Treatment of chronic bacterial prostatitis

Abstract

Bacterial infection of the prostate can be demonstrated by the Meares & Stamey 4-glass or the pre and post prostate massage (PPM) 2-glass test in only about 10% of men with symptoms of chronic prostatitis. NIH-category II chronic bacterial prostatitis (CBP) is mainly caused by Gram-negative uropathogens, whereas the role of certain Gram-positive and sexually-transmitted pathogens is still discussed. For treatment, fluoroquinolones are considered the drugs of choice because of their favorable pharmacokinetic properties and their broad antimicrobial spectrum, with the best evidence supporting ciprofloxacin and levofloxacin. The optimal duration of treatment and follow-up is at least 28 days and 6 months, respectively. Relapse and reinfection due to antimicrobial resistant pathogens are major problems in chronic bacterial prostatitis, and the increasing resistance of E. coli against fluoroquinolones in many countries is of great concern. In patients with pathogens resistant to fluoroquinolones, currently no evidence-based recommendation can be given, though antibacterial therapy may be attempted, based on the results of antibiograms. A three month course of treatment with trimethoprim-sulfamethoxazole may be be tentatively administered, though eradication rates with these agents are relatively low, and strong and modern evidence-based foundations for this recommendation are missing. Quality randomized trials are urgently needed to validate the usage of a number of non-fluoroquinolone antibacterial agents whose efficacy in chronic bacterial prostatitis has been reported in the frame of noncomparative single-cohort studies or case series.