Treatment of chronic bacterial prostatitis

Bacterial infection of the prostate can be demonstrated by the Meares & Stamey 4-glass or the pre and post prostate massage (PPM) 2-glass test in only about 10% of men with symptoms of chronic prostatitis/chronic pelvic pain syndrome. Chronic bacterial prostatitis is mainly caused by Gram-negative uropathogens. The role of Gram-positives, such as staphylococci and enterococci, and atypicals, such as chlamydia, ureaplasmas, mycoplasmas, are still debateable. For treatment, fluoroquinolones are considered the drugs of choice because of their favourable pharmacokinetic properties and their antimicrobial spectrum, with the best evidence supporting ciprofloxacin and levofloxacin. The optimal treatment duration is 28 days. Relapse and reinfection due to antimicrobial resistant pathogens are major problems in chronic bacterial prostatitis. The increasing resistance of E. coli against fluoroquinolones in many countries is of great concern in that respect. In patients with pathogens resistant to fluoroquinolones, but susceptible to trimethoprim-sulfamethoxazole, a three month course of treatment with trimethoprim-sulfamethoxazole can be administered. In patients with pathogens resistant to fluoroquinolones and trimethoprim-sulfamethoxazole, currently no recommendation can be given. Clinical trials with other antibiotics are urgently needed in this patient population.