Recommendations

1.1 Managing acute prostatitis

1.1.1 Be aware that acute prostatitis:

  • is a bacterial infection of the prostate needing treatment with antibiotics

  • is usually caused by bacteria entering the prostate from the urinary tract

  • can occur spontaneously or after medical procedures such as prostate biopsy

  • can last several weeks

  • can cause complications such as acute urinary retention and prostatic abscess.

Treatment

1.1.2 Offer an antibiotic (see the recommendations on choice of antibiotic) to people with acute prostatitis. Take account of:

  • the severity of symptoms

  • the risk of developing complications or having treatment failure, particularly after medical procedures such as prostate biopsy

  • previous urine culture and susceptibility results

  • previous antibiotic use, which may have led to resistant bacteria.

1.1.3 Obtain a midstream urine sample before antibiotics are taken and send for culture and susceptibility testing.

1.1.4 When results of urine cultures are available:

  • review the choice of antibiotic, and

  • change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow spectrum antibiotic wherever possible.

Advice when an antibiotic prescription is given

1.1.5 When an antibiotic is given, give advice about:

  • the usual course of acute prostatitis (several weeks)

  • possible adverse effects of the antibiotic, particularly diarrhoea and nausea

  • seeking medical help if:

    • symptoms worsen at any time, or

    • symptoms do not start to improve within 48 hours of taking the antibiotic, or

    • the person becomes systemically very unwell.

Reassessment

1.1.6 Reassess if symptoms worsen at any time, taking account of:

  • other possible diagnoses

  • any symptoms or signs suggesting a more serious illness or condition, such as acute urinary retention, prostatic abscess or sepsis

  • previous antibiotic use, which may have led to resistant bacteria.

Referral

1.1.7 Refer people with acute prostatitis to hospital if:

  • they have any symptoms or signs suggesting a more serious illness or condition (for example sepsis, acute urinary retention or prostatic abscess), or

  • their symptoms are not improving 48 hours after starting the antibiotic.

See the evidence and committee discussion on antibiotics.

1.2 Self-care

1.2.1 Advise people with acute prostatitis about using paracetamol (with or without a low‑dose weak opioid, such as codeine) for pain, or ibuprofen if this is preferred and suitable.

1.2.2 Advise people with acute prostatitis about drinking enough fluids to avoid dehydration.

See the evidence and committee discussion on self-care.

1.3 Choice of antibiotic

1.3.1 When prescribing an antibiotic for acute prostatitis, take account of local antimicrobial resistance data and follow table 1 for adults aged 18 years and over.

1.3.2 Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

1.3.3 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

1.3.4 Review antibiotic treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed, based on an assessment of the person's history, symptoms, clinical examination, urine and blood tests.

Table 1 Antibiotics for adults aged 18 years and over

Antibiotic 1

Dosage and course length

First-choice oral antibiotics (guided by susceptibilities when available) 2

Ciprofloxacin (consider safety issues3)

500 mg twice a day for 14 days then review4

Ofloxacin (consider safety issues3)

200 mg twice a day for 14 days then review4

Alternative first-choice oral antibiotic if a fluoroquinolone antibiotic is not appropriate (seek specialist advice; guided by susceptibilities when available) 2

Trimethoprim

200 mg twice a day for 14 days then review4

Second-choice oral antibiotics (after discussion with specialist)

Levofloxacin (consider safety issues3)

500 mg once a day for 14 days then review4

Co‑trimoxazole5

960 mg twice day for 14 days then review4

First-choice intravenous antibiotics (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available). Antibiotics may be combined if sepsis a concern 2,6

Ciprofloxacin (consider safety issues3)

400 mg twice or three times a day

Levofloxacin (consider safety issues3)

500 mg once a day

Cefuroxime

1.5 g three or four times a day

Ceftriaxone

2 g once a day

Gentamicin

Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration7

Amikacin

Initially 15 mg/kg once a day (maximum per dose 1.5 g once a day), subsequent doses adjusted according to serum amikacin concentration (maximum 15 g per course)7

Second-choice intravenous antibiotics

Consult local microbiologist

1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.

2 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.

3 See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

4 Review treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed based on clinical assessment.

5 Co-trimoxazole should only be considered when there is bacteriological evidence of sensitivity and good reasons to prefer this combination to a single antibiotic (BNF, August 2018).

6 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total of 14 days then review.

7 Therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018).

See the evidence and committee discussion on choice of antibiotic.

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