What is the recommended treatment for chronic bacterial prostatitis caused by Enterococcus faecalis?

Treatment of Chronic Bacterial Prostatitis Caused by Enterococcus faecalis

Levofloxacin 500 mg orally once daily for 28 days is the recommended first-line treatment for chronic bacterial prostatitis caused by Enterococcus faecalis. 1

First-Line Treatment Options

• Levofloxacin 500 mg orally once daily for 28 days is FDA-approved specifically for chronic bacterial prostatitis due to Enterococcus faecalis and has demonstrated high microbiological eradication rates 1
• Fluoroquinolones (particularly levofloxacin) show low resistance rates against E. faecalis strains causing chronic bacterial prostatitis in clinical studies, making them suitable therapeutic agents 2
• The European Association of Urology guidelines recognize fluoroquinolones as effective agents for treating bacterial prostatitis 3

Alternative Treatment Options (for fluoroquinolone-resistant or intolerant patients)

• Fosfomycin 3g orally every 24 hours for 1 week followed by 3g every 48 hours for a total of 6-12 weeks (consider longer duration if prostatic calcifications are present) 4

  • Particularly effective against multidrug-resistant strains
  • Achieves high microbiological eradication rates (86% at end of treatment)
  • Clinical cure rates of 82% at end of treatment and 73% at 6 months 4

• Ampicillin or amoxicillin (if susceptible):

  • High-dose ampicillin (18-30g IV daily in divided doses) or amoxicillin 500 mg orally/IV every 8 hours 3
  • Particularly effective for urinary tract infections due to E. faecalis 3

• Linezolid 600 mg IV or orally every 12 hours (duration dependent on clinical response) 3

  • Recommended for enterococcal infections with strong evidence 3

Diagnostic Considerations

• Perform the Meares and Stamey 2- or 4-glass test to confirm chronic bacterial prostatitis and identify the causative pathogen 3
• Obtain expressed prostatic secretions (EPS) or post-prostatic massage urine (VB3) for culture and susceptibility testing 1, 2
• Consider transrectal ultrasound in selected cases to rule out prostatic abscess 3

Treatment Duration and Monitoring

• Standard treatment duration for chronic bacterial prostatitis is 4-6 weeks to ensure complete eradication 5, 6
• For complicated cases or those with prostatic calcifications, consider extending treatment to 12 weeks 4
• Monitor for clinical response (improvement in symptoms) and obtain follow-up cultures to confirm microbiological eradication 4

Special Considerations

• Resistance patterns of E. faecalis in chronic bacterial prostatitis show high resistance to tetracycline (97.5%), erythromycin (95%), and trimethoprim/sulfamethoxazole (31.5%), making these agents unsuitable as empiric therapy 2
• For multidrug-resistant E. faecalis, consider combination therapy or consultation with an infectious disease specialist 3
• Avoid aminoglycosides as monotherapy due to variable resistance patterns and poor prostatic penetration 7

Common Pitfalls and Caveats

• Inadequate treatment duration is a common cause of treatment failure and relapse; ensure a minimum of 4 weeks of therapy 5, 6
• Poor penetration of antibiotics into the prostate is a significant challenge; choose agents with favorable pharmacokinetic properties (lipid solubility, appropriate pKa) 7
• Distinguishing between bacterial prostatitis and non-bacterial prostatitis/prostatodynia is crucial as antimicrobial therapy is ineffective for non-bacterial forms 6
• Fluoroquinolone resistance is increasing globally; always obtain susceptibility testing to guide therapy 2, 5