What is the antibiotic of choice for prostatitis?

Antibiotic of Choice for Prostatitis

Fluoroquinolones, particularly levofloxacin and ciprofloxacin, are the first-line antibiotics of choice for prostatitis due to their favorable pharmacokinetic profile and broad-spectrum activity against common causative pathogens. 1

Types of Prostatitis and Antibiotic Selection

Acute Bacterial Prostatitis

• First-line therapy: Fluoroquinolones (levofloxacin 500 mg once daily or ciprofloxacin 500 mg twice daily)
• Duration: 2-4 weeks 1
• Alternative regimens: Ceftriaxone plus doxycycline (if systemic illness or inability to tolerate oral intake) 2
• Hospitalization criteria: Systemically ill patients, urinary retention, inability to tolerate oral intake, or risk factors for antibiotic resistance 2

Chronic Bacterial Prostatitis

• First-line therapy: Fluoroquinolones (levofloxacin 500 mg once daily or ciprofloxacin 500 mg twice daily)
• Duration: 4-6 weeks, may be extended to 6-12 weeks if improvement occurs 1
• Clinical evidence: Levofloxacin 500 mg once daily has shown equivalent efficacy to ciprofloxacin 500 mg twice daily in randomized controlled trials 3, 4

Pathogen-Specific Treatment

For atypical pathogens, the following regimens are recommended:

1. Chlamydia trachomatis:

   • Azithromycin 1.0-1.5 g single dose OR
   • Doxycycline 100 mg twice daily for 7 days 1
   • Note: Azithromycin shows improved eradication and clinical cure rates compared to ciprofloxacin for chlamydial prostatitis 5

2. 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

3. Ureaplasma urealyticum:

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

Diagnostic Considerations

Proper diagnosis is crucial before initiating antibiotic therapy:

• The Meares and Stamey 2- or 4-glass test is strongly recommended to confirm bacterial prostatitis 1
• Collection should include first-void urine, midstream urine, expressed prostatic secretions, and post-massage urine 1
• Microbiological evaluation for atypical pathogens should be performed 1

Important Clinical Caveats

1. Do not initiate antibiotics without proper diagnosis unless the patient presents with fever (acute prostatitis) 1

• Perform appropriate investigations within a reasonable time period (preferably within 1 week) 6
• During this period, provide symptomatic relief with appropriate analgesia 6

1. Treatment duration considerations:

• Minimum duration should be 2-4 weeks 6
• If no improvement in symptoms, treatment should be reassessed 6
• If improvement occurs, continue for at least another 2-4 weeks 6
• Do not continue antibiotic treatment for 6-8 weeks without evaluating its effectiveness 6

1. Common pitfalls to avoid:

• Inadequate treatment duration leading to recurrence 1
• Unnecessary prolonged antibiotic exposure 1
• Initiating antibiotics without proper microbiological sampling 1
• Failing to consider atypical pathogens in chronic prostatitis cases 1, 5

Fluoroquinolones remain the cornerstone of prostatitis treatment due to their ability to penetrate prostatic tissue and achieve sufficient concentrations at the site of infection 6, 5. For patients with chronic bacterial prostatitis caused by obligate intracellular pathogens, macrolides have shown higher microbiological and clinical cure rates compared to fluoroquinolones 5.