Doctors Fret Over Rise In Prostate Biopsy Infections

May 23, 2011
Originally published on May 23, 2011 3:00 pm

Well over a million U.S. men are thought to get prostate biopsies every year — a test that involves firing needles into a man's prostate gland from a probe stuck into his backside.

For the vast majority, the test isn't fun, but it's not dangerous.

But specialists are worrying about an increasing risk of complications from prostate biopsy, especially hard-to-treat bloodstream infections that can send men to the ICU and require weeks of heavy-duty antibiotic treatment.

Chicago attorney Tom Hayward is an example. His biopsy wasn't as painful as he expected, and the next day, he played tennis and worked a full day. But at the end of the day, something odd and alarming happened after he started out for a dinner engagement.

"From that point forward, for about an hour, I can't tell you how I got where I did, except I was on ... the three busiest expressways in Chicago," Hayward says.

A 'Dramatic Change' In Mental Status

When Hayward didn't show up for dinner, his wife got concerned. Police located his car because it had an onboard navigational system. By that point, Hayward had realized he was way off-course.

"Fifteen minutes later, one of my sons, who's a lawyer here in town, pulled me over and said, 'Give me the keys,' " Hayward says. "He called an ambulance and took me to a local hospital."

Hayward's urologist, Dr. Anthony Schaeffer, says he suffered a raging infection caused by bacteria present in his gut before the biopsy. The biopsy introduced the bugs into Hayward's bloodstream.

Schaeffer says this kind of bloodstream infection can cause "a very sudden and dramatic change in [mental] status."

Doctors all over the world are increasingly concerned about post-biopsy infections. At last week's annual meeting of the American Urological Association, there were 10 reports on the phenomenon.

"It's a growing problem, and people are recognizing it," says Dr. Robert Nam of the University of Toronto.

He led a study, published last year in the Journal of Urology, that documents a steady increase in infections serious enough to require hospitalization among all Ontario men undergoing prostate biopsies.

A Dramatic Rise In Infections

"The rate went from 1 percent to 4 percent," Nam says. "That's a huge increase. A fourfold increase over a 10-year period in hospital admission rates for a diagnostic procedure is high, very high — concerningly high."

It may not sound like a lot, but applied to a million men undergoing prostate biopsies, it suggests 40,000 could be suffering serious infections, if the Ontario data are any guide.

A recent U.S. study, conducted by Johns Hopkins researchers on records of more than 150,000 Medicare patients, found that 7 percent suffer serious complications requiring hospital care within 30 days after prostate biopsy.

Only a fraction of these are infections — about four in 1,000, or a tenth of the Ontario sample. But Dr. Stacy Loeb, who led the study, notes that the rate of serious infections has been going up sharply over the past decade, while noninfectious complications have been flat.

"Compared to a control group of men who did not undergo prostate biopsy, patients who had a prostate biopsy had almost a threefold increased risk of hospitalization," Loeb says, "and a substantially increased risk of hospitalization for infection."

She says nonwhite men had twice the infection risk as whites.

The underlying problem, many say, is the spread of antibiotic-resistant microbes.

"Unfortunately, there's been a rise of bugs that are resistant to our antibiotics," Loeb says. "So even though they're given to try to prevent infection, they may not work in that situation."

Urologists typically give men an everyday antibiotic such as ciprofloxacin to take before and after a biopsy to reduce the infection risk.

Killing The Bugs To Prevent Infections

Prostate biopsy inherently poses a risk of infection because the needles that grab a tiny piece of prostate tissue can transport bacteria through the rectal wall into the prostate and bloodstream.

Specialists are trying to figure out how to prevent biopsy-related infections.

Schaeffer, the Northwestern University urologist who performed attorney Tom Hayward's biopsy, co-authored a study presented last week on a method that he says has reduced his hospital's post-biopsy infection rate to zero.

It involves checking a man's intestinal tract to see if he harbors resistant bacteria and giving him the most effective antibiotics — before his biopsy.

"The point is that this directed preventive therapy is designed to kill the bugs that are there, versus just guessing as to what bugs might be there," Schaeffer says.

Meanwhile, his Northwestern colleague, Robert Nadler, says the infection risk is causing a lot of soul-searching about prostate biopsies.

"This is forcing urologists to really step back and take a look and say, 'Does this patient really need a biopsy?' " Nadler says.

By the way, you might be wondering if Tom Hayward's biopsy discovered cancer.

"Fortunately negative," Hayward reports. "The good news is the biopsies were negative. The bad news is the end result almost put me in the ground."

But Hayward wouldn't hesitate to get another biopsy if his doctor told him to. Next time, though, he would be on guard for any fever afterward.

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RENEE MONTAGNE, Host:

Now we turn to another problem with a common diagnostic test - prostate biopsies. Well over a million U.S. men get these biopsies every year. For the vast majority, the test isn't fun, but it's not dangerous either. Still, NPR's Richard Knox reports that doctors are worried about an increasing number of complications that can be sudden and life-threatening.

RICHARD KNOX: Like lots of other guys, Tom Hayward's doctor urged him to have a prostate biopsy after a blood test indicated he might have cancer. It's called a PSA test. The biopsy involved firing tiny needles into the prostate gland to get tissue samples. The actual procedure wasn't as bad as Hayward expected.

TIM HAYWARD: It went fine. You know, it's not the most pleasant procedure in town, but it's not that uncomfortable, and it didn't take that long.

KNOX: Next morning, he played tennis, had a full day of meetings. And at five, he got into his car and headed off to a dinner engagement.

HAYWARD: And from that point forward, for about - for an hour, I can't tell you, you know, how I got where I did, except I was on one of the three of the busiest expressways in Chicago.

KNOX: When he didn't show up for the dinner, his wife got worried. Police located his car because it had an on-board navigation system. By that point, Hayward realized he was way off-course.

HAYWARD: Fifteen minutes later, one of my sons, who's a lawyer here in town, pulled me over and said, give me the keys, and called an ambulance and took me to a local hospital.

KNOX: His doctor, Anthony Schaeffer, says a high fever had put Hayward into a mental fog. Hayward's problem? A raging infection.

ANTHONY SCHAEFFER: It can very quickly. It's a very sudden and dramatic change in their status.

KNOX: Hayward's infection was caused by antibiotic-resistant bacteria that were present in his gut before the biopsy. The biopsy had introduced these bugs into his bloodstream. Doctors are usually able to cure these infections. But often, men require hospital intensive care and weeks of heavy-duty antibiotics. Now, post-biopsy infections like these are not common, but they're more common than they were a few years ago. That's according to Dr. Robert Nam at the University of Toronto. He did a study of how often Ontario men suffer serious infections after prostate biopsies.

ROBERT NAM: It went from one percent to four percent.

KNOX: That's a small number, but a huge increase.

NAM: A four-fold increase over a 10-year period in hospital admission rates for a diagnostic procedure, I think, is high, very high - concerningly high.

KNOX: It's happening in the U.S., too. Johns Hopkins researchers did a big study of Medicare patients and found a sharp increase in serious infections. At last week's annual meeting of the American Urological Association, there were no fewer than 10 reports on the subject. One involved Anthony Schaeffer - Tom Hayward's doctor. His focus is on preventing these infections. Schaeffer and his colleagues at Northwestern University say they've been able to cut infections to zero by checking before a biopsy to see if a man harbors antibiotic-resistant bacteria. If he does, they give him antibiotics they know will knock out the resistant bugs.

SCHAEFFER: The point is that this directive preventive therapy is designed to kill the bugs that are there versus just guessing as to what bugs might be there.

KNOX: His colleague, Robert Nadler, says the infection risk is causing a lot of soul-searching about prostate biopsies.

ROBERT NADLER: I think this is forcing urologists to really step back and take a look to say: Does this patient really need a biopsy? And I think that's what's happening.

KNOX: By the way, you might be wondering whether Tom Hayward's biopsy discovered cancer.

(SOUNDBITE OF LAUGHTER)

HAYWARD: The good news is the biopsies were negative. The bad news is the end result almost put me in the ground.

KNOX: A high-priced test.

HAYWARD: You're absolutely right. It's a high-priced test.

KNOX: Richard Knox, NPR News.

(SOUNDBITE OF MUSIC)

MONTAGNE: This is NPR News. Transcript provided by NPR, Copyright NPR.