Medication Summary
The different prostatitis categories are treated with various medical therapies, depending on the underlying pathology. Penetration of the prostate represents a barrier to adequate antibiosis and is essential for the treatment of bacterial prostatitis. [40] If the patient is having systemic symptoms, admission is warranted for intravenous antibiotics, hydration, and analgesia.
While the majority of chronic prostatitis cases can be treated with a 4-week course of fluoroquinolone therapy, [40] antibiotic regimens can vary with the species of bacteria or local drug resistance, and some patients may require long-term antibiosis. [50]
Chronic prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis also may be treated with alpha-blocking agents or diazepam with sitz baths.
Antibiotics
Class Summary
Empiric antibiotics should be tailored toward treating gram-negative pathogens. Sexually transmitted diseases (STDs), where Neisseria gonorrhoeae and Chlamydia trachomatis are the primary suspected pathogens, also should be considered, especially in patients younger than 35 years.
Current Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection recommend single-dose IM ceftriaxone, plus single-dose oral azithromycin or 7 days of oral doxycycline. [42] Cotreatment offers the benefits of hindering the development of antimicrobial resistant gonococci and providing coverage against C trachomatis infection, which often accompanies gonococcal infection. Fluoroquinolone antibiotics no longer are recommended to treat gonorrhea in the United States. Consider pseudomonal coverage with cefepime in the setting of acute bacterial prostatitis with a history of recent instrumentation.
For the treatment of chronic bacterial prostatitis, where Enterobacteriaceae, enterococci, and Pseudomonas aeruginosa are common pathogens, consider trimethoprim/sulfamethoxazole (Bactrim), cefepime, or fluoroquinolones for 28 days or more as empiric agents.
For nonbacterial prostatitis caused by Chlamydia and Ureaplasma species, which are difficult to culture, an empiric trial of doxycycline or erythromycin should be instituted.
Levofloxacin (Levaquin)
This fluoroquinolone is indicated to treat acute and chronic bacterial prostatitis due to Escherichia coli, E faecalis, or Staphylococcus epidermidis. It has good concentration in the prostate. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. It provides good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Levofloxacin acts by inhibition of DNA gyrase activity.
Ofloxacin
Ofloxacin is a fluoroquinolone that is a pyridine carboxylic acid derivative with a broad-spectrum bactericidal effect.
Ciprofloxacin (Cipro, Cipro XR, Proquin XR)
This agent is a fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Ciprofloxacin has no activity against anaerobes. Continue treatment for at least 2 days (7-14 d typical) after signs and symptoms have disappeared.
Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra DS)
Trimethoprim inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except P aeruginosa.
Ceftriaxone (Rocephin)
A third-generation cephalosporin with broad-spectrum, gram-negative activity, ceftriaxone has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Its bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins.
This agent exerts its antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Ceftriaxone is highly stable in the presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of the dose is excreted unchanged in urine, and the remainder is secreted in bile and ultimately in feces as microbiologically inactive compounds. Ceftriaxone reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations of less than 25 mcg/mL to 85% bound at 300 mcg/mL.
Doxycycline (Adoxa, Monodox, Doryx, Vibramycin)
Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Doxycycline is used to treat nonbacterial prostatitis caused by Chlamydia species. Chlamydia and Ureaplasma are difficult to culture; therefore, an empiric trial of doxycycline should be instituted.
Alpha-adrenergic antagonists
Class Summary
These agents are used in the treatment of benign prostatic hypertrophy. Studies suggest that combining alpha-blockers with antibiotics may reduce the risk for prostatitis recurrence in chronic prostatitis. Alpha-blockers reduce bladder outlet obstruction and thus improve voiding dysfunction that may be associated with prostatic swelling with prostatitis. Alpha-blockers also may have a role to improve symptoms in chronic pelvic pain syndrome.
Terazosin
Quinazoline compound that counteracts alpha1-induced adrenergic contractions of bladder neck, terazosin facilitates urinary flow in the presence of prostate inflammation.
Tamsulosin (Flomax)
An alpha-adrenergic blocker, specifically targeting the A1 receptors, tamsulosin has the advantage of causing relatively less orthostatic hypotension, and it requires no gradual up-titration from the initial introductory dosage. On the other hand, a higher incidence of ejaculatory dysfunction exists with this medication (8.4-18.1%).
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Bacterial prostatitis. Expressed prostatic fluid contains more than 10 white blood cells per high-power field, indicating prostatitis.
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A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.
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Urine culture with greater than 100,000 colony-forming units (CFU) of Escherichia coli, the most common pathogen in acute and chronic prostatitis. Chronic bacterial prostatitis must be confirmed and diagnosed using a urine culture.
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Treatment algorithm for chronic bacterial prostatitis. Courtesy of Frontiers Media [Xiong S, Liu X, Deng W, Zhou Z, Li Y, Tu Y, et al. Pharmacological Interventions for Bacterial Prostatitis. Front Pharmacol. 2020. 11:504. Online at https://www.frontiersin.org/articles/10.3389/fphar.2020.00504/full].
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Treatment algorithm for acute bacterial prostatitis. Courtesy of Frontiers Media [Xiong S, Liu X, Deng W, Zhou Z, Li Y, Tu Y, et al. Pharmacological Interventions for Bacterial Prostatitis. Front Pharmacol. 2020. 11:504. Online at https://www.frontiersin.org/articles/10.3389/fphar.2020.00504/full].
