Acute Bacterial Prostatitis

Background

• Acute bacterial prostatitis is a bacterial infection of the prostate gland typically causing acute pelvic pain and urinary tract symptoms.
• Up to 16% of men have prostatitis during their lifetime and of those up to 10% are diagnosed with acute bacterial prostatitis.
• Most cases of acute bacterial prostatitis are due to uropathogens, most commonly Escherichia coli.
• In nosocomial-acquired infections, organisms such as Pseudomonas aeruginosa and enterococci are also common.
• Risk factors include urinary tract manipulation such as catheterization, cystoscopy, prostate biopsy, prostate surgery, anatomic abnormalities such as benign prostatic hypertrophy, high-risk sexual behaviors, and immunocompromise.

Evaluation

• Diagnosis of bacterial prostatitis is made clinically based on acute onset of:
  • irritative urinary tract symptoms such as dysuria, frequency, and urgency.
  • obstructive urinary tract symptoms such as straining, hesitancy, weak stream, incomplete voiding, or urinary retention.
  • fever and other signs of systemic illness.
  • suprapubic, perineal, rectal, and/or genital pain.
  • tender and enlarged prostate on digital rectal exam (do not perform prostate massage).
• Obtain midstream urine for urinalysis and urine culture.
  • Urinalysis may support an early diagnosis and culture should identify a bacterial cause and guide any change in the antibiotic choice.
  • Consider a urine Gram stain to guide the initial therapy while awaiting the culture results.
• Consider a complete blood count and a blood culture if the patient has systemic symptoms or bacteremia is suspected (Weak recommendation).
• The Prostatic-specific antigen (PSA) should not be performed in the acute setting. It will likely be elevated and is not a recommended test for the diagnosis of prostatitis.
• Imaging is typically reserved for when an abscess is suspected (poor response to antibiotic therapy) or when signs of urinary retention are present.

Management

• If the patient is unable to urinate and is in urinary retention, indwelling, intermittent, or suprapubic catheterization may be necessary.
• Empiric choice of antibiotic is based on the ability of an antibiotic to penetrate the prostate, the suspected pathogen, and the local antibiotic resistance patterns.
  • For uncomplicated cases, common options include either of:
    • a fluoroquinolone, if local resistance is known to be < 10% (for example, ciprofloxacin 500 mg orally twice daily or levofloxacin 500 mg orally once daily)
    • co-trimoxazole (trimethoprim/sulfamethoxazole) 160 mg/800 mg orally twice daily
  • For patients at risk for sexually transmitted infection, combination therapy with coverage for Neisseria gonorrhoeae and Chlamydia trachomatis is appropriate. (See Gonococcal Urethritis and Chlamydia Genital Infection for additional information.)
  • For hospitalized patients:
    • For patients who do not have risk factors for antibiotic resistance and are not severely ill, options include::
      • ceftriaxone 1-2 g IV every 24 hours plus levofloxacin 500-750 mg IV every 24 hours
      • piperacillin/tazobactam 3.375 g IV every 6 hours
      • a fluoroquinolone (for example, ciprofloxacin 400 mg IV every 12 hours or levofloxacin 500-750 mg IV every 24 hours); however, the European Association of Urology (EAU) recommends against fluoroquinolone monotherapy in hospitalized patients with acute prostatitis
    • For patients who do not have risk factors for antibiotic resistance and are severely ill:
      • Preferred regimens include any of:
        • piperacillin/tazobactam 3.375 g IV every 6 hours plus aminoglycosides
        • cefotaxime 2 g IV every 4 hours plus aminoglycosides
        • ceftazidime 2 g IV every 8 hours plus aminoglycosides
      • Alternative regimens include a fluoroquinolone plus an aminoglycosides or a carbapenem.
    • For patients of any severity with risk factors for antibiotic resistance:
      • For patients with prior fluoroquinolone use or known fluoroquinolone resistance rates > 10%:
        • Preferred regimens include piperacillin/tazobactam 3.375 g IV every 6 hours, ceftazidime 2 g IV every 8 hours, or cefepime 2 g IV every 12 hours, with the addition of an aminoglycoside if the patient is clinically unstable.
        • Alternative regimens include ceftriaxone 1 g IV every 24 hours (plus an aminoglycosides if the patient is clinically unstable) or ertapenem 1 g IV every 24 hours.
      • For patients with transurethral or transrectal manipulation and risk of:
        • extended spectrum beta-lactamase-producing Escherichia coli, see Extended Spectrum Beta-Lactamases (ESBLs) for details on empiric antibiotic options.
        • Pseudomonas species infection:
          • preferred regimens include piperacillin/tazobactam 3.375 g IV every 6 hours, ceftazidime 2 g IV every 8 hours, or cefepime 2 g IV every 12 hours, with the addition of an aminoglycoside if the patient is clinically unstable
          • alternative regimens include imipenem/cilastatin 500 mg IV every 6 hours or meropenem 500 mg IV every 8 hours
        • fluoroquinolone resistance, see above for preferred regimens.
  • Consider the addition of vancomycin or ampicillin if the patient's history or urine Gram stain (gram-positive) suggests enterococci.
  • Empiric coverage for methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci may be appropriate based on the patient's history or prior microbiologic data.
  • Adjust antibiotics based on culture results.
• Antibiotics are usually given for 10-14 days, but 4-6 weeks may be needed based on the response to treatment and the severity of disease.
• For patients having IV therapy, transition to an oral antibiotic regimen after clinical improvement and continue therapy to complete 2-6 weeks.
• Supportive care may include nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and alpha-1 blockers (such as tamsulosin) for lower urinary tract symptoms, but no evidence specific to use in prostatitis.
• Consider an evaluation for a prostatic abscess or an anatomic abnormality for persistent symptoms or recurrence.