What is the recommended treatment for acute prostatitis?

Treatment of Acute Bacterial Prostatitis

For acute bacterial prostatitis, initiate broad-spectrum antibiotics targeting gram-negative bacteria—either intravenous piperacillin-tazobactam, ceftriaxone, or oral ciprofloxacin—for 2-4 weeks total duration, with most patients achieving 92-97% clinical success. 1

Initial Assessment and Diagnostic Workup

Perform a gentle digital rectal examination only—vigorous prostatic massage is absolutely contraindicated due to risk of inducing bacteremia. 2 The prostate will typically feel tender, enlarged, or boggy on examination. 3

Obtain the following diagnostic tests immediately:

• Midstream urine culture to identify the causative organism and guide antibiotic selection 2
• Blood cultures, especially if the patient is febrile 2
• Complete blood count to assess for leukocytosis 2
• Transrectal ultrasound in selected cases to rule out prostatic abscess 2

Antibiotic Selection Strategy

Empiric Therapy Selection

Choose antibiotics based on local resistance patterns—fluoroquinolone resistance should ideally be less than 10% for empiric use. 2 Target gram-negative bacteria (E. coli, Klebsiella, Pseudomonas), which cause 80-97% of acute bacterial prostatitis cases. 2, 1

Outpatient vs Inpatient Decision

Hospitalize patients who are:

• Systemically ill with fever, chills, or sepsis
• Unable to voluntarily urinate
• Unable to tolerate oral intake
• Have risk factors for antibiotic resistance or healthcare-associated infections 3, 2

Specific Antibiotic Regimens

For hospitalized patients requiring IV therapy:

• Piperacillin-tazobactam (broad-spectrum coverage) 1, 3
• Ceftriaxone (excellent gram-negative coverage) 1, 3
• Ciprofloxacin 400 mg IV twice daily, with goal of switching to oral once clinically improved 2

For outpatients or step-down therapy:

• Ciprofloxacin (oral fluoroquinolone with excellent prostatic penetration) 1, 4
• Levofloxacin (alternative fluoroquinolone) 1

Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates. 2

Treatment Duration and Monitoring

Assess clinical response after 48-72 hours of antibiotic therapy. 2 If the patient is improving, continue antibiotics for a total of 2-4 weeks. 2, 1 This duration is critical—stopping antibiotics prematurely can lead to chronic bacterial prostatitis. 2

Fluoroquinolones are particularly effective because they achieve prostatic tissue concentrations up to 4 times higher than serum levels due to pH trapping in inflamed prostatic tissue. 4

Common Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute prostatitis—this can precipitate bacteremia and sepsis 2
• Do not use amoxicillin/ampicillin empirically given high resistance rates 2
• Do not stop antibiotics early even if symptoms improve—complete the full 2-4 week course to prevent chronic infection 2
• Do not delay treatment in systemically ill patients—initiate broad-spectrum IV antibiotics immediately 3

Adjunctive Supportive Measures

Provide symptomatic relief with:

• Appropriate analgesia for pain control 5
• Urinary catheterization if urinary retention develops 3
• Hydration and supportive care 3