Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

signs of sepsis

1st line – intravenous antibiotic therapy

Back
ACUTE
|
signs of sepsis
1st line – 

intravenous antibiotic therapy

Patients with acute prostatitis presenting with fever and severe perineal pain require parenteral antibiotics, guided by susceptibilities when available: a broad-spectrum penicillin (e.g., piperacillin/tazobactam), a third-generation cephalosporin (e.g., cefotaxime, ceftazidime), or a fluoroquinolone (e.g., ciprofloxacin) is recommended.[14][27][44][Evidence C]​​ 

Any of these may be combined with an aminoglycoside if the patient is critically ill.[14] See Sepsis in adults.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system (CNS) effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[46]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Primary options

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

More

OR

cefotaxime: 1-2 g intravenously every 8-12 hours

OR

ceftazidime sodium: 1-2 g intravenously every 8 hours

OR

ciprofloxacin: 400 mg intravenously every 12 hours

Consider – intravenous aminoglycoside

Back
ACUTE
|
signs of sepsis
Consider – 

intravenous aminoglycoside

Treatment recommended for SOME patients in selected patient group

An aminoglycoside (e.g., gentamicin) is required if the patient is critically ill.

Primary options

gentamicin: 5-7mg/kg intravenously every 24 hours

More

Plus – nonsteroidal anti-inflammatory drug (NSAID)

Back
ACUTE
|
signs of sepsis
Plus – 

nonsteroidal anti-inflammatory drug (NSAID)

Treatment recommended for ALL patients in selected patient group

NSAIDs can be given to relieve pain, reduce inflammation, and alleviate smooth muscle (bladder) spasm.

NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

Primary options

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

Plus – switch to oral antibiotic therapy

Back
ACUTE
|
signs of sepsis
Plus – 

switch to oral antibiotic therapy

Treatment recommended for ALL patients in selected patient group

As the patient improves, parenteral treatment can be discontinued and replaced with oral treatment. Oral treatment is generally started after intravenous antibiotic treatment is completed (generally after 24 hours of defervescence).

Choice of antibiotic should be guided by sensitivities. Treatment should generally continue for 2 to 4 weeks.[14][27][44]​

Systemic fluoroquinolone antibiotics, such as ciprofloxacin or levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and CNS effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[46]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Primary options

ciprofloxacin: 500 mg orally twice daily

OR

levofloxacin: 750 mg orally once daily

OR

cephalexin: 500 mg orally twice to four times daily

Plus – relief of obstruction

Back
ACUTE
|
signs of sepsis
|
with obstruction
Plus – 

relief of obstruction

Treatment recommended for ALL patients in selected patient group

Patients with difficulty voiding may require catheterization. Insertion of a suprapubic catheter has been recommended in the past because it was thought that the presence of a catheter in the urethra might obstruct the urethral ducts, increasing the risk of a prostatic abscess. However, most patients require only a brief period of catheterization, and a urethral catheter is acceptable.

Consider – surgical intervention

Back
ACUTE
|
signs of sepsis
|
with prostatic abscess
Consider – 

surgical intervention

Treatment recommended for SOME patients in selected patient group

Rarely, a prostatic abscess may develop. Such patients require intravenous antibiotic therapy and may require surgical intervention.

Aspiration of pus with culture and sensitivity may aid choice of agent. Aspiration may be achieved through transrectal or perineal aspiration, which may be performed under ultrasound guidance. The antibiotic regimen should be decided in consultation with an infectious disease specialist.

Endoscopic intervention using a Collins knife may be used to “uncap” the abscess.

In patients with signs of sepsis, transurethral resection of the prostate and cavity drainage may be necessary.

without signs of sepsis

1st line – oral antibiotic therapy

Back
ACUTE
|
without signs of sepsis
1st line – 

oral antibiotic therapy

Offer an oral antibiotic to patients with less severe acute bacterial prostatitis without signs of sepsis.

The recommended first-line treatment option is a fluoroquinolone (e.g., ciprofloxacin, ofloxacin, levofloxacin).​[27][44] Trimethoprim/sulfamethoxazole (or trimethoprim alone) is a secondary option; however, Escherichia coli - the most common causative pathogen - may be resistant to this drug in some areas.[27][44]​​

Treatment should generally continue for 2 to 4 weeks.[14][27][44]​

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and CNS effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[46]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Primary options

ciprofloxacin: 500 mg orally twice daily

OR

ofloxacin: 200 mg orally twice daily

OR

levofloxacin: 750 mg orally once daily

Secondary options

sulfamethoxazole/trimethoprim: 160 mg orally twice daily

More

OR

trimethoprim: 200 mg orally twice daily

Consider – nonsteroidal anti-inflammatory drug (NSAID)

Back
ACUTE
|
without signs of sepsis
Consider – 

nonsteroidal anti-inflammatory drug (NSAID)

Treatment recommended for SOME patients in selected patient group

NSAIDs can be given to relieve pain, reduce inflammation, and alleviate smooth muscle (bladder) spasm.

NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

Primary options

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

Plus – relief of obstruction

Back
ACUTE
|
without signs of sepsis
|
with obstruction
Plus – 

relief of obstruction

Treatment recommended for ALL patients in selected patient group

Patients with difficulty voiding may require catheterization. Insertion of a suprapubic catheter has in the past been recommended, as it was thought that the presence of a catheter in the urethra might obstruct the urethral ducts, increasing the risk of a prostatic abscess. However, most patients require only a brief period of catheterization, and a urethral catheter is acceptable.

Consider – surgical intervention

Back
ACUTE
|
without signs of sepsis
|
with prostatic abscess
Consider – 

surgical intervention

Treatment recommended for SOME patients in selected patient group

Rarely, a prostatic abscess may develop. Such patients require intravenous antibiotic therapy and may require surgical intervention.

Aspiration of pus with culture and sensitivity may guide choice of agent. Agree the antibiotic regimen in consultation with an infectious disease specialist.

Aspiration may be achieved through transrectal or perineal aspiration, which may be performed under ultrasound guidance.

Endoscopic intervention using a Collins knife may be used to “uncap” the abscess.

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer