Prostate biopsy is a current and well-codified procedure; antibiotic prophylaxis and rectal enema limit the risk of infection. To date, there has been no reported viral transmission between patients due to a contaminated ultrasound probe. In this study, we report the case of a patient who contracted the hepatitis C virus after transrectal prostate biopsy as part of an individual screening for prostate cancer.
In urology, prostate biopsy is currently the only means to confirm a diagnosis of prostate cancer, the most prevalent cancer found in men. Approximately from 120,000 to 150,000 biopsies are conducted each year in France, resulting in 50,000 new diagnoses of prostate cancer. Prostate biopsies are primarily conducted transrectally, and the risk of infection with an antibiotic prophylaxis such as quinolone is estimated to be between 2 and 5% (versus 30 to 40% without an antibiotic prophylaxis) [
Mr. S., 53 years of age without any particular medical history, received an ultrasound-guided prostate biopsy as part of an individual screening for prostate cancer. He had a PSA of 5.62 ng/mL and a nonsuspicious digital rectal examination (prostate estimated at 60 g). The biopsy was conducted without any special procedures such as sterile ECBU or urine culture. The anatomopathological report did not show any outbreak of carcinomatous proliferation. Four weeks after the biopsy, the patient presented a pseudo-influenza syndrome associated with hepatic cytolysis (20 times normal). The etiological workup showed discretely positive anti-HCV antibodies and a C virus PCR of 6 log. Other viral serologies, such as A, B, and mononucleosis, were negative (the last transaminases performed in this patient in 2007 were normal). The diagnosis of acute hepatitis C was then raised. The etiological investigation of Mr. S. was noted by the absence of transfusions and intravenous (IV) drug abuse as well as various risk factors usually associated with this condition. Moreover, the results of serological tests performed on patients who received prostate biopsies in the three days preceding the biopsy of Mr. S. all came back negative, as did those of the sampling doctor and the consulting nurse. The internal report by the CLIN of the establishment concerned revealed that nearly 36% of the protective sheaths were perforated after biopsies and that nondisposable, reusable metal puncture guides that could have been contaminated were used. The report of the forensic expert stated (on the advice of virology experts) that during the cleaning of medical devices, especially endoscopes and ultrasound probes, an organic film deposited on the apparatus during sterilization can protect a virus for a relatively long time, between 10 and 15 days at the most, and that it is therefore not impossible that the contamination of Mr. S. could have occurred via a probe or guide that was used up to two weeks prior to the biopsy in question.
Faced with this array of arguments, the establishment believes that Mr. S. was likely contaminated during his prostate biopsy and will therefore be compensated accordingly.
The nosocomial and nontransfusional transmission of HCV has become an important means of infection, though it remains secondary to contamination by IV drug abuse (70% of the 50,000 new cases annually) [
The risk of nosocomial transmission of HCV seems to be limited to invasive medicosurgical procedures
Cases of transmission of HCV by endorectal prostate biopsy are extremely rare.
Experts have noted the existence of a “bio film” that could protect and trap the virus on the protection guide used in biopsies and other procedures. In fact, during the investigation of a patient infected with HCV, stains consisting of blood, secretions, and remains of mucosa after biopsy were deposited even in the inner channel of the guide. Even if the instruments are cleaned immediately after the procedure, manual washing does not always eliminate organic contaminants. It is possible that oxidizing disinfectants, which act on the surface of debris, form a “bio film,” a protective covering that prevents the thorough action of the disinfectants. During subsequent use, the debris and its bio film could detach and contaminate the next patient. This mode of contamination is more common when the washing time is short, when the delay between contamination and washing is long, and when the equipment is old or scratched. Currently, the only way to completely avoid transmission linked to a “bio film” is to use new equipment for every examination, which is not practical for certain procedures such as endoscopies and laryngoscopies. This contamination is therefore theoretically more common when the hospital service accommodates carrier patients [
Experts have also revealed that nearly one-third of protective sheaths are perforated. Use of these protective shields was evaluated by the High Council of Public Health in 2007. This study initially specified that bacterial and viral transmissions in particular were extremely rare during tests such as prostate biopsies. The only reported case of infection was of a bacterial transmission of
The integrity of protective sheaths, measured by the rate of perforation, has been the subject of several studies, particularly concerning transvaginal and transrectal probes. These studies, which include comparative and noncomparative and randomized and nonrandomized studies, focused on protective sheaths or condoms (used as sheaths). Perforation is detected either visually or by tests, such as leakage of water or of hydrogen peroxide, that differ according to the study. Overall rates of perforation range from 1 to 8% and vary according to the type of protection tested and the detection method [
Another point to note is that microorganisms can also be preserved and protected on biopsy guides for several days by the “bio film.” International recommendations call for prostate biopsies using a single-use biopsy guide or, if it is reusable, to sterilize it in an autoclave with water vapor. In 2006, an investigation conducted by several hospital services alerted the American authorities, particularly the FDA, to numerous failures in sterilization of medical equipment used in prostate biopsies [
The FDA [
This reported case of contamination following a prostate biopsy should encourage practitioners to scrupulously adhere to the recommendations regarding existing sterilization norms, to use protective sheaths, to verify the integrity of protective sheaths after use, and to use single-use puncture guides.
There is no conflict of interests.