Prostatitis medical therapy
|
Prostatitis Microchapters |
|
Diagnosis |
|
Treatment |
|
Case Studies |
|
Prostatitis medical therapy On the Web |
|
American Roentgen Ray Society Images of Prostatitis medical therapy |
|
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.
Antimicrobial regimen
Acute Bacterial Prostatitis
- 1. Uncomplicated (with low risk of STD pathogens)[1]
- 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
- 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.
References
- ↑ 1.0 1.1 Lipsky BA, Byren I, Hoey CT (2010). "Treatment of bacterial prostatitis". Clin Infect Dis. 50 (12): 1641–52. doi:10.1086/652861. PMID 20459324.
- ↑ Schaeffer AJ, National Institute of Diabetes and Digestive and Kidney Diseases of the US National Institutes of Health (2004). "NIDDK-sponsored chronic prostatitis collaborative research network (CPCRN) 5-year data and treatment guidelines for bacterial prostatitis". Int J Antimicrob Agents. 24 Suppl 1: S49–52. doi:10.1016/j.ijantimicag.2004.02.009. PMID 15364307.