Location
Suwanee, GA
Start Date
11-5-2023 1:00 PM
End Date
11-5-2023 4:00 PM
Description
Background:
Prostate cancer (PCa) is the most common cancer in men, and the second most common cause of cancer deaths in the United States. Approximately 1 million Americans undergo prostate biopsies annually, with 97% undergoing the transrectal prostate biopsy (TRPB). While TRPB is reliable and relatively low risk, nearly 7% of patients develop infectious complications, with 3% requiring hospitalization due to sepsis. Risk factors for developing infection post-TRPB include antibiotic resistance, >10 biopsy cores, diabetes mellitus, indwelling catheter, and African-American ethnicity. Identifying risk factors, considering a transperineal biopsy approach, and utilizing pre-procedural practices like rectal sterilization, screening urinalysis, prophylactic antibiotics, or rectal culture can significantly minimize infectious complications.
Case Description:
A healthy 66-year-old Asian male, with a family history of prostate cancer, complains of worsening nocturia. He denies fever, fatigue, weight change, back or abdominal pain, hematuria, dysuria, polydipsia, or history of recurring infections.
Vitals including body mass index (BMI) are within normal range. The prostate is enlarged and non-tender on digital rectal exam. His prostate-specific antigen rose from 2.4 to 5.8 in a year, and a prostate MRI indicated high suspicion for cancer. Following rectal enema prep, urinalysis screen, and betadine sterilization, ultrasound-guided TRPB was performed. Antibiotic prophylaxis included intravenous ciprofloxacin and ceftriaxone followed by three days of oral cefdinir. Twelve biopsies were sampled, and the patient was discharged home in good condition.
The following evening, he developed fever, chills, and malaise. He was disoriented in the Emergency Department, with a temperature of 101.2 Fahrenheit, blood pressure 150/82, heart rate 109, respiratory rate 24, and 94% oxygen saturation. Urinalysis revealed leukocytes, blood, glucose, and protein. HbA1c was 6.4%. His condition improved with IV fluid resuscitation, empiric vancomycin and aztreonam in the ED, and meropenem during the remainder of his hospitalization. Peripheral blood cultures confirmed pan-sensitive E. coli. He was discharged home on oral cefuroxime 500mg BID for thirteen more days, and experienced no further complications. Prostate pathology reports confirmed adenocarcinoma, for which he successfully completed radiation therapy.
Discussion:
Recognizing risk factors as well as following proper infection prevention protocols are essential in minimizing potential TRPB-related complications. While the number of biopsy cores may have contributed to our patient’s progression of urosepsis, he was otherwise seemingly low risk for post-procedural infection at first glance. However, a thorough retrospective review of the patient’s history brings into question whether his borderline diabetic HbA1c level played a role in his unfortunate outcome. This consideration stems from a study demonstrating a progression of altered inflammatory and immune responses in both prediabetic and diabetic patients, highlighting that biochemical changes responsible for diabetic-related complications are evident to a degree in prediabetics. Further studies are needed to explore prediabetes as a direct risk factor for post-procedural infectious complications. Depending on these results, infection-prevention strategies currently in place for diabetics (i.e. rectal cultures and broader antibiotic coverage) may prove helpful for certain prediabetic patients as well. Until then, these potential suggestions exist on speculation alone.
Embargo Period
6-27-2023
Included in
A seemingly low risk patient develops urosepsis as a complication of transrectal prostate biopsy: A case study
Suwanee, GA
Background:
Prostate cancer (PCa) is the most common cancer in men, and the second most common cause of cancer deaths in the United States. Approximately 1 million Americans undergo prostate biopsies annually, with 97% undergoing the transrectal prostate biopsy (TRPB). While TRPB is reliable and relatively low risk, nearly 7% of patients develop infectious complications, with 3% requiring hospitalization due to sepsis. Risk factors for developing infection post-TRPB include antibiotic resistance, >10 biopsy cores, diabetes mellitus, indwelling catheter, and African-American ethnicity. Identifying risk factors, considering a transperineal biopsy approach, and utilizing pre-procedural practices like rectal sterilization, screening urinalysis, prophylactic antibiotics, or rectal culture can significantly minimize infectious complications.
Case Description:
A healthy 66-year-old Asian male, with a family history of prostate cancer, complains of worsening nocturia. He denies fever, fatigue, weight change, back or abdominal pain, hematuria, dysuria, polydipsia, or history of recurring infections.
Vitals including body mass index (BMI) are within normal range. The prostate is enlarged and non-tender on digital rectal exam. His prostate-specific antigen rose from 2.4 to 5.8 in a year, and a prostate MRI indicated high suspicion for cancer. Following rectal enema prep, urinalysis screen, and betadine sterilization, ultrasound-guided TRPB was performed. Antibiotic prophylaxis included intravenous ciprofloxacin and ceftriaxone followed by three days of oral cefdinir. Twelve biopsies were sampled, and the patient was discharged home in good condition.
The following evening, he developed fever, chills, and malaise. He was disoriented in the Emergency Department, with a temperature of 101.2 Fahrenheit, blood pressure 150/82, heart rate 109, respiratory rate 24, and 94% oxygen saturation. Urinalysis revealed leukocytes, blood, glucose, and protein. HbA1c was 6.4%. His condition improved with IV fluid resuscitation, empiric vancomycin and aztreonam in the ED, and meropenem during the remainder of his hospitalization. Peripheral blood cultures confirmed pan-sensitive E. coli. He was discharged home on oral cefuroxime 500mg BID for thirteen more days, and experienced no further complications. Prostate pathology reports confirmed adenocarcinoma, for which he successfully completed radiation therapy.
Discussion:
Recognizing risk factors as well as following proper infection prevention protocols are essential in minimizing potential TRPB-related complications. While the number of biopsy cores may have contributed to our patient’s progression of urosepsis, he was otherwise seemingly low risk for post-procedural infection at first glance. However, a thorough retrospective review of the patient’s history brings into question whether his borderline diabetic HbA1c level played a role in his unfortunate outcome. This consideration stems from a study demonstrating a progression of altered inflammatory and immune responses in both prediabetic and diabetic patients, highlighting that biochemical changes responsible for diabetic-related complications are evident to a degree in prediabetics. Further studies are needed to explore prediabetes as a direct risk factor for post-procedural infectious complications. Depending on these results, infection-prevention strategies currently in place for diabetics (i.e. rectal cultures and broader antibiotic coverage) may prove helpful for certain prediabetic patients as well. Until then, these potential suggestions exist on speculation alone.