What are the next steps for a patient with prostatitis, initially treated with IV (intravenous) Rocephin (Ceftriaxone) and transitioned to oral Levaquin (Levofloxacin), who has developed urinary retention, has an elevated white blood cell count (leukocytosis), and is afebrile, with a decrease in Prostate-Specific Antigen (PSA) levels from 20 to 7, and is currently on Flomax (Tamsulosin)?

Management of Complicated Prostatitis with Urinary Retention

Continue oral levofloxacin, maintain Foley catheter drainage, add an aminoglycoside (amikacin 15 mg/kg IV once daily) given the persistent leukocytosis and urinary retention despite appropriate antibiotic therapy, and obtain urine culture with sensitivities to guide definitive therapy. 1, 2

Immediate Assessment and Monitoring

• Obtain urine culture and blood cultures immediately to identify the causative organism and guide antibiotic selection, as this is essential for tailoring therapy in complicated infections 3, 1
• Evaluate for prostatic abscess with imaging (transrectal ultrasound or CT) given the urinary retention, persistent leukocytosis (WBC 18), and enlarged prostate despite 2 weeks of appropriate antibiotics 2
• Assess for urinary obstruction or anatomic abnormalities that may require urologic intervention, as these factors significantly impact treatment success 1

Antibiotic Management

The current regimen requires intensification given the clinical picture:

• Add amikacin 15 mg/kg IV once daily to the existing levofloxacin regimen 1. This combination is indicated because:

  • Persistent leukocytosis (WBC 18) despite 2 weeks of antibiotics suggests inadequate source control or resistant organisms 1
  • Urinary retention with Foley catheter increases risk of multidrug-resistant organisms 1
  • The European Urology guidelines recommend adding an aminoglycoside when there is concern for resistant organisms or severe infection requiring hospitalization 1

• Continue levofloxacin 750 mg once daily as it achieves excellent prostatic tissue penetration and maintains activity against common uropathogens 4, 5, 6. The high-dose regimen maximizes concentration-dependent bactericidal activity 4

• Duration of therapy should be 4-6 weeks total for acute bacterial prostatitis with complications (urinary retention, persistent infection) 2. The initial IV therapy with ceftriaxone plus current oral levofloxacin counts toward this total duration 2

Catheter Management

• Maintain Foley catheter until urinary retention resolves, typically requiring continued alpha-blocker therapy (tamsulosin) and reassessment after infection control 2
• Monitor for catheter-associated complications including secondary infection with resistant organisms 1
• Plan trial of void after 3-7 days of adequate antibiotic therapy and clinical improvement (resolution of fever, decreasing WBC, symptomatic improvement) 2

Adjusting Therapy Based on Culture Results

Once culture and sensitivity results are available:

• Narrow antibiotic spectrum to the most specific agent with the narrowest spectrum that covers the identified pathogen 3, 1
• If gram-negative organism susceptible to fluoroquinolones, continue levofloxacin monotherapy and discontinue amikacin after 2-4 days of clinical improvement 1
• If resistant organism identified, adjust to appropriate agent based on sensitivities and continue for full 4-6 week course 2
• If cultures are negative, consider non-bacterial causes or inadequate specimen collection; may need expressed prostatic secretions or post-prostatic massage urine 2

Red Flags Requiring Urologic Consultation

• Prostatic abscess on imaging requires drainage (transrectal or transperineal aspiration) in addition to antibiotics 2
• Failure to improve after 48-72 hours of appropriate antibiotic therapy suggests abscess, obstruction, or resistant organism 2
• Recurrent urinary retention after catheter removal may require transurethral resection of prostate (TURP) or other surgical intervention 2

Monitoring Parameters

• Daily assessment of clinical status: fever curve, pain level, ability to void 2
• WBC count every 2-3 days until normalizing 1
• Renal function monitoring given aminoglycoside use and potential for fluoroquinolone accumulation in renal impairment 7, 5
• PSA should not be rechecked until at least 4-6 weeks after infection resolution, as it will remain elevated during active infection and treatment 2

Common Pitfalls to Avoid

• Do not discontinue antibiotics prematurely even if symptoms improve; acute bacterial prostatitis requires minimum 4 weeks of therapy to prevent chronic bacterial prostatitis 2
• Do not remove Foley catheter until infection is controlled and patient demonstrates clinical improvement, as premature removal may lead to recurrent retention and worsening infection 2
• Do not assume treatment failure based on PSA alone; the decrease from 20 to 7 indicates response to therapy, though PSA may remain elevated for weeks 2
• Avoid concurrent administration of levofloxacin with antacids, iron, or multivitamins containing divalent cations, as these significantly reduce absorption; separate by at least 2 hours 7, 5