What medications are used to treat prostatitis?

Medications for Prostatitis

Acute Bacterial Prostatitis

For outpatient treatment of acute bacterial prostatitis, ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks is the first-line choice when local fluoroquinolone resistance is below 10%. 1

Outpatient Oral Regimens

• Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks achieves 92-97% success rates and is the preferred first-line agent 1, 2
• Levofloxacin 750 mg orally once daily serves as an alternative fluoroquinolone option, with dosing considerations based on local resistance patterns 1
• Fluoroquinolones are preferred because they achieve prostatic tissue penetration ratios of up to 4:1 (prostate level:serum level) due to pH trapping in inflamed prostatic tissue 3

Inpatient Parenteral Regimens (for 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 1-2 g IV once daily or cefotaxime 2 g IV three times daily are first-choice parenteral options 1
• Ciprofloxacin 400 mg IV twice daily can be used parenterally, with transition to oral antibiotics once clinically improved 1, 4
• Piperacillin-tazobactam 2.5-4.5 g IV three times daily provides broad-spectrum coverage 1, 2
• Amikacin is a second-choice option for severe prostatitis 1
• Carbapenems or novel broad-spectrum agents should be reserved for healthcare-associated infections with multidrug-resistant organisms 1

Treatment Duration and Monitoring

• Complete a total of 2-4 weeks of antibiotic therapy 1, 4
• Assess clinical response after 48-72 hours of treatment 4
• Failure to improve within 3 days requires reevaluation for abscess formation, alternative pathogens, or urological complications 5

Critical Pitfalls to Avoid

• Never perform prostatic massage in acute bacterial prostatitis due to risk of bacteremia and sepsis 1, 4
• Avoid amoxicillin or ampicillin empirically due to very high worldwide resistance rates exceeding 50% 4
• Do not stop antibiotics prematurely as this can lead to chronic bacterial prostatitis 4

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Chronic Bacterial Prostatitis

For chronic bacterial prostatitis, a minimum 4-week course of levofloxacin or ciprofloxacin is first-line therapy. 2

Recommended Regimens

• Levofloxacin 500 mg orally once daily for at least 4 weeks demonstrates 92% clinical success at 5-12 days post-treatment, with 61.9% sustained success at 6 months 6, 3, 7
• Ciprofloxacin 500 mg orally twice daily for at least 4 weeks is an alternative fluoroquinolone option 6, 8
• Levofloxacin shows advantages over ciprofloxacin with higher bacterial clearance rates (86.06% vs 60.03%) and lower microbiological recurrence rates (4.00% vs 19.25%) in comparative trials 7

Atypical Pathogen Coverage

Testing for atypical pathogens including Chlamydia trachomatis and Mycoplasma species is recommended, as these require specific antimicrobial therapy. 1

• Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days for Chlamydia trachomatis and Mycoplasma 1
• Up to 74% of chronic bacterial prostatitis cases are due to gram-negative organisms, particularly E. coli 4, 2

Diagnostic Confirmation

• The Meares-Stamey 4-glass test or simplified 2-specimen variant should be used to diagnose chronic bacterial prostatitis, requiring a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1, 4

Treatment Duration Considerations

• If symptoms improve after 2-4 weeks, continue treatment for at least an additional 2-4 weeks to achieve clinical cure and pathogen eradication 8
• Do not continue antibiotics for 6-8 weeks without appraising effectiveness 8

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

For CP/CPPS with urinary symptoms, α-blockers are first-line therapy, not antibiotics. 2

Non-Antibiotic First-Line Therapy

• α-blockers (tamsulosin, alfuzosin) achieve NIH-CPSI score improvements of -10.8 to -4.8 points compared to placebo 2
• Treatment responses to α-blockers are greater with longer durations (6-24 weeks) in α-blocker-naïve patients 3

Adjunctive Therapies

• Anti-inflammatory drugs (ibuprofen) provide modest NIH-CPSI score improvements of -2.5 to -1.7 points 2
• Pregabalin achieves NIH-CPSI score difference of -2.4 points 2
• Pollen extract shows NIH-CPSI score difference of -2.49 points 2

Key Distinction

• CP/CPPS is not frequently caused by a culturable infectious agent and requires management focused on symptom relief rather than antimicrobials 4
• Diagnosis is made when evaluation does not identify infection, cancer, urinary obstruction, or urinary retention as the cause 2

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Special Considerations

Local Resistance Patterns

Local resistance patterns should guide antibiotic selection, with fluoroquinolone resistance ideally less than 10% for empiric use. 1, 4

Prostatic Abscess

• When prostatic abscess is present, total antibiotic duration must be 4-6 weeks minimum to prevent chronic bacterial prostatitis 5
• Reassess at 48-72 hours with repeat clinical examination and consider imaging to evaluate abscess size 5

Common Causative Organisms

• Gram-negative bacteria (E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa) cause 80-97% of acute bacterial prostatitis cases 4, 2
• Gram-positive bacteria (Staphylococcus aureus, Enterococcus species) can also cause acute bacterial prostatitis 4