Prostate Cancer and Prostatic Diseases (2008) 11, 207–208 & 2008 Nature Publishing Group All rights reserved 1365-7852/08 $30.00 www.nature.com/pcan
CASE REPORT
Acute bacterial meningitis after transrectal needle biopsy of the prostate: a case report H Erdogan1, MN Ekinci2, MB Hoscan2, A Erdogan3 and H Arslan1 1
Department of Infectious Diseases and Clinical Microbiology, Baskent University, Ankara, Turkey; 2Department of Urology, Baskent University Alanya Research and Practice Center, Baskent University, Ankara, Turkey and 3Department of Gastroenterology, Baskent University, Ankara, Turkey
Transrectal biopsy of the prostate (TBP) is the most accurate method of diagnosing prostate cancer. Although debate remains, prophylactic antibiotic therapy is most frequently used to prevent infectious complications after TBP. Here, we present a case of Escherichia coli meningitis after TBP despite quinolone prophylaxis. Prostate Cancer and Prostatic Diseases (2008) 11, 207–208; doi:10.1038/pcan.2008.11; published online 4 March 2008
Keywords: antibiotic prophylaxis; complications; Escherichia coli; meningitis; prostate biopsy
Introduction Carcinoma of the prostate is the most common cancer in men. Transrectal biopsy of the prostate (TBP) represents the most accurate means of diagnosing prostate cancer and is one of the most common procedures performed by urologists. Although TBP generally is considered a safe procedure, complications secondary to TBP are some of the most common adverse events encountered in clinical practice. The procedure is associated with traumatic and infective complications.1 Bacterial meningitis is a rare and serious complications of TBP. To date, only five cases have been reported in the literature2–6 with the most common pathogen being Escherichia coli. Here, we present a case of E. coli meningitis after TBP despite quinolone prophylaxis.
Case report A 71-year-old man with type 2 diabetes mellitus was admitted with a high fever and a loss of consciousness. Two days earlier, a TBP had been taken with an 18-guage biopsy needle (Topnotch; Boston Scientific, Natick, MA, USA), under transrectal ultrasonography guidance owing to suspicious prostate adenocarcinoma after antibiotic prophylaxis with oral ciprofloxacin 500 mg. The Correspondence: Dr MB Hoscan, Department of Urology, Baskent University Alanya Research and Practice Center, Baskent University, Antalya 7400, Turkey. E-mail:
[email protected] This case report was presented at the Congress of The Turkish Microbiological Society and The Turkish Society of Clinical Microbiology and Infectious Disease (Klimik Society), 14–18 March 2007, Antalya, Turkey. Received 24 September 2007; accepted 16 January 2008; published online 4 March 2008
patient had a history of urine retention requiring a urinary catheter and had used ciprofloxacin to treat urinary tract infections during the previous month. A physical examination revealed somnolence, neck stiffness and a positive Kernig’s sign. The results of all other systemic tests were unremarkable. A lumbar puncture was performed. An evaluation of the cerebrospinal fluid (CSF) demonstrated the following: white blood count was 8400 mm 3 (polymorphonuclear leukocyte, 90%); protein, 126 g per 100 ml; glucose, 30 mg per 100 ml (1.65 mmol l 1); and the concurrent blood glucose was 181 mg per 100 ml (9.6 mmol l 1). Gram staining of the CSF demonstrated Gram-negative bacilli. The patient was empirically treated with intravenous meropenem (2 g every 8 h). A culture of the CSF was positive for E. coli, and the isolates were resistant to ciprofloxacin on a standard disk diffusion test. An E-test strip (ceftazidime-clavulanate) was used to detect extendedspectrum b-lactamases, and the organism was found to be negative for extended-spectrum b-lactamases. The antibiotic therapy was changed to intravenous ceftriaxone (2 g every 12 h) and was completed in 21 days. After the antibiotic therapy, the patient made a full recovery during 1-month follow-up.
Comment Most infectious complications after TBP are limited to symptomatic urinary tract infections and low-grade febrile illnesses, which can be readily treated with oral. However, recent studies show that 2% of patients will go on to develop a febrile urinary tract infection, bacteremia or acute prostatitis and will require hospitalization that includes administration of intravenous antibiotics.7 It is common practice to use antibiotics prophylactically to reduce the potentially dangerous infectious complica-
Acute bacterial meningitis after TBP H Erdogan et al
208
tions of TBP. However, antibiotic prophylaxis for TBP is not standardized, and differing regimens exist. Microbiological principles dictate that the choice of therapy should be directed at likely causative agents with a peak level coinciding with instrumentation and persisting for an adequate duration.8 Current evidence suggests that fluoroquinolones are the prophylactic treatment of choice because of their broad spectrum of action, their adequacy in treating common urinary and colorectal flora, their high concentration within prostatic tissue and their ease of oral administration.9 Because fluoroquinolones have been prescribed more commonly for community-acquired urinary tract infections, their extensive use has led to the development of resistant bacteria in the general clinical setting. Resistance rates for ciprofloxacin against community-acquired urinary tract infections have been reported as being between 0 and 38%.10 To prevent infective complications, other preparatory regimens than antibiotic therapy have been used empirically in various institutions, including enemas and povidone-iodine rectal lavage before biopsy. Until recently, their effectiveness on infective complications after TBP had not been definitively addressed. Bacterial meningitis in adults is a severe disease with high fatality and morbidity rates, and Gram-negative bacilli have been an infrequent cause of meningitis. Gram-negative bacilli may be isolated from the CSF of patients after head trauma or neurosurgical procedures and may be found in neonates, the elderly, immunosuppressed patients and patients with Gram-negative septicemia.2–6 Clinicians must remember that high resistance rates for production of extended-spectrum b-lactamases may be associated with ciprofloxacin use.10 The emergence of multidrug-resistant antibiotics (especially the emergence of resistance to third-generation cephalosporins) has resulted in a significant reduction in available treatment options for Gram-negative bacillary meningitis. Therefore, in our patient, we began empiric meropenem, due to their ability to penetrate into CSF and not hydrolyzed by extended-spectrum b-lactamases, which was later switched to third-generation cephalosporins.
Prostate Cancer and Prostatic Diseases
Owing to rising resistance rates, quinolones are questioned as reliable agents used for prophylactic treatment of infections following TBP. If risk factors for fluoroquinolone resistance, such as urinary tract abnormalities, age over 50 years, history of fluoroquinolone use, urinary catheterization or complicated urinary tract infection, alternative antibiotics therapies should be considered with regard to local antimicrobial susceptibility patterns.
References 1 Aus G, Ahlgren G, Bergdahl S, Hugosson J. Infection after transrectal core biopsies of the prostate—risk factors and antibiotic prophylaxis. Br J Urol 1996; 77: 851–855. 2 Sandvik A, Stefansen D. Escherichia coli meningitis following prostate biopsy. Tidsskr Nor Laegeforen 1982; 102: 499–500. 3 Meisel F, Jacobi C, Kollmar R, Hug A, Schwaninger M, Schwab S. Acute meningitis after transrectal prostate biopsy [in German]. Urologe A 2003; 42: 1611–1615. 4 Rodriguez-Patron Rodriguez R, Navas Elorza E, Quereda Rodriguez-Navarro C, Mayayo Dehesa T. Meningitis caused by multiresistant E.coli after an echo-directed transrectal biopsy [in Spanish]. Actas Urol Esp 2003; 27: 305–307. 5 Shen ZJ, Chen SW, Wang H, Zhou XL, Zhao JP. Life-threatening meningitis resulting from transrectal prostate biopsy. Asian J Androl 2005; 7: 453–455. 6 Samson D, Seguin T, Conil JM, Georges B, Samii K. Multiresistant Escherichia coli meningitis after transrectal prostate biopsy [in French]. Ann Fr Anesth Reanim 2007; 26: 88–90. 7 Lindert KA, Kabalin JN, Terris MK. Bacteremia and bacteriuria after transrectal ultrasound guided prostate biopsy. J Urol 2000; 164: 76–80. 8 Grabe M. Perioperative antibiotic prophylaxis in urology. Curr Opin Urol 2001; 11: 81–85. 9 Shandera KC, Thibault GP, Deshon Jr GE. Efficacy of one dose fluoroquinolone before prostate biopsy. Urology 1998; 52: 641–643. 10 Arslan H, Azap OK, Ergonul O, Timurkaynak F, Urinary Tract Infection Study Group. Risk factors for ciprofloxacin resistance among Escherichia coli strains isolated from community-acquired urinary tract infections in Turkey. J Antimicrob Chemother 2005; 56: 914–918.
