What is the recommended treatment for acute prostatitis?

Treatment of Acute Prostatitis

For acute bacterial prostatitis, fluoroquinolones (ciprofloxacin 500 mg twice daily or levofloxacin 500 mg once daily) are the recommended first-line treatment for 2-4 weeks due to their superior prostatic tissue penetration and high efficacy against common uropathogens. 1

Antibiotic Selection

The treatment approach depends on severity of illness:

Outpatient Treatment (Mild to Moderate Cases)

• First-line options:

  • Ciprofloxacin 500 mg twice daily for 2-4 weeks 1, 2
  • Levofloxacin 500 mg once daily for 2-4 weeks 1

• Alternative options:

  • Doxycycline 100 mg twice daily for 2-4 weeks (particularly effective for atypical pathogens such as Chlamydia, Mycoplasma, and Ureaplasma) 1
  • Trimethoprim-sulfamethoxazole 960 mg twice daily for 4 weeks 3, 4

Inpatient Treatment (Severe Cases)

Hospitalization with intravenous antibiotics is indicated for patients who are:

• Systemically ill (fever, chills)
• Unable to urinate voluntarily
• Unable to tolerate oral intake
• At risk for antibiotic resistance 2

Recommended IV regimens:

• Third-generation cephalosporin with gentamicin 3
• Ceftriaxone and doxycycline 2
• Piperacillin/tazobactam 2

Duration of Treatment

Despite early symptom improvement, complete the full antibiotic course:

• Acute bacterial prostatitis: 2-4 weeks 1, 3, 5
• Chronic bacterial prostatitis: 4-6 weeks (up to 12 weeks in some cases) 1, 4, 6

Diagnostic Approach

For proper diagnosis and treatment planning:

• Urine culture before starting antibiotics to identify the causative organism and determine antibiotic sensitivity 1, 2
• Digital rectal examination to assess for tender, enlarged, or boggy prostate (note: prostatic massage should be avoided in acute prostatitis due to risk of bacteremia) 2
• Blood cultures if systemic symptoms are present 1
• Consider transrectal ultrasound if prostatic abscess is suspected 1

Adjunctive Measures

In addition to antibiotics, supportive care includes:

• Adequate hydration
• Analgesics for pain management
• Alpha-blockers (such as tamsulosin) for urinary symptoms 1, 6
• Bed rest during acute phase 1

Monitoring and Follow-up

• Reevaluate within 3 days if no improvement is seen 1
• Clinical reassessment after 2 weeks to evaluate symptom improvement 1
• Urine culture at the end of treatment to confirm eradication 1
• Repeat PSA measurement 3 months after resolution if it was elevated during infection 1

Common Pitfalls and Caveats

• Avoid premature discontinuation of antibiotics when symptoms improve, as this may lead to treatment failure and development of chronic prostatitis 1, 5
• Recognize potential complications such as prostatic abscess, which may require drainage 2
• Consider antibiotic resistance patterns in your local area when selecting empiric therapy 2
• Treat sexual partners when sexually transmitted infections are identified 1
• Avoid transrectal prostate biopsy during active infection 1

Special Considerations

For atypical pathogens, specific regimens include:

• 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; if macrolide-resistant, use moxifloxacin 400 mg daily for 7-14 days 1