Guidance
Summary of the evidence
Summary of the evidence
Self-care
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No systematic reviews, randomised controlled trials (RCTs) or observational studies of the efficacy of non-antimicrobial treatments for acute prostatitis were identified.
Committee discussion on self-care
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Antibiotics
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Acute prostatitis is a bacterial infection needing prompt treatment with antibiotics.
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Gram-negative bacteria are the most common causative pathogens in acute prostatitis, most commonly Escherichia coli, Proteus species, Klebsiella species and Pseudomonas species.
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Complications of acute prostatitis include acute urinary retention secondary to prostatic oedema, chronic prostatitis, prostatic abscess, bacteraemia, epididymitis and pyelonephritis.
Efficacy of antibiotics
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No systematic reviews, RCTs or observational studies of the efficacy of antibiotics for treating acute prostatitis were identified.
Safety of antibiotics
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Fluoroquinolones can interact with NSAIDs, potentially increasing the risk of seizures (BNF, August 2018). Tendon damage (including rupture) has been reported rarely in people receiving fluoroquinolones (BNF, August 2018), and the European Medicines Agency's Pharmacovigilance Risk Assessment Committee (press release October 2018) has recommended restricting the use of these antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons and bones and the nervous system. Fluoroquinolones remain appropriate in acute prostatitis, which is a severe infection.
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Antibiotic-associated diarrhoea occurs in 2% to 25% of people taking antibiotics, depending on the antibiotic used (NICE clinical knowledge summary on diarrhoea – antibiotic associated).
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About 10% of the general population claim to have a penicillin allergy; this has often been because of a skin rash that occurred during a course of penicillin in childhood. Fewer than 10% of people who think they are allergic to penicillin are truly allergic. See the NICE guideline on drug allergy for more information.
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People with a history of immediate hypersensitivity to penicillins may also react to cephalosporins and other beta‑lactam antibiotics (BNF, August 2018).
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Aminoglycoside doses are based on weight and renal function and whenever possible treatment should not exceed 7 days (BNF, August 2018).
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There are restrictions on the use of co-trimoxazole in the UK. It should only be used in urinary tract infections where there is bacteriological evidence of sensitivity and good reasons to prefer this antibiotic (BNF, August 2018).
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See the summaries of product characteristics and BNF for information on contraindications, cautions and adverse effects of individual medicines.
Committee discussion on antibiotics
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Choice of antibiotic
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Many antibiotics penetrate the prostate gland poorly, but fluoroquinolones reach therapeutic levels in the prostate. 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 (Lipsky et al. 2010). In acute prostatitis, where there is intense inflammation of the prostate gland, antibiotic penetration can be better than in chronic prostatitis (National guidelines for the management of prostatitis, BASHH, 2001).
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Several guidelines make recommendations on antibiotic choice based on expert consensus and overviews of the literature on pharmacokinetics and antimicrobial resistance patterns. These include:
Committee discussion on choice of antibiotic
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Antibiotic course length
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Several guidelines make recommendations on antibiotic course length based on expert consensus and overviews of the literature on pharmacokinetics and antimicrobial resistance patterns. These include:
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In line with Department of Health and Social Care guidance (Start smart – then focus), the NICE guideline on antimicrobial stewardship recommends considering a review of intravenous antibiotic prescriptions at 48 to 72 hours, documenting response to treatment and any available culture and susceptibility results to determine if the antibiotic should be continued or switched to a narrower spectrum or an oral antibiotic.
Committee discussion on antibiotic course length
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Antibiotic prophylaxis for preventing infective complications, including acute prostatitis, after biopsy
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One double blind RCT from Iran (Dadashpour et al. 2016) and 4 observational studies from Taiwan, Turkey or Korea (Lee et al. 2015, Chiang et al. 2007, Ryu et al. 2016 and Bulut et al. 2015) compared the effectiveness of various short-term antibiotic regimens in preventing complications, including acute prostatitis, after prostate biopsy. All the observational studies were retrospective analyses of medical records, often with non-concurrent controls. The prophylactic antibiotics varied, but most studies used a fluoroquinolone. The definition of post-biopsy complications, including acute prostatitis, varied between clinical symptoms (fever more than 38°C or more than 39°C, chills, dysuria, frequent urination and pelvic pain), abnormal digital rectal examination or urinalysis.
Committee discussion on preventing acute prostatitis and other complications after prostate biopsy
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