What are the recommended antibiotic choices, dosing, and treatment durations for acute bacterial prostatitis, chronic bacterial prostatitis, and chronic prostatitis/chronic pelvic pain syndrome?

Antibiotic Treatment for Prostatitis

Acute Bacterial Prostatitis

For mild-to-moderate acute bacterial prostatitis in outpatients, prescribe ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks if local fluoroquinolone resistance is below 10%. 1, 2

Outpatient Oral Therapy (Mild-to-Moderate Cases)

• First-line: Ciprofloxacin 500-750 mg orally twice daily for 2-4 weeks 1, 2, 3
• Alternative fluoroquinolone: Levofloxacin 750 mg orally once daily for 2-4 weeks 2
• Critical caveat: Avoid fluoroquinolones if local resistance exceeds 10% or if the patient received them within the past 6 months 1

Inpatient IV Therapy (Severe Cases with Fever/Systemic Toxicity)

Hospitalize patients who cannot tolerate oral medications, show signs of systemic toxicity, or have risk of urosepsis (occurs in 7.3% of cases). 1, 2

• First-line IV options:
  • Ceftriaxone 1-2 g IV once daily 2, 4, 3
  • Cefotaxime 2 g IV three times daily 2
  • Piperacillin-tazobactam 2.5-4.5 g IV three times daily 2, 3
• Alternative IV fluoroquinolone: Ciprofloxacin 400 mg IV twice daily, transitioning to oral once clinically improved 1, 2
• Second-choice: Amikacin for severe cases 2
• For healthcare-associated infections with enterococci: Use ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility; reserve carbapenems for multidrug-resistant organisms 1, 2

Special Considerations for Young Men (<35-40 Years)

Add coverage for sexually transmitted pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma) in men under 35-40 years old or those with STI risk factors. 1, 2, 4

• Combination regimen: Ceftriaxone 250-1000 mg IM/IV once daily PLUS doxycycline 100 mg orally twice daily for 7 days 2, 4
• Alternative for atypical pathogens: Azithromycin 1 g orally as a single dose 1, 2
• For men who have sex with men with proctitis: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg twice daily for 7 days; extend doxycycline to 3 weeks if lymphogranuloma venereum is suspected 2

Critical Pitfalls to Avoid

• Never perform prostatic massage in acute bacterial prostatitis due to risk of bacteremia and sepsis 1, 2, 4
• Avoid amoxicillin/ampicillin empirically due to resistance rates exceeding 50% worldwide 1, 4
• Avoid trimethoprim-sulfamethoxazole empirically unless susceptibility is confirmed, as resistance rates are high 1
• Do not stop antibiotics prematurely (before completing 2-4 weeks), as this leads to chronic bacterial prostatitis 1, 4

Monitoring and Follow-Up

• Reassess clinical response at 48-72 hours (defervescence, reduced pain, ability to void) 1, 4
• Obtain midstream urine culture before initiating antibiotics to guide therapy adjustments 1, 4
• Failure to improve within 3 days requires reevaluation for abscess, alternative pathogens, or urological complications 4

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Chronic Bacterial Prostatitis

For chronic bacterial prostatitis, prescribe a fluoroquinolone for a minimum of 4-6 weeks if local resistance is below 10%. 1, 5, 6, 3

First-Line Therapy

• Ciprofloxacin 500-750 mg orally twice daily for 4-6 weeks 6, 3
• Levofloxacin 500 mg orally once daily for minimum 4 weeks 3
• Treatment duration: 4-12 weeks required to prevent relapse 1, 5, 6

Diagnostic Confirmation

• Use the Meares-Stamey 4-glass test (or simplified 2-specimen variant) showing a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1, 2
• Test for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) which require specific antimicrobial therapy 1, 2

Coverage for Atypical Pathogens

• Doxycycline 100 mg orally twice daily for 7 days (or up to 2-3 months for complete eradication) 2
• Azithromycin 1 g orally as a single dose for Mycoplasma coverage 1, 2
• For ureaplasmal prostatitis (20-40% of nongonococcal urethritis): Doxycycline 100 mg twice daily for 7 days; if tetracycline-resistant, switch to erythromycin base 500 mg four times daily for 14 days 2

Treatment Algorithm

1. Initial 2-week trial: Start fluoroquinolone (if resistance <10%) 5
2. Assess response: Continue only if pre-treatment cultures are positive and/or patient reports improvement 5
3. Total duration: 4-6 weeks minimum; extend to 4-12 weeks if needed to prevent relapse 1, 5, 6
4. Do not continue beyond 6-8 weeks without reassessing effectiveness 6

Key Causative Organisms

• Up to 74% are gram-negative organisms, particularly E. coli 1, 3
• Other pathogens: Proteus mirabilis, Enterobacter species, Serratia marcescens 1
• Atypical pathogens: Chlamydia trachomatis, Mycoplasma species (especially in men <35 years) 1, 2

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

CP/CPPS is NOT frequently caused by culturable bacteria and does not routinely require antibiotics; focus on symptom management with α-blockers as first-line therapy. 1, 7, 3

Diagnostic Criteria

• Pelvic pain lasting ≥3 months of the preceding 6 months without documented uropathogenic infection 1, 7, 3
• Pain locations: perineum, suprapubic region, testicles, penile tip; often worsened by urination or ejaculation 1
• Urinary symptoms: frequency, urgency, incomplete emptying 1

When to Consider Antibiotics

Only prescribe a 4-6 week trial of antibiotics if there is clinical, bacteriological, or immunological evidence of prostate infection. 2, 6, 7

• Empiric trial: Fluoroquinolone (ciprofloxacin or levofloxacin) for 2-4 weeks initially 5, 7
• Continue only if: Pre-treatment cultures are positive OR patient reports positive effects 5
• Do not exceed 6-8 weeks without appraisal of effectiveness 6

First-Line Non-Antibiotic Therapy

• α-blockers (tamsulosin, alfuzosin) for urinary symptoms: NIH-CPSI score improvement of -10.8 to -4.8 vs placebo 3
• Anti-inflammatory drugs (ibuprofen): NIH-CPSI score improvement of -2.5 to -1.7 vs placebo 3
• Pregabalin: NIH-CPSI score improvement of -2.4 vs placebo 3
• Pollen extract: NIH-CPSI score improvement of -2.49 vs placebo 3

Important Distinctions

• CP/CPPS accounts for more than 90% of chronic prostatitis cases 7
• Many patients describe "pressure" or "discomfort" rather than overt pain and may deny pain when directly questioned 1
• Significant overlap with interstitial cystitis/bladder pain syndrome; evaluate for IC/BPS in men with bladder-centered pain 1

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Summary Treatment Algorithm

Acute Bacterial Prostatitis

• Outpatient (mild-moderate): Ciprofloxacin 500-750 mg PO BID × 2-4 weeks 1, 2
• Inpatient (severe): Ceftriaxone 1-2 g IV daily or piperacillin-tazobactam 2.5-4.5 g IV TID, transition to oral when improved 2, 3
• Age <35-40 or STI risk: Add doxycycline 100 mg PO BID × 7 days 1, 2, 4

Chronic Bacterial Prostatitis

• First-line: Ciprofloxacin 500-750 mg PO BID or levofloxacin 500 mg PO daily × 4-6 weeks minimum 6, 3
• Atypical pathogens: Add doxycycline 100 mg PO BID × 7 days or azithromycin 1 g PO × 1 1, 2

CP/CPPS

• First-line: α-blockers (tamsulosin, alfuzosin) 3
• Empiric antibiotic trial: Only if infection suspected; fluoroquinolone × 2-4 weeks, continue only if effective 5, 7