management of acute prostatitis

Last edited 06/2021 and last reviewed 06/2021

Diagnosis:

  • clinical presentation
  • exclusion of epididymo-orchitis by palpating the testicles
  • isolation of causative organism from urinary sample

Management recommendations for acute prostatitis in primary care (1,2)

  • send MSU for culture and start antibiotics
    • obtain a midstream urine sample before antibiotics are taken and send for culture and susceptibility testing
      • when results of urine cultures are available:
        • review the choice of antibiotic,
        • and change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow spectrum antibiotic wherever possible

  • fluroquinolones achieve higher prostate levels (1)
    • where fluoroquinolone resistance is a concern, other antibiotics that can reach therapeutic prostate levels include third-generation cephalosporins (such as ceftriaxone), carbapenems (such as imipenem or ertapenem), some aminoglycosides, aztreonam, piperacillin, minocycline, doxycycline, erythromycin, clindamycin and trimethoprim (2)
    • in acute prostatitis, where there is intense inflammation of the prostate gland, antibiotic penetration can be better than in chronic prostatitis (2)

  • when prescribing an antibiotic for acute prostatitis, take account of local antimicrobial resistance data and follow antibiotic guidance below

  • oral antibiotics are first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics

  • review antibiotic treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed, based on an assessment of the person's history, symptoms, clinical examination, urine and blood tests

Refer people with acute prostatitis to hospital if:

  • any symptoms or signs suggesting a more serious illness or condition (for example sepsis, acute urinary retention or prostatic abscess),
  • or their symptoms are not improving 48 hours after starting the antibiotic

Antibiotics1 for adults aged 18 years and over

First-choice oral antibiotic (guided by susceptibilities when available)2

  • Ciprofloxacin3 500 mg twice a day for 14 days then review4 OR
  • Ofloxacin3 200 mg twice a day for 14 days then review4

Alternative first-choice oral antibiotic for adults unable to take a fluoroquinolone (guided by susceptibilities when available)2

  • Trimethoprim 200 mg twice a day for 14 days then review4

Second-choice oral antibiotic (after discussion with specialist)

  • Levofloxacin3 500 mg once a day for 14 days then review4 OR
  • Co-trimoxazole5 960 mg twice day for 14 days then review4

First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available). Antibiotics may be combined if sepsis a concern2,6

Ciprofloxacin3 400 mg twice or three times a day
Levofloxacin3 500 mg once a day
Cefuroxime 1.5 g three or four times a day
Ceftriaxone 2 g once a day
Gentamicin Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration7
Amikacin Initially 15 mg/kg once a day (maximum per dose 1.5 g once a day), subsequent doses adjusted according to serum amikacin concentration (maximum 15 g per course)7

Second-choice intravenous antibiotic > consult local microbiologist

1 see BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.

2 check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.

3 the European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are appropriate in acute prostatitis which is a severe infection.

4 review treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed based on clinical assessment.

5 co-trimoxazole should only be considered when there is bacteriological evidence of sensitivity and good reasons to prefer this combination to a single antibiotic (BNF, August 2018).

6 review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total of 14 days then review.

7 therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018).

Notes:

  • some guidance states (3) that in less severe cases
    • an oral fluoroquinolone (e.g. ciprofloxacin 500mg bd) for 10 days may be sufficient

  • if severe infection requiring hospitalisation (3,4)
    • parenteral administration of high doses of bactericidal antibiotics - for example a a broad-spectrum penicillin, a third-generation cephalosporin or a fluoroquinolone, have been recommended
      • initial therapy, these regimens may be combined with an aminoglycoside
      • after normalisation of infection parameters, oral therapy can be substituted and continued for a total of about 2-4 weeks
    • a suprapubic catheter should be placed in men with increased residual volume
    • abscess drainage as required - per urethra with a rectoscope or through the perineum
      • small abscesses, patients may be treated conservatively by the administration of antibiotic agents together with the placement of a suprapubic catheter (3)

  • supportive treatment options like alpha blockers, antipyretics may be beneficial

Avoid transurethral manipulation by catheter and cystoscopy.

Reference: