What is the recommended antibiotic therapy for bacterial prostatitis?

Antibiotic Therapy for Bacterial Prostatitis

Fluoroquinolones are the first-line treatment for bacterial prostatitis due to their favorable pharmacokinetic profile and broad-spectrum coverage against common causative pathogens. 1

Classification and Pathogens

Bacterial prostatitis is classified into two main types:

1. Acute Bacterial Prostatitis (ABP)

   • Primarily caused by Enterobacterales 2
   • Presents with fever, perineal pain, and urinary symptoms

2. Chronic Bacterial Prostatitis (CBP)

   • Encompasses a broader spectrum of pathogens including atypical microorganisms 2
   • Characterized by recurrent UTIs
   • Most common pathogens: Escherichia coli, Enterococcus faecalis, and Staphylococcus epidermidis 3, 4

First-Line Treatment Recommendations

For Chronic Bacterial Prostatitis:

• Fluoroquinolones (preferred first-line agents):
  • Levofloxacin: 500 mg once daily for 28 days 3, 5
  • Ciprofloxacin: 500 mg twice daily for 28 days 4, 5

For Specific Pathogens:

• Chlamydia trachomatis:

  • Azithromycin 1.0-1.5 g single dose OR
  • Doxycycline 100 mg twice daily for 7 days 1

• Mycoplasma genitalium:

  • Azithromycin 500 mg on day 1, then 250 mg for 4 days
  • For macrolide-resistant strains: Moxifloxacin 400 mg daily for 7-14 days 1

• Ureaplasma urealyticum:

  • Doxycycline 100 mg twice daily for 7 days OR
  • Azithromycin 1.0-1.5 g single dose 1

Treatment Duration

• Acute bacterial prostatitis: 2-4 weeks 6
• Chronic bacterial prostatitis: 4-6 weeks, may be extended to 6-12 weeks if improvement occurs 1, 6

Clinical Considerations

1. Diagnosis:

   • Proper diagnosis is essential before initiating antibiotics
   • For CBP, the Meares and Stamey 2- or 4-glass test is recommended 1

2. Treatment efficacy:

   • Fluoroquinolones have shown high eradication rates (70-80%) in long-term follow-up studies 7
   • Levofloxacin once daily is as effective as ciprofloxacin twice daily, with similar microbiological eradication rates (75% vs 76.8%) 5

3. Potential complications:

   • Consider prostatic abscess in patients not responding to antibiotics
   • Transrectal ultrasound may be necessary to rule out abscess 1

4. Relapse prevention:

   • Long-term suppressive antibiotic therapy may be useful in selected patients with recurrent bacteriuria 6

Common Pitfalls to Avoid

• Initiating antibiotics without proper microbiological diagnosis
• Inadequate treatment duration leading to recurrence
• Overlooking non-bacterial causes of prostatitis symptoms
• Failing to treat sexual partners in cases of sexually transmitted infections 1

Treatment Outcomes

Studies comparing fluoroquinolones have demonstrated similar efficacy:

• Levofloxacin vs. ciprofloxacin showed comparable clinical success rates (75% vs 72.8%) and microbiological eradication rates (75% vs 76.8%) 5
• Ciprofloxacin has shown excellent results particularly for E. coli prostatitis, with eradication rates of 92% at 3 months and 70-80% at 12-24 months 7

Fluoroquinolones are preferred due to their excellent penetration into prostatic tissue and broad-spectrum activity against both gram-negative and gram-positive organisms commonly implicated in bacterial prostatitis.