Prophylactic Antibiotics and Foley Catheter use in Transperineal Needle Biopsy of the Prostate

0022-534 7/84/1314-0687$02.00/0 Vol. 131, April

THE JOURNAL OF UROLOGY

Copyright© 1984 by The Williams & Wilkins Co.

Printed in U.S.A.

PROPHYLACTIC ANTIBIOTICS AND FOLEY CATHETER USE IN TRANSPERINEAL NEEDLE BIOPSY OF THE PROSTATE MICHAEL G. PACKER, PAUL RUSSO

AND

WILLIAM R. FAIR*

From the Division of Urology, Washington University School of Medicine, St. Louis, Missouri

ABSTRACT

We studied retrospectively 162 patients undergoing transperineal needle biopsy of the prostate. All patients had urine cultures before biopsy. Patients were divided into 4 groups: group 1-no antibiotics (44), group 2-antibiotics before and after biopsy (69), group 3-antibiotics after biopsy only (42) and group 4-antibiotics before biopsy only (7). Groups were similar in average age (65 years) and pathologic diagnosis (prostatic cancer in 28 per cent and a benign prostate in 72 per cent). Of the 162 patients 4 (2.5 per cent) had positive urine cultures preoperatively. Post-biopsy urine cultures were obtained in 86 patients and 2 (2 per cent) were positive. Only 12 patients (11 per cent) required catheters for postoperative urinary retention. Complications occurred in 9 patients (5.5 per cent): 7 (4.3 per cent) had febrile episodes, 1(0.6 per cent) had a documented postoperative urinary tract infection and 1(0.6 per cent) sustained a large pelvic hematoma. No statistically significant difference could be found among the 4 groups in regard to complication rate. This study demonstrates no advantage to the routine use of antibiotics or Foley catheters in transperineal needle biopsy of the prostate, provided the urine is sterile before biopsy. Cost analysis of these data demonstrates a considerable savings when routine antibiotics and Foley catheters are not used. Approximately 75,000 new cases of prostatic cancer are diagnosed each year. 1 The National Survey of Prostate Cancer found that the diagnosis was made by transperineal needle biopsy 13 per cent of the time. 2 Manipulation of the genitourinary system when the urine is infected predisposes the patient to bacteremia and septicemia. 3· 4 The value of prophylactic antibiotics in transrectal prostate biopsies has been demonstrated in reducing postoperative febrile episodes and urinary tract infections. 5 The efficacy of perioperative antibiotics in transperineal needle biopsies of the prostate has not been shown. Also, the role of routine placement of indwelling urinary catheters after biopsy has not been clarified. This study examines the use of antibiotics and catheters during transperineal needle biopsy of the prostate. MATERIALS AND METHODS

The hospital and outpatient records of 162 patients who underwent transperineal needle biopsy of the prostate and had preoperative urine cultures at Washington University Medical Center between 1979 and 1982 were reviewed. The Vim Silverman or Tru-cut needles were used for biopsies by full-time faculty, clinical attending urologists and urology residents. Multiple cores were obtained from each patient. A povidone-iodine solution was used to prepare the perineum. Only patients with documented preoperative urine cultures were included in the study. The following factors were examined: preoperative and postoperative urine cultures, antibiotic and catheter usage, complications and pathological findings. Foley catheters were placed while the patient was in the operating room or within 24 hours for urinary retention. Urine cultures were considered negative if colony counts were <10,000 colony-forming units per ml. Fever was defined as temperature >38C ;;;;i48 hours after biopsy. Followup urine cultures were obtained ;;;;i2 weeks postoperatively. Patient groups were divided as follows: group 1-no antibiotics, group Accepted for publication November 11, 1983. Read at annual meeting of American Urological Association, Las Vegas, Nevada, April 17-21, 1983. *Requests for reprints: Division of Urology, Washington University School of Medicine, 4960 Audubon Ave., St. Louis, Missouri 63110. 687

2-antibiotics before and after biopsy, group 3-antibiotics after biopsy only and group 4-antibiotics before biopsy only. Chi-square analysis was used to evaluate complications among the 4 groups. The cost of Foley catheters, drainage bags, antibiotics and hospital stay were based on the current rates used at Barnes Hospital, St. Louis, Missouri. The total number of antibiotic doses received by each patient was recorded. Combination antibiotic therapy often was used. The total expense for antibiotics used per group was computed and divided by the number of patients in each group, yielding the average cost of antibiotics per patient. Similarly, catheter expense was calculated on a per patient basis. Cost projections were based on data from the American Cancer Society Cancer Statistics,1 the Third National Cancer Survey2 and data obtained from our study. RESULTS

Patient groups were similar in regard to mean age (65 years) and distribution of pathological findings (28 per cent cancer and 72 per cent benign conditions) (table 1). Preoperative urine cultures were positive in 4 of the 162 patients (2.5 per cent), all of whom were in group 2. Postoperative urine cultures were obtained in 86 patients (53 per cent) and were positive in 2 in group 2. Of these 2 patients 1 had a Pseudomonas aeruginosa urinary tract infection before and after needle biopsy, and experienced a febrile episode to 38.9C. The other patient had sterile urine before biopsy and had an indwelling catheter placed after biopsy. The postoperative course was complicated by a Pseudomonas aeruginosa urinary tract infection and urinary retention. Indwelling catheters were placed routinely in 54 patients (33 per cent) while they were in the operating room after needle biopsy. Catheters were placed most frequently in group 2 (33 patients), while group 1 had the lowest incidence of catheter placement (4 patients). Of the remaining 108 patients 12 (11 per cent) required catheterization for urinary retention, 9 of whom were in group 1 (table 2). A wide variety of antibiotics was used, with trimethoprimsulfamethoxazole and cephalosporins being the most common.

688

PACKER, RUSSO AND FAIR TABLE

Group 2 No.(%)

Group 1 No.(%) No. pts. Mean age (yrs.) Pathological findings: Ca Benign Urine cultures: Pos. preop. Postop.: No. obtained No. pos.

No. placed in operating room No. for postop. retention Total No. catheters

Group 3 No.(%)

Group 4 No.(%)

42

7 67

44 62

69 66

65

14 (32) 30 (68)

21 (30) 48 (70)

9 (21) 33 (79)

2 (29) 5 (71)

0 (0)

4 (6)

0 (0)

0 (0)

33 (47) 2 (6)

30 (68) 0 (0)

TABLE

1

2. Catheter use Group 3 Group 4 No./To.tal (%)

Group 1

Group 2

4

33

17

0

54/162 (33)

9

2

1

o.

12/108 (11)

13

35.

18

0

66/162 (41)

In group 2 different antibiotics often were. used in the same patient before and after biopsy. Combination therapy also was given in this. group. There were 9 patients with postoperative complications, for an over-all complication rate of 5.5 per cent: 7 (4.3 per cent) had febrile episodes, 1 had a documented postoperative urinary tract infection and 1 sustained a large. pelvic hematoma requiring blood transfusion. No statistically si~ificant difference could be found among the. 4 groups in regard to complications (table 3). The pathologic diagnosis had no bearing on the complications observed .. Cost analysis of antibiotic use is shown in table. 4. Group 2, patients used a total of $1,500 in perioperative antibiotics for an average expense per patient of $:20, group 3 used $630 in postoperative antibiotics for an average of $15 per patient and the antibiotic expense was $3 per patient in group 4. DISCUSSION

Many urologists contend that transperineal needle biopsy of the prostate requires routine use of prophylactic antibiotics and Foley catheters .. However, represeJiltative studies do not address these points thoroughly but concentrate more on diagnostic accuracy and complication rate. 6- 9 Only 1 recent study described antibiotic and catheter use fully. 6 Genitourinary surgery has been assigned traditionally to the clean-contaminated category. 10 However, preoperative documentation of sterile urine should reassign elective genitourinary surgery into the clean category. Infectious complications are low in this group and, therefore, prophylactic. antibiotics are not indicated routinely. 11 There also is a general misconception that the perineum is a contaminated region and this may encourage. the use of prophylactic antibiotics. Lowbury demonstrated that the, perineal skin yielded relatively low densities of gram-negative and grampositive.organisms when compared to other skin sites.12 Topical antiseptic solutions, such as povidone-iodine, should provide optimal antimicrobial effect before transperineal needle biopsy.13 Under normal conditions the prostate should be sterile. During transperineal biopsy it is possible for the needle to enter the bladder but there should be no bacteremic complications if the urine is sterile. Thus, with sterile urine, adequate skin preparation and sterile technique, the entire procedure should be classified as clean and have a low rate of infectious complications. Our data support this premise. Group 1, with sterile pre-biopsy urine cultures, did not have an increased incidence

19 (45) 0 (0)

4 (57) 0 (O)

Totals No.(%) 162 65 46 (28) 116 (72) 4 (2.5) 86 (53) 2 (2)

of infectious complications despite the lack of perioperative antibiotics. Among the 4 groups, only 1 positive postoperative urine culture could be considered a complication of the procedure despite perioperative antibiotics. This patient had sterile urine preoperatively, and received cephalosporins before and after biopsy and during indwelling catheterization. A resistant Pseudomonas aeruginosa urinary tract infection probably resulted because of the combined use of a broad-spectrum antibiotic in the. presence of an indwelling forei~ body. In this hospital setting a resistant organism was selected. Urinary retention occurred in only 12 of 108 patients (11 per cent) who did not receive. a catheter while in the operating room. Gm.up 1 had the large.st number of catheters placed for postoperative urinary retention (9) and the fewest number placed while in the operating room after biopsy (4). Group 2 included only 2 patients with postoperative urinary retention. However,, 33 of 69 patients in this group had intraope.rative placement of catheters .. It is illogical to catheteriz.e all patients undergoing biopsy simply to avoid retention in a small number of patients. Should the patient complain of obstructive symptoms or s,uffer from retention postoperatively, short-term catheterization then is indicated. Table 3 demonstrates an over-all eomplication rate of 5.5 per cent~ which is similar to that reported p:reviously. 0-~ Antibiotics had no role in reducing complications se,en in our patients. In the patient with a history of prostatitis localization studies are necessary and should be done. before biopsy. 14 If prostatic infoction is present appropriate therapy should be. instituted and biopsy, should he postponed until the infection resolves. The rationale for the use of prophylactic antibiotics in the absence of prostatitis is lacking, especially since effective prostatic antibiotic levels often are difficult to achieve. 15 Approximately 75,000 new cases of p:rostatic cancer are diagnosed each year,1 of which 13 per cent are diagnosed by transperineal biopsy.2 Our study demonstrated that nearly 30 per cent of transperineal biopsies were for malignant disease and 70 per cent were for benign conditions. Thus, a conservative estimate reveals that at least 32,500 transperineal needle biopsies of the prostate are performed each year. Table 5 demonstrates the projected expense when routine catheters and antibiotics are used. We estimated that the use of an indwelling catheter added at least 1 day to the hospital stay (this may be an underestimation). Projected on a national scale, these measurns would represent a cost-containment of nearly 3 million dollars per year. Additionally, patients would be spared from toxic side effects of unnecessary antibiotics and catheter-related morbidity. A randomized, double-blind, controlled prospective study would be the best way to clarify the role of prophylactic antibiotics in this procedure. In such a study documentation of the number of cores obtained at the time of biopsy could clarify the question of whether the degree of prostatic trauma had a role in postoperative urinary retention. Also, prostatic localization studies could be performed on all patients before and

689 TABLE 3, Complicatiorts

Group l

3

]'fa

No,(%)

2 1

Febrile Pelvic hen1atoma Postop. urinary tract infection Totals

0 3 (6.8)

Total cost by group Antibiotics (expense/pt.)

Group 2

Group 3

Group 4

0 0

1,500 20

630 15

20

New cases of prostatic Ca per yr. Estimated total transperineal biopsies per yr.* New cases of prostatic Ca diagnosed by transperineal route Projected cost-containment on national level: Antibiotics Catheters Hospital stay Total cost

Total Cost

0

2 (4.8)

0

$20/pt. $13/pt. $175/day

$450,000 $170,000 $2,275,000 $2,895,000

75,000 32,500 9,750

23,400 pts.1" 13,000 pts.:j: 1 extra day

7(4.3) l (0.6) 1 (0.6) 9 (5.5)

0

3

Unit Cost

0 0

4 (5.8)

TABLE 5 No.

Totals No.(%)

3 (4.3) 0 l (1.4)

TABLE 4. Cost of antibiotics reported to the nearest dollar Group 1

Group 4 No.(%)

* Based on data from ou1' study that prcstatic cancer was diagnosed in 30 per cent of all needie biopsies performed. t Based on 72 per cent of our patients receiving antibiotics. :j: Based on 40 per cent of our patients receiving catheters.

after biopsy to detect a subgroup of chronic or subclinical prostatitis, which could predispose patients to postoperative morbidity. Single antimicrobial agents could be tested against the control group. Even though our study is retrospective it does confirm the low morbidity of the procedure without perioperative antibiotics when the urine is sterile and antibacterial skin preparation is used. REFERENCE§ 1. Silverberg, E.: Cancer statistics. CA, 33: 9, 1983. 2. Murphy, G. P., N., Pontes, J. Schmitz, R. L.,

C. R., Schmidt, J. and Mettlin, C.: national sul'vey cancer in the United States by the Ame:rican College of uw"~""''°· J. UroL, 127: 928, 1982. 3. Scott, W.: Blood stream infections in urology: a report of eightytwo cases. J, UroL, 21: 527, 1929. 4. SuHivan, J\T. Sutter, V, L., Carter, W. T., Attebery, H. R. and Finegold, S. · Bacteremia after ~c,,w.vuu,,uu tract tion: bacteriological aspects

2 (4.8) 0

culture systems. Appl. Microbiol., 23: 1101, 1972. 5. Crawford, E. D., Haynes, A. L., Jr., Story, M. W. and Borden, T. A.: Prevention of urinary tract infection and sepsis following transrectal prostatic biopsy. J. UroL, 127: 449, 1982. 6. Catalona, W. J.: Yield from routine prostatic needle biopsy in patients more than 50 years old referred for urologic evaluation: a preliminary report. J. Urol., 124: 844, 1980. 7. Fortunoff, S.: Needle biopsy of the prostate: a review of 346 biopsies. J. Urol., 87: 159, 1962. 8. Kaufman, J. J. and Schultz, J. I.: Needle biopsy of the prostate: a re-evaluation. J. Urol., 87: 164, 1962. 9. Parry, W. L. and Finelli, J. F.: Biopsy of prostate. J. UroL, 84: 643, 1960. 10. Cruse, P. J. and Foord, R.: The epidemiology of wound infection. A IO-year prospective study of 62,939 wounds. Surg. Clin. N. Amer., 60: 27, 1980. 11. Russo, P., Packer, M. G. and Fair, W. R.: Prophylactic antibiotics in uro!ogic surgery. Sem. l: 155, 1983. 12. Lowbury, E. J.: Gram-negative on the skin. Brit. J. Derm., suppl. 1, 81: 55, 1969. 13. Topical antiseptics and antibiotics. Med. Lett. Drug, 19: 83, 1977. 14. Stamey, T. A.: Antibacterial management of prostatectomy. In: Pathogenesis and Treatment of Urinary Tract Infections. Baltimore: The Williams & Wilkins Co., chapt. 10, pp. 590-599, 1980. 15. Fair, W. R. and Cordonnier, J. J.: The pH of prostatic fluid: a reappraisal and therapeutic implications. J. Urol., 120: 695, 1978.

EDITORIAL COMMENT I wonder whether the authors have had experience performing transperinea! needle biopsy as an outpatient procedure. This procedure would seem to represent a logical extension of their conclusions, particularly since it relates to over-al! hospital costs. We routinely perform the procedure in the outpatient clinic at our institution and have been satisfied with the results. Chari.es B. Brendl.er Brady Urological Institute The Johns Hopkins Hospital Baltimor
REPLY BY AUTHORS While transperineal needle bicpsy of the prnstate is not done routinely as an outpatient procedure at our institution om· data show that it may be done safely provided. the nr,2m)ei·at1ve urine is sterile and postoperati'le urim,xy retentior, is ""·vE;m£soo~.