Infection Control for Prostate Biopsies: Before, During, and After the Procedure

When it comes to the diagnosis and treatment of prostate cancer, prostate biopsies represent a primary and pivotal tool, playing an indispensable role in accurate assessment and guiding informed decision-making. However, missteps in the implementation of effective infection prevention techniques during prostate biopsies – particularly those guided by ultrasound – can frequently lead to elevated infection risks, putting patients in harm’s way. As such, it’s vital that proper measures be taken to minimize infection risks, while also ensuring procedural effectiveness.

Breaking Down the Numbers:

Consider the following statistics:  

• In the United States, the infection rate subsequent to ultrasound-guided prostate biopsies experienced a sizable increase from 2001 to 2007, rising from 5.9 to 7.2%. ¹
• While infection rates stabilized from 2007 to 2015, “post-biopsy emergency room visits rose from 0.2% to 0.5%...hospitalizations rose from 0.5% to 1.3%...and intensive care unit admissions increased from 0.1% to 0.3%.” ²
• Infection risks related to prostate biopsies aren’t just contained to the United States: according to Lancet, “Globally, 50,000-150,000 are thus hospitalized for an infection after a prostate biopsy each year – and this number is increasing.” ³

The landscape of prostate biopsy risks and complications is diverse and multifaceted, warranting careful consideration by both medical practitioners and patients alike. Some of the notable risks and side effects include:

• Infections, including sepsis: Sepsis risk has been described in up to 1-2% of cases after transrectal biopsy (or 1 to 2 of every 100 men), while the transperineal approach has demonstrated a substantially lower rate of 0.002% (or 1 in 500 men). ^{4 5} 
• Temporary Erectile Dysfunction: A temporary decrease in erectile function has been observed in a small percentage of men, with a 2015 study reporting an increased risk of temporary ED after biopsy of approximately 5%. ⁶
• Rectal Bleeding: Another potential complication is rectal bleeding, with massive rectal hemorrhage post-biopsy having been reported in up to 1% of cases. ⁷
• Hematoma: The biopsy procedure can also lead to the formation of a hematoma (blood clot) within the prostate or surrounding tissues, causing pain and other symptoms. ⁸
• Hematuria and Hematospermia: Instances of blood in the urine or semen may arise as a result of prostate biopsies (both transrectal and transperineal). ⁹
• Prostatitis: Prostate biopsies can also result in temporary inflammation of the prostate gland, causing pain, fever, and discomfort. ¹⁰
• Urinary Retention and Catheter Placement: Up to 4.4% of men may experience urinary retention, often necessitating the placement of a catheter post-biopsy. ¹¹

The Importance of Infection Control Measures – Before, During, and After Prostate Biopsies:

Developing robust infection control measures before, during, and after prostate biopsies is of paramount importance to ensure patient safety and prevent the spread of potential infections. By addressing infection control at all stages of the biopsy process, healthcare providers can minimize the risk of complications, safeguard patient well-being, and maintain the overall efficacy of prostate biopsies as a vital diagnostic tool.

Infection Control Strategies Before Prostate Biopsy:

Patient evaluation and education:

Be sure to conduct a thorough patient assessment before the procedure, including a review of their medical history, allergies, and any medications or supplements the patient is taking. Ensure that the patient doesn't have any serious medical conditions, and educate the patient about the procedure, including the potential risks and benefits. ¹²

Perform hand hygiene:

Washing hands with soap and water for at least 20 seconds - or using alcohol-based hand sanitizer before and after a prostate biopsy – is a good idea after any medical procedure, and can help to eliminate potential pathogens from the hands of healthcare providers. This practice not only protects the patient from infection but also safeguards the healthcare team by reducing the risk of cross-contamination. ¹³

Create a sterile environment:

Creating a sterile field in the biopsy area – including using sterile drapes, ¹⁴ implementing sterile gloves for all healthcare providers involved, ¹⁵ and utilizing sterile instruments for the procedure ¹⁶ – can significantly impact the potential for contamination risk. For healthcare providers, strictly adhering to such measures is a significant aspect of maintaining a controlled and infection-resistant environment.

Prepare the skin:

Cleaning the perineal area with an antiseptic solution like chlorhexidine or povidone-iodine before a prostate biopsy is essential, as these solutions can help to kill harmful bacteria on the skin, reducing the risk of infection. (Also worth noting: after application, allowing the solution to completely air dry for 2 minutes is crucial to best ensure its effectiveness). ¹⁷

Infection Control Strategies During Prostate Biopsy:

Utilize sterile gel and probe covers during the procedure:

To enhance safety during critical procedures like prostate biopsies and prevent infection outbreaks, it is crucial to adhere to evidence-based infection prevention practices. According to the Journal of Diagnostic Medical Sonography, failure to follow these practices – including proper transducer cleaning, disinfection, and the use of appropriate transducer covers and sterile gel – can lead to infection outbreaks. ¹⁸ Utilizing sterile gel packets specifically designed for one-time use is recommended for procedures involving mucous membrane contact, as highlighted by the UK Health Security Agency. ¹⁹ Additionally, the EFSUMB Guidelines on Interventional Ultrasound strongly advocate for the use of sterile probe covers during ultrasound-guided interventions, like prostate biopsies. ²⁰ These measures collectively reduce the risk of transmitting bacteria and pathogens, ensuring the safety of both patients and healthcare practitioners.

Choose one of two prostate biopsy methods: transperineal or transrectal 

Prostate biopsies can be categorized into two primary methods: transrectal and transperineal procedures. The former, which currently constitutes approximately 99% of all prostate biopsies, ⁵ involves guiding the biopsy needle through the rectum. While widely practiced, this method presents a spectrum of risks, with one of the most alarming being the potential for sepsis, a life-threatening infection (as indicated by the Journal of Urology, the transrectal prostate biopsy technique "presents a rate of post-procedural sepsis of 0.3-0.8% and hospitalization of 1.1% due to post-biopsy infections). ²¹

Meanwhile, the transperineal approach – which sees the biopsy needle guided through the perineum – offers a markedly lower risk profile (specifically, a 0.1% rate of sepsis and hospitalization risk of 0.9%, according to the Journal of Urology) ²⁵ and has been gaining in popularity in recent years, due in large part to what many perceive as its increased safety and accuracy over transrectal prostate biopsies. “Given the increased safety and accuracy reported in the literature, more and more patients are demanding a transperineal biopsy instead of a transrectal biopsy,” said Richard Szabo, MD, a urologist at the Southern California Permanente Medical Group in Orange County. “The American Urological Association guidelines on prostate biopsy are presently being revised and may soon join with the EUA in recommending the transperineal over transrectal approach.” ⁵

(Our recent blog post, “Transperineal & Transrectal Prostate Biopsies for Cancer Detection,” breaks down the advantages and considerations associated with each approach.)

Consider whether an antibiotic is required to reduce the risk of infection:

Using an antibiotic in conjunction with a transrectal or transperineal biopsy can serve as a safeguard against potential infections. According to Nature Urology Review, “antibiotic prophylaxis with fluroquinolones has been shown to be effective for reducing infection rates.” ²² Furthermore, the transperineal method has demonstrated a notable decrease in post-biopsy complications – especially urosepsis – even when quinolone antibiotics are not used. This approach maintains a satisfactory cancer detection rate (CRD) while also preserving diagnostic sensitivity, particularly when compared to TRUSBx. ²³

Infection Control Strategies After Prostate Biopsy:

Properly handle gel and probe covers after the procedure:

After the procedure, healthcare workers should take care to examine and dispose of the transducer cover in an appropriate container, while cleaning the transducer of any remaining material that might still be present (i.e. remaining gel, visible soil, bioburden, debris, biological matter, etc.) ¹² These extra steps can help to ensure the safety of both patients and staff, while helping to ensure an infection-free environment for future procedures.

Clean and disinfect reusable equipment: 

Cleaning and high-level disinfection of equipment after each prostate biopsy procedure plays an important role in safeguarding patient well-being and preventing contamination. The American Urological Association (AUA) recommends that "the manufacturer recommendations for sterilization and high-level disinfection methods for specific devices should be reviewed and followed." ²⁴ Furthermore, the AUA points to more information provided from the Association for Medical Ultrasound (AIUM), which in their official statement suggests that "preparation of internal transducers between patients requires routine mandatory high-level disinfection (HLD) and the use of a high-quality single-use transducer cover during each examination." ²⁶

SDMS recommends that healthcare workers take care to first clean their equipment thoroughly before high-level disinfection, removing any visible debris, biological matter, or reside from their equipment’s surfaces, which can serve to potentially shield microorganisms from the disinfection process). Devices should then undergo high-level disinfection (which the CDC defines as the chemical destruction of all microorganisms ²⁴), which can be conducted both manually or automatically, with a variety of different types of high-level disinfectants, including ortho-phthalaldehyde (OPA), glutaraldehyde, hydrogen peroxide, or peracetic acid. ¹²

Store devices properly:

Adhering to appropriate storage procedures can, according to SDMS, “reduce the risk of re-contamination of the transducer from environmental contaminants or accidental contamination.” ¹² In their “Sonographer Best Practices for Infection Prevention and Control,” SDMS recommends utilizing proper storage practices, including storage covers, boxes, or cabinets (particularly those featuring HEPA filtration); they also emphasize the importance of maintaining a clear demarcation between clean and soiled transducers (based on disinfection level), as well as well as clearly labeling the container with information such disinfection level, storage data, and maximum storage duration. ¹²

Transport devices properly:

Per SDMS’ recommendations, transducers should be transported post-reprocessing in a designated container, ideally marked with a biohazard symbol to indicate clean or dirty status. While transporting the transducers, care should be taken to handle the container to prevent potential cross-contamination, including maintaining them in a position that is directly parallel to the floor. ¹²

Partner with CIVCO:

TP Pivot Pro is the first transperineal biopsy guide to offer precise access to the entire prostate gland through its unique pivoting feature. Designed with clinicians, for clinicians, the guide offers parallel and angling options of the introducer needle while maintaining visualization within the imaging plane, without the need to remove the introducer needle from the patient. TP Pivot Pro also securely attaches to a range of biplane probe diameters, removing the need to tape the transducer.
Explore TP Pivot Pro at www.civco.com/tp-pivot-pro. 

References:

#1: Risk factors for infection after prostate biopsy in the United States: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549646/
 
#2: Why are prostate biopsy infection rates on the rise? https://sperlingprostatecenter.com/why-are-prostate-biopsy-infection-rates-on-the-rise/
 
#3: Is it time to abandon routine antibiotics for transperineal prostate biopsy? https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00419-4/fulltext
 
#4: Incidence of sepsis following transrectal ultrasound guided prostate biopsy at a tertiary-care medical center in Lebanon: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811227/#:~:text=The%20reported%20incidence%20of%20urinary,after%20TRUS%20biopsy%20(9).
 
#5: Death spurs country's shift to safer prostate biopsies: (https://www.medscape.com/viewarticle/989696#vp_2) 
 
#6: Can a man develop erectile dysfunction (ED) after a prostate biopsy?: https://www.issm.info/sexual-health-qa/can-a-man-develop-erectile-dysfunction-ed-after-a-prostate-biopsy#:~:text=They%20reported%20an%20increased%20risk,months%20later%2C%20had%20not%20worsened
 
#7: The management of rectal bleeding following transrectal prostate biopsy: a review of the current literature: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869041/#:~:text=Massive%20rectal%20hemorrhage%20post%2Dbiopsy,up%20to%201%25%20of%20cases.&text=Al%2DOtaibi%20et%20al%20report,pulmonary%20edema%2C%20and%20atrial%20fibrillation.
 
#8: Pelvic hematoma following transrectal ultrasound-guided prostate needle biopsy: a case report and literature review: https://www.sciencedirect.com/science/article/pii/S1879522613000833
 
#9: Systematic review of complications of prostate biopsy: https://www.sciencedirect.com/science/article/pii/S0302283813005587#:~:text=After%20biopsy%2C%20hematuria%20and%20hematospermia,reason%20for%20hospitalization%20after%20biopsy.
 
#10: Post-prostate biopsy acute bacterial prostatitis and screening cultures using selective media: an overview: https://onlinelibrary.wiley.com/doi/full/10.1111/iju.14824
 
#11: A prospective evaluation of the impact of trans-rectal prostate biopsy on the voiding function of patients: https://afju.springeropen.com/articles/10.1186/s12301-020-00062-5
 
#12: What is a prostate biopsy? The procedure, recovery, results, and more: https://www.medicalnewstoday.com/articles/317601#preparation
 
#13: CDC: Hand Hygiene in Healthcare Settings: https://www.cdc.gov/handhygiene/providers/index.html
 
#14: Outpatient transperineal prostate biopsy under local anaesthesia is safe, well tolerated, and feasible: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9314011/
 
#15: NHS: Glove selection guide https://www.infectionpreventioncontrol.co.uk/content/uploads/2018/12/Glove-selection-guide-January-2015.pdf
 
#16: Five tips for a safe endocavity biopsy: https://us.edm-imaging.com/blogs/blog/five-tips-safe-endocavity-biopsy
 
#17: Effect of rectal mucosa cleansing on acute prostatitis during prostate biopsy: a randomized prospective study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7053991/
 
#18: SDMS - Guidelines for Infection Prevention and Control in Sonography: Reprocessing the Ultrasound Transducer: https://journals.sagepub.com/doi/epub/10.1177/8756479320933256
 
#19: Good infection prevention practice: using ultrasound gel: https://www.gov.uk/government/publications/ultrasound-gel-good-infection-prevention-practice/good-infection-prevention-practice-using-ultrasound-gel
 
#20: EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I: General Aspects: https://pubmed.ncbi.nlm.nih.gov/26468774/
​
#21: Infection rate after transperineal prostate biopsy with and without prophylactic antibiotics: https://www.auajournals.org/eprint/AYIGAYWQKNEHV4J5CGDN/full 

#22: Reducing infection rates after prostate biopsy: https://www.nature.com/articles/nrurol.2013.322
 
#23: Transperineal Prostate Biopsies Using Local Anesthesia: Experience with 1,287 Patients. Prostate Cancer Detection Rate, Complications and Patient Tolerability: https://pubmed.ncbi.nlm.nih.gov/30835607/
 
#24: American Urological Association: The Prevention and Treatment of the More Common Complications Related to Prostate Biopsy Update: https://www.auanet.org/guidelines-and-quality/quality-and-measurement/quality-improvement/clinical-consensus-statement-and-quality-improvement-issue-brief-(ccs-and-qiib)/prostate-needle-biopsy-complications  
 
#25: American Urological Association: Nonantibiotic strategies for the prevention of infectious complications following prostate biopsy: a systematic review and meta-analysis: https://www.auajournals.org/doi/10.1097/JU.0000000000001399 

#26: The Association for Medical Ultrasound: Guidelines for cleaning and preparing external- and internal-use ultrasound transducers and equipment between patients as well as safe handling and use of ultrasound coupling gel: https://www.aium.org/resources/official-statements/view/guidelines-for-cleaning-and-preparing-external--and-internal-use-ultrasound-transducers-and-equipment-between-patients-as-well-as-safe-handling-and-use-of-ultrasound-coupling-gel 

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