Summary of the evidence

Self-care

  • 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

  • Based on experience, the committee agreed that it was reasonable to advise adults with acute prostatitis about paracetamol (with or without a low‑dose weak opioid, such as codeine) for self-care management of pain. These medicines have a well-established efficacy and safety profile for managing pain.

  • If preferred and suitable, ibuprofen could be considered. However, the safety profile of non-steroidal anti-inflammatory drugs (NSAIDs) and drug interactions (potential increased risk of seizures with fluoroquinolones) should be taken into account when selecting pain relief.

  • Based on experience that dehydration is often cited as a cause of urinary tract infections, the committee agreed that people should be advised about drinking enough fluids to avoid dehydration.

Antibiotics

  • Acute prostatitis is a bacterial infection needing prompt treatment with antibiotics.

  • Gram-negative bacteria are the most common causative pathogens in acute prostatitis, most commonly Escherichia coli, Proteus species, Klebsiella species and Pseudomonas species.

  • Complications of acute prostatitis include acute urinary retention secondary to prostatic oedema, chronic prostatitis, prostatic abscess, bacteraemia, epididymitis and pyelonephritis.

Efficacy of antibiotics

  • No systematic reviews, RCTs or observational studies of the efficacy of antibiotics for treating acute prostatitis were identified.

Safety of antibiotics

  • 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.

  • 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).

  • 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.

  • People with a history of immediate hypersensitivity to penicillins may also react to cephalosporins and other beta‑lactam antibiotics (BNF, August 2018).

  • Aminoglycoside doses are based on weight and renal function and whenever possible treatment should not exceed 7 days (BNF, August 2018).

  • 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).

  • See the summaries of product characteristics and BNF for information on contraindications, cautions and adverse effects of individual medicines.

Committee discussion on antibiotics

  • The committee agreed that acute prostatitis is a bacterial infection needing prompt treatment with antibiotics, but no evidence was identified to support this.

  • The committee was aware of several guidelines, which reflect current practice, that make recommendations based on expert consensus and overviews of the literature on pharmacokinetics and antimicrobial resistance patterns.

  • Based on experience, the committee agreed that adults with acute prostatitis should be offered an antibiotic. Urine should be sent for culture to confirm susceptibility of the bacteria and inform treatment choice.

  • The committee agreed that if the results of urine culture suggest the bacteria are resistant to the antibiotic given, adults with acute prostatitis should be contacted and the antibiotic should be changed. In line with good antimicrobial stewardship, narrow-spectrum antibiotics should be used wherever possible, and antibiotics switched from intravenous to oral where applicable.

  • The committee agreed that if symptoms do not start to improve within 48 hours of taking an antibiotic, people should be referred to hospital because of concerns around complications, such as acute urinary retention or prostatic abscess, and treatment failure because of resistant bacteria.

Choice of antibiotic

Committee discussion on choice of antibiotic

  • No evidence was identified to guide the choice of antibiotics for treating acute prostatitis. The committee was aware of several guidelines, which reflect current practice, that make recommendations based on expert consensus and overviews of the literature on pharmacokinetics and antimicrobial resistance patterns.

  • Based on experience, the committee agreed that treating acute prostatitis requires high doses of fluoroquinolones, second- or third-generation cephalosporins or broad-spectrum penicillins (possibly combined with an aminoglycoside), with intravenous or oral use based on the severity of symptoms and the ability to take oral medicines. These antibiotics reach therapeutic levels in the prostate, and are in line with current guidelines and practice.

  • Nationally for England, resistance of E. coli (the main causative organism of acute prostatitis) in laboratory processed urine specimens to the following antibiotics is:

    • ciprofloxacin: 10.6% (varies by area from 7.8% to 13.7%)

    • trimethoprim: 30.3% (varies by area from 27.1% to 33.4%)
      (Public Health England. Antimicrobial resistance quarterly surveillance: March 2018).

  • The committee also discussed that prescribers should be aware of their local antimicrobial prescribing data, because resistance rates do vary by area.

  • Based on experience and resistance data, the committee agreed that the choice of first- and second-line oral antibiotics for managing acute prostatitis are:

    • First-choice: ciprofloxacin or ofloxacin (fluoroquinolones), or trimethoprim (for adults unable to take a fluoroquinolone). Fluoroquinolones are more effective against a wider range of urinary pathogens than trimethoprim. But for adults unable to take a fluoroquinolone, trimethoprim is recommended. Trimethoprim generally has a lower risk of resistance in men, and can reach therapeutic prostate levels.

    • Second-choice: levofloxacin (a fluoroquinolone) or co-trimoxazole

  • The committee agreed that second-choice oral antibiotics should be reserved for use after discussion with a specialist. This is to preserve the use of the broader spectrum fluoroquinolone, levofloxacin, for people with a more severe infection, and because of restrictions on the use of co‑trimoxazole in the UK.

  • The committee was aware of the European Medicines Agency's Pharmacovigilance Risk Assessment Committee recommendation to restrict the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons and bones and the nervous system. However, they discussed that fluoroquinolone antibiotics are the mainstay of treatment in acute prostatitis, which is a severe infection. The committee was keen to point out, however, that fluoroquinolone safety concerns should be taken into account on an individual patient basis.

  • The committee agreed that the choice of intravenous antibiotics for managing acute prostatitis in people who are severely unwell or unable to take oral antibiotics (with combined use if sepsis is a concern) are:

    • ciprofloxacin or levofloxacin (fluoroquinolones)

    • cefuroxime or ceftriaxone (second- or third-generation cephalosporins)

    • gentamicin or amikacin (aminoglycosides).

  • This choice allows intravenous antibiotics to be selected based on the severity of illness and likely pathogens, antibiotic susceptibilities from culture results when available, and local resistance data.

  • The committee noted that use of broad-spectrum antibiotics, such as fluoroquinolones or later-generation cephalosporins, can create a selective advantage for bacteria resistant to these second-line broad-spectrum agents, allowing such strains to proliferate and spread. And, by disrupting normal flora, broad-spectrum antibiotics can leave people susceptible to harmful bacteria such as Clostridium difficile in community settings. However, these antibiotics are appropriate for the empirical treatment of acute prostatitis, where coverage of more resistant strains of common bacterial pathogens is required.

Antibiotic course length

Committee discussion on antibiotic course length

  • No evidence was identified to guide antibiotic course length for treating acute prostatitis. The committee was aware of several guidelines that make recommendations based on expert consensus and overviews of the literature on pharmacokinetics and antimicrobial resistance patterns.

  • Based on experience, the committee agreed that treating acute prostatitis requires oral antibiotics for between 2 and 4 weeks, with initial intravenous antibiotics if adults are unable to take oral antibiotics or are severely unwell. This is in line with current guidelines and practice.

  • However, in line with good antimicrobial stewardship, the shortest course that is likely to be effective should be prescribed to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects. First-line antibiotics for acute prostatitis are fluoroquinolones, which are broad-spectrum antibiotics. These antibiotics, in particular, should be used for the shortest effective time because they can create a selective advantage for bacteria resistant to these 'last-line' broad-spectrum agents, and can leave people susceptible to Clostridium difficile.

  • Use of intravenous antibiotics should be reviewed by 48 hours (taking into account the person's response to treatment and susceptibility results from urine culture) and switched to oral treatment where possible.

  • The committee agreed that a minimum of a 14-day course of all the recommended antibiotics was required for acute prostatitis. At 14 days, treatment should be reviewed, and either stopped or continued for a further 14 days as needed based on clinical assessment. From experience, the committee discussed that whether to continue treatment or not would be based on the person's history or risk of developing chronic prostatitis, their current symptoms and any recent examination, urine and blood test results. Continued symptoms, such as fever or lower urinary tract symptoms (dysuria, frequency, urgency, or acute urinary retention) require ongoing treatment.

Antibiotic prophylaxis for preventing infective complications, including acute prostatitis, after biopsy

  • 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

  • The committee reviewed the available evidence and agreed that it was limited by its design (mostly observational studies) and its relevance to UK practice (studies were undertaken in Iran, Taiwan, Turkey and Korea where the choice of antibiotics may be very different).

  • The committee agreed that the limitations with the evidence base, and the wide range of antibiotics included at varying dosage regimens, makes interpretation of study findings difficult.

  • The committee agreed that the available evidence on antibiotic prophylaxis was insufficient to make recommendations and local microbiologists should be consulted.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)