What medications are used to treat prostatitis?

Medications for Prostatitis

For acute bacterial prostatitis, use ciprofloxacin 500-750 mg twice daily orally for 2-4 weeks if local fluoroquinolone resistance is less than 10%, or use intravenous ceftriaxone or cefotaxime for severe cases requiring hospitalization. 1, 2

Acute Bacterial Prostatitis

Outpatient Oral Therapy (Mild-to-Moderate Cases)

• Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks is the first-line choice when local fluoroquinolone resistance is below 10%. 1, 3
• Levofloxacin 500 mg orally once daily for 28 days is an alternative fluoroquinolone option with equivalent efficacy. 4, 5
• Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates. 1, 2

Inpatient Intravenous Therapy (Severe Cases)

Hospitalization with IV antibiotics is indicated for patients unable to tolerate oral medications, those with risk of urosepsis (occurs in 7.3% of cases), or those with fever and systemic toxicity. 1

• Ceftriaxone or cefotaxime are first-choice IV options for severe prostatitis. 2, 6
• Ciprofloxacin 400 mg IV twice daily can be used as parenteral therapy, with transition to oral antibiotics once clinically improved. 1
• Piperacillin-tazobactam is another broad-spectrum IV option for severe cases. 3
• Amikacin is a second-choice option for severe prostatitis. 2

Treatment Duration and Monitoring

• Assess clinical response after 48-72 hours of treatment. 1
• Complete a total of 2-4 weeks of antibiotic therapy to prevent progression to chronic bacterial prostatitis. 1, 3
• Stopping antibiotics prematurely can lead to chronic bacterial prostatitis, so complete the full treatment course. 1

Chronic Bacterial Prostatitis

First-Line Therapy

• Levofloxacin 500 mg orally once daily for a minimum of 4 weeks is the preferred fluoroquinolone. 4, 3, 7, 5
• Ciprofloxacin 500 mg orally twice daily for a minimum of 4 weeks is an alternative. 3, 8, 5
• Levofloxacin showed superior bacterial clearance rates (86.06% vs 60.03%) and lower recurrence rates (4.00% vs 19.25%) compared to ciprofloxacin in Chinese patients. 7

Treatment Duration

• Minimum 4-week course is required for chronic bacterial prostatitis. 3, 8, 5
• If improvement occurs after 2-4 weeks, continue treatment for at least another 2-4 weeks to achieve clinical cure and pathogen eradication. 8
• Do not continue antibiotics for 6-8 weeks without appraising effectiveness. 8

Microbiological Diagnosis

• Use the Meares-Stamey 4-glass test (first-void urine, midstream urine, expressed prostatic secretions, post-massage urine) to diagnose chronic bacterial prostatitis, with a positive result showing 10-fold higher bacterial count in expressed prostatic secretions than midstream urine. 1, 8
• A simplified 2-specimen variant (midstream urine and expressed prostatic secretions only) can be used. 1
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, as these require specific antimicrobial therapy. 9, 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

CP/CPPS is not frequently caused by a culturable infectious agent and requires different management focused on symptom relief rather than antimicrobials. 1

When Antibiotics Are NOT Indicated

• CP/CPPS presents as pelvic pain or discomfort for at least 3 months with urinary symptoms but without evidence of bacterial infection. 3
• Do not routinely use antibiotics for CP/CPPS unless there is clinical, bacteriological, or immunological evidence of prostate infection. 8

Non-Antibiotic First-Line Therapy

• α-blockers (tamsulosin, alfuzosin) are first-line for CP/CPPS with urinary symptoms, with NIH-CPSI score improvement of -10.8 to -4.8 compared to placebo. 3
• Anti-inflammatory drugs (ibuprofen) provide modest benefit with NIH-CPSI score difference of -2.5 to -1.7 versus placebo. 3
• Pregabalin (NIH-CPSI score difference = -2.4) and pollen extract (NIH-CPSI score difference = -2.49) are other options. 3

Special Considerations for Atypical Pathogens

Chlamydia trachomatis and Mycoplasma

When testing identifies these atypical pathogens in chronic bacterial prostatitis:

• Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice daily for 7 days are recommended regimens. 9
• Alternative regimens include levofloxacin 500 mg orally once daily for 7 days or ofloxacin 300 mg orally twice daily for 7 days. 9

Common Pathogens and Resistance Patterns

• Gram-negative bacteria cause 80-97% of acute bacterial prostatitis cases, including Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. 1, 3
• Up to 74% of chronic bacterial prostatitis cases are due to gram-negative organisms, particularly E. coli. 1, 3
• Gram-positive bacteria (Staphylococcus aureus, Enterococcus species, Group B streptococci) can also cause acute bacterial prostatitis. 1
• E. coli and Enterococcus faecalis are the most common isolates in chronic bacterial prostatitis. 4, 5

Critical Pitfalls to Avoid

• Never perform prostatic massage in acute bacterial prostatitis due to risk of bacteremia. 9, 1
• Local resistance patterns should guide antibiotic selection, with fluoroquinolone resistance ideally less than 10% for empiric use. 1
• For healthcare-associated infections with enterococci, use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility. 1
• Oral cephalosporins like cefpodoxime have poor prostatic tissue penetration and are not recommended for prostatitis despite efficacy in other urinary tract infections. 1