The role of quinolones in the treatment of chronic bacterial prostatitis

Effectiveness and limits of antimicrobial treatment on seminal leukocyte concentration and related reactive oxygen species production in patients with male accessory gland infection

To evaluate whether bacteriological cure, sperm outcome, spontaneous pregnancy rate and white blood cell (WBC)-related reactive oxygen species (ROS) production were related to the extent of the infection and to an intermittent and repetitive antimicrobial treatment, 122 patients with bacterial [>10(5) colony-forming units (CFU)/ml] male accessory gland infections (MAGI) were studied. According to ultrasound criteria, patients had prostatitis (PR, n = 52), prostatovesiculitis (PV, n = 32) or prostatovesiculoepididymitis (PVE, n = 38). Each group was further subdivided into two subsets: one subset (PR, n = 40; PV, n = 20; PVE, n = 25) was given ofloxacin or doxycycline for 14 consecutive days per month for 3 months; the other subset (PR, n = 12; PV, n = 12; PVE, n = 13) received no treatment. The female partners were also treated. All patients were evaluated before, during (1 and 3 months) and after (3 months) treatment. The bacteriological cure rate was the highest (92.5%) after the third antibiotic course in PR, followed by PV (70.4%), and the lowest in PVE (52.0%). At 3 months after therapy discontinuation, some sperm parameters, seminal WBC concentration and ROS generation (assessed in the 45% Percoll fraction) were ameliorated in PR and PV, whereas no improvement occurred in patients with PVE, except for the percentage of coiled tails. Antibiotic treatment in PR and PV patients led to positive effects on sperm output and spontaneous pregnancy rate (40%) by removing pro-oxidant noxae (microbial and/or WBC-related ROS production). The persistent infertility, dyspermia and sperm-derived ROS overproduction in PVE may relate to a significant percentage of antibiotic-independent re-infection and/or to low antioxidative epididymal properties, which persisted following antimicrobial treatment.

A double-blind, randomized, controlled multicentre study to compare the efficacy of ciprofloxacin with pivampicillin as oral therapy for epididymitis in men over 40 years of age

OBJECTIVE

To compare the efficacy and safety of ciprofloxacin 500 mg orally twice daily with pivampicillin 700 mg orally twice daily for 10 days in men with acute epididymitis and over 40 years of age.

PATIENTS AND METHODS

The study comprised 172 men who entered a prospective, controlled, randomized, double-blind, trial of pivampicillin and ciprofloxacin. The median (range) age of the 158 patients eligible for the efficacy analysis was 58 (41-85) years; 41% had previously had a urinary tract infection and 27% had previously had epididymitis. Only one patient had a urethral catheter and 38% were sexually active. About half of the patients were admitted to hospital.

RESULTS

No bacteria could be cultured from samples in 53% of the patients; Escherichia coli could be cultured from 35% and the remaining isolates were the expected urinary pathogens. None of the patients had Gonococci and only one in each group had Chlamydia. Mycoplasma hominis was detected in three patients only and M. genitalium was detected in three, while Ureaplasma was detected in 24 (15%). The treatment failed in 48 patients; in 15 of 76 (20%) receiving ciprofloxacin and in 33 of 82 (40%) receiving pivampicillin. This corresponds to a reduction in the risk of failure of 20.5% (95% confidence limits 6.6-40.2%, P=0. 006). The principal cause of failure was an unsatisfactory clinical response requiring changed antibiotic treatment in 27 patients; adverse events were responsible for failure in 14. The in vitro resistance of cultured bacteria was low in both groups, at approximately 4%. Adverse events, mainly gastro-intestinal, occurred in 17 of 83 (21%) patients starting on ciprofloxacin and in 33 of 89 (37%) receiving pivampicillin (P=0.04).

CONCLUSION

For epididymitis in men over the age of 40 years ciprofloxacin 500 mg orally twice daily is more effective than pivampicillin 700 mg orally twice daily. Furthermore, ciprofloxacin has a lower incidence of adverse events.

Diffusion of piperacillin, cefotiam, minocycline, amikacin and ofloxacin into the prostate

BACKGROUND

The successful treatment of bacterial prostatitis depends on an effective antimicrobial concentration in prostatic tissue against the infecting organism. In this study we compared the diffusion of 5 types of antimicrobials into the prostate.

METHODS

The concentrations of piperacillin, cefotiam, minocycline, amikacin, and ofloxacin were determined in prostatic fluid, prostatic tissue, and serum 2.5 to 3 hours after a single administration from 55 patients with benign prostatic hypertrophy.

RESULTS

Although amikacin showed the highest mean concentration both in prostatic tissue and prostatic fluid, the prostatic tissue/serum ratio was significantly higher (P < 0.01) for ofloxacin (1.49 +/- 0.80) and minocycline (0.94 +/- 0.39) compared with those for amikacin (0.49 +/- 0.21) and piperacillin (0.21 +/- 0.15). Also, the prostatic fluid/serum ratio was lower than the prostatic tissue/serum ratio for each drug, however, the prostatic fluid/serum ratio of ofloxacin was significantly higher than that of other antimicrobials tested (P < 0.01).

CONCLUSION

These results support earlier studies demonstrating that fluoroquinolones are a useful class of antimicrobials for the treatment of chronic bacterial prostatitis. They also suggest that in view of the pharmacokinetic properties and antimicrobial activities, amikacin and minocycline may be alternate antimicrobial options for selected patients with bacterial infections of the prostate.

Management of complicated urinary tract infection in older patients

Urinary tract infection (UTI) in older persons is a common medical problem that is seen in both the ambulatory and institutional settings. It affects older women and men with a gender prevalence ratio of 2:1, respectively. UTI in older persons can be a complex problem in terms of the approach to diagnosis, treatment, and prevention. In this report the discussion will begin with the unique aspects of UTI in older persons, particularly as they relate to UTI in the younger, general population. The remaining discussion will then focus on three complicated clinical circumstances and conditions of UTI in the geriatric population: non-catheter recurrent UTI, asymptomatic bacteriuria, and catheter-related bacteriuria and UTI.

Penetration of ciprofloxacin into prostatic fluid, ejaculate and seminal fluid in volunteers after an oral dose of 750 mg

To evaluate an effective dose for the treatment of bacterial prostatitis the concentrations of ciprofloxacin were measured in prostatic fluid, ejaculate and the cell-free seminal fluid of 15 healthy volunteers who received an oral dose of 750 mg. ciprofloxacin while in a fasting state. Venous blood samples were taken in all subjects at 1, 2, 3 and 4 hours. In 6 subjects blood samples were also taken after 8 and 12 hours. Urine was collected in all subjects during 0 to 4 hours and in the 6 subjects also during 4 to 8 hours and 8 to 12 hours. Prostatic fluid could be obtained in 10 subjects by prostatic massage 4 hours after drug intake. So as not to contaminate the urethra with ciprofloxacin the subjects were not allowed to void until 4 hours after drug intake. Iopamidol (3.162 gm.), a renal contrast agent, was administered intravenously concomitantly with oral ciprofloxacin intake. After 8 hours iohexol (3.235 gm.) was administered intravenously. These agents were measured in prostatic fluid, ejaculate and seminal fluid to assess the contamination of those fluids by urine. All drug measurements were done by high pressure liquid chromatography. The median plasma concentrations of ciprofloxacin were 2.1 mg./l. at 1 hour (maximum concentration), 0.9 mg./l. at 4 hours and 0.2 mg./l. at 12 hours. The median concentration in prostatic fluid was 0.23 mg./l. with a fluid-to-plasma concentration ratio of 0.23. The median concentration in the ejaculate (seminal fluid) after 4 hours was 7.4 mg./l. (6.6 mg./l.) and after 12 hours it was 2.0 mg./l. (1.9 mg./l.) with corresponding ejaculate (seminal fluid)-to-plasma concentration ratios of 8.4 (7.7) and 8.0 (6.6), respectively. Thus, ciprofloxacin is concentrated several-fold in ejaculate and seminal fluid but not in prostatic fluid. According to the results the concentrations of ciprofloxacin in prostatic fluid exceed the minimal inhibitory concentration-90% for Enterobacteriaceae but not for Pseudomonas, enterococci and staphylococci, whereas the concentrations in ejaculate and seminal fluid are sufficiently elevated to include the total spectrum of sensitive strains causing bacterial prostatis.

Penetration of ofloxacin into prostatic fluid, ejaculate and seminal fluid

The penetration of ofloxacin into prostatic fluid, ejaculate and seminal fluid was measured by a high-pressure liquid chromatography (HPLC) method after intravenous infusion (60 min) of 400 mg in six healthy male volunteers. The median concentration of ofloxacin in prostatic fluid was about one-third and that in ejaculate and seminal fluid about twice that in corresponding plasma. The results of the study indicate good penetration of ofloxacin into prostatic fluid, ejaculate and seminal fluid. Ofloxacin should thus be of value for the treatment of chronic bacterial prostatitis and vesiculitis.