What is the treatment for acute prostatitis?

Acute Prostatitis Treatment

For acute bacterial prostatitis, initiate empiric broad-spectrum antibiotics immediately—use oral fluoroquinolones (ciprofloxacin 500-750 mg twice daily or levofloxacin 500-750 mg once daily) for outpatients who can tolerate oral therapy, or intravenous beta-lactams (piperacillin-tazobactam or ceftriaxone) for severe cases requiring hospitalization, continuing for 2-4 weeks total. 1, 2, 3

Immediate Diagnostic Steps

Before starting antibiotics, obtain:

• Midstream urine culture to identify the causative organism and guide therapy 1, 2
• Blood cultures in febrile patients 1
• Complete blood count to assess for leukocytosis 1
• Gentle digital rectal examination only—avoid vigorous prostatic massage or manipulation due to risk of inducing bacteremia 1, 2

Antibiotic Selection Algorithm

For Outpatient Management (Mild-Moderate Cases)

First-line oral therapy:

• Ciprofloxacin 500-750 mg twice daily for 2-4 weeks if local fluoroquinolone resistance is <10% 1, 2, 3
• Levofloxacin 500-750 mg once daily for 2-4 weeks as an alternative 2, 4
• Fluoroquinolones achieve 92-97% success rates and have superior prostatic tissue penetration with penetration ratios up to 4:1 3, 4

Critical resistance threshold: Do not use fluoroquinolones empirically if local resistance exceeds 10% 1

For Inpatient Management (Severe Cases, Fever, Unable to Tolerate Oral)

Parenteral therapy options:

• Piperacillin-tazobactam (intravenous dosing) 3
• Ceftriaxone 1-2 g IV once daily 1, 3
• Ciprofloxacin 400 mg IV twice daily with transition to oral once clinically improved 1

Hospitalization is indicated for patients with risk of urosepsis (occurs in 7.3% of cases) or inability to tolerate oral medications 1

Pathogen Coverage

Target gram-negative bacteria, which cause 80-97% of acute bacterial prostatitis:

• Escherichia coli (most common) 1, 3
• Klebsiella pneumoniae 1, 3
• Pseudomonas aeruginosa 1, 3
• Gram-positive organisms (Staphylococcus aureus, Enterococcus species) in 3-20% of cases 1

Agents to Avoid

Never use amoxicillin or ampicillin empirically due to very high worldwide resistance rates and poor efficacy 1, 2

Treatment Duration and Follow-up

• Total duration: 2-4 weeks of antibiotic therapy 1, 2, 3
• Assess clinical response at 48-72 hours and adjust antibiotics based on culture results 1
• Do not stop antibiotics prematurely—incomplete treatment can lead to chronic bacterial prostatitis 1

Special Populations

For healthcare-associated infections with suspected enterococci:

• Use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility 1
• Consider carbapenems or novel broad-spectrum agents only when early culture results indicate multidrug-resistant organisms 1

Common Pitfalls

• Avoid vigorous prostatic massage—this can precipitate bacteremia in acute infection 1, 2
• Do not use oral cephalosporins (like cefpodoxime) as first-line—they have poor prostatic tissue penetration despite efficacy in other urinary tract infections 1
• Do not use trimethoprim-sulfamethoxazole empirically unless the organism is known to be susceptible, as resistance rates are high 5
• Ensure adequate treatment duration—stopping at 7-10 days risks progression to chronic bacterial prostatitis 1