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

Antimicrobial regimen

Acute Bacterial Prostatitis

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

• 1.1 Enterobacteriaceae (especially Escherichia coli)

• Preferred regimen: Ciprofloxacin 400 mg IV or 500 mg PO bid OR Levofloxacin 500–750 mg IV/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: Ampicillin 1–2 g IV q4h OR Vancomycin 15 mg/kg q12h
• Alternative regimen: Levofloxacin 750 PO qd OR Linezolid 600 mg q12h
• Note: Use intravenous therapy if systemically ill; switch to oral therapy when stable

• 1.3 Pseudomonas aeruginosa

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

• 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

• 3.1 Fluoroquinolone-resistant Enterobacteriaceae

• Preferred regimen: Ertapenem 1 g IV qd
• Alternative regimen: Ceftriaxone 1 g IV qd or Imipenem 500mg IV q6h OR Tigecycline 100 mg IV x 1 dose then 50 mg IV q12h

• 3.2 ES or AmpC beta lactamase producing Enterobacteriaceae

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

• 3.3 Fluoroquinolone-resistant pseudomonas

• Preferred regimen: Imipenem 500 mg IV q6h
• Alternative regimen: Meropenem 500 mg IV q8h

• 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.