What antibiotics are used to treat bacterial prostatitis?

Antibiotic Treatment for Bacterial Prostatitis

Ciprofloxacin is the first-choice antibiotic for treating chronic bacterial prostatitis, with a recommended dosage of 500 mg twice daily for 4-6 weeks, due to its superior prostatic tissue penetration and documented efficacy. 1

Types of Bacterial Prostatitis and First-Line Treatments

Acute Bacterial Prostatitis

• First-line antibiotics:
  • Ciprofloxacin 500 mg twice daily for 2-4 weeks
  • Levofloxacin 500 mg once daily for 2-4 weeks 1, 2
  • Trimethoprim-sulfamethoxazole (when local resistance rates <20%) 1

Chronic Bacterial Prostatitis

• First-line antibiotics:
  • Ciprofloxacin 500 mg twice daily for 4-6 weeks 1
  • Levofloxacin 500 mg once daily for 4-6 weeks 1, 2
  • Doxycycline 100 mg twice daily for 4-6 weeks (especially for atypical pathogens) 1

Antibiotic Selection Based on Pathogen

Common Bacterial Pathogens

• E. coli, Enterococcus, Staphylococcus:
  • Fluoroquinolones (ciprofloxacin, levofloxacin) are most effective due to excellent prostatic tissue penetration 1, 2
  • Levofloxacin has documented efficacy against E. coli, Enterococcus faecalis, and S. epidermidis in chronic bacterial prostatitis 2

Atypical 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:

  • Doxycycline 100 mg twice daily for 4-6 weeks 1

Enterococcal Infections

• Treatment options:
  • Daptomycin 8-12 mg/kg IV daily
  • Ampicillin 200 mg/kg/day IV in 4-6 doses
  • Linezolid 600 mg PO every 12 hours 1

Treatment Duration

• Acute bacterial prostatitis: 2-4 weeks (even when symptoms improve early) 1
• Chronic bacterial prostatitis: 4-6 weeks to ensure complete eradication 1

Important Considerations

Diagnostic Testing

• Midstream urine culture is essential to guide antibiotic selection 1
• The Meares and Stamey 2- or 4-glass test is strongly recommended for accurate diagnosis 1

Prostatic Penetration

• Antibiotics with good prostatic tissue penetration are crucial for effective treatment
• Fluoroquinolones, macrolides, tetracyclines, and trimethoprim have favorable pharmacokinetic properties for prostatic penetration 1
• Penicillins, cephalosporins, and aminoglycosides generally do not penetrate well into chronically inflamed prostatic tissue 3

Monitoring and Follow-up

• Clinical reassessment after 2 weeks to evaluate symptom improvement
• Urine culture at the end of treatment to confirm eradication
• Repeat PSA measurement 3 months after resolution if elevated during infection 1

Potential Complications

• Treatment failure may result from:
  • Inadequate treatment duration
  • Poor antibiotic selection
  • Overlooking prostatic abscess
  • Using antibiotics with poor prostatic penetration 1

Safety Warnings

• The FDA has issued warnings about fluoroquinolone side effects affecting tendons, muscles, joints, nerves, and central nervous system 1
• Monitor renal function and drug levels for aminoglycosides
• Weekly CPK levels for daptomycin and complete blood count for linezolid 1

Contraindications and Cautions

• Avoid prostatic massage in acute bacterial prostatitis 1
• Consider hospitalization and IV antibiotics for patients who are systemically ill, unable to urinate voluntarily, unable to tolerate oral intake, or have risk factors for antibiotic resistance 4

By selecting antibiotics with good prostatic penetration and appropriate spectrum of activity against the causative pathogens, bacterial prostatitis can be effectively treated, reducing the risk of complications and recurrence.