Management of acute prostatitis

Diagnosis:

• clinical presentation
• exclusion of epididymo-orchitis by palpating the testicles
• isolation of causative organism from urinary sample

Management recommendations for acute prostatitis in primary care (1,2)

• send MSU for culture and start antibiotics
  • obtain a midstream urine sample before antibiotics are taken and send for culture and susceptibility testing
    • when results of urine cultures are available:
      • review the choice of antibiotic,
      • and change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow spectrum antibiotic wherever possible
        
        
• fluroquinolones achieve higher prostate levels (1)
  • where fluoroquinolone resistance is a concern, other antibiotics that can reach therapeutic prostate levels include third-generation cephalosporins (such as ceftriaxone), carbapenems (such as imipenem or ertapenem), some aminoglycosides, aztreonam, piperacillin, minocycline, doxycycline, erythromycin, clindamycin and trimethoprim (2)
  • in acute prostatitis, where there is intense inflammation of the prostate gland, antibiotic penetration can be better than in chronic prostatitis (2)
    
    
• when prescribing an antibiotic for acute prostatitis, take account of local antimicrobial resistance data and follow antibiotic guidance below
  
  
• oral antibiotics are first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics
  
  
• review antibiotic treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed, based on an assessment of the person's history, symptoms, clinical examination, urine and blood tests

Refer people with acute prostatitis to hospital if:

• any symptoms or signs suggesting a more serious illness or condition (for example sepsis, acute urinary retention or prostatic abscess),
• or their symptoms are not improving 48 hours after starting the antibiotic

Antibiotics1 for adults aged 18 years and over

First-choice oral antibiotic (guided by susceptibilities when available)2

• Ciprofloxacin3 500 mg twice a day for 14 days then review4 OR
• Ofloxacin3 200 mg twice a day for 14 days then review4

Alternative first-choice oral antibiotic for adults unable to take a fluoroquinolone (guided by susceptibilities when available)2

• Trimethoprim 200 mg twice a day for 14 days then review4

Second-choice oral antibiotic (after discussion with specialist)

• Levofloxacin3 500 mg once a day for 14 days then review4 OR
• Co-trimoxazole5 960 mg twice day for 14 days then review4

First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available). Antibiotics may be combined if sepsis a concern2,6

Second-choice intravenous antibiotic > consult local microbiologist

1 see BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.

2 check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.

3 the European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are appropriate in acute prostatitis which is a severe infection.

4 review treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed based on clinical assessment.

5 co-trimoxazole should only be considered when there is bacteriological evidence of sensitivity and good reasons to prefer this combination to a single antibiotic (BNF, August 2018).

6 review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total of 14 days then review.

7 therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018).

Notes:

• some guidance states (3) that in less severe cases
  
  • an oral fluoroquinolone (e.g. ciprofloxacin 500mg bd) for 10 days may be sufficient
• if severe infection requiring hospitalisation (3,4)
  • parenteral administration of high doses of bactericidal antibiotics - for example a a broad-spectrum penicillin, a third-generation cephalosporin or a fluoroquinolone, have been recommended
    • initial therapy, these regimens may be combined with an aminoglycoside
    • after normalisation of infection parameters, oral therapy can be substituted and continued for a total of about 2-4 weeks
  • a suprapubic catheter should be placed in men with increased residual volume
  • abscess drainage as required - per urethra with a rectoscope or through the perineum
    • small abscesses, patients may be treated conservatively by the administration of antibiotic agents together with the placement of a suprapubic catheter (3)
      
      
• supportive treatment options like alpha blockers, antipyretics may be beneficial

Avoid transurethral manipulation by catheter and cystoscopy.

Reference:

• Public Health England (October 2014). Management of infection guidance for primary care for consultation and local adaptation
• NICE (October 2018).Prostatitis (acute): antimicrobial prescribing
• Ludwig M. Diagnosis and therapy of acute prostatitis, epididymitis and orchitis.Andrologia. 2008 Apr;40(2):76-80.
• Naber KG et al. EAU guidelines for the management of urinary and male genital tract infections. Eur Urol 2001;40:576-588 (updated 2006).
• Public Health England (June 2021). Managing common infections: guidance for primary care