Prostatitis medical therapy
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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)
- 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.
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 OR Levofloxacin 500 mg PO qd
- Preferred regimen (2): TMP-SMX 160 mg PO bid
- 1.2. Pathogen-directed therapy
- 1.1 Enterobacteriaceae (especially Escherichia coli)
- Preferred regimen: Ciprofloxacin 500 mg PO bid OR Levofloxacin 500 mg PO qd
- Alternative regimen: TMP-SMX DS (160 mg TMP) bid
- Note: 2 weeks duration of therapy may be sufficient; if patient remains symptomatic, extend to 4 weeks
- 1.2 Enterococcus species
- Preferred regimen: Amoxicillin 500 mg PO q8h OR Vancomycin 15 mg/kg q12h
- Alternative regimen: Levofloxacin 750 PO qd OR Linezolid 600 mg q12h
- Note (1): Use intravenous therapy if systemically ill; switch to oral therapy when stable
- Note (2): Amoxicillin is not active against Enterococcus faecium
- 1.3 Staphylococcus aureus
- Preferred regimen:
- 1.3 Pseudomonas aeruginosa
- Preferred regimen: Ciprofloxacin 400 mg tid
- Alternative regimen: Piperacillin-tazobactam 4.5 g IV q6h
- 2. Hospitalization
- 2.1. Empirical therapy
- Preferred regimen (1): (Ciprofloxacin 400 mg IV bid OR Levofloxacin 500-750 mg IV qd) ± (Gentamicin 5 mg/kg IV qd OR Tobramycin 5 mg/kg IV qd)
- Alternative regimen: Ceftriaxone 1 g IV qd ± (Gentamicin 5 mg/kg IV qd OR Tobramycin 5 mg/kg IV qd)
- Note: Avoid gentamicin/tobramycin among patients with impaired renal function
- '2.2. Enterococcus species '
- Preferred regimen: Ampicillin 2 g IV q6h
- Note: Ampicillin is not active against Enterococcus faecium
- 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 who fail to completely respond to antimicrobial therapy should be evaluated for either resistance or development of prostatic abscess.
- 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.