Chronic prostatitis: antibiotic treatment

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

Acute prostatitis proceeds as a serious infectious disease with symptoms of intoxication, intense pain in the perineum, impaired urination; accompanied by a fever. Such patients showed parenteral administration of cephalosporins of the third generation (ceftriaxone) at a dose of 1-2 g / day. The first days it is advisable to administer an antibiotic in the form of intravenous drip infusion 1-2 times a day; As the temperature normalizes, you can switch to intramuscular injection. If necessary, you can combine cephalosporins with nitrofuran chemotherapy drugs [furazidine (furamag)], aminoglycosidamn and macrolides in standard dosages. Simultaneously, 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 reparatory treatment (tissue therapy, vitamins, antioxidants, microcirculation improving agents, 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 the sowing of mycobacterium tuberculosis (MBT).

Treatment with antibiotics of chronic prostatitis is absolutely indicated when the growth of pathogenic microflora in the exprimates of the gonads in a titer of at least 103 cfu is detected against the background of an increased number of leukocytes in the secretion of the prostate and / or pyospermia.

It is very important to think carefully about the choice of antibiotics. First, it should be borne in mind that only very few antibacterial drugs accumulate in sufficient concentration in the prostate tissue. Among them some fluoroquinolones (primarily levofloxacin, ciprofloxacin, ofloxacin, sparfloxacin), aminoglycosides (e.g., gentamicin), trimethoprim (but under the conditions of Russia it has limited application due to the high degree of resilience to the urinary tract microflora), macrolides ( azithromycin, clarithromycin), tetracycline. Consider the pros and cons of these groups of drugs.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]

Fluoroquinolone with chronic bacterial prostatitis

Good pharmacokinetics, high concentration in prostate tissue, good bioavailability. Equivalent pharmacokinetics for oral and parenteral administration (ciprofloxacin, ofloxacin, levofloxacin, sparfloxacin). Ciprofloxacin and ofloxacin have a prolonged release form - OD tablets, which allow to release the active substance evenly during the day and thereby maintain the equilibrium concentration of the drug. Optimal for prostatitis should be considered levofloxacin (floracid), ciprofloxacin, sparfloxacin (especially in association with intracellular sexually transmitted infections), to a lesser extent - norfloxacin.

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

Recommended doses:

• levofloxacin (tavanik, floracid, eleflox) at 500 mg / day;
• ciprofloxacin (tsiprobay, tsiprinol) at 500 mg / day;
• ciprofloxacin (digit OA) at 1,000 mg / day;
• ofloxacin (zanocin OD, ofloxin) at 800 mg / day;
• sparfloxacin (sparflon) 200 mg twice a day.

[13], [14], [15], [16], [17], [18], [19], [20], [21]

Trimethoprim

Well penetrates the parenchyma of the prostate. Along with the tablets, there is a form of the drug for intravenous administration. In modern conditions, the advantages of trimethoprim can be attributed to the pluses. However, although the drug is active against the most important pathogens, it does not affect Pseudomonas spp., Some enterococci and some representatives of the genus Enterobacteriaceae, which limits the use of this drug in patients on chronic prostatitis. Trimethoprim is available in combination with sulfamethoxazole (400 or 800 mg of sulfamethoxazole + 80 or 160 mg of trimethoprim, respectively, the tablet of the combined preparation contains 480 or 960 mg of active substance).

Recommended doses:

• co-trimoxazole (Biseptol 480) 2 tablets twice a day.

Tetracyclines

Also produced in two forms of administration, highly active against chlamydia and mycoplasmas, so their effectiveness is higher for chronic prostatitis associated with sexually transmitted diseases. Optimal is doxycycline (junidox soluteba), which has better pharmacokinetic data and tolerability.

Recommended doses:

• doxycycline (junidox soluteab) - 200 mg / day.

Macrolides

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

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

Other drugs

You can recommend a combined preparation of safocid. Its uniqueness lies in the fact that it contains a complete combined one-day course of treatment in a single blister (4 tablets): 1 tab. Fluconazole (150 mg), 1 tablet of azithromycin (1.0 g), and 2 tablets of secretinazole A, 1.0 g. This combination, taken simultaneously, allows 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), and against fungi of the genus Candida (fluconazole).

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

Indications for the admission of the safocid: uncomplicated urinary tract infections, sexually transmitted infections, such as gonorrhea, trichomoniasis, chlamydia and fungal infections, accompanying their specific cystitis, urethritis, vulvovaginitis and cervicitis.

In acute uncomplicated disease, a single reception of the safocid complex is enough, in case of a chronic process, a complete set is required for 5 days.

European guidelines for managing patients with infections of the kidneys, urinary tract and male genital organs, compiled by a team of authors led by Naber KG, insist that with bacterial chronic prostatitis, as well as in chronic prostatitis with signs of inflammation (categories II and III A), antibiotics should be appoint for 2 weeks after the establishment of the primary diagnosis. After this, the patient's condition is reevaluated, and antibiotic therapy is continued only if the positive result of the culture material taken before the treatment is positive or if the patient demonstrates a marked improvement against the background of antibiotic treatment. The recommended total duration of treatment is 4-6 weeks. Oral therapy is preferred, but the doses of antibiotics should be high.

The efficacy of antibiotics in the so-called inflammatory syndrome of chronic pelvic pain (what we consider to be latent chronic prostatitis) by the authors of the manual with reference to studies by Krieger JN et al. Is also explained by the probable presence of bacterial microflora, not detected by conventional diagnostic methods.

Here are several options for basic treatment of patients with acute prostatitis HIP and latent HIP.

Scheme of treatment for acute prostatitis

The following drugs are recommended:

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

The scheme of treatment for chronic infectious and latent infectious prostatitis

It is important - at the primary reception, an examination algorithm should be maintained. Initially, a 3-glass urine sample with its bacteriological study, then - a digital rectal examination, obtaining a prostate secret for its microscopy and sowing. The sowing is intended to reveal the nonspecific microflora and mycobacterium tuberculosis; on the evidence - sexually transmitted infections. If a secretion of less than 25 white blood cells is found in the field of vision, tamsulosin (omniks) should be tested for 5-7 days with repeated prostate massage and repeated examination of its secretion. If the number of leukocytes does not increase, and the crops are negative, the disease should be attributed to non-infectious prostatitis (chronic pelvic pain syndrome) and to conduct appropriate pathogenetic and symptomatic therapy. If more than 25 white blood cells are visualized in the initial analysis or their number increases after the test therapy, the disease should be considered as infectious or latent infection. In this case, the basis of treatment is antibiotic therapy - empirical at the beginning, and corrected after receiving the results of bacteriological research.