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Editorial Comment from Dr Togo to Hospital admissions after transrectal ultrasound‐guided biopsy of the prostate in men diagnosed with prostate cancer: A database analysis in England

A prostate biopsy procedure is indispensable for detection of prostate cancer, and the transrectal approach is carried out worldwide. Although genitourinary tract infections after a prostate biopsy are infrequent, antimicrobial prophylaxis is given when appropriate, as an increase in incidence of febrile infection with resistant organisms after such procedure has been reported, with profound clinical and economic impacts. In addition, potentially fatal infective complications including septic shock after a prostate biopsy procedure have also been documented. This is a large retrospective study that investigated the complication rate and analyzed risk factors after transrectal prostate biopsy procedure carried out in England. The study findings are interesting in this era of increasing multidrug-resistant bacterial infections, and might influence clinical practice. The present study is similar to a Japanese study that has been reported in International Journal of Urology. The Japanese study was based on a retrospective review of case notes from 212 065 procedures carried out between 2004 and 2006, and found that 1.1% and 0.07% of the patients had fever and sepsis, respectively. Our group also retrospectively investigated the incidence of genitourinary tract infection in 5895 patients who underwent a transrectal and/or transperineal prostate biopsy between January and December 2011 at 46 institutions belonging to the Japanese Research Group for Urinary Tract Infection. Univariate analysis results showed older age (P = 0.015) and avoidance of disinfection in the rectum (P = 0.0001) as possible factors for infection with the transrectal approach, whereas an indwelling urethral catheter (P < 0.001), use of immunosuppressive agents (P = 0.009) and steroid administration (P < 0.001) were candidates with the transperineal approach. In contrast, multivariate analysis showed no risk factors for infectious complications after a prostate biopsy with either approach. Hospitalization was required in 0.63% of those cases (transrectal 0.73%, transperineal 0.24%). There has been a recent increase in multidrug-resistant pathogens, which is a serious problem, and recent studies have highlighted four approaches that can be used to prevent infection after a prostate biopsy. First is careful objective determination of patients who require a transrectal ultrasound-guided biopsy of the prostate procedure. Nomograms and predictive models, new biomarkers and derivatives of prostate-specific antigen, as well as the newly employed multiparametric magnetic resonance imaging, are helpful for selecting patients at increased risk of prostate cancer, as an unnecessary prostate biopsy procedure must be avoided in those cases. Second, routine rectal swab culture findings can indicate the need for prophylactic antibiotics by characterization of antimicrobial resistance in the rectal flora, though its cost might not be covered by insurance in several countries. Taylor et al. reported that targeted antimicrobial prophylaxis based on the results of rectal swab cultures obtained from patients undergoing a transrectal prostate biopsy reduced the incidence of postoperative infectious complications as well as the cost of care. Third, a transperineal approach might offer an alternative method for obtaining prostate tissue samples. Although it is not routinely carried out worldwide, this procedure is executed in one-quarter of the institutions in Japan. Kakehi et al. reported that febrile infection and sepsis were more frequently observed after a transrectal biopsy as compared with a perineal approach in Japanese patients (P < 0.0001). The final approach is escalation of prophylaxis using parenteral antimicrobials, such as carbapenems or second or third generation cephalosporins, though we believe that this might not be the best choice, as it can cause collateral damage.