Chronic prostatitis: treatment with antibiotics

Antibiotics are absolutely indicated for acute bacterial prostatitis, are recommended for patients with bacterial chronic prostatitis, including latent, and can be used as test therapy for inflammatory non-infectious prostatitis.

Acute prostatitis occurs as a severe infectious disease with symptoms of intoxication, intense pain in the perineum, urination disorders; accompanied by fever. Such patients are prescribed parenteral administration of third-generation cephalosporins (ceftriaxone) at a dose of 1-2 g/day. During the first days, it is advisable to administer the antibiotic as an intravenous drip infusion 1-2 times a day; as the temperature normalizes, you can switch to intramuscular administration of the drug. If necessary, cephalosporins can be combined with nitrofuran chemotherapeutic agents [furazidin (furamag)], aminoglycosides and macrolides in standard dosages. At the same time, massive detoxification and anti-inflammatory therapy is carried out. The duration of antimicrobial treatment is at least 2 weeks, after which the patient is recommended a course of reparative treatment (tissue therapy, vitamins, antioxidants, agents that improve microcirculation, etc.) lasting 6 weeks. The question of surgical intervention is decided individually. Fluoroquinolones [levofloxacin (floracid), ciprofloxacin, ofloxacin (ofloxin)] can be used as an alternative therapy, but only after performing cultures for Mycobacterium tuberculosis (MBT).

Antibiotic treatment of chronic prostatitis is absolutely indicated when growth of pathogenic microflora is detected in the gonads' samples in a titer of at least 103 CFU against the background of an increased number of leukocytes in the prostate secretion and/or pyospermia.

It is very important to carefully select antibiotics. First, it should be borne in mind that only very few antibacterial drugs accumulate in sufficient concentration in prostate tissue. These include some fluoroquinolones (primarily levofloxacin, ciprofloxacin, ofloxacin, sparfloxacin), aminoglycosides (for example, gentamicin), trimethoprim (but in Russia it has limited use due to the high degree of resistance to it of the urinary tract microflora), macrolides (azithromycin, clarithromycin), tetracycline. Let's consider the pros and cons of the listed groups of drugs.

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Fluoroquinolone for chronic bacterial prostatitis

Good pharmacokinetics, high concentration in prostate tissue, good bioavailability. Equivalent pharmacokinetics when taken orally and parenterally (ciprofloxacin, ofloxacin, levofloxacin, sparfloxacin). Ciprofloxacin and ofloxacin have a prolonged release form - OD tablets, allowing for uniform release of the active substance throughout the day and thereby maintaining an equilibrium concentration of the drug. Levofloxacin (floracid), ciprofloxacin, sparfloxacin (especially in association with intracellular sexually transmitted infections), and to a lesser extent - norfloxacin should be considered optimal for prostatitis.

All fluoroquinolones have high activity against typical and atypical pathogens, including Pseudomonas aeruginosa. Disadvantages include photo- and neurotoxicity. In general, fluoroquinolones can be considered first-line drugs in the treatment of patients with chronic prostatitis, but only after excluding tuberculosis.

Recommended doses:

• levofloxacin (tavanic, floracid, eleflox) 500 mg/day;
• ciprofloxacin (tsiprobay, tsiprinol) 500 mg/day;
• ciprofloxacin (Tsifran OD) 1,000 mg/day;
• ofloxacin (zanocin OD, ofloxin) 800 mg/day;
• sparfloxacin (sparflo) 200 mg twice daily.

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Trimethoprim

It penetrates well into the prostate parenchyma. Along with tablets, there is a form of the drug for intravenous administration. In modern conditions, the low cost of trimethoprim can be considered an advantage. However, although the drug is active against the most significant pathogens, it does not act on Pseudomonas spp., some enterococci and some representatives of the genus Enterobacteriaceae, which limits the use of this drug in patients with chronic prostatitis. Trimethoprim is available in combination with sulfamethoxazole (400 or 800 mg of sulfamethoxazole + 80 or 160 mg of trimethoprim; accordingly, a tablet of the combined drug contains 480 or 960 mg of the active substance).

Recommended doses:

• co-trimaxazole (biseptol 480) 2 tablets twice a day.

Tetracyclines

Also available in two forms of administration, highly active against chlamydia and mycoplasma, so their effectiveness is higher in chronic prostatitis associated with sexually transmitted diseases. Optimal is doxycycline (Unidox Solutab), which has the best pharmacokinetic data and tolerability.

Recommended doses:

• doxycycline (Unidox Solutab) - 200 mg/day.

Macrolides

Macrolides (including azalides) should be used only under certain conditions, since there are only a small number of scientific studies confirming their effectiveness in prostatitis, and this group of antibiotics is inactive against gram-negative bacteria. But you should not completely abandon the use of macrolides, since they are quite active against gram-positive bacteria and chlamydia; they accumulate in the prostate parenchyma in high concentrations and are relatively non-toxic. The optimal drugs in this group are clarithromycin (fromilid) and azithromycin. Recommended doses:

• azithromycin (sumamed, zitrolide) 1000 mg/day for the first 1-3 days of treatment (depending on the severity of the disease), then 500 mg/day;
• clarithromycin (fromilid) 500-750 mg twice a day.

Other drugs

The combination drug Safocid can be recommended. Its uniqueness lies in the fact that it contains a full combined one-day course of treatment in one blister (4 tablets): 1 tablet of fluconazole (150 mg), 1 tablet of azithromycin (1.0 g) and 2 tablets of secnidazole A of 1.0 g. Such a combination, taken simultaneously, allows achieving a bactericidal effect against Trichomonas vaginalis, gram-positive and gram-negative anaerobes, including Gardnerella vaginalis (secnidazole), against Chl trachomatis, Mycoplasma genitalium, gram-positive and gram-negative microflora (azithromycin), as well as against Candida fungi (fluconazole).

Thus, safocid meets all WHO requirements for drugs used to treat sexually transmitted infections, including the treatment of chronic prostatitis: efficiency of at least 95%, low toxicity and good tolerability, the possibility of a single dose, oral administration, slow development of resistance to the therapy.

Indications for taking Safocid: combined uncomplicated sexually transmitted infections of the genitourinary tract, such as gonorrhea, trichomoniasis, chlamydia and fungal infections, accompanying specific cystitis, urethritis, vulvovaginitis and cervicitis.

In case of acute uncomplicated disease, a single dose of the Safocid complex is sufficient; in case of chronic process, it is necessary to take the full set for 5 days.

The European guidelines for the management of patients with kidney, urinary tract and male genital tract infections, compiled by a team of authors led by Naber KG, insist that in bacterial chronic prostatitis, as well as in chronic prostatitis with signs of inflammation (categories II and III A), antibiotics should be prescribed for 2 weeks after the initial diagnosis. The patient's condition is then re-evaluated, and antibiotic therapy is continued only if the pre-treatment culture is positive or if the patient shows marked improvement with antibiotic therapy. The recommended total duration of treatment is 4-6 weeks. Oral therapy is preferred, but antibiotic doses should be high.

The effectiveness of antibiotics in the so-called inflammatory syndrome of chronic pelvic pain (what we consider latent chronic prostatitis) is also explained by the authors of the guideline, citing studies by Krieger JN et al., by the probable presence of bacterial microflora that is not detected by conventional diagnostic methods.

Here are some options for basic treatment of patients with acute prostatitis (CIP) and latent CIP.

Treatment regimen for acute prostatitis

The following medications are recommended:

• ceftriaxone 1.0 g per 200 ml of 0.9% sodium chloride solution intravenously by drip 2 times a day for 5 days, then intramuscularly for 5 days;
• furazidin (furamag) 100 mg three times a day for 10 days;
• paracetamol (perfalgan) 100 ml intravenously by drip at night daily for 5 days;
• meglumine sodium succinate (Reamberin) 200 ml intravenously by drip every other day, 4 infusions in total;
• tamsulosin 0.4 mg daily;
• other symptomatic therapy - individually according to indications.

Treatment regimen for chronic infectious and latent infectious prostatitis

Important - the examination algorithm must be followed at the initial appointment. First, a 3-glass urine sample with its bacteriological examination, then a digital rectal examination, obtaining prostate secretion for its microscopy and sowing. Sowing is designed to identify non-specific microflora and tuberculosis mycobacteria; according to indications - sexually transmitted infections. If less than 25 leukocytes are detected in the prostate secretion in the field of vision, test therapy with tamsulosin (omnic) should be carried out for 5-7 days with repeated prostate massage and repeated examination of its secretion. If the number of leukocytes does not increase, and the cultures are negative, the disease should be attributed to non-infectious prostatitis (chronic pelvic pain syndrome) and appropriate pathogenetic and symptomatic therapy should be carried out. If the initial analysis visualizes more than 25 leukocytes in the field of view or their number increases after test therapy, the disease should be considered infectious or latent infectious. In this case, the basis of treatment is antibacterial therapy - empirical at the beginning, and corrected after receiving the results of bacteriological research.