What is the recommended treatment for patients presenting with symptoms of prostatitis?

Treatment of Prostatitis

For acute bacterial prostatitis, initiate empiric broad-spectrum antibiotics targeting gram-negative uropathogens (particularly E. coli) with either IV ciprofloxacin 400 mg twice daily or other parenteral options, transitioning to oral therapy once clinically improved, for a total duration of 2-4 weeks. 1, 2

Acute Bacterial Prostatitis

Initial Assessment and Diagnosis

• Perform a gentle digital rectal examination only—avoid vigorous prostatic massage or vigorous DRE as this risks inducing bacteremia 1
• Obtain midstream urine culture to identify causative organisms 1
• Collect blood cultures, especially if the patient is febrile 1
• Check complete blood count to assess for leukocytosis 1
• Consider transrectal ultrasound in selected cases to rule out prostatic abscess 1

Empiric Antibiotic Therapy

• Target common gram-negative uropathogens (E. coli and other Enterobacterales), which cause 80-97% of acute bacterial prostatitis cases 1, 2
• Parenteral options include ciprofloxacin 400 mg IV twice daily, with transition to oral antibiotics once clinically improved 1
• Alternative broad-spectrum IV options include piperacillin-tazobactam or ceftriaxone, which have 92-97% success rates 2
• Consider local fluoroquinolone resistance patterns—empiric fluoroquinolone use is appropriate only when resistance is <10% 1
• For patients with risk factors for antibiotic resistance or healthcare-associated infections, consider broader spectrum options initially 1

Treatment Duration and Follow-up

• Assess clinical response after 48-72 hours of treatment 1
• Complete a total of 2-4 weeks of antibiotic therapy 1, 2
• Gram-positive organisms (Staphylococcus aureus, Enterococcus species, Group B streptococci) can also cause acute bacterial prostatitis and may require alternative coverage 1

Chronic Bacterial Prostatitis

Diagnostic Confirmation

• Perform the Meares-Stamey 2- or 4-glass test to confirm chronic bacterial prostatitis, which shows a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1, 3
• Obtain culture specimens to determine antimicrobial susceptibility patterns 3
• Up to 74% of chronic bacterial prostatitis cases are due to gram-negative organisms, particularly E. coli 1, 4

Antibiotic Selection

• Fluoroquinolones are first-line therapy, specifically levofloxacin or ciprofloxacin, due to favorable prostatic tissue penetration (penetration ratios up to 4:1) 3, 5, 4, 6
• Levofloxacin 500 mg orally once daily is FDA-approved for chronic bacterial prostatitis caused by E. coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis 5
• Clinical studies demonstrate levofloxacin achieves 75% microbiologic eradication rates and 75% clinical success rates at 5-18 days post-therapy 5
• For fluoroquinolone-resistant strains, consider ampicillin-based regimens (ampicillin 200 mg/kg/day IV in 4-6 doses), with gentamicin added for synergistic effect in severe cases 3

Treatment Duration

• Minimum 4-week course of fluoroquinolones is required for chronic bacterial prostatitis 3, 2, 7
• If symptoms improve after 2-4 weeks, continue treatment for at least an additional 2-4 weeks to achieve clinical cure and pathogen eradication 7
• Do not continue antibiotic treatment for 6-8 weeks without appraising effectiveness 7
• Long-term clinical success rates at 24-45 days post-therapy are approximately 67% with levofloxacin 5

Key Clinical Pitfalls

Diagnostic Errors

• Never perform vigorous prostatic massage in suspected acute prostatitis—this is contraindicated due to bacteremia risk 1
• Consider acute epididymitis in the differential diagnosis (epididymal tenderness rather than prostate tenderness) 1
• Do not rely solely on ejaculate analysis for diagnosis of chronic bacterial prostatitis 3

Antibiotic Resistance Considerations

• Fluoroquinolone resistance is increasing and poses significant clinical problems 6
• Some Pseudomonas aeruginosa isolates may develop resistance rapidly during levofloxacin treatment 5
• Culture and susceptibility testing should be performed periodically during therapy to monitor for emerging resistance 5

Treatment Timing

• Unless the patient presents with fever, do not initiate antibiotics immediately except in acute prostatitis—complete the diagnostic work-up within 1 week first 7
• During the work-up period, provide appropriate analgesia for symptom relief 7