What is the recommended treatment for acute bacterial prostatitis, chronic bacterial prostatitis, and CP/CPPS (chronic prostatitis/chronic pelvic pain syndrome)?

Treatment of Prostatitis

Acute Bacterial Prostatitis (ABP)

For acute bacterial prostatitis, start fluoroquinolones (ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks) as first-line therapy for mild-to-moderate cases when local resistance is <10%, or use intravenous ceftriaxone plus doxycycline for severe cases requiring hospitalization. 1, 2

Diagnostic Approach Before Treatment

• Avoid prostatic massage or vigorous digital rectal examination due to risk of bacteremia and sepsis 1, 2
• Perform gentle digital rectal examination to assess for prostatic tenderness and rule out abscess 2
• Obtain midstream urine culture to identify causative organisms (E. coli in 80-97% of cases) 1, 2, 3
• Collect blood cultures and complete blood count, especially in febrile patients 1, 2
• Consider transrectal ultrasound if prostatic abscess is suspected 1, 2

Antibiotic Selection Algorithm

Mild-to-Moderate Cases (Outpatient):

• First-line: Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks if local fluoroquinolone resistance <10% 1, 2, 3
• Avoid fluoroquinolones if: Patient used them in last 6 months, local resistance >10%, or healthcare-associated infection 2, 4
• Alternative: Trimethoprim-sulfamethoxazole only if organism is known to be susceptible (high resistance rates) 2
• Never use: Amoxicillin or ampicillin empirically due to 75% median E. coli resistance globally 2, 4

Severe Cases (Hospitalization Indicated):

• First-line: Ceftriaxone 1-2 g IV daily plus doxycycline 100 mg orally every 12 hours 2, 4, 3
• Alternative: Piperacillin-tazobactam 4.5 g IV every 6-8 hours 3
• Transition to oral fluoroquinolones once clinically improved (typically after 48-72 hours) 2

Hospitalization Criteria

Admit patients who have: 2

• Inability to tolerate oral medications
• Signs of systemic toxicity or risk of urosepsis (occurs in 7.3% of cases)
• Suspected prostatic abscess

Special Populations

Men <35 years old: Add doxycycline 100 mg orally every 12 hours for 7 days to cover Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species 2

Healthcare-associated infections with enterococci: Use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility; reserve carbapenems only for multidrug-resistant organisms confirmed by culture 2

Treatment Duration and Follow-Up

• Minimum duration: 2-4 weeks total 1, 2, 3
• Assess clinical response at 48-72 hours 2
• Critical pitfall: Stopping antibiotics prematurely leads to chronic bacterial prostatitis in approximately 10% of cases 2, 5

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Chronic Bacterial Prostatitis (CBP)

For chronic bacterial prostatitis, prescribe fluoroquinolones (ciprofloxacin or levofloxacin) for a minimum of 4 weeks and up to 12 weeks to prevent relapse, after confirming diagnosis with the Meares-Stamey test. 2, 3, 6

Diagnostic Confirmation

• Perform the Meares-Stamey 4-glass test (or simplified 2-glass variant) showing ≥10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1, 2, 7
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species, which require specific antimicrobial therapy 1, 2
• E. coli causes up to 74% of chronic bacterial prostatitis cases 2, 3

Antibiotic Selection

• First-line: Levofloxacin or ciprofloxacin for minimum 4 weeks, extending to 12 weeks if needed 2, 3, 6
• Alternative if susceptible: Trimethoprim-sulfamethoxazole 6
• For atypical pathogens: Doxycycline 100 mg orally every 12 hours 2, 6
• Emerging option for multidrug-resistant organisms: Fosfomycin 6

Treatment Duration

• Minimum: 4 weeks 2, 7, 3
• Optimal: 4-12 weeks to achieve eradication and prevent relapse 2, 7, 6
• If no improvement after 2-4 weeks, stop and reconsider diagnosis 7
• If improvement occurs, continue for at least another 2-4 weeks 7

Partner Management

• Treat all sexual partners within preceding 60 days when sexually transmitted pathogens are identified 2
• Patient should abstain from sexual activity for 7 days after starting therapy and until partners are treated 2

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

For CP/CPPS, prescribe alpha-blockers (tamsulosin, alfuzosin, doxazosin, or terazosin) as first-line therapy, not antibiotics, since this condition is not caused by culturable bacteria. 2, 4, 3

Diagnostic Criteria

• Pelvic pain or discomfort for ≥3 months of the preceding 6 months 2, 3
• Pain locations: perineum, suprapubic area, testicles, penile tip, lower back 2
• Associated urinary symptoms: frequency, urgency, incomplete emptying 2
• Negative urine culture and Meares-Stamey test ruling out bacterial infection 2, 7
• Postvoid residual measurement to exclude urinary retention 3

First-Line Treatment: Alpha-Blockers

All alpha-blockers are equally effective with NIH-CPSI score reduction of 4.8 to 10.8 points (6-point change is clinically meaningful): 4, 3

• Tamsulosin (lower orthostatic hypotension risk, higher ejaculatory dysfunction risk)
• Alfuzosin
• Doxazosin
• Terazosin

Common adverse effects: orthostatic hypotension, dizziness, tiredness, ejaculatory problems, nasal congestion 4

Adjunctive Therapies

• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score difference vs placebo = -2.5 to -1.7 3
• Pregabalin: NIH-CPSI score difference vs placebo = -2.4 3
• Pollen extract: NIH-CPSI score difference vs placebo = -2.49 3

What NOT to Use

• Do not prescribe antibiotics unless there is documented bacterial infection 2, 7
• Do not use 5-alpha reductase inhibitors (finasteride, dutasteride) as they are only effective for benign prostatic hyperplasia with prostatic enlargement 4

Overlap with Interstitial Cystitis/Bladder Pain Syndrome

• Evaluate for IC/BPS in men with bladder-centered pain 2
• Some patients fulfill criteria for both conditions and require combined therapeutic strategies 2

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Common Pitfalls to Avoid

• Never perform prostatic massage in acute bacterial prostatitis – this can cause life-threatening bacteremia 1, 2
• Do not use amoxicillin/ampicillin empirically – 75% global E. coli resistance 2, 4
• Avoid fluoroquinolones if used in last 6 months or local resistance >10% 2, 4
• Do not stop antibiotics prematurely in acute bacterial prostatitis – leads to chronic bacterial prostatitis in 10% of cases 2, 5
• Do not prescribe antibiotics for CP/CPPS – it is not a bacterial infection 2, 7, 3
• Do not treat chronic bacterial prostatitis for <4 weeks – inadequate duration causes relapse 2, 3, 6