What is the treatment for bacterial prostatitis?

Treatment of Bacterial Prostatitis

For bacterial prostatitis, the recommended treatment is fluoroquinolones, with levofloxacin 500 mg once daily for 28 days being the first-line therapy for chronic bacterial prostatitis, and broad-spectrum antibiotics for acute bacterial prostatitis. 1, 2

Types of Bacterial Prostatitis

Acute Bacterial Prostatitis

• Characterized by sudden onset of fever, chills, pelvic pain, and urinary symptoms 2
• Caused primarily by gram-negative bacteria (80-97% of cases), including Escherichia coli, Klebsiella, and Pseudomonas 3, 2
• Gram-positive bacteria such as Staphylococcus aureus, Enterococcus species, and Group B streptococci can also cause acute bacterial prostatitis 3

Chronic Bacterial Prostatitis

• Defined as persistent bacterial infection of the prostate, typically presenting as recurrent UTIs from the same strain 2
• Up to 74% of cases are due to gram-negative organisms, particularly E. coli, with other pathogens including Proteus mirabilis, Enterobacter species, and Serratia marcescens 3, 2
• Enterococcus faecalis is also a common isolate in chronic bacterial prostatitis 4

Diagnostic Approach

• Midstream urine culture can identify the causative organism in acute bacterial prostatitis 3
• The Meares-Stamey 4-glass test is the gold standard for diagnosing chronic bacterial prostatitis, involving collection of first-void urine, midstream urine, expressed prostatic secretions, and post-massage urine 3, 4
• Important: Avoid prostatic massage in acute bacterial prostatitis due to risk of bacteremia 3

Treatment Algorithm

Acute Bacterial Prostatitis

1. For outpatient treatment (mild to moderate cases):

   • Oral fluoroquinolones: Ciprofloxacin 500 mg twice daily or Levofloxacin 750 mg once daily for 2-4 weeks 2, 5

2. For inpatient treatment (severe cases or unable to tolerate oral intake):

   • Intravenous broad-spectrum antibiotics such as:
     • Piperacillin-tazobactam 2.5-4.5 g three times daily 2, 5
     • Ceftriaxone 1-2 g once daily 2, 5
     • Followed by oral fluoroquinolones upon improvement 2

Chronic Bacterial Prostatitis

1. First-line therapy:

   • Levofloxacin 500 mg once daily for 28 days (minimum 4 weeks) 1, 2, 6
   • OR Ciprofloxacin 500 mg twice daily for 28 days 1, 4

2. For fluoroquinolone-resistant pathogens:

   • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 4-12 weeks 2

Treatment Efficacy

• Levofloxacin 500 mg once daily for 28 days has shown clinical success rates of 75% for chronic bacterial prostatitis 1, 4
• Ciprofloxacin 500 mg twice daily for 28 days has shown similar clinical success rates of 72.8% 1, 4
• Levofloxacin may have better prostatic penetration than ciprofloxacin and offers the advantage of once-daily dosing 6
• Broad-spectrum antibiotics for acute bacterial prostatitis have a 92-97% success rate when prescribed for 2-4 weeks 2

Special Considerations

• Ciprofloxacin may be less effective for Streptococcus faecalis (Enterococcus faecalis) prostatitis, with treatment failures reported 7
• For multidrug-resistant pathogens, antibiotic selection should be based on culture results and susceptibility testing 2
• In cases of recurrent chronic bacterial prostatitis despite appropriate antibiotic therapy, consider longer treatment courses (up to 12 weeks) or surgical intervention for anatomical abnormalities 6
• For cases of chronic bacterial prostatitis that fail multiple antibiotic treatments, phage therapy may be considered as an experimental approach, particularly for E. faecalis infections 8