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Acute prostatitis

The NICE guidance on antimicrobial prescribing in acute prostatitis starts from the point of a diagnosis having been made, and gives recommendations on choice of antibiotic, self-care and reassessment (NICE 2018, NG110). We have included information on diagnosing prostatitis taken from BASHH – Sexually Transmitted Infections in Primary Care 2013.

This article was updated in January 2024.

The 2018 NICE antimicrobial prescribing guidance on the treatment of acute prostatitis strongly supports the use of quinolones (NICE 2018, NG110).

In January 2024, the MHRA introduced further limitations on the prescribing of fluoroquinolones (MHRA 2024).

Systemic fluoroquinolones must only be prescribed when other antibiotics commonly recommended for that infection are inappropriate (MHRA drug safety update 2024).

NICE is reviewing the impact of this advice on its guidance, and we have included more detail on this dilemma below.

Recognising and diagnosing acute prostatitis

Acute prostatitis: diagnosis
(BASHH – Sexually Transmitted Infections in Primary Care 2013)

Headlines

Acute prostatitis:

Is a rare, potentially serious bacterial infection of the prostate which needs treating with antibiotics.

Is usually caused by bacteria from the urinary tract.

Can last for several weeks.

Causes

Urinary pathogens such as E. coli, Proteus, Klebsiella, Pseudomonas or Enterococci.

Sexually-transmitted infections (less commonly) such as chlamydia or gonorrhoea.

Bladder outflow obstruction.

Direct trauma, including medical procedures, e.g. urethral instrumentation/prostate biopsy.

Diagnosis

Consider in a man presenting with:

A sudden onset of fever.

Urinary symptoms such as dysuria, frequency, urgency or acute urinary retention.

Pain: perineal/suprapubic (or may have penile pain, low back pain, pain on opening bowels or with ejaculation).

Tender, swollen prostate on rectal examination.

So, if you are about to diagnose a UTI but there are more than the usual symptoms, stop and think – could this be prostatitis?
The RCGP/BASHH joint guideline said you may feel a warm prostate, but the whole of the Red Whale team has to confess it has never felt a warm prostate, ever!

Differential diagnosis

Urinary tract infection.

Other prostatitis problems: chronic prostatitis, benign prostatic hypertrophy.

Epididymo-orchitis.

Local cancer (prostate, colorectal, bladder).

Investigations

Midstream urine sample for all: send for culture and sensitivity testing. (Do not wait for results to start antibiotics. Send to the laboratory and start antibiotics empirically, but review antibiotic choice once report back – see below.)
Consider a sexual health screening depending on history and risk factors.

NICE on acute prostatitis

Drug dilemma: quinolones

In October 2018, NICE published antimicrobial prescribing guidance for the treatment of acute prostatitis. The guidance strongly supported the use of quinolones, at a time when the risks of quinolones had recently been highlighted by the European Medicines Agency (NICE 2018, NG110).

NICE made its recommendations on which antibiotics to use based on expert consensus. Many antibiotics penetrate the prostate poorly, but fluoroquinolones reach therapeutic levels in the prostate. Trimethoprim is an alternative, but fluoroquinolones are more effective against a wider range of urinary pathogens than trimethoprim. Prostatitis is classed as a severe infection, and, at that time, NICE felt these factors justified the use of quinolone antibiotics.

In January 2024, the MHRA updated its guidance on the prescribing of fluoroquinolones to state that they must only be used when all other antibiotics commonly recommended for that infection are inappropriate (MHRA 2024).

NICE is assessing the impact of the MHRA warning on the recommendations in this guideline.

An overview of the risks of quinolones can be found in the Quinolones (the -floxacins): the risks article on Red Whale Knowledge.

Acute prostatitis: antimicrobial prescribing (NICE 2018, NG110)
Management: when to refer
Refer to secondary care if: Symptoms or signs of sepsis, acute urinary retention or prostatic abscess. Symptoms are not improving after 48h of antibiotics in primary care.
Management in primary care
General advice: Drink plenty of fluids. Analgesia: Paracetamol (+/- low-dose weak opioid). NICE suggests ibuprofen can be used if no contraindications, but quinolones increase the risk of seizures, and taking NSAIDs at the same time may increase this risk further (EMA, October 2018). Prescribe antibiotics as below. Warn patients that symptoms usually last several weeks.
Antibiotics
If previous urine culture/sensitivities are available, this can help guide antibiotic choice. Antibiotic choices for adults (18y and over): (If considering a quinolone, be aware of the 2024 MHRA advice on these drugs and discuss these with the patient: see Quinolones (the -floxacins): the risks article in the online handbook for more information.)
First-choice oral antibiotic:	Ciprofloxacin 500mg twice a day for 14d OR Ofloxacin 200mg twice a day for 14d.	All courses are for 14d. Review at 14d and decide whether a further 14d of antibiotics are required (see below).
Alternative first-choice oral antibiotic if unable to take fluoroquinolones:	Trimethoprim 200mg twice a day for 14d.
Second-choice oral antibiotic: (after discussion with specialist)	Levofloxacin 500mg once a day for 14d OR Co-trimoxazole 960mg twice a day for 14d.
After starting antibiotics: Look out for the culture result, and change the antibiotic if indicated based on culture. Safety-net well: warn men to seek help if: Symptoms worsen at any time/systemically unwell. They are not improving within 48h of starting antibiotics: NICE says admit (increased risk of complications). Review antibiotic treatment for ALL at 14d: decide whether to stop after 14d or continue for 28d total: NICE outlines that 2–4w of oral antibiotic are required to treat acute prostatitis (based on expert consensus). The shortest effective course should be used. If a patient is managed for acute prostatitis in secondary care, NICE suggests they are reviewed after 14d oral antibiotics; it is likely this follow-up will be in primary care. So, who should have 28d of antibiotics? It is not entirely clear! NICE suggests a longer course is needed based on that person's history, their risk of developing chronic prostatitis, their current symptoms and any recent examination, urine +/- blood test results. NICE says that those who have continued symptoms such as a fever, LUTS or acute urinary retention will require longer treatment. However, an ongoing fever could be classed as a non-response to initial antibiotic, and NICE says to admit if not responding after 48h of antibiotics. Tamsulosin, sometimes used in chronic prostatitis, is not suggested in the NICE guideline on acute prostatitis.

Complications

Acute prostatitis is associated with the following complications (BASHH – Sexually Transmitted Infections in Primary Care 2013).

Acute urinary retention secondary to prostatic oedema.
Bacteraemia.
Epididymitis.
Pyelonephritis.
Prostatic abscess.
Chronic prostatitis (1 in 10 men with acute prostatitis develop chronic prostatitis).

Acute prostatitis

Rare, severe bacterial infection of the prostate which requires antibiotic treatment.

Consider if fever, urinary symptoms, pain (perineal/suprapubic) and a tender prostate on rectal examination.

NICE is assessing the impact of 2024 MHRA advice against the use of fluoroquinolone antibiotics on the recommendations in its guideline. Trimethoprim may be a suitable alternative.

Look out for the culture result, and change the antibiotic if indicated based on culture.

Safety-net well: warn men to seek help if:

Symptoms worsen at any time/systemically unwell.

They do not start to improve within 48h of starting antibiotics: NICE says admit (increased risk of complications).

ALL patients should be reviewed after 14d to decide if to continue antibiotics for a further 14d.

Articles

Quinolones (the -floxacins): the risks

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Acute prostatitis