What is the management of acute bacterial prostatitis?

Etiology, Clinical Features, and Management of Acute Bacterial Prostatitis

The first-line treatment for acute bacterial prostatitis is broad-spectrum antibiotics such as piperacillin-tazobactam, ceftriaxone, or ciprofloxacin for 2-4 weeks, which has a success rate of 92-97%. 1, 2

Etiology

Acute bacterial prostatitis is an infection of the prostate gland typically caused by:

• Gram-negative bacteria (80-97% of cases), primarily:
  • Escherichia coli
  • Klebsiella species
  • Pseudomonas species 2
• Less commonly, enterococci and other gram-positive organisms 1

Common routes of infection include:

• Ascending urethral infection
• Reflux of infected urine into prostatic ducts
• Hematogenous spread
• Lymphatic spread
• Iatrogenic causes (transrectal prostate biopsy, urinary catheterization) 3

Clinical Features

Acute bacterial prostatitis typically presents with:

• Systemic symptoms:

  • Fever and chills
  • Malaise
  • Nausea and vomiting 2, 3

• Urinary symptoms:

  • Dysuria
  • Urinary frequency and urgency
  • Urinary retention
  • Nocturia 3

• Pelvic and perineal symptoms:

  • Pelvic pain
  • Perineal pain
  • Low back pain 3

• Physical examination findings:

  • Tender, enlarged, and/or boggy prostate on digital rectal examination
  • Suprapubic tenderness 3

Diagnostic Evaluation

1. Laboratory studies:

   • Urinalysis and urine culture (mandatory) 1
   • Blood cultures if sepsis is suspected
   • Complete blood count
   • PSA (may be elevated but not diagnostic) 1

2. Important note: Avoid vigorous prostate massage as it may lead to bacteremia and sepsis 1

3. Imaging:

   • Generally unnecessary for initial diagnosis
   • Consider CT scan or excretory urography if:
     • Patient remains febrile after 72 hours of treatment
     • Clinical deterioration occurs
     • Prostatic abscess is suspected 1

Management

Initial Antibiotic Therapy

Parenteral options (for hospitalized patients):

• Piperacillin-tazobactam 2.5-4.5g IV three times daily
• Ceftriaxone 1-2g IV once daily
• Cefotaxime 2g IV three times daily
• Ciprofloxacin 400mg IV twice daily
• Levofloxacin 750mg IV once daily
• Consider aminoglycosides in combination with ampicillin for severe cases 1

Oral options (for outpatient treatment):

• Ciprofloxacin 500mg twice daily
• Levofloxacin 500mg once daily 1, 2

Duration: 2-4 weeks 1, 2

Treatment Adjustment and Monitoring

1. Adjust antibiotics based on culture and antibiogram results (needed in approximately 76.6% of cases) 1

2. Clinical reassessment after 2 weeks to evaluate symptom improvement 1

3. Follow-up urine culture at the end of treatment to confirm eradication 1

4. PSA measurement 3 months after resolution if it was elevated during infection 1

Supportive Measures

• Adequate hydration
• Analgesics for pain control
• Alpha-blockers for urinary symptoms
• Urinary catheterization if severe urinary retention occurs (suprapubic catheter preferred over urethral catheter) 1, 3

Indications for Hospitalization

• Systemically ill patient
• Unable to tolerate oral intake
• Urinary retention
• Risk factors for antibiotic resistance
• Immunocompromised status 3

Complications

• Prostatic abscess
• Sepsis
• Progression to chronic bacterial prostatitis (occurs in approximately 10% of cases) 1
• Epididymo-orchitis

Prevention

• Antimicrobial prophylaxis is strongly recommended for all patients undergoing transrectal prostate biopsy 1
• Consider transperineal approach for prostate biopsy in high-risk patients

Special Considerations

• Antibiotic resistance: Fluoroquinolone resistance is increasing; consider local resistance patterns when selecting empiric therapy 1, 4

• Atypical pathogens: For specific pathogens, consider:

  • Chlamydia trachomatis: azithromycin 1.0-1.5g single dose or doxycycline 100mg twice daily for 7 days
  • Mycoplasma genitalium: azithromycin 500mg on day 1, then 250mg for 4 days; if macrolide-resistant, use moxifloxacin 400mg daily for 7-14 days
  • Enterococcal infections: daptomycin 8-12mg/kg IV daily, ampicillin 200mg/kg/day IV in 4-6 doses, or linezolid 600mg PO every 12 hours 1

• Reserve carbapenems and new broad-spectrum antibiotics for patients with culture results indicating multiresistant organisms 1