Proposed study design in prostatitis

Antimicrobial treatment of prostatitis

The aim of this review is to emphasize the role of antimicrobial treatment in prostatitis. Especially in chronic bacterial prostatitis, the selection of an appropriate antimicrobial agent with optimal pharmacokinetics for prostatic secretion and tissue is important. The theoretical background of drug penetration into the prostate is outlined, emphasizing the phenomenon of ion-trapping and the role of nonionic diffusion of weak acids, bases and amphoteric drugs across biological membranes with a pH gradient. Determination of drug concentrations in human prostatic secretion are problematic because of possible urinary contamination. Studies have been carried out mainly in healthy volunteers. The results have to be interpreted with caution, if not care was taken to rule out or at least identify urinary contamination. Analyzing the concentrations of various fluoroquinolones in prostatic and seminal fluid as well as in prostatic tissue, it becomes obvious that the fluoroquinolones differ not only in plasma concentrations but also in their penetration ability to these sites. In spite of intensive investigations, our knowledge is still limited concerning the mechanisms that govern the transport of antibiotic drugs into and their activity in the various prostatic compartments and how the findings can be applied clinically. Nevertheless, overall the concentrations at the site of infection of most of the fluoroquinolones with this indication should be sufficient for the treatment of chronic bacterial prostatitis and vesiculitis caused by susceptible pathogens.

Chronic bacterial prostatitis (NIH type II): diagnosis, therapy and influence on the fertility status

In only approximately 10% of men with symptoms of chronic prostatitis/chronic pelvic pain syndrome bacterial infection of the prostate can be demonstrated by the Meares and Stamey 4-glass or the pre- and post-prostate massage (PPM) two-glass test. Chronic bacterial prostatitis is mainly caused by Gram-negative uropathogens. The role of Gram-positives, atypicals and anaerobes is still debatable. For treatment, fluoroquinolones are considered the drugs of choice because of their favourable pharmacokinetic properties and their antimicrobial spectrum. As relapse and re-infection are a major problem in chronic bacterial prostatitis, only the results of studies with a follow up period of at least 6 months are meaningful. Analysing the concentrations of various fluoroquinolones in prostatic and seminal fluid as well as in prostatic tissue, it becomes, however, obvious that fluoroquinolones differ not only in plasma concentrations, but also in their penetration ability to these sites. Nevertheless, the concentrations at the site of infection of most fluoroquinolones with this indication should be sufficient for the treatment of chronic bacterial prostatitis caused by susceptible pathogens. On the other hand, male accessory gland infection has been linked to male infertility. However, there is still a lack of evidence showing that bacterial prostatitis would have a negative impact on sperm quality.

Therapy for prostatitis, with emphasis on bacterial prostatitis

The prostatitis syndrome is classified in bacterial prostatitis as confirmed or suspected infection and chronic pelvic pain syndrome (CPPS). Bacterial prostatitis is a disease entity that is diagnosed clinically and by evidence of inflammation and infection localised to the prostate. According to the duration of symptoms, bacterial prostatitis is described as either acute or chronic. Acute bacterial prostatitis can be a serious infection and administration of high doses of bactericidal antibiotics are required. In chronic bacterial prostatitis, and if infection is strongly suspected in CPPS, a fluoroquinolone should be administered initially for 2 weeks. Antibiotics should only be continued for a total of approximately 4-6 weeks, if pre-treatment cultures are positive and/or the patient has reported positive effects from the treatment. Patients with CPPS are treated empirically with various medical and physical modalities. Until now, despite the existence of some scientifically valid studies, no definite recommendations have been made because patients with CPPS are most likely to represent a heterogeneous group of diseases and therapeutic outcome is always uncertain.

Current challenges in the treatment of complicated urinary tract infections and prostatitis

Serious urinary tract infections (UTIs) and acute bacterial prostatitis in adults cause significant morbidity and economic burden. Chronic bacterial prostatitis is a rather rare condition seen in urological practice, however, in certain occasions difficult to treat. In this paper, we review the bacterial etiologies and the resistance patterns found in adults with serious UTIs and bacterial prostatitis, and discuss considerations for selecting optimal antimicrobial therapy. The role of fluoroquinolones as targeted therapy for serious UTIs is highlighted. The use of effective antimicrobial therapy is the foundation of management of serious UTIs and bacterial prostatitis. Selection of the optimal antimicrobial agent must take into account patient-specific factors; infection characteristics (e.g., severity, community- vs. institutional- or hospital-acquired, need for IV agent, UTI, prostatitis); local resistance pattern; pharmacokinetic and pharmacodynamic principles; and cost. Fluoroquinolones are among the alternatives for empirical antibiotic treatment of serious UTIs and acute bacterial prostatitis. In serious UTIs activity of the antimicrobial agent against Pseudomonas aeruginosa needs to be taken into account. In chronic bacterial prostatitis fluoroquinolones are the first choice because of their favourable pharmacokinetic properties at the site of infection. Targeted antimicrobial therapy--emphasising the correct antibacterial spectrum and correct dosage--is likely to provide important benefits, such as reduced morbidity and associated costs, reduced emergence of resistance and maintenance of class efficacy.

The role of antibiotics in chronic bacterial prostatitis

The role of antibiotic treatment in prostatitis is described. The selection of an appropriate antimicrobial agent with optimal pharmacokinetics for prostatic secretion and tissue is important, particularly in chronic bacterial prostatitis (CBP). The theoretical background of drug penetration into the prostate is outlined, emphasising the phenomenon of ion trapping and the role of non-ionic diffusion of weak acids, bases and amphoteric drugs across biological membranes with a pH gradient. Determination of drug concentrations in human prostatic secretion is problematic because of possible urinary contamination. Studies have been carried out mainly in healthy volunteers. The results must be interpreted with caution if no care was taken to rule out or at least to identify urinary contamination. Analysing the concentrations of various fluoroquinolones in prostatic and seminal fluid as well as in prostatic tissue, it becomes obvious that the fluoroquinolones differ not only in plasma concentrations but also in their penetration to these sites. In spite of intensive investigations, our knowledge is still limited regarding the mechanisms that govern the transport of antibiotics into and their activity in the various prostatic compartments and how these findings can be applied clinically. Nevertheless, the concentrations at the site of infection of most of the fluoroquinolones should be sufficient for the treatment of CBP and vesiculitis caused by susceptible pathogens.

Fluoroquinolone Antimicrobial Agents in the Treatment of Prostatitis and Recurrent Urinary Tract Infections in Men

Chronic bacterial prostatitis is the most frequent cause for recurrent urinary tract infection in young and middle-aged men. The selection of an appropriate antimicrobial agent that has optimal pharmacokinetics for urine and prostatic secretion and tissue is important in both entities. Fluoroquinolones possess several pharmacologic characteristics that favor them for treatment of urinary tract infection and prostatitis. The pharmacokinetics of fluoroquinolones and the theoretical background of drug penetration into the prostate are outlined. Analyzing the concentrations of various fluoroquinolones in urine, prostatic and seminal fluid, and in prostatic tissue, it becomes obvious that the fluoroquinolones differ in plasma concentrations and in their concentrations at these sites. Nevertheless, overall, the concentrations at the site of infection of most of the fluoroquinolones should be sufficient for the treatment of chronic bacterial prostatitis and vesiculitis and recurrent urinary tract infection in men caused by susceptible pathogens.

Fluoroquinolone antimicrobial agents in the treatment of prostatitis and recurrent urinary tract infections in men

Chronic bacterial prostatitis is the most frequent cause for recurrent urinary tract infection in young and middle-aged men. The selection of an appropriate antimicrobial agent that has optimal pharmacokinetics for urine and prostatic secretion and tissue is important in both entities. Fluoroquinolones possess several pharmacologic characteristics that favor them for treatment of urinary tract infection and prostatitis. The pharmacokinetics of fluoroquinolones and the theoretical background of drug penetration into the prostate are outlined. Analyzing the concentrations of various fluoroquinolones in urine, prostatic and seminal fluid, and in prostatic tissue, it becomes obvious that the fluoroquinolones differ in plasma concentrations and in their concentrations at these sites. Nevertheless, overall, the concentrations at the site of infection of most of the fluoroquinolones should be sufficient for the treatment of chronic bacterial prostatitis and vesiculitis and recurrent urinary tract infection in men caused by susceptible pathogens.

Lomefloxacin versus ciprofloxacin in the treatment of chronic bacterial prostatitis

A total of 182 patients with chronic bacterial prostatitis (CBP) were recruited into this multicentre prospective, randomized clinical study. Of these, 93 were treated orally with lomefloxacin (LOMX) 400 mg once daily and 89 with ciprofloxacin (CIPX) 500 mg twice daily for 4 weeks. At 5-9 days 90/90 vs 86/86, at 4-6 weeks 82/83 vs 82/82, at 3 months 80/79 vs 78/75, and at 6 months 78/75 vs 75/72 patients aging from 18 to 70 years were evaluable bacteriologically/clinically according to a modified intention to treat evaluation. The most frequent pathogens were Escherichia coli, followed by staphylococci, enterococci and Proteus mirabilis. At 5-9 days, 4-6 weeks, 3 and 6 months after therapy the rates of eradication without superinfection per evaluable patients (100%) were 80, 72, 74, and 63% in the LOMX group and 84, 81, 82, and 72% in the CIPX group and (cure and improvement) rates were 98 vs 97%, 84 vs 90%, 86 vs 89%, and 81 vs 89%. There were no statistically significant differences (P < 0.05) between the results of the two treatment groups. Nine (5 vs 4) patients were withdrawn because of adverse events. From the bacteriological and clinical results including adverse events, the oral treatment of CBP over 4 weeks with LOMX 400 mg once daily was comparably effective and tolerable with that of CIPX 500 mg twice daily.

Predictors of patient response to antibiotic therapy for the chronic prostatitis/chronic pelvic pain syndrome: a prospective multicenter clinical trial

PURPOSE

To our knowledge antibiotics are the most popular choice of therapy for all categories of the chronic prostatitis/chronic pelvic pain syndrome. We determine if culture, leukocyte and/or antibody status of prostate specific specimens predicts patient response to antibiotic therapy.

MATERIALS AND METHODS

Patients clinically diagnosed with the chronic prostatitis/chronic pelvic pain syndrome according to the National Institutes of Health (NIH) definition had a lower urinary tract evaluation that included standard microscopy and culture of prostate specific specimens, and determination of the ratio of voided bladder 3 and voided bladder 2 antibody levels against a panel of identified prostate pathogens (enzyme linked immunosorbent assay methodology). Symptom evaluation consisted of the NIH chronic prostatitis symptom index (derived) pain scale 0 to 21, symptom severity index scale 0 to 100, symptom frequency questionnaire scale 0 to 50 and quality of life scale 0 to 6. Patients were stratified according to microscopy, culture and immune status, were treated with 12 weeks of ofloxacin, and were assessed at 4, 12 and 24 weeks with symptom scores as well as global assessments.

RESULTS

Based on leukocyte and culture results, 102 evaluable patients were stratified into categories II (14%), IIIA (48%) and IIIB (38%) of the chronic prostatitis/chronic pelvic pain syndrome. Of the cases 23% were categorized as antibody positive and 77% as antibody negative. Average age was 42 +/- 10 years and 92% of patients were white. Of the patients 57% believed that they had moderate to marked improvement. All categories of the chronic prostatitis/chronic pelvic pain syndrome and patients in whom antibody was positive or negative had significant improvement in the NIH chronic prostatitis symptom index, symptom severity index, symptom frequency questionnaire and quality of life scores compared with baseline (p <0.001). There was no significant difference in patient response to the stratification based on culture, leukocyte, that is categories II, IIIA and IIIB had same beneficial response, or antibody status.

CONCLUSIONS

Culture, leukocyte and antibody status of prostate specific specimens does not predict antibiotic response in patients with the chronic prostatitis/chronic pelvic pain syndrome. The perceived beneficial effect of antibiotics needs to be evaluated in a randomized placebo controlled trial.