The information below is based on NICE Guideline NG110 Prostatitis (acute): antimicrobial prescribing (October 2018)

Acute prostatitis is a bacterial infection of the prostate which needs treatment with antibiotics. It is caused by bacteria entering the prostate from the urinary tract and can last several weeks.

Consider chronic prostatitis if the symptoms have been present for longer than several weeks.

Self-care advice:

• Consider paracetamol or if preferred and suitable, ibuprofen for pain or fever
• Drink adequate fluids to avoid dehydration
• If defecation is painful — a stool softener such as lactulose or docusate may be helpful

Suspect acute prostatitis in a man who presents with signs and symptoms of:

• A urinary tract infection (UTI):
  • Dysuria, frequency, urgency
• Prostatitis:
  • Perineal, penile, or rectal pain
  • Acute urinary retention, obstructive voiding symptoms (difficulty voiding, hesitancy, straining to urinate, weak stream).
  • Low back pain, pain on ejaculation
  • Tender, swollen, warm prostate (on gentle rectal examination)
• Bacteraemia:
  • Rigors, arthralgia, or myalgia
  • Fever, tachycardia

Consider acute prostatitis as a sexually transmitted infection (STI) in younger adults, and those with a clinical history (i.e. high-risk sexual behaviour or symptoms suggesting a possible STI for example urethral discharge). People with risk factors and a clinical history of an STI should be screened for chlamydia and gonorrhoea, and if an STI is suspected a referral to a Genito-Urinary Medicine (GUM) clinic is the most appropriate action.

Considerations when prescribing antibiotics:

When considering antibiotics (see specifics below), take account of severity of symptoms, risk of complications or having treatment failure (particularly after medical procedures such as prostate biopsy), previous urine culture and susceptibility results, and previous antibiotic use which may have led to resistant bacteria.

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• Alternative 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 lead to resistant organisms
• Consider CRGs if referral required:
  • Prostatitis Suspected - Northern Locality, Eastern Locality
  • Chronic pelvic pain syndrome - Northern Locality, Eastern Locality

Offer immediate antibiotic prescription to men with acute prostatitis taking account of the considerations above.

Send midstream urine for culture and susceptibility and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Refer to hospital if the patient:

• cannot take oral antibiotics, or
• has symptoms which are not improving 48 hours after starting antibiotic, or
• is severely unwell / has any symptoms or signs suggesting a more serious illness or condition (see above)

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 (4 weeks treatment may prevent chronic prostatitis).

Where antibiotics are indicated

Many antibiotics penetrate the prostate poorly, but fluoroquinolones reach therapeutic levels in the prostate and therefore remain an appropriate first line option in acute prostatitis.

Ciprofloxacin

• 500mg twice a day for 14 days (extend for a further 14 days if needed, see above)
• Systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate (see MHRA Drug Safety Updates below)
• Patients should be advised to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint, feet, or abdomen swelling, peripheral neuropathy, rapid onset of shortness of breath, new-onset of heart palpitations, and central nervous system effects: including new or worsening depression or psychosis, and to seek immediate medical attention.

Ofloxacin

• 200mg twice a day for 14 days (extend for a further 14 days if needed, see above)
• Systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate (see MHRA Drug Safety Updates below)
• Patients should be advised to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint, feet, or abdomen swelling, peripheral neuropathy, rapid onset of shortness of breath, new-onset of heart palpitations, and central nervous system effects: including new or worsening depression or psychosis, and to seek immediate medical attention.

Drug Safety Updates for Ciprofloxacin and Ofloxacin (refer to 5.1.12 Quinolones for further details).

• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
• MHRA Drug Safety Update (December 2020): Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk.
• MHRA Drug Safety Update (September 2023): Fluoroquinolone antibiotics: suicidal thoughts and behaviour.
• MHRA Drug Safety Update (January 2024): Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate.

If quinolones not tolerated, contraindicated or used within the previous 6 months

Trimethoprim

• 200mg twice a day for 14 days (extend for a further 14 days if needed, see above)
• See section: 5.1.8 Sulfonamides and trimethoprim

Alternative antibiotic choice

If worsening of symptoms on antibiotic treatment options above, consult local microbiologist.