Acute prostatitis and recurrent lower UTI in men in Secondary Care

Publication: 22/10/2013  
Next review: 18/06/2024  
Clinical Guideline
CURRENT 
ID: 3503 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Acute prostatitis and recurrent lower UTI in men in Secondary Care

Lower UTIs are uncommon in men <65 years without functional or anatomical abnormalities.

Prostatitis should be considered in any man presenting with an UTI.  Recurrent isolation of the same organism in a man with recurrent lower UTI symptoms should prompt a clinical review for prostatitis.

Acute bacterial prostatitis causes a swollen and painful prostate.  Patients may also have symptoms of lower UTI (dysuria and frequency), obstruction of the urethra (causing retention), fever and systemic signs of infection.

Recent instrumentation and manipulation of the urinary tract, including traumatic catheterisation, are at risk of more complicated prostatitis (e.g. abscess, uncommon or multiple pathogens).

Chronic prostatitis (symptoms for more than 3 months) is most commonly non-infective, although chlamydia (and other sexually transmitted infections) can be a cause and should be ruled out.

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DIAGNOSTICS

All patients

Urine sample from MC&S
(NB - dipstick screening is not advised for those over 65 years)

USS to assess any post-void residual urine

Following resolution of prostatitis men should be referred for investigations to exclude structural abnormality

STI (e.g. Chlamydia) suspected

First pass urine sample for chlamydia & Gonorrhoea PCR
Refer to Leeds Sexual Health

Upper UTI symptoms

Renal Ultrasound

Symptoms not settling and tender prostate

Prostate US scan

Patients with signs of severe sepsis or being started on IV antibiotics

Blood culture prior to antibacterials being started

Prostate abscess identified

Aspiration of pus (transperineal, or transrectal if the former is not possible)

Prostatic massage for secretions is NOT advised.

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EMPIRICAL TREATMENT (renal dose adjustment may be required)

  • Do NOT treat asymptomatic bacteriuria or pyuria
  • Repeated sterile pyuria should prompt futher investigation and a referral to Urology.
  • If your patient has had a recent urine culture(s), please use the sensitivity results to provide directed therapy (see table for order of preference).
  • Ensure adequate fluids and offer appropriate (simple) analgesia
  • Notes on empirical options:
  • Doses assume normal renal and hepatic function

Empirical options for prostatitis.

Severity classification

Recommended treatment

Notes

Duration

Mild

Moderate-severe

No sepsis

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly

MHRA1 warning

Avoid if recent treatment failure (recurrence of symptoms) with this agent. 

14 days

2-4 weeks

Clinical assessment and review of antibiotics at 2 weeks to review need for further antibiotics or not.

Sepsis or Severe Sepsis

1st line

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly

Avoid in penicillin allergy

14 days

2-4 weeks

Clinical assessment and review of antibiotics at 2 weeks to review need for further antibiotics or not.

2nd line

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly (IV 400mg 12-hourly if unable to take/absorb PO)

+/- Gentamicin* in severe sepsis

MHRA1 warning

Discuss with Microbiology if recent treatment failure with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin and allergy to penicillin.

Gentamicin* can be added empirically whilst awaiting culture results if the patient does not initially respond to single agent therapy.

*Gentamicin prescribing guidance can be found here.  LTHT uses once daily dosing with 7mg/kg IBW (ideal body weight) and the Yorkshire Hartford Nomogram for monitoring and dosing frequency.  A level should be taken following all treatment doses of gentamicin.

Previous resistant organism (MR-GNB growth), including Pseudomonas aeruginosa

If the patient has a history of isolating MR-GNB (e.g. ESBL, AMP-C, CPE) in any sample, or Pseudomonas aeruginosa from the urinary tract (including swabs of sites of entry to the urinary tract, e.g. nephrostomy or cathether) refer to susceptibility results and discuss with Microbiology as needed.

MR-GNB = Multi-resistant gram negative bacillus; ESBL = extended spectrum beta-lactamase producer; AMP-C = producer of the gene AMP-C; CPE = carbapenemase producing enterobacterales.

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REVIEW BY 72 HOURS

By 72 hours of antibacterial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.

You should document the outcome of the review in the medical notes.

IVOS

If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria consider switching using the oral options listed in the table above. 
A - Afebrile for 24 hours
C - Clinically improving
E - Eating and drinking
D - not Deep seated infection

Stop

  • If no signs of infection and diagnostics support this decision.

Change

If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis (including renal calculi, obstruction, abscess, etc).

Continue

If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch.

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DIRECTED THERAPY

The table below is in order of preference based on culture results of a single pathogen, if there is mixed growth, please contact Microbiology to discuss further.

Doses assume normal renal and hepatic function.

 

Treatment

Notes

Duration of treatment: 2-4 weeks
Chlamydial prostatitis: 4 weeks

1st line

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly
(IV 400mg 12-hourly if unable to take PO)

If Pseudomonas aeruginosa the dose should be increased to PO 750mg 12-hourly (IV 400mg 8-hourly)

MHRA1 warning

2nd line

Trimethoprim PO 200mg 12-hourly

 

3rd line

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole PO 960mg 12-hourly (can be given IV if needed at the same dose)

Monitoring for prolonged courses is required (see BNF)

Chlamydial prostatitis

Doxycycline electronic Medicines Compendium information on Doxycycline PO 100mg 12-hourly

Chlamydial prostatitis only

Contact Microbiology to discuss if the isolated organism is not susceptible to any of these agents or they are contra-indicated.

Many antibiotics have poor penetration into the prostate and so may not be suitable for the treatment of prostatitis.

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NON-ANTIMICROBIAL MANAGEMENT

Referral to urology for follow-up is advised, particularly where the UTIs are recurrent or the patient is immunosuppressed or has diabetes mellitus.

Provenance

Record: 3503
Objective:
Clinical condition:

Acute prostatitis and recurrent UTI in men

Target patient group: Adults >16 years
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

FOOTNOTES
1 See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019).

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