Rationale for oral antibiotic therapy for acute bacterial prostatitis
See Approach to managing acute bacterial prostatitis for principles of antibiotic choice.
Options for oral treatment of acute bacterial prostatitis are limited by the poor penetration of many antibiotics into the prostate once the initial phase of intense inflammation has resolvedLam, 2023National Institute for Clinical Excellence (NICE), 2018Yebes, 2023.
Oral antibiotics with favourable prostate penetration are ciprofloxacin, trimethoprim, trimethoprim+sulfamethoxazole, doxycycline and azithromycinBonkat, 2024Karaiskos, 2019Lam, 2023. Prostate penetration of oral beta-lactam antibiotics (eg cefalexin or amoxicillin) becomes limited as the prostate inflammation settlesLam, 2023Yebes, 2023. Nitrofurantoin has inadequate prostate penetration irrespective of prostate inflammationLam, 2023Yebes, 2023.
At the time of writing, approximately 12% of Escherichia coli urine isolates from adults in the community in Australia are resistant to ciprofloxacin, and approximately 20% are resistant to trimethoprim. Therefore, ciprofloxacin is the recommended first-line empirical oral therapy for acute bacterial prostatitisAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2023Bonkat, 2024National Institute for Clinical Excellence (NICE), 2018.
Doxycycline and azithromycin are used to treat acute bacterial prostatitis caused by sexually transmissible pathogensBonkat, 2024. For sexually active males1 with acute bacterial prostatitis, consider testing for Chlamydia trachomatis and Neisseria gonorrhoeae if empirical therapy has failedBonkat, 2024Lam, 2023.
Fosfomycin may be an option for the treatment of acute bacterial prostatitis caused by some multidrug-resistant bacteria, but more information is needed before it can be recommendedKaraiskos, 2019Yebes, 2023.