decreased from 12 percent in the early 1990s to about 5 percent by 2007 in the study of men enrolled in Medicare. So don’t let a fear of infection deter you from having a prostate biopsy if you and your doctor decide it’s appropriate.

“The best way to reduce a biopsy complication is to reduce unnecessary biopsies,” said Edward Schaeffer, M.D., Ph.D., an associate professor at Johns Hopkins University School of Medicine. Considering all the evidence, here’s what our medical experts advise.

• Consider skipping prostate-cancer screening altogether. It can detect prostate cancer early, but testing 1,000 men every one to four years from age 55 to 69 has been shown to prevent up to one death from the disease. Also, PSA testing can lead to unneeded biopsies. Consumer Reports says men ages 50 to 74 should talk with a doctor to see whether the benefits of the test outweigh the risks based on several factors. Older men rarely need the PSA test because the cancer typically progresses so slowly that treatment doesn’t improve survival. Younger men should consider testing only if they’re at high risk, because the cancer is uncommon before age 50. (Risk factors include a family history of the disease, being African-American, and smoking.)

• Don’t assume that you need a biopsy if your PSA is elevated. Other causes for high PSA levels may include an enlarged prostate, recent sexual intercourse, prostatitis, and even long bicycle rides. It’s often reasonable to wait and repeat the PSA blood test. Discuss with your doctor whether the potential benefit of a biopsy outweighs the harm.

• If you decide to have a biopsy, ask your urologist to first do a rectal swab to determine if you are harboring antibiotic resistant bacteria. It should be done about a week before the biopsy so that results can guide the choice of antibiotics, reserving broad-spectrum antibiotics for when they are needed. Insurance usually covers the test.

• A transperineal biopsy, which avoids the bacteria-laden rectum by inserting a needle through the perineum (the space between the anus and the scrotum), is another available option, but it’s not often used to reduce the risk of infection. That procedure is more typically used in rare cases where, for instance, a traditional rectal biopsy isn’t possible.