Reducing Infection Risk with Povidone-Iodine Before Transrectal Prostate Biopsy

Overview

This systematic review and meta-analysis of 10 randomized controlled trials including 3,297 patients demonstrates that povidone-iodine (PI) rectal disinfection combined with antibiotic prophylaxis (AP) significantly reduces infectious complications, including fever and sepsis, after transrectal ultrasound-guided prostate biopsy (TRUS-PB). The findings support the European Association of Urology guidelines recommending PI use prior to TRUS-PB to mitigate infection risk.

Background

Transrectal ultrasound-guided prostate biopsy (TRUS-PB) remains widely used for prostate cancer diagnosis despite higher infection risks compared to the transperineal approach. Infectious complications such as acute bacterial prostatitis, fever, and sepsis occur in up to 6.3% of cases due to rectal bacterial translocation. Povidone-iodine (PI) rectal disinfection has been proposed to reduce these infections, but prior evidence on its efficacy, especially in reducing sepsis when combined with antibiotic prophylaxis, has been inconclusive. This study aimed to clarify the role of PI disinfection in reducing infectious complications following TRUS-PB.

Data Highlights

Key Findings

• PI rectal disinfection plus antibiotic prophylaxis significantly reduces the risk of infectious complications compared to antibiotic prophylaxis alone.
• The combined use of PI and AP lowers the incidence of fever post-TRUS-PB across multiple RCTs.
• PI use is associated with a reduction in sepsis rates, clarifying previous uncertainties regarding its efficacy in sepsis prevention.
• Most included studies used fluoroquinolones or β-lactamase antibiotics as prophylaxis, with PI providing additional infection risk reduction.
• Heterogeneity among studies was assessed and accounted for, supporting the robustness of the meta-analytic findings.

Clinical Implications

Clinicians performing TRUS-PB should incorporate povidone-iodine rectal disinfection alongside standard antibiotic prophylaxis to reduce infectious complications, including fever and sepsis. This practice aligns with current European Association of Urology guidelines and may improve patient safety by mitigating infection risks inherent to the transrectal biopsy approach.

Conclusion

Pre-biopsy rectal disinfection with povidone-iodine combined with antibiotic prophylaxis effectively decreases infectious complications following TRUS-PB. These findings reinforce guideline recommendations and support routine PI use to enhance procedural safety.

References

1. EAU Guidelines 2023 -- Prostate Biopsy and Infection Prevention
2. Sharpe et al. 2023 -- Efficacy of Povidone-Iodine in TRUS-PB
3. Cochrane Handbook 2023 -- Risk of Bias Assessment