What are the recommended antibiotics for treating prostatitis?

Antibiotic Selection in Prostatitis

For prostatitis treatment, fluoroquinolones (particularly levofloxacin and ciprofloxacin) are the first-line antibiotics due to their excellent prostate penetration and broad spectrum coverage against common uropathogens. 1, 2

Types of Prostatitis and Antibiotic Selection

Acute Bacterial Prostatitis

• Empiric therapy should target common uropathogens, particularly gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) which cause 80-97% of cases 1, 3
• For hospitalized patients requiring IV therapy, options include:
  • Fluoroquinolones (ciprofloxacin 400 mg IV twice daily or levofloxacin 750 mg IV daily) 1
  • Extended-spectrum cephalosporins (ceftriaxone 1-2 g IV daily) 3
  • Piperacillin-tazobactam (2.5-4.5 g IV three times daily) 3
• For outpatient oral therapy:
  • Ciprofloxacin 500 mg twice daily 4
  • Levofloxacin 500 mg once daily 2
• Duration: 2-4 weeks total antibiotic therapy 1, 3

Chronic Bacterial Prostatitis

• Fluoroquinolones are first-line due to their favorable pharmacokinetic profile and penetration into prostatic tissue 2, 5
  • Levofloxacin 500 mg once daily for 28 days 2
  • Ciprofloxacin 500 mg twice daily for 28 days 4
• Microbiological eradication rates are approximately 72-77% for fluoroquinolones 6
• Common pathogens include E. coli (most common), Enterococcus faecalis, and Staphylococcus epidermidis 2

Special Considerations

Diagnostic Approach

• For acute bacterial prostatitis:

  • Avoid prostatic massage due to risk of bacteremia 1
  • Obtain midstream urine culture to identify causative organisms 1
  • Blood cultures should be collected in febrile patients 1

• For chronic bacterial prostatitis:

  • Meares-Stamey 4-glass test is the gold standard for diagnosis 1, 5
  • A positive result indicates a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1

Antibiotic Resistance Considerations

• Local resistance patterns should guide antibiotic selection 1
• Fluoroquinolone resistance should ideally be less than 10% for empiric use 7
• Consider broader spectrum options for patients with risk factors for antibiotic resistance or healthcare-associated infections 1

Follow-up

• Assess clinical response after 48-72 hours of treatment in acute bacterial prostatitis 1
• For chronic bacterial prostatitis, treatment should be continued for at least 4 weeks if there is clinical improvement 5
• If no improvement in symptoms occurs, treatment should be reconsidered 5

Common Pitfalls

• Inadequate duration of therapy (minimum 2-4 weeks for acute, 4 weeks for chronic bacterial prostatitis) 1, 5
• Failure to obtain appropriate cultures before initiating antibiotics (except in severe acute prostatitis) 5
• Vigorous prostatic massage in acute prostatitis, which can lead to bacteremia 1
• Not considering local resistance patterns when selecting empiric antibiotics 1
• Continuing ineffective antibiotics beyond 6-8 weeks without reassessment 5