Prostatitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Usama Talib, BSc, MD [3]

Overview

Antimicrobial therapy is indicated for acute and chronic prostatitis. Patients are generally treated in an outpatient setting unless severe disease (e.g. bacteremia) is suspected. Empirical therapy for both acute and chronic prostatitis includes monotherapy with either ciprofloxacin, levofloxacin, or TMP-SMX for at least 6 weeks. When culture results are obtained, antimicrobial therapy may be narrowed down to cover the causative pathogen more adequately. Addition of alpha blocker may be considered for the symptomatic management of bacterial prostatitis. Inflammatory prostatitis may be treated with NSAIDs, allopurinol, or cernilton. Patients not responding to medical therapy or without improvement in the fever after 36 hours of therapy should be investigated for an abscess or any other complication by using ultrasound, CT scan or an MRi.

Medical Therapy

• The approach to the medical therapy for acute bacterial prostatitis is given below

History and Physical Examination

❑ Urine culture & Urinalysis: All patients ❑ Postvoid residual urine: If suspecting obstruction

Mild to Moderately Ill ❑ TMP/SMX 160/800mg PO BID for 6 weeks OR ❑ Ciprofloxacin 500mg PO BID for 6 weeks

Seriously ill or Possible urosepsis ❑ Admit patient ❑ Ampicillin 2g IV q6h PLUS Gentamicin 5mg/kg q24h or 1.5mg/kg every eight hours untill afebrile

Fever Persists or Not Improving ❑ Non contrast Pelvic CT with cuts through the prostate or ❑ Transrectal Ultrasonography

Negative ❑ Modify antibiotics based on culture results

Positive ❑ Confirms diagnosis of Prostatic Abscess ❑ Consult urology for drainage

Afebrile ❑ TMP/SMX 160/800mg PO BID for 6 weeks OR ❑ Ciprofloxacin 500mg PO BID for 6 weeks

Chronic Prostatitis/Chronic Pelvic Pain Syndorme (CPPS)

• The approach towards medical therapy for chronic prostatitis (i.e chronic bacterial prostatitis) is as under

Chronic Prostatitis/CPPS

Predominant urinary symptoms ❑ Alpha blocker

Combination of urinary and pain symptoms ❑ Finasteride ❑ Non pharmacological therapy ( e.g Biofeedback) ❑ Phytotherapy ❑ Consult Urology

Predominant pain symptoms ❑ Anti inflammatory drugs

*Adopted from Ameican Family Physician

Acute and Chronic Bacterial Prostatitis

• All patients with bacterial prostatitis (both acute and chronic) require empiric antimicrobial therapy until culture results are obtained.
• Addition of alpha blocker may be considered for the symptomatic management of bacterial prostatitis. Warm sitz baths may also be helpful.
• 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 treatment 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

• 1.2.5. Healthcare associated

• Preferred regimen: Ertapenem 1 g IV qd for 6 weeks OR Cefepime 2g IV q12h for 6 weeks OR Imipenem 500 mg IV q6h for 6 weeks OR Cephalexin 500 mg PO q6h for 6 weeks OR Ceftriaxone 1 g IV qd 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

Chronic Bacterial Prostatitis

• Chronic Bacterial Prostatitis

• 1. Fluoroquinolone-susceptible organisms

• Preferred regimen: Ciprofloxacin 500 mg PO q12h for at least 6 weeks OR Levofloxacin 500 mg PO qd for at least 6 weeks
• Alternative regimen: TMP-SMX single dose DS bid for at least 6 weeks

• 2. Chlamydia spp.

• Preferred regimen: Azithromycin 500 mg PO qd for 3 days/week for a total of 3 weeks
• Alternative regimen: Doxycycline 100 mg PO bid for 4-6 weeks

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 may be re-evaluated at 7 days following the initiation of therapy. Patients should also be re-evaluated monthly during the administration of 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 prostate 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 be evaluated to determine possible causes of prostatitis, including structural abnormalities of the urinary tract.

Chronic Prostatitis/Chronic Pelvic Pain Syndorme (CPPS)

A patient newly diagnosed with chronic prostatitis or CPPS should be considered for the presence of predominant urinary or pain symptoms and started on the following medications

• 1. Predominant urinary symptoms

• Add an alpha blocker

• 2. Combination of urinary and pain symptoms

• Finasteride
• Non pharmacological therapy ( e.g Biofeedback)
• Phytotherapy (use of plants and plant derived products)
• Consult Urology

• 3. Predominant pain symptoms

• Add anti-inflammatory medications

Non-Bacterial Prostatitis

• Patients with non-bacterial causes of prostatitis should be evaluated thoroughly for structural abnormalities and malignancies.
• Patients with inflammatory prostatitis and no evidence of bacterial prostatitis may be treated with NSAIDs and/or cernilton and/or allopurinol.
• The following drugs have been reported to be effective in the symptomatic managemnet of patients with chronic disease:

• Irritation:

• Anticholinergic agents
• Allopurinol

• Pain:

• Diazepam
• Cyclobenzaprine
• Methocarbamol
• NSAIDs
• Alpha blockers
• Gabapentin
• Amitriptyline