Acute Bacterial Prostatitis Treatment

A 70 year old man with a history of BPH, HTN and dyslipidemia presents with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. He denies GI upset and is taking fluids without difficulty. He denies sexual activity with others for the past three years. He is alert, oriented and appears slightly uncomfortable while seated. Abdominal and scrotal exam are WNL, there is no penile discharge and digital rectal exam reveals a tender, enlarged prostate. UA reveals positive leukocyte esterase and > 10 WBCs per HPF. With a working diagnosis of acute bacterial prostatitis, which of the following is the most appropriate antimicrobial option in this clinical scenario?  

A. Ciprofloxacin PO x 10 days 

B. IM Ceftriaxone as a one-time dose with doxycycline PO BID X 10 days 

C. IV piperacillin with tazobactam for 5 days 

D. Nitrofurantoin PO BID x 5 days.  

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 70-year-old man with a history of BPH, hypertension, and dyslipidemia presents with a 3-day history of perineal pain, intermittent fever, gas, dysuria, and difficulty initiating urine stream. He denies GI upset and is taking fluids without difficulty. He denies sexual activity with others for the past 3 years. He is alert, oriented, and appears slightly uncomfortable while seated. 

Abdominal and scrotal exams are within normal and there is no penile discharge, and digital rectal exam reveals a tender, enlarged prostate. UA. reveals positive leukocyte estarase and greater than 10 WBCs for a high-powered field. With a working diagnosis of acute bacterial prostatitis. Which of the following is the most appropriate antimicrobial option in this clinical scenario? 

A: Ciprofloxacin PO x10 days. 

B: IM ceftriaxone as a one-time dose with doxycycline PO BID x10 days.  

C: IV piperacillin with tazobactam for 5 days.  

D: Nitrofurantoin PO BID for 5 days. 

The correct answer is a ciprofloxacin PO x10 days. First, where should we start? Let's determine what kind of a question this is. Given we're being asked to choose a therapy, obviously this is a planned intervention question. And if you recall, AANP just calls this plan and ANCC breaks it down to two domains: plan and intervention. Little bit of background information. Acute bacterial prostatitis is a self-defining disease where the prostate is inflamed due to bacterial infection. This condition is considered a complicated UTI, as a structure adjacent to the urinary tract is involved. 

So urinary tract think, the bladder, and the adjacent structure being the prostate. This point should be kept in mind when treating acute bacterial prostatitis, as the prostate is an organ that is not easily penetrated by many antimicrobials. Sepsis and prostate abscess are potential complications. As in with all infectious disease, choosing the right antimicrobial is key to safe practice. 

And the other part to keep in mind is the natural history of acute bacterial prostatitis, or how it would progress without treatment. It's actually not all that well-known. But it appears as if very few people will get over acute bacterial prostatitis, recover from it without getting antimicrobial therapy. Using principles of empiric antimicrobial therapy, knowledge of what bugs cause this condition is key to choosing the right drug. 

The contributing uropathogens differ by a number of patient factors. In adults, usually in males aged 35 years and under and others at risk for STI, gonorrhea or chlamydia will be common contributors, and older men, particularly with BPH or men at lower risk for STI infection with gram-negative organisms such as E.coli or Pseudomonas, are usually the contributors. And additional men to consider above and beyond antimicrobial, particularly when there was a report of urinary hesitancy, is an alpha-1 blocker such as tamsulosin due to the inflammation associated with this condition, the prostatic outlet is often narrow and the alpha-1 blocker can help with this and also reduce the risk of urinary retention and need for subsequent catheterization.  

With this information in mind, let's take a look at the question again. A 70-year-old man with a history of BPH, hypertension, and dyslipidemia presents with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. 

He denies GI upset and is taking fluids without difficulty. He denies sexual activity with others for the past 3 years. He is alert, oriented, and appears slightly uncomfortable when seated. Abdominal and scrotal exams are within normal limits and there's no penile discharge. Digital rectal exam reveals a tender, enlarged prostate. Urinalysis reveals positive leukocyte esterase in greater than 10 WBCs for a high-powered field. With a working diagnosis of acute bacterial prostatitis, which of the following is the most appropriate option in this clinical scenario? 

I'm going to go off script for just a moment now and let you know the following. If you reread this clinical presentation, he is out of the textbook for a case of an older man. Lower risk for STIs, who has BPH, and is presenting with acute bacterial prostatitis. In other words, he is like the poster child for bacterial BPH. 

So, if you're struggling with your differential on that, read over that case scenario again, and you're going to have a really good idea of what the most common presentation of this condition is. All right. So now let's look at the treatment options. A: Ciprofloxacin PO for 10 days. This is the correct answer. The fluoroquinolones, the antimicrobial class with the -floxacin suffix, are usually used. 

First-line in outpatient treatment of acute bacterial prostatitis. In a patient like this one more time: older adult, lower STI risk when given in a dose that is sufficient. So, in other words, it's usually a gram of ciprofloxacin per day. Usually dose 500mg per day. This drug class provides excellent prostate penetration. The length of therapy is correct as well because I know we get so accustomed in women of reproductive age with uncomplicated lower UTIs of treating for like 3 to 5 days, and not 10 days. 

But because this is a complicated UTI, it needs to be treated for the 10 days. An alternative to the ciprofloxacin would be levofloxacin, and the dose would be 750mg daily for 10 or as much as 14 days. You know, this is one of those scenarios where you're going to read one source that will say cirpo or levo for 10 days, and then you read another source, it says cipro or levo all for 10 to 14 days and you go, great, which one's going to be on boards? 

The boards will not do that to you. You would never get a question like this that then the next answer is levofloxacin for 14 days. No, no, no, no, no. You'll never get a question like that because that doesn't test your clinical decision making. I'm going to throw in one more comment about this before I move on to the other choices. 

Please note his gut works okay, and because he's denying GI upset, he's taking fluids. Okay, some PO antibiotics work just as well as IV antibiotics, as a general rule, when the gut works. Option B: IM Ceftriaxone as a one-time dose with doxycycline PO for 10 days. This would be an appropriate choice if there was a history of significant STI risk. Not present in this situation. 

I would also perhaps expect to hear a complaint of penile discharge or something along those lines. This answer is incorrect. C: IV piperacillin with tazobactam for 5 days. First of all, I'll say it one more time. There's no need for a parenteral antimicrobial. Recall pharm 101 says never inject what you can give. His gut works. 

Go ahead and use it. In addition, this antibiotic combination is occasionally used when oral therapy fails or with prostatic abscess or sepsis. This is an example of what I call an inpatient answer. In other words, you might have seen this given for a person with sepsis with acute bacterial prostatitis getting IV piperacillin-tazobactam. You might have seen it in the inpatient setting. 

And in other words, this is somebody who either failed outpatient therapy or became so sick they were already septic and therefore needed to be admitted to the hospital. This does not apply to outpatient care with a patient such as this. D: Nitrofurantoin PO BID times 5 days. This is incorrect. Well, 5 days of nitro if you're entering as is first-line therapy for an uncomplicated lower UTI or cystitis. 

This medication does not concentrate in the prostate. And therefore you'd have a failure of therapy. As an addition-as I mentioned, usually with prostatitis it's a 10 to 14 day antimicrobial force. Key takeaway: as with all antimicrobial therapy knowing the causative bugs is critical to choosing the right drug. Additional factors in antimicrobial prescribing include route and length of therapy. 

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