Management of Prostatic Abscess / Prostatitis

• uncommon urological emergency
• Patients with diabetes mellitus, renal insufficiency and immune suppression are particularly at risk. 
• Urethral catheterisation, lower urinary tract instrumentation and a prostate biopsy are among the possible predisposing factors

Common Causative Organism

• Enterobacteriacae (particularly Escherichia coli) and Staphylococcus aureus are the commonest causative organisms 
• Klebsiella, Proteus, and Pseudomonas, and gram-positive Enterococcus species are often isolated as well.
• Organisms like Mycobacterium tuberculosis and Candida species might be found

Treatment

• Empiric therapy should be initiated
• Minimal duration of treatment is four weeks
• however, the optimal period has been shown to be six weeks, because of the possible persistence of bacteria (acute bacterial prostatitis)
• A four- to six-week course of therapy is usually recommended; however, a six- to 12-week course for chronic bacterial prostatitis

Choice of antibiotic
Fluoroquinolones

• No specific guideline exists for the treatment of grampositive organisms, but the fluoroquinolones have adequate gram-positive coverage, as well as excellent gram-negative coverage, and they penetrate the prostate well
•  ciprofloxacin 500 mg PO every 12 hours or levofloxacin 500 mg PO daily have six-month clinical cure rates of about 60 to 70 percent when given for four weeks or longer

Azithromycin or Doxycycline

• C. trachomatis and N. gonorrhoeae are best treated with azithromycin (Zithromax) or doxycycline
• azithromycin (500 mg daily for three days each week for three weeks) had higher rates of bacterial eradication

TMP-Sulphamethoxazole

•  A longer course of six or more weeks may be needed to achieve clinical cure with other agents, such as trimethoprim-sulfamethoxazole
• Although trimethoprim/sulfamethoxazole (Bactrim, Septra) may be considered, the tissue penetration may not be as effective, and in many areas of the United States there is evidence of increasing uropathogenic resistance

Penicillin derivatives

• commonly used to treat acute bacterial prostatitis, have not been shown to provide good symptom relief for chronic bacterial prostatitis

Antimicrobial penetration into prostatic tissue

• low pH of prostatic fluid permits antibiotics with alkaline pKas (such as fluoroquinolones and sulfonamides) to achieve high concentrations in prostatic tissue more readily 
• ideal choices for therapy of bacterial prostatitis include those agents that have optimal prostatic penetration.
• In addition to fluoroquinolones and sulfonamides, other agents with good to excellent penetration into prostatic fluid and tissue include tetracyclines and macrolides
• Fosfomycin also appears to achieve reasonable intraprostatic concentrations in uninflamed prostate

References:

1. www.uptodate.com
2. Prostatitis: Diagnosis and Treatment. August 15, 2010 ◆ Volume 82, Number 4