What is the antibiotic of choice for prostatitis?

Antibiotic of Choice for Prostatitis

Fluoroquinolones, specifically ciprofloxacin and levofloxacin, are the first-line antibiotics of choice for prostatitis due to their favorable antibacterial spectrum and pharmacokinetic profile. 1

Classification and Treatment Approach

Acute Bacterial Prostatitis (ABP)

• Primarily caused by Enterobacterales
• Treatment duration: 2-4 weeks 1
• First-line therapy: Fluoroquinolones (ciprofloxacin or levofloxacin)
• For severely ill patients requiring hospitalization: Consider intravenous antibiotics such as ceftriaxone and doxycycline, or piperacillin/tazobactam 2

Chronic Bacterial Prostatitis (CBP)

• Involves a broader spectrum of pathogens, including atypical microorganisms
• Treatment duration: 4-6 weeks, may be extended to 6-12 weeks if improvement occurs 1
• First-line therapy: Fluoroquinolones (ciprofloxacin or levofloxacin)

Pathogen-Specific Treatment

For Traditional Pathogens (Enterobacterales, particularly E. coli)

• Ciprofloxacin 500 mg twice daily or levofloxacin 500 mg once daily 3
  • Both have shown equivalent clinical and microbiological efficacy in randomized trials
  • Levofloxacin offers the advantage of once-daily dosing 3

For Atypical Pathogens

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 4

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

Important Clinical Considerations

• Diagnosis confirmation: Before initiating antibiotics (except in acute prostatitis with fever), confirm diagnosis using the Meares and Stamey 2- or 4-glass test 1
• Treatment duration: Minimum 2-4 weeks; inadequate duration can lead to recurrence 1, 5
• Treatment assessment: Evaluate effectiveness at 4-6 weeks; do not continue antibiotics beyond 6-8 weeks without reassessment 5
• Resistance concerns: Consider local resistance patterns when selecting antibiotics
• Follow-up: Essential to assess treatment success and monitor for complications such as prostatic abscess 1

Caveats and Pitfalls

• Avoid initiating antibiotics without proper diagnosis unless the patient presents with fever (acute prostatitis) 1
• Be aware that fluoroquinolone resistance is increasing globally, which may affect treatment success
• For patients with recurrent or refractory prostatitis, consider longer treatment courses (6-12 weeks) 1
• Consider macrolides rather than fluoroquinolones for prostatitis caused by intracellular pathogens 4
• Monitor for adverse effects of fluoroquinolones, including tendinopathy and central nervous system effects 6