Empiric Therapy Regimens
Empiric therapeutic regimens for prostatitis are outlined below, including those for acute prostatitis and chronic prostatitis.
Outpatient therapy for acute prostatitis
At risk for sexually transmitted diseases [1, 2, 3, 4] :
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Ceftriaxone 500 mg IM single dose or
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Cefixime 400 mg PO single dose, then doxycycline 100mg BID for 10 days
No risk for sexually transmitted diseases:
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Ciprofloxacin 500 mg PO BID for 10-14 days or
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Levofloxacin 500-750 mg PO daily for 10-14 days or
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Trimethoprim/sulfamethoxazole (TMP/SMX) 160/800mg PO BID for 10-14 days
Treatment can be extended for an additional 2 weeks if the patient remains symptomatic. Antibiotics can be adjusted based on culture results prior to extending treatment. [5]
Inpatient therapy for acute prostatitis: acutely ill and/or suspected sepsis
If the patient appears toxic (presents with systemic illness, fever, urinary incontinence, does not tolerate oral intake, or is at risk for antibiotic resistance), broad-spectrum antibiotics and hospitalization must be considered. After initial improvement with parenteral antibiotics, acute bacterial prostatitis may be managed with outpatient care to complete a 2-4 week course of oral antibiotics with urologic follow-up. Therapy can be tailored based on previous cultures. Transrectal imaging (ultrasonography, non-contrast CT/ MRI) should be conducted to rule out abscess. Urine culture should be repeated 1 week post completion of antibiotic regimen.
Non-toxic and no antibiotic resistance risk factors:
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Ciprofloxacin 400 mg IV q12h or
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Levofloxacin 50-750 mg IV q24h [6] or
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Ceftriaxone 1-2 g IV q24h and l evofloxacin 500-750 mg IV q24h or
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Piperacillin/tazobactam 3.375 g IV q6h
Toxic/unstable and no antibiotic resistance risk factors [1, 2, 7, 8, 9, 10, 11] :
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Piperacillin/tazobactam 3.375 mg IV q6h and gentamicin 7 mg/kg IV q24h or
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Piperacillin/tazobactam 3.375 mg IV q6h and amikacin 15 mg/kg IV q24h or
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Cefotaxime 2 g IV q4h and gentamicin 7 mg/kg IV q24h or
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Ceftazidime 2 g IV q8h and gentamicin 7 mg/kg IV q24h or
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Ciprofloxacin 400 mg IV q12h and gentamicin 7 mg/kg IV q24h or
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Ertapenem 1 g IV q24h or
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Imipenem/cilastatin 500 mg IV q6h or
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Meropenem 500 mg IV q8h
Severely toxic and risk for antibiotic resistance:
Transrectal manipulation [6, 12] :
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Piperacillin/tazobactam 3.375 mg IV q6h and gentamicin 7 mg/kg IV q24h or
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Piperacillin/tazobactam 3.375 mg IV q6h and amikacin 15 mg/kg IV q24h
Transurethral manipulation [13, 14] :
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Piperacillin/tazobactam 3.375 mg IV q6h with or without gentamicin 7 mg/kg IV q24h or ceftazidime 2 g IV q8h with or without gentamicin 7 mg/kg IV q24h or
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Cefepime 2 g IV q12h with or without gentamicin 7 mg/kg IV q24h
Fluoroquinolone resistance [15, 16] :
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Piperacillin/tazobactam 3.375 mg IV q6h with or without gentamicin 7 mg/kg IV q24h or
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Ceftazidime 2 g IV q8h with or without gentamicin 7 mg/kg IV q24h or
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Cefepime 2 g IV q12h with or without gentamicin 7 mg/kg IV q24h
Chronic bacterial prostatitis (CBP)
Considerations for chronic bacterial prostatitis (CBP) include the following:
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75% of patients will show resolution with antibiotic therapy (ex, fosfomycin or a zithromycin) for 4-12 weeks or may need long-term low dose of antibiotics for pain management, up to 6 months [17, 18, 19]
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Alpha-antagonists may be administered for long-term management to maintain adequate urinary flow, (ex, silodosin )
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Non-steroidal anti-inflammatory drugs and muscle relaxants may reduce chronic inflammation and reduce CBP-associated pain (ex, ibuprofen, aspirin, naproxen sodium, cyclobenzaprine, clonazepam)
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Glycosaminoglycans such as chondroitin sulfate and neuromodulators such as amitriptyline, nortriptyline and pregabalin may be used as supplemental agents
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Prostatic massage may be performed to express fluids from prostatic ducts to alleviate pressure from inflammatory fluids
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Physiotherapy, specifically, pelvic floor exercises can help reduce pelvic tension (ex, myofascial release, Kegel exercises, paradoxical relaxation)
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Warm sitz baths, heating pads, donut-shaped cushions and acupuncture may help alleviate pelvic pressure and pain
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Prostatic or ureteral surgery may be required for refractory disease
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Diet and exercise may play a role in CBP management, higher water intake may be recommended