Infectious Disease Compendium

Prostatitis

A 2015 NEJM review of UTI in old men.

Diagnosis

Infection of the prostate. Diagnosis on cultures taken after prostatic massage.

Patient have fever, malaise, myalgias, dysuria, urinary frequency/hesitancy, and pelvic pain.

Epidemiologic Risks

Sex, enlarged prostate.

Four kinds: Acute bacterial prostatitis, Chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis.

Microbiology

Acute: Neisseria gonorrhoeae, gram-negative enteric organisms (like E. coli the most common cause).

Chronic: E. coli, K. pneumonia, Enterobacter species, P. mirabilis, Enterococci are common causes.

Occasional causes include Candida, Blastomyces dermatitidis, Histoplasma, Mycobacterium tuberculosis, and non tuberculous Mycobacterium (especially BCG for bladder cancer therapy), Cryptococcus neoformans.

Empiric Therapy

Get cultures, then the only antibiotics that get good levels in the prostate are TMP and quinolones, tetracyclines, macrolides. An acutely inflamed prostate is penetrated by most antibiotics (not nitrofurantoin).

All recommendations in order of preference. (Review:PubMed)

Uncomplicated (with low risk of STD pathogens) Enterobacteriaceae (especially Escherichia coli)

Ciprofloxacin 400 mg iv or 500 mg po BID or levofloxacin 500–750 mg iv/po QD, trimethoprim/sulfamethoxazole DS (160 mg TMP) BID. For 30 days. Cefoxitin works for ESBL (PubMed).

Enterococcus species: Ampicillin 1–2 g IV every 4 h; vancomycin 15 mg/kg every 12 h levofloxacin 750 po QD; linezolid 600 mg every 12 h Use intravenous therapy if systemically ill; switch to oral therapy when stable

Pseudomonas : Ciprofloxacin 400 mg TID, piperacillin/tazobactam 4.5 g iv every 6 h.

Uncomplicated (with risk of STD pathogens)

Neisseria gonorrhoeae or Chlamydia trachomatis: Ceftriaxone 250 mg IM or cefixime 400 mg po 1 dose PLUS doxycycline 100 mg po BID or azithromycin 500 mg po QD Fluoroquinolones not recommended for gonococcal infection Treat for 2 weeks in most cases.

Uncomplicated, with risk of an ES or AmpC beta lactamase producing Enterobacteriaceae Fluoroquinolone-resistant

Ertapenem 1 g iv QD ceftriaxone 1 g iv QD or imipenem 500 mg iv every 6 h or tigecycline 100 mg iv 1 dose then 50 mg iv every 12.

ES or AmpC beta lactamase producing Enterobacteriaceae

Ertapenem 1 g iv QD cefepime 2 g iv every 12 h or imipenem 500 mg iv every 6 h or tigecycline 100 mg iv 1 dose then 50 mg iv every 12 h

Consider extending duration of antibiotic resistant pathogen therapy to 4 weeks.

Fluoroquinolone-resistant Pseudomonas

Imipenem 500 mg iv every 6 h meropenem 500 mg iv every 8 h

Complicated by bacteremia or suspected prostatic abscess Enterobacteriaceae or Enterococcus species

Ciprofloxacin 400 mg iv every 12 h or levofloxacin 500 mg iv every 24 h ceftriaxone 1–2 g iv every 24 h plus levofloxacin 500–750 mg po QD, or ertapenem 1 g iv every 24 h or piperacillin/tazobactam3.375 g iv every 6 h Treat for 4 weeks.

Obtain blood cultures. Consider genitourinary imaging. Change iv to po regimen when blood cultures are sterile and abscess drained.

Chronic

Enterobacteriaceae: ciprofloxacin 400 mg iv every 12or levofloxacin 500 mg iv every 24 h trimethoprim/sulfamethoxazole 1 dose DS BID.

For resistant gram-negatives, consider fosfomycin (PubMed, PubMed), one gram a day for 12-16 weeks.

Staphylococcus species: azithromycin 500 mg po QD or Doxycycline 100 mg BID.

Duration of therapy 4–6 weeks. Consider suppressive therapy if relapses occur.

Pearls

Chronic prostatitis/chronic pelvic pain syndrome may or not be infectious and does not respond well to therapy.

Last Update: 01/08/19.