Prostatitis medical therapy: Difference between revisions
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:*Bacteremia | :*Bacteremia | ||
:*Cannot tolerate oral antibiotics | :*Cannot tolerate oral antibiotics | ||
:*Monitoring when at-risk of decompensation (e.g. patients when major co-morbidities) | :*Monitoring when at-risk of decompensation (e.g. patients when major co-morbidities such as diabetes mellitus or HIV) | ||
*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. | *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. | ||
*The duration of therapy is controversial. Due to limited penetration of antimicrobial agents into the prostate tissue, therapy for 6 weeks is recommended by experts to prevent development of chronic disease. | |||
*Patients with prostatitis with evidence of sexually transmitted infections (e.g. ''Chlamydia'' or ''N. gonorrhea'') should be treated for both conditions. To view the traetment of ''Chlamydia'', click Chlamydia infection medical therapy|'''here''']]. To view the treatment of ''N. gonorrhea'', click Gonorrhea medical therapy|here]]. | |||
===Antimicrobial regimen=== | ===Antimicrobial regimen=== | ||
====Acute Bacterial Prostatitis==== | ====Acute Bacterial Prostatitis==== | ||
| Line 18: | Line 20: | ||
:*'''1. Outpatient setting''' | :*'''1. Outpatient setting''' | ||
::*'''1.1. Empirical therapy''' | ::*'''1.1. Empirical therapy''' | ||
:::*Preferred regimen (1): [[Ciprofloxacin]] 500 mg PO bid {{or}} [[Levofloxacin]] 500 mg PO qd | :::*Preferred regimen (1): [[Ciprofloxacin]] 500 mg PO bid for 6 weeks {{or}} [[Levofloxacin]] 500 mg PO qd for 6 weeks | ||
:::*Preferred regimen (2): [[TMP-SMX]] 160 mg PO bid | :::*Preferred regimen (2): [[TMP-SMX]] 160 mg PO bid for 6 weeks | ||
:::*Note: Nitrofurantoin, commonly used in lower urinary tract infections, should be avoided among men with prostatitis | |||
::*'''1.2. Pathogen-directed therapy''' | ::*'''1.2. Pathogen-directed therapy''' | ||
::*1.1 | :::*'''1.2.1. ''Enterobacteriaceae'' (especially ''Escherichia coli'')''' | ||
:::* Preferred regimen: [[Ciprofloxacin]] 500 mg PO bid {{or}} [[Levofloxacin]] 500 mg PO qd | ::::* Preferred regimen: [[Ciprofloxacin]] 500 mg PO bid for 6 weeks {{or}} [[Levofloxacin]] 500 mg PO qd for 6 weeks | ||
:::* Alternative regimen: [[TMP-SMX]] DS (160 mg TMP) bid | ::::* Alternative regimen: [[TMP-SMX]] DS (160 mg TMP) bid for 6 weeks | ||
:::* | :::*'''1.2.2. ''Enterococcus species'' ''' | ||
::::* Preferred regimen: [[Amoxicillin]] 500 mg PO q8h for 6 weeks {{or}} [[Vancomycin]] 15 mg/kg q12h for 6 weeks | |||
:::* Preferred regimen: [[Amoxicillin]] 500 mg PO q8h {{or}} [[Vancomycin]] 15 mg/kg q12h | ::::* Alternative regimen: [[Levofloxacin]] 750 PO qd for 6 weeks {{or}} [[Linezolid]] 600 mg q12h for 6 weeks | ||
:::* 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 (1): Use intravenous therapy if systemically ill; switch to oral therapy when stable | ::::* Note (2): Amoxicillin is not active against ''Enterococcus faecium'' | ||
:::*Note (2): Amoxicillin is not active against ''Enterococcus faecium'' | :::*'''1.2.3. ''Pseudomonas aeruginosa'' ''' | ||
::*1.3 | ::::* Preferred regimen: [[Ciprofloxacin]] 400 mg tid for 6 weeks | ||
::::* Alternative regimen: [[Piperacillin-tazobactam]] 4.5 g IV q6h for 6 weeks | |||
:::*'''1.2.4. Methicillin sensitive ''Staphylococcus spp.''''' | |||
:::* Preferred regimen: [[Ciprofloxacin]] 400 mg tid | ::::*Preferred regimen: [[Cephalexin]] 500 mg PO q6h for 6 weeks {{or}} [[Dicloxacillin]] 500 mg PO q6h for 6 weeks | ||
:::* Alternative regimen: [[Piperacillin-tazobactam]] 4.5 g IV q6h | |||
:*'''2. Hospitalization''' | :*'''2. Hospitalization''' | ||
::*'''2.1. Empirical therapy''' | ::*'''2.1. Empirical therapy''' | ||
:::*Preferred regimen | :::*Preferred regimen: ([[Ciprofloxacin]] 400 mg IV bid for 6 weeks {{or}} [[Levofloxacin]] 500-750 mg IV qd for 6 weeks) '''±''' ([[Gentamicin]] 5 mg/kg IV qd for 6 weeks {{or}} [[Tobramycin]] 5 mg/kg IV qd for 6 weeks) | ||
:::*Alternative regimen: [[Ceftriaxone]] 1 g IV qd '''±''' ([[Gentamicin]] 5 mg/kg IV qd {{or}} [[Tobramycin]] 5 mg/kg IV qd) | :::*Alternative regimen: [[Ceftriaxone]] 1 g IV qd for 6 weeks '''±''' ([[Gentamicin]] 5 mg/kg IV qd for 6 weeks {{or}} [[Tobramycin]] 5 mg/kg IV qd for 6 weeks) | ||
:::*Note: Avoid gentamicin/tobramycin among patients with impaired renal function | :::*Note: Avoid gentamicin/tobramycin among patients with impaired renal function | ||
::*'''2.2. ''' '' | :::*Patients who respond to IV antibiotics should be converted to oral therapy within 1-2 days of symptomatic improvement | ||
:::*Preferred regimen: [[Ampicillin]] 2 g IV q6h | ::'''*2.2. Pathogen-directed therapy''' | ||
:::*Note: Ampicillin is not active against ''Enterococcus faecium'' | :::*'''2.2.1. ''Enterococcus species'' ''' | ||
::::* Preferred regimen: [[Ampicillin]] 2 g IV q6h for 6 weeks | |||
::::* Note: Ampicillin is not active against ''Enterococcus faecium'' | |||
:::*'''2.2.2. Methicillin sensitive ''Staphylococcus spp.''''' | |||
::::* Preferred regimen: [[Nafcillin]] 2g IV q4h-q6h for 6 weeks | |||
:::*'''2.2.3. Methicillin resistant ''Staphylococcus aureus''''' | |||
::::*Preferred regimen: [[Vancomycin 15-20 mg/lg/dose q8h-q12h for 6 weeks | |||
::::*Note: Each vancomycin dose should not exceed 2 g | |||
*2. '''Uncomplicated (with risk of STD pathogens)''' | *2. '''Uncomplicated (with risk of STD pathogens)''' | ||
| Line 76: | Line 84: | ||
===Follow-up=== | ===Follow-up=== | ||
*Patients should be re-evaluated following the completion of the antimicrobial therapy regimen. | *Patients should be re-evaluated following the completion of the antimicrobial therapy regimen. | ||
*Patients who fail to | *Patients generally report symptomatic improvement at day 2 - day 6 of antimicrobial therapy. Patients who fail to respond to antimicrobial therapy should be evaluated for either resistance or development of prostatic abscess. | ||
*A urine culture may be obtained at day 7 of antimicrobial therapy. A negative culture is associated with good prognosis, whereas positive cultures are associated with development of chronic disease and usually warrant the administration of alternative antibiotic regimens. | |||
*Following recovery, patients should evaluated to determine possible causes of prostatitis, including structural abnormalities of the urinary tract. | *Following recovery, patients should evaluated to determine possible causes of prostatitis, including structural abnormalities of the urinary tract. | ||
==References== | ==References== | ||
Revision as of 18:56, 5 October 2015
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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 such as diabetes mellitus or HIV)
- 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.
- The duration of therapy is controversial. Due to limited penetration of antimicrobial agents into the prostate tissue, therapy for 6 weeks is recommended by experts to prevent development of chronic disease.
- Patients with prostatitis with evidence of sexually transmitted infections (e.g. Chlamydia or N. gonorrhea) should be treated for both conditions. To view the traetment of Chlamydia, click Chlamydia infection medical therapy|here]]. To view the treatment of N. gonorrhea, click Gonorrhea medical therapy|here]].
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 for 6 weeks OR Levofloxacin 500 mg PO qd for 6 weeks
- Preferred regimen (2): TMP-SMX 160 mg PO bid for 6 weeks
- Note: Nitrofurantoin, commonly used in lower urinary tract infections, should be avoided among men with prostatitis
- 1.2. Pathogen-directed therapy
- 1.2.1. Enterobacteriaceae (especially Escherichia coli)
- Preferred regimen: Ciprofloxacin 500 mg PO bid for 6 weeks OR Levofloxacin 500 mg PO qd for 6 weeks
- Alternative regimen: TMP-SMX DS (160 mg TMP) bid for 6 weeks
- 1.2.2. Enterococcus species
- Preferred regimen: Amoxicillin 500 mg PO q8h for 6 weeks OR Vancomycin 15 mg/kg q12h for 6 weeks
- Alternative regimen: Levofloxacin 750 PO qd for 6 weeks OR Linezolid 600 mg q12h for 6 weeks
- Note (1): Use intravenous therapy if systemically ill; switch to oral therapy when stable
- Note (2): Amoxicillin is not active against Enterococcus faecium
- 1.2.3. Pseudomonas aeruginosa
- Preferred regimen: Ciprofloxacin 400 mg tid for 6 weeks
- Alternative regimen: Piperacillin-tazobactam 4.5 g IV q6h for 6 weeks
- 1.2.4. Methicillin sensitive Staphylococcus spp.
- Preferred regimen: Cephalexin 500 mg PO q6h for 6 weeks OR Dicloxacillin 500 mg PO q6h for 6 weeks
- 2. Hospitalization
- 2.1. Empirical therapy
- Preferred regimen: (Ciprofloxacin 400 mg IV bid for 6 weeks OR Levofloxacin 500-750 mg IV qd for 6 weeks) ± (Gentamicin 5 mg/kg IV qd for 6 weeks OR Tobramycin 5 mg/kg IV qd for 6 weeks)
- Alternative regimen: Ceftriaxone 1 g IV qd for 6 weeks ± (Gentamicin 5 mg/kg IV qd for 6 weeks OR Tobramycin 5 mg/kg IV qd for 6 weeks)
- Note: Avoid gentamicin/tobramycin among patients with impaired renal function
- Patients who respond to IV antibiotics should be converted to oral therapy within 1-2 days of symptomatic improvement
- *2.2. Pathogen-directed therapy
- 2.2.1. Enterococcus species
- Preferred regimen: Ampicillin 2 g IV q6h for 6 weeks
- Note: Ampicillin is not active against Enterococcus faecium
- 2.2.2. Methicillin sensitive Staphylococcus spp.
- Preferred regimen: Nafcillin 2g IV q4h-q6h for 6 weeks
- 2.2.3. Methicillin resistant Staphylococcus aureus
- Preferred regimen: [[Vancomycin 15-20 mg/lg/dose q8h-q12h for 6 weeks
- Note: Each vancomycin dose should not exceed 2 g
- 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 generally report symptomatic improvement at day 2 - day 6 of antimicrobial therapy. Patients who fail to respond to antimicrobial therapy should be evaluated for either resistance or development of prostatic abscess.
- A urine culture may be obtained at day 7 of antimicrobial therapy. A negative culture is associated with good prognosis, whereas positive cultures are associated with development of chronic disease and usually warrant the administration of alternative antibiotic regimens.
- 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.