What is the treatment for bacterial prostatitis?

Treatment for Bacterial Prostatitis

The first-line treatment for bacterial prostatitis is fluoroquinolone antibiotics, specifically ciprofloxacin 500 mg twice daily or levofloxacin 500 mg once daily for 2-4 weeks for acute bacterial prostatitis, and a minimum of 4 weeks for chronic bacterial prostatitis. 1, 2

Types of Bacterial Prostatitis and Diagnosis

Bacterial prostatitis is classified into two main types:

1. Acute Bacterial Prostatitis:

   • Presents with fever, chills, and urinary symptoms
   • Caused by gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) in 80-97% of cases
   • Requires prompt antibiotic treatment

2. Chronic Bacterial Prostatitis:

   • Persistent bacterial infection causing recurrent UTIs from the same strain
   • Up to 74% of cases due to gram-negative organisms like E. coli
   • Requires longer antibiotic courses

Antibiotic Treatment Recommendations

For Acute Bacterial Prostatitis:

• Initial therapy options:

  • Intravenous options (for severe cases):
    • Piperacillin-tazobactam (2.5-4.5 g three times daily)
    • Ceftriaxone (1-2 g daily)
  • Oral options (for mild-moderate cases):
    • Ciprofloxacin (500 mg twice daily for 2-4 weeks)
    • Levofloxacin (500 mg once daily for 2-4 weeks)
    • Doxycycline (100 mg twice daily for 2-4 weeks)

• Success rate: 92-97% when prescribed for 2-4 weeks 2

For Chronic Bacterial Prostatitis:

• First-line therapy:
  • Fluoroquinolones for minimum 4 weeks:
    • Ciprofloxacin (500 mg twice daily)
    • Levofloxacin (500 mg once daily) - FDA approved for chronic bacterial prostatitis due to E. coli, E. faecalis, or methicillin-susceptible S. epidermidis 3
  • Alternative: Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 4 weeks) 4

Special Considerations

For 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)
  • If macrolide-resistant: moxifloxacin (400 mg daily for 7-14 days) 1

For Prostatic Abscess:

• Requires drainage in addition to antibiotic treatment
• Transrectal ultrasound-guided drainage is recommended 1

Monitoring and Follow-up

• Clinical reassessment after 2 weeks
• Urine culture at the end of treatment
• Consider PSA measurement 3 months after resolution if elevated during infection 1

Treatment Challenges and Considerations

• Prostatic tissue has poor antibiotic penetration, requiring antibiotics with good pharmacokinetic properties
• Fluoroquinolones have excellent prostatic penetration compared to other antibiotics
• Rising antibiotic resistance is a concern, particularly with fluoroquinolones
• Chronic bacterial prostatitis often requires prolonged treatment and may have frequent relapses 5

Comparative Efficacy of Antibiotics

• No significant differences in clinical or microbiological efficacy between different fluoroquinolones (ciprofloxacin, levofloxacin, lomefloxacin, ofloxacin, prulifloxacin) 6, 7
• For chlamydial prostatitis, macrolides (azithromycin) showed higher microbiological and clinical cure rates compared to fluoroquinolones 6

Common Pitfalls to Avoid

1. Inadequate treatment duration: Shorter courses often lead to treatment failure and recurrence
2. Incorrect antibiotic selection: Choose antibiotics with good prostatic penetration
3. Failure to identify and drain prostatic abscesses: Can lead to treatment failure
4. Missing atypical pathogens: Consider testing for Chlamydia and Mycoplasma in cases not responding to conventional therapy
5. Not addressing underlying urological abnormalities: These can contribute to recurrent infections

Remember that early and adequate treatment is crucial to prevent complications such as prostatic abscesses, sepsis, or progression to chronic prostatitis 1.