Pneumonia and sepsis due to carbapenem-resistant Klebsiella Pneumoniae after transrectal prostate biopsy

Abstract

Transrectal ultrasound-guided prostate biopsy (TRUSPB) with local anesthesia and prophylactic antibiotics is the most commonly used diagnostic method for prostate cancer today. Even though TRUSPB has a low complication rate, infective complications may arise on occasion. Despite the fact that prophylaxis is controversial to prevent infective complications after TRUSPB, quinolones (ciprofloxacin, ofloxacin, levofloxacin) and trimethoprim-sulfamethoxazole are the most frequently preferred antibiotics in prophylaxis. However, as with many antibiotics today, there is an increase in resistance to trimethoprim-sulfamethoxazole and quinolones. This report describes a case of sepsis due to carbapenem-resistant Klebsiella pneumoniae and pneumonia following transrectal prostate biopsy.

Introduction

The most commonly used diagnostic method for prostate cancer is a transrectal ultrasoundguided prostate biopsy (TRUSPB), which is performed in urology using local anesthesia and prophylactic antibiotics. During this procedure, the biopsy needle enters the prostate tissue from the rectal mucosa and carries the rectal flora to the prostate tissue. Although prophylaxis to prevent infective complications after TRUSPB is controversial, quinolones (ciprofloxacin, ofloxacin, levofloxacin) and trimethoprim-sulfamethoxazole are the most commonly used antibiotics in prophylaxis. After oral administration, these antibiotics concentrate in the colorectal region, urine, kidney, prostate, and feces and have long-term urinary bactericidal activities. However, as with many antibiotics today, there is an increase in resistance to trimethoprim-sulfamethoxazole and quinolones.[1-3]

Healthcare-associated infections (HCAIs) are a global threat with high morbidity and mortality. One of the most serious threats to public health is antimicrobial resistance, especially among Gram-negative (GN) bacteria.[4] Klebsiella pneumoniae strains account for 3-8% of all HCAIs and are the most common cause of urinary tract infection, pneumonia, and bacteremia.[4-6] According to the results of a multicenter study examining antibiotic resistance in HCAIs in 2015-2018 from our country; there was a significant increase (60-72%) in quinolone resistance for K. pneumoniae. [7] Carbapenem-resistant K. pneumoniae (CRK) is a global current problem that results in treatment failure. Chronic renal failure, diabetes mellitus, immunosuppression, malignancy, history of the cerebrovascular event, history of surgery, trauma, invasive procedures (foley catheter, central catheter, mechanical ventilation, etc.), use of antimicrobial therapy are all risk factors for CRK.[4]

This report describes a case of sepsis due to carbapenem-resistant K. pneumoniae and pneumonia following transrectal prostate biopsy.

Case Report

A 75-year-old male patient was admitted to the emergency room with complaints of fever, anorexia, cough, and general discomfort that lasted three days. The patient’s history was unremarkable except for a transrectal ultrasound-guided prostate biopsy performed approximately seven days ago in the patient’s history, who did not have any chronic disease other than complaints of prostatism. A written informed consent was obtained from the patient.

It was learned that ciprofloxacin 500 mg tablet prophylaxis was administered to the patient before the procedure and the patient was discharged after no complications developed as a result of the procedure. On physical examination, the fever was 38.7°C, the blood pressure was 80/40 mmHg, and the heart rate was 138/min. The patient in the follow-up was conscious and had basal rales in both lungs. Other system examinations were normal. In his laboratory tests; hemoglobin: 11.3 g/dL, platelets (PLT): 85,000/μL, white blood cell: 23,300/μL (neutrophils: 19,300/μL), blood urea nitrogen: 114 mg/dL, creatinine: 2.1 mg/dL, AST: 114 U/L, ALT: 103 U/L, CRP: 239 mg/dL, sedimentation: 96 mm/h, procalcitonin: 26.15 ng/mL. The patient was hospitalized with a preliminary diagnosis of sepsis and pneumonia. Following the collection of blood and urine cultures, empiric intravenous (IV) renal-dose meropenem 2x1 g treatment was started. In addition, hydration and other medical support treatments were administered to the patient due to sepsis. The patient, however, whose metabolic acidosis persisted, was transferred to a different facility, to the intensive care unit. The blood culture taken on the third day of hospitalization revealed carbapenem-resistant K. pneumoniae growth. In the patient’s urine culture, there was also CRK growth with the same antibiogram. To identify isolates grown in cultures and perform antibiotic susceptibility tests, the VITEK 2 Compact (bioMérieux, Craponne, France) automated system was used. The antibiotic susceptibility results were interpreted using the EUCAST (European Committee on Antimicrobial Susceptibility Testing) values. The intensive care unit was informed about the arrangement of meropenem 2x1 g dose IV+colistin methanesulfonate 2x150 mg IV antibiotic treatment based on the results of the culture antibiogram. The patient was admitted to our service on the seventh day of his hospitalization after his metabolic findings improved, his septic condition regressed, and his need for intensive care was eliminated. The patient was discharged with full recovery after receiving 14 days of combined antibiotic therapy and improving clinical and laboratory parameters.

Discussion

Although transrectal ultrasound-guided prostate biopsy is a reliable diagnostic method with a very low complication rate, infective complications such as pyuria, prostatitis, epididymitis, or life-threatening urosepsis can occur afterward. The most common bacterial agents of these infective complications are Escherichia coli (E. coli), K. pneumoniae, and other Gram-negative bacilli.[1,2] Bacteremia following a prostate biopsy is usually asymptomatic and often undetectable. Many symptomatic infections are induced by E. coli. Other pathogens that have been reported include Enterococci, Klebsiella spp., Bacteroides fragilis, and Clostridium spp.[3,8] Carignan et al.[9] reported that while the rate of sepsis after TRUSPB was 0.52% in 2002-2009, it increased to 2.15% in 2010-2011 in their series of 5,798 patients. According to a study conducted in Saudi Arabia, seven (5%) of 139 patients who underwent TRUSPB were hospitalized due to complications, and four (2.8%) of patients were hospitalized due to an uncomplicated urinary tract infection.[10] According to the literature, the rate of serious (major) complications having followed prostate biopsy is 1%, and these complications include meningitis and sepsis.[9,11] In the presented case, sepsis due to CRK developed after TRUSPB.

In their study, Henry et al.[12] reported that the average time to develop an infection after the transrectal prostate biopsy was one day.

Dede et al.[13] noted that the patients’ complaints began on the day of the procedure and that they applied to the health center within 0-2 days. According to Simsir et al.,[14] patients should be monitored for five days after the procedure for infective complications. In the presented case, the complaints began three days after the biopsy, and the patient took the ciprofloxacin at home for two days before being admitted to the hospital five days later.

In a transrectal prostate biopsy, antibiotic prophylaxis recommendations differ. In a multicenter study involving 144 hospitals in Europe, 48 different treatment protocols were determined to be used for prophylaxis, with fluoroquinolones (81%) and oral metronidazole (55%) being the most preferred antibiotics.[15] Ciprofloxacin prophylaxis was also used in the presented case.

Ciprofloxacin, as in the case presented, is widely used in TRUSPB antibiotic prophylaxis. AlKhateeb et al.[6] reported ciprofloxacin resistance in 90.9% of E. coli and K. pneumoniae strains grown in cultures taken from patients who developed infective complications after TRUSPB. According to Taylor et al.,[16] ciprofloxacin resistance was 19.0% in rectal swab samples from 865 patients who underwent TRUSPB, the rate of infective complications was 3.6%, and 48% of those who developed infective complications had ciprofloxacin resistance. The grown CRK strain was also found to be ciprofloxacin-resistant in our study.

Due to the increasing antibiotic resistance rates in E. coli and K. pneumoniae strains, several studies have reported that 3 g oral fosfomycin can be used for TRUSPB.[17-19] This issue, however, is still controversial.

In conclusion, we believe that antibiotic treatments used for prophylaxis in prostate biopsy performed with transrectal ultrasonography under antibiotic prophylaxis should be reconsidered in view of rising antibiotic resistance.

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

The authors received no financial support for the research and/or authorship of this article.

References

1. Akduman B , Crawford ED. Transrectal ultrasoundguided prostate biopsy: Current approach. Türk Üroloji Dergisi - Turkish Journal of Urology 2010;36:25-32.
2. Aron M, Rajeev TP, Gupta NP. Antibiotic prophylaxis for transrectal needle biopsy of the prostate: A randomized controlled study. BJU Int 2000;85:682-5.
3. Ecke TH, Gunia S, Bartel P, Hallmann S, Koch S, Ruttloff J. Complications and risk factors of transrectal ultrasound guided needle biopsies of the prostate evaluated by questionnaire. Urol Oncol 2008;26:474-8.
4. Alkan Çeviker S, Günal Ö, Kılıç SS. Risk factors for nosocomial carbapenem-resistant Klebsiella infections. FNG & Demiroğlu Bilim Tıp Dergisi 2019;5:124-33.
5. Weist K, Högberg LD. ECDC publishes 2015 surveillance data on antimicrobial resistance and antimicrobial consumption in Europe. Euro Surveill 2016;21:30401.
6. Us E, Tekeli A, Arikan Akan O, Dolapci I, Sahin F, Karahan ZC. Ankara Universitesi Tıp Fakültesinde 2004-2007 yılları arasında izole edilen karbapeneme dirençli Klebsiella pneumoniae suşlarının moleküler epidemiyolojisi. Mikrobiyol Bul 2010;44:1-10.
7. Aydın M, Azak E, Bilgin H, Menekse S, Asan A, Mert HTE, et al. Changes in antimicrobial resistance and outcomes of health care-associated infections. Eur J Clin Microbiol Infect Dis 2021;40:1737-42.
8. Rodríguez LV, Terris MK. Risks and complications of transrectal ultrasound. Curr Opin Urol 2000;10:111-6.
9. Carignan A, Roussy JF, Lapointe V, Valiquette L, Sabbagh R, Pépin J. Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: Time to reassess antimicrobial prophylaxis? Eur Urol 2012;62:453-9.
10. AlKhateeb SS, AlShammari NA, AlZughaibi MA, Ghazwani YG, Alrabeeah KA, Albqami NM. The prevalence of urinary tract infection, or urosepsis following transrectal ultrasound-guided prostate biopsy in a subset of the Saudi population and patterns of susceptibility to flouroquinolones. Saudi Med J 2016;37:860-3.
11. Shen ZJ, Chen SW, Wang H, Zhou XL, Zhao JP. Life-threatening meningitis resulting from transrectal prostate biopsy. Asian J Androl 2005;7:453-5.
12. Ho HS, Ng LG, Tan YH, Yeo M, Cheng CW. Intramuscular gentamicin improves the efficacy of ciprofloxacin as an antibiotic prophylaxis for transrectal prostate biopsy. Ann Acad Med Singap 2009;38:212-6.
13. Dede G, Şencan İ, Dede O, Şentürk G, Haykır A. Transrektal prostat iğne biyopsisi sonrası gelişen üriner sistem infeksiyonları deneyimlerimiz. Dicle Tıp Dergisi 2014;41:108-12.
14. Simsir A, Kismali E, Mammadov R, Gunaydin G, Cal C. Is it possible to predict sepsis, the most serious complication in prostate biopsy? Urol Int 2010;84:395-9.
15. Taylor HM, Bingham JB. The use of prophylactic antibiotics in ultrasound-guided transrectal prostate biopsy. Clin Radiol 1997;52:787-90.
16. Taylor S, Margolick J, Abughosh Z, Goldenberg SL, Lange D, Bowie WR, et al. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int 2013;111:946-53.
17. Gardiner BJ, Mahony AA, Ellis AG, Lawrentschuk N, Bolton DM, Zeglinski PT, et al. Is fosfomycin a potential treatment alternative for multidrugresistant gram-negative prostatitis? Clin Infect Dis 2014;58:e101-5.
18. Falagas ME, Giannopoulou KP, Kokolakis GN, Rafailidis PI. Fosfomycin: Use beyond urinary tract and gastrointestinal infections. Clin Infect Dis 2008;46:1069-77.
19. Roberts MJ, Bennett HY, Harris PN, Holmes M, Grummet J, Naber K, et al. Prostate biopsyrelated infection: A systematic review of risk factors, prevention strategies, and management approaches. Urology 2017;104:11-21.