Prostatitis medical therapy

Urinary Tract Infections Main Page
Prostatitis Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Prostatitis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-Ray
CT scan
Echocardiography and Ultrasound
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Future or Investigational Therapies
Case Studies
Case #1
Prostatitis medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Prostatitis medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Prostatitis medical therapy
CDC on Prostatitis medical therapy
Prostatitis medical therapy in the news
Blogs on Prostatitis medical therapy
Directions to Hospitals Treating Prostatitis
Risk calculators and risk factors for Prostatitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Antimicrobial therapy is indicated for acute and chronic prostatitis. The specific antimicrobial regimen depends on the disease course (complicated vs. uncomplicated) and the causative bacteria.

Medical Therapy

• All patients with prostatitis require empirical antimicrobial therapy until culture results are obtained.
• Generally, patients are treated in the outpatient setting. The indications to hospitalize patients include the following:

• Bacteremia
• Cannot tolerate oral antibiotics
• Monitoring when at-risk of decompensation (e.g. patients when major co-morbidities such as diabetes mellitus or HIV)

• Data on the efficacy of treatment regimens for prostatitis is limited. The choice of antibiotic depends on regional Enterobacteriaceae drug resistance and adequate drug penetration into the prostate tissue.
• The duration of therapy is controversial. Due to limited penetration of antimicrobial agents into the prostate tissue, therapy for 6 weeks is recommended by experts to prevent development of chronic disease.
• Patients with prostatitis with evidence of sexually transmitted infections (e.g. Chlamydia or N. gonorrhea) should be treated for both conditions.

To view the traetment of Chlamydia, click here.

To view the treatment of N. gonorrhea, click here.

Antimicrobial regimen

Acute Bacterial Prostatitis

• 1. Uncomplicated (with low risk of STD pathogens)

• 1. Outpatient setting

• 1.1. Empirical therapy

• Preferred regimen (1): Ciprofloxacin 500 mg PO bid for 6 weeks OR Levofloxacin 500 mg PO qd for 6 weeks
• Preferred regimen (2): TMP-SMX 160 mg PO bid for 6 weeks
• Note: Nitrofurantoin, commonly used in lower urinary tract infections, should be avoided among men with prostatitis

• 1.2. Pathogen-directed therapy

• 1.2.1. Enterobacteriaceae (especially Escherichia coli)

• Preferred regimen: Ciprofloxacin 500 mg PO bid for 6 weeks OR Levofloxacin 500 mg PO qd for 6 weeks
• Alternative regimen: TMP-SMX DS (160 mg TMP) bid for 6 weeks

• 1.2.2. Enterococcus species

• Preferred regimen: Amoxicillin 500 mg PO q8h for 6 weeks OR Vancomycin 15 mg/kg q12h for 6 weeks
• Alternative regimen: Levofloxacin 750 PO qd for 6 weeks OR Linezolid 600 mg q12h for 6 weeks
• Note (1): Use intravenous therapy if systemically ill; switch to oral therapy when stable
• Note (2): Amoxicillin is not active against Enterococcus faecium

• 1.2.3. Pseudomonas aeruginosa

• Preferred regimen: Ciprofloxacin 400 mg tid for 6 weeks
• Alternative regimen: Piperacillin-tazobactam 4.5 g IV q6h for 6 weeks

• 1.2.4. Methicillin sensitive Staphylococcus spp.

• Preferred regimen: Cephalexin 500 mg PO q6h for 6 weeks OR Dicloxacillin 500 mg PO q6h for 6 weeks

• 2. Hospitalization

• 2.1. Empirical therapy

• Preferred regimen: (Ciprofloxacin 400 mg IV bid for 6 weeks OR Levofloxacin 500-750 mg IV qd for 6 weeks) ± (Gentamicin 5 mg/kg IV qd for 6 weeks OR Tobramycin 5 mg/kg IV qd for 6 weeks)
• Alternative regimen: Ceftriaxone 1 g IV qd for 6 weeks ± (Gentamicin 5 mg/kg IV qd for 6 weeks OR Tobramycin 5 mg/kg IV qd for 6 weeks)
• Note: Avoid gentamicin/tobramycin among patients with impaired renal function
• Patients who respond to IV antibiotics should be converted to oral therapy within 1-2 days of symptomatic improvement

*2.2. Pathogen-directed therapy

• 2.2.1. Enterococcus species

• Preferred regimen: Ampicillin 2 g IV q6h for 6 weeks
• Note: Ampicillin is not active against Enterococcus faecium

• 2.2.2. Methicillin sensitive Staphylococcus spp.

• Preferred regimen: Nafcillin 2g IV q4h-q6h for 6 weeks

• 2.2.3. Methicillin resistant Staphylococcus aureus

• Preferred regimen: [[Vancomycin 15-20 mg/lg/dose q8h-q12h for 6 weeks
• Note: Each vancomycin dose should not exceed 2 g

• 2. Uncomplicated (with risk of STD pathogens)

• 2.1 Neisseria gonorrhoeae or Chlamydia trachomatis

• Preferred regimen: Ceftriaxone 250 mg IM OR Cefixime 400 mg PO single dose AND Doxycycline 100 mg PO bid OR Azithromycin 500 mg PO qd
• Alternative regimen: Fluoroquinolones not recommended for gonococcal infection
• Note: Treat for 2 weeks in most cases. Obtain urine nucleicacid amplification test for N.gonorrhoeae and C.trachomatis

• 3 Uncomplicated, with risk of antibiotic resistant pathogen / healthcare-associated infection

• 3.1 Fluoroquinolone-resistant Enterobacteriaceae

• Preferred regimen: Ertapenem 1 g IV qd OR Cefepime 2g IV q12h OR Imipenem 500 mg IV q6h OR Tigecycline 100 mg IV single dose then 50 mg IV q12h

Note: Gentamicin may or may not be added to any of the above antibiotics

• 3.2 ES or AmpC beta lactamase producing Enterobacteriaceae

• Preferred regimen: Ertapenem 1 g IV qd OR Cefepime 2g IV q12h OR Imipenem 500 mg IV q6h OR Tigecycline 100 mg IV single dose then 50 mg IV q12h

• 4. Complicated by bacteremia or suspected prostatic abscess

• 4.1 Enterobacteriaceae or Enterococcus species

• Preferred regimen: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 500 mg IV q24h
• Alternative regimen: Ceftriaxone 1–2 g IV q24h AND Levofloxacin 500–750 mg PO qd OR Ertapenem 1 g IV q24h OR piperacillin-tazobactam 3.375 g IV q6h
• Note: Treat for 4 weeks. Obtain blood cultures; Consider genitourinary imaging; Change IV to PO regimen when blood cultures are sterile and abscess drained.

Chronic Bacterial Prostatitis

• Chronic Bacterial Prostatitis

• 1. Enterobacteriaceae (Enterococcus species)

• Preferred regimen: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 500 mg IV q24h
• Alternative regimen: TMP-SMX single dose DS bid

• 2. Staphylococcus species

• Preferred regimen: Azithromycin 500 mg PO qd
• Alternative regimen: Doxycycline 100 mg PO bid

• Note: Duration of therapy 4–6 weeks; Consider suppressive therapy if relapses occur.

Treatment of Sexual Partners

• Treatment of sexual partners is not necessary in either acute or chronic prostatitis when sexually transmitted infections are ruled out.

Follow-up

• Patients should be re-evaluated following the completion of the antimicrobial therapy regimen.
• Patients generally report symptomatic improvement at day 2 - day 6 of antimicrobial therapy. Patients who fail to respond to antimicrobial therapy should be evaluated for either resistance or development of prostatic abscess.
• A urine culture may be obtained at day 7 of antimicrobial therapy. A negative culture is associated with good prognosis, whereas positive cultures are associated with development of chronic disease and usually warrant the administration of alternative antibiotic regimens.
• Following recovery, patients should evaluated to determine possible causes of prostatitis, including structural abnormalities of the urinary tract.