Prostate biopsy-related sepsis: Epidemiology, risk stratification, and prevention strategies

Prostate biopsy remains an essential diagnostic procedure for confirming prostate cancer; however, biopsy-related infectious complications can result in emergency department visits, hospitalization, sepsis, and, rarely, septic shock. The infectious risk is particularly relevant to the transrectal approach, in which the biopsy needle traverses the rectal mucosa and can introduce enteric organisms into prostatic tissue and the bloodstream. The transition from transrectal to transperineal biopsy is the most important contemporary procedural development in infection prevention. Transperineal biopsy avoids direct traversal of the rectal mucosa and is associated with a lower infectious burden. Randomized evidence also indicates that transperineal biopsy can be performed under local anesthesia, and selected patients may undergo the procedure without antibiotic prophylaxis. When transrectal biopsy remains necessary, prevention should be based on local resistance patterns and individual risk, with consideration of rectal povidone-iodine preparation and targeted or otherwise appropriately selected antimicrobial prophylaxis. Management of suspected post-biopsy sepsis requires prompt recognition, microbiological sampling, early empiric antimicrobial therapy, assessment and treatment of organ dysfunction, appropriate fluid and vasopressor therapy when indicated, source control when necessary, and subsequent antimicrobial de-escalation according to microbiological results.