In seriously ill patients with possible sepsis, broad-spectrum parenteral antibiotics
with activity against P. aeruginosa are usually preferred as initial therapy (Table 71-
4). Suitable antibiotic choices include antipseudomonal cephalosporins (e.g.,
(e.g., ciprofloxacin, levofloxacin), and aztreonam. These antibiotics are at least as
effective as the aminoglycosides and lack the ototoxic and nephrotoxic potential.
However, these fluoroquinolone and β-lactam agents are more costly and associated
with the emergence of resistant organisms and superinfection.
In general, antipseudomonal β-lactam antibiotics remain the drugs of choice for
103 Although combination therapy may be useful initially
in neutropenic patients with urologic sepsis, it should be narrowed to single-agent
therapy once culture results are available.
103 The recommended duration of antibiotic
therapy in seriously ill patients is 10 to 14 days.
J.W. has developed asymptomatic bacteriuria. Should this be treated?
A systemic antibiotic selected specifically for the infecting organism will
temporarily result in sterile urine. Reinfection, often by a resistant organism, occurs
in 30% to 50% of these cases if closed drainage catheterization is continued during
23 For this reason, it generally is recommended that systemic antimicrobial
therapy be initiated after or just before catheter removal.
catheterization is necessary in many patients and because bacteriuria is an inevitable
consequence, it is often recommended that asymptomatic patients (such as J.W.) be
left untreated to avoid the complications of recolonization and potential infection
104 Therapy must be started, however, if fever, flank
pain, or other symptoms indicative of an actual UTI develop.
CASE 71-11, QUESTION 2: Is systemic antimicrobial prophylaxis useful for J.W.?
The benefits of systemic antibiotics in preventing catheter-induced UTI are not
clear. Studies using closed drainage systems with diligent catheter care indicate that
systemic antibiotics decrease the daily and overall incidence of infection in patients
with sterile urines before catheterization.
36 The preventive effect of antimicrobials
is greatest for short-term catheterizations or during the first 4 to 7 days of long-term
36 Thereafter, the rate of infection increases. Although the overall
infection rate remains lower than in untreated patients, the emergence of resistant
organisms is significant. Therefore, in deciding to use systemic antimicrobials, it is
important to consider the patient’s underlying diseases, risk factors, probable
duration of catheterization, and potential complications of drug toxicity or resistant
organisms that can result from the chronic use of antimicrobials. Because long-term
catheterization is anticipated for J.W., antimicrobial prophylaxis for J.W. is not
CASE 71-11, QUESTION 3: J.W. eventually recovers urinary continence and the catheter is able to be
Because asymptomatic bacteriuria in patients with urinary catheters is very
common (approximately 25% with short-term catheterization and virtually 100%
long-term) but is associated with few complications, antibiotic therapy for
asymptomatic bacteriuria is not recommended as long as the catheter remains in
23 However, antibiotic treatment may be considered in asymptomatic women
with catheter-acquired bacteriuria that persists >48 hours after catheter removal.
Such patients may be treated with either a single large dose or a 3-day regimen of
TMP–SMX, even if the patient is asymptomatic.
probably should be treated with a 10-day course; however, the optimal duration in
this age group is unknown. Whether these same treatment regimens are advisable in
male patients requires further study.
Incidence, Prevalence, and Epidemiology
Prostatitis is an acute or chronic inflammatory condition affecting the prostate,
approximately 5% of cases being caused by proven bacterial infections.
noninfectious types of prostatitis include chronic calculus prostatitis, nonbacterial
prostatitis, and prostatodynia.
12 Chronic bacterial prostatitis, defined as prostatitis
in which symptoms persist for at least 3 months, is one of the most common causes of
recurrent UTI in men. The lifetime probability of a man being diagnosed with
prostatitis is greater than 25%; recurrence rates reportedly range from 20% to
12 Approximately 5% of men with acute prostatitis will experience chronic
Etiology, Pathogenesis, and Predisposing Factors
Acute bacterial prostatitis in most patients probably begins as an ascending infection
of the urethra. A simple UTI then eventually involves reflux of infected urine into the
ejaculatory and prostatic ducts through the prostate gland, where bacteria are difficult
12 Acute prostatitis may also result from urethral stricture or after
instrumentation of the urinary tract or prostate biopsy, especially in the presence of
bacteriuria at the time of the procedure.
12 Bacterial prostatitis is predominantly
caused by aerobic gram-negative bacilli, with E. coli causing 50% to 90% of cases.
Other Enterobacteriaceae such as Proteus and Klebsiella account for an additional
10% to 30% of cases, followed by Enterococcus (5% to 10%) and Pseudomonas
(<5%); less common causes include staphylococci, streptococci, and atypical
organisms such as C. trachomatis, T. vaginalis, and Ureaplasma urealyticum.
Chronic prostatitis is commonly associated with spinal cord injuries, infectious
stones, anatomic or physiologic abnormalities of the urinary tract such as obstruction
or voiding dysfunction, and immune dysfunction. However, recurrent infections are
also commonly caused by relapses of acute prostatitis caused by persistence of
12 Normally, men secrete a prostatic antibacterial factor;
however, this substance is often absent or significantly reduced in men with chronic
prostatitis. The most common pathogens isolated from chronic bacterial prostatitis
a r e E. coli (>80% of cases) and other gram-negative bacilli, although atypical
bacteria have also been more commonly reported in chronic prostatitis compared to
Clinical Presentation and Diagnosis
Acute bacterial prostatitis is characterized by the sudden onset of chills and fever;
perineal and low back pain; urinary urgency and frequency; nocturia, dysuria, and
generalized malaise; and prostration. Patients may also complain of myalgias,
arthralgias, and symptoms of bladder outlet obstruction. Rectal examination usually
discloses an exquisitely tender, swollen prostate that is firm and warm to the touch.
The pathogens generally can be identified by culture of the voided urine. In patients
with acute bacterial prostatitis, prostatic massage (see following discussion) should
be avoided because of patient discomfort and the risk of bacteremia.
diagnosis of acute prostatitis is therefore usually based on clinical presentation and
The clinical manifestations of chronic bacterial prostatitis are highly variable and
many patients are asymptomatic. The disease usually is suspected when a male
patient treated for UTI or acute prostatitis relapses. The diagnosis of chronic
prostatitis is confirmed by examination of expressed prostatic secretions.
ensure accurate localization (i.e., to distinguish prostatic from urethral bacteria),
segmented urine samples are taken. The first 10 mL of voided urine represents the
urethral sample, the midstream urine collected represents the bladder sample, and the
first 10 mL voided immediately after prostatic massage represents the prostate
sample. When the bladder sample is sterile or nearly so, bacterial prostatitis is
diagnosed if the bacterial count in the prostate sample is at least one logarithm
greater than that in the urethral sample.
Treatment of bacterial prostatitis is challenged by poor penetration of many
antibiotics across the non-fenestrated prostatic capillaries and through prostatic
epithelium into infected tissues and fluids. Fluoroquinolones are often considered the
preferred antibiotics for treatment of acute or chronic prostatitis because of good
penetration into the prostate (10%–50% of serum concentrations) and good activity
against most causative pathogens, although fluoroquinolone resistance has become a
12 Trimethoprim alone or TMP–SMX are also commonly used
agents. β-Lactams, tetracyclines, macrolides, and clindamycin have also been
successfully used in the treatment of both acute and chronic infections, but their
penetration into the prostatic tissues and fluids may be somewhat less than the
fluoroquinolones or TMP–SMX. Also, the antimicrobial activity of these drugs is not
necessarily ideal for covering the most common causative pathogens.
duration of antibiotic therapy in acute prostatitis is usually 2 to 4 weeks, depending
on the severity of the infection and rate of response to treatment.
prostatitis is usually treated for 4 to 6 weeks, although longer courses may be
required in the presence of prostate stones or other types of genitourinary pathology,
and long-term suppressive therapy is sometimes used for patients with a history of
rapid and/or multiple recurrences.
12 Monitoring parameters consist primarily of
clinical signs and symptoms, and the end point of treatment is complete resolution of
12 Supportive treatment consists primarily of drugs for
symptomatic relief such as acetaminophen or nonsteroidal anti-inflammatory agents;
warm compresses to the perineal area are also sometimes recommended, although
there are few data to support this practice.
treatment for D.G.’s repeated acute episodes of bacterial prostatitis?
Most antibacterial drugs appropriate for UTI, including sulfonamides, can be used
to treat acute bacterial prostatitis because the diffuse, intense inflammation of the
prostate gland allows many drugs to readily penetrate into the prostatic fluid and
tissues. Antimicrobial therapy should be continued for at least 2 to 4 weeks to
prevent the development of chronic prostatitis.
CASE 71-12, QUESTION 2: Taking into account the pathophysiology of prostatitis, what would be a
reasonable choice of therapy for D.G. should he have future recurrences of prostatitis?
In addition to antibiotics, other supportive measures may provide symptomatic
relief to patients with acute bacterial prostatitis. These measures include liberal
hydration, nonsteroidal anti-inflammatory drugs for pain relief, sitz baths, and stool
In retrospect, sulfonamides were appropriate for D.G. because they effectively
treated his infections. Other options, particularly the fluoroquinolones, would also
have been appropriate in the treatment of D.G.’s episodes of acute prostatitis.
Most antibiotics that are acidic do not readily cross the prostatic epithelium into
the alkaline prostatic fluid except in the presence of acute inflammation.
Theoretically, the high alkalinity of prostatic fluids should impair the diffusion of
trimethoprim and enhance the diffusion of tetracyclines, certain sulfonamides, and
macrolide antibiotics, such as erythromycin. Nevertheless, TMP–SMX historically
has the best documented cure rates in the treatment of acute and chronic bacterial
prostatitis. Long-term therapy of chronic bacterial prostatitis with TMP–SMX for 4
to 16 weeks is associated with a cure rate of 32% to 71%, which significantly
exceeds the cure rate associated with short-term therapy of 2 or fewer weeks.
The fluoroquinolones are alternatives to TMP–SMX and are now considered by
many to be the agents of choice for the treatment of prostatitis.
studies have documented bacteriologic cure in 80% to 90% of patients treated with
norfloxacin, ciprofloxacin, or levofloxacin for 4 to 12 weeks, rates comparable to or
substantially higher than those achieved with TMP–SMX.
have an important role in the treatment of prostatitis owing to their bactericidal
activity against common pathogens and excellent penetration into prostatic tissues
and fluid. The fluoroquinolones are often used as initial empiric therapy of prostatitis
and are also excellent alternatives to other agents in patients who are unresponsive or
intolerant to conventional therapy, or in those infected with resistant organisms.
Fluoroquinolones also have been used for chronic suppressive therapy (one-half
normal doses) in patients who relapse after conventional treatment.
D.G. should be treated with TMP–SMX for a minimum of 6 weeks; some
authorities recommend a 2- to 3-month total course of therapy. If an adequate trial of
TMP–SMX is unsuccessful, fluoroquinolone therapy can be used. Alternatively, a
fluoroquinolone could be used as initial therapy for this or future episodes.
If D.G. continues to experience recurrent infections after a trial of fluoroquinolone
therapy, chronic low-dose treatment with TMP–SMX, fluoroquinolones, or
nitrofurantoin can alleviate the symptoms of episodic bladder infection associated
with chronic bacterial prostatitis. Infections eventually recur with greater frequency
in most of these patients. Chronic, low-dose antibacterial therapy sterilizes the
bladder, alleviates symptoms, confines bacteria to the prostate, and prevents
infection of and damage to the rest of the urinary tract. Chronic bacterial prostatitis is
one of the few indications for continuous antibiotic therapy.
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