In the acute phase of the infection, there are several therapeutic options, even with B-lactams despite their low prostatic penetration that could be an option in countries with high resistance rates to quinolones. But once the uroculture is positive we have to choose ATB with good prostatic penetration.
Our first option would be ciprofloxacin 500 mg/12h (or 750 mg/12h, what do you think?) Or cotrimoxazole 160/800 mg/12h.
If we decide to treat with a third generation cefalospirin such as cefixim the dose would probably be 400 mg/day (or 400 mg/12h, what do you think?).
In case of an acute prostatitis due to Enterococcus: amoxicillin 500 mg/8h.
Another doubt would be regarding the duration of treatment: 2 vs 4 weeks.
What are your thoughts?
Hi Alejandro,
As a general rule, we get very few prostatitis cases in my part of the world. However as you mentioned either ciprofloxacin 400mg/12h (IV)/ Levofloxacin 500mg/24h (IV) or cotrimoxazole 160/800/12h (some authors say 6 hourly) would be ideal. Continue till there is clinical improvement and switch to oral therapy with the same drugs (cipro-500mg/12h, levoflox-750mg/24h and cotrimox-160/800/12h) for 2 weeks. Bio-availability of the above drugs are good.
Drug of choice for E. faecalis is ampicillin 500mg/6h. For E. faecium the choice would be vancomycin, daptomycin, linezolid, etc.
Hi Michael
Generally, we would start treatment with a third generation cephalosporin due to the high frequency of resistance to quinolones. If we isolate a microorganism susceptible to fluoroquinolones then we would switch to ciprofloxacin or levofloxacin for instance. Taking into account the PK/PD I'm not sure of whether use 500/12h or a higher dose of 750 mg/12h in order to achieve high prostatic concentrations.
Regarding E. faecalis, the problem with amoxicillin is the low prostatic penetration. Given that the strainof E. faecalis is susceptible to quinolones, would you switch to levofloxacin instead of amoxicillin?
Kind regards
Alejandro,
I was under the impression that the scenario there in relation to quinolones was better than India. You are right about increasing the dose to 750mg/12h in sensitive cases. What about aminoglycosides, which have good prostatic penetration, or maybe even nitrofurantoin. The problem with the prostate is trying to get an effective concentration of any antibiotic there. What makes it worse is that the antibiotics which can concentrate to a reasonable degree are usually resistant (cipro, levo, co-trimox).
Regarding E. faecalis, i would prefer not use a quinolone as they are not very effective against Enterococci. We get consistently raised MICs here and so do not use them. Besides the literature also says that quinolones have variable efficacy against Enterococcal infections. Ampicillin may be a better choice as compared to amoxycillin. I am sorry i cannot give you a good reference, but this link to Merck Manuals may be helpful (http://www.merckmanuals.com/vet/pharmacology/systemic_pharmacotherapeutics_of_the_urinary_system/bacterial_urinary_tract_infections.html).
Regards
Cefixim poorly penetrates the prostate. Now it also depends on the MIC. Also doubling the dosage does not result in a double availability of the drug, the fector is less than two. In prostate seems that maximal concentration is about 1mug, which is low.
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