Concerns With Antibiotics Used To Treat Prostatitis

In our latest question and answer, the pharmacist discusses concerns with the antibiotics used to treat prostatitis.

Question

I was prescribed levofloxacin by my urologist for potential prostatitis. I am concerned about taking a broad-spectrum antibiotic that will wipe out so many good gut bacteria, as I am prone to anxiety, depression, and OCD. I am in a good place with my mental health and am afraid to destroy good serotonin-producing gut bacteria with an antibiotic. Is there a less broad, less potent antibiotic that may not do as much harm to the gut microbiome? I know this is all a shot in the dark since prostate bacteria cannot really be detected well, much less cultured. Not even sure if the prostatitis is caused by bacteria. Thank you!

Asked by Cam On Jun 20, 2022

Answered by
Medical Content Reviewed By HelloPharmacist Staff

Published Jun 20, 2022
Last updated Jun 20, 2022

Key points

  • First-line antibiotics for the treatment of prostatitis include levofloxacin, ciprofloxacin, and Bactrim (sulfamethoxazole/trimethoprim).
  • Antibiotic treatment is often initiated without a culture test and is based on the most common types of bacteria that cause prostatitis, which are E.Coli, Proteus species, various other Enterobacterales and Pseudomonas aeruginosa.
  • Sometimes, alternative antibiotics, like doxycycline and azithromycin, can be used, and they are less 'broad-spectrum' than many other options. They don't unfortunately, penetrate the prostate tissue well.
  • Antibiotic treatment for prostatitis is about 6 weeks of continuous treatment.
  • Appropriate antibiotic choice, and supplementing with probiotics, can help with long-term antibiotic side effects.

Thanks for reaching out! I certainly understand your concerns here.

The treatment of prostatitis is a fairly broad topic, so I'll focus this answer on what is important to you, and that is the specific antibiotics used, and which are less 'broad-spectrum'.

Antibiotic Treatment Of Prostatitis

For most individuals, antibiotic therapy is empiric, meaning that treatment starts before there is a culture completed that appropriately identifies the causative bacteria, and is based on educated assumptions and experience.

Oftentimes, a urine culture will be done, which can help guide therapy but isn't always conclusive, and in more severe cases, a blood culture is done. Again though, most people are given antibiotics before any conclusive tests are done.

The specific antibiotics that are recommended to be 'first-line' are chosen based on the fact that there are four types of bacteria that most commonly cause prostatitis. They are:

  • E. coli (>50% of cases)
  • Proteus species
  • Various other Enterobacterales
  • Pseudomonas aeruginosa

The number of available antibiotics for the treatment of prostatitis is actually somewhat limited since they not only have to have activity against the causative bacteria, they need to be able to penetrate the tissue in the prostate.

Based on this, there are only a few recommended first-line antibiotics:

The above antibiotics are chosen initially since they tend to cover the most common bacteria that cause prostatitis and they penetrate the prostate tissue well.

In some cases, other antibiotics can be used, but generally only if a urine culture shows a non-common causative bacteria (e.g. Staphylococcus aureus) or there are allergies to consider.

In these cases, antibiotics like doxycycline and macrolides have been used but they very often have little activity against the bacteria that cause prostatitis.

Spectrum Of Activity

You were specifically concerned with an antibiotic being broad-spectrum (i.e. covers the most types of bacteria, such as gram-positive, gram-negative, aerobic, anaerobic, etc...).

Out of the recommended first-line antibiotics, the fluoroquinolones likely have the broadest spectrum of activity, with levofloxacin covering slightly more organisms, in general, than ciprofloxacin.

Bactrim is also considered a broad-spectrum antibiotic but has slightly less activity than the fluoroquinolones do.

The other antibiotics I mentioned in the section above, doxycycline and azithromycin, are much less 'broad-spectrum' than any of the first-line recommended agents, but as mentioned, they don't tend to be used first since they don't have the level of activity and don't penetrate the prostate tissue like the other antibiotics do.

Duration Of Therapy

What can be argued to be a bigger issue when talking about antibiotics for prostatitis, is the duration of therapy.

Unlike most bacterial infections, that are treated for 5-10 days, antibiotic treatment for prostatitis is very often for up to six weeks.

Demonstrable symptoms tend to go away in 2 to 6 days after starting therapy, but the treatment time extends far beyond that.

This brings up the question of what can an individual do to help maintain their 'normal' gastrointestinal bacteria flora while being treated.

Help Prevent Side Effects

As you brought up in your question, broad-spectrum antibiotics certainly can upset your normal bacterial flora, simply because they cover so many different types of bacteria.

Ideally, you are able to take an antibiotic that covers the bacteria that is causing the infection (and not target all the other bacteria), for the shortest time possible.

That ideal scenario doesn't happen very often when treating prostatitis.

There are a few options here though.

For one, as mentioned, Bactrim is slightly less of a broad-spectrum antibiotic than levofloxacin.

Two, urine cultures are common tests that are ordered to help guide treatment (even though most people are started on an initial antibiotic anyway). If your urine culture comes back for something specific that your doctor relates to your prostatitis, the antibiotic choice may be more tailored (i.e. you may have an option for a less 'broad-spectrum' antibiotic).

Third, I would recommend taking probiotics for the duration of your treatment.

There, unfortunately, isn't a lot of evidence that probiotics have a definitive benefit to reduce antibiotic-associated side effects, but they are still not a bad idea, since they generally cause no harm.

One strain, in particular, Lactobacillus rhamnosus GG, has some of the strongest evidence for it and may be an option for you.

Final Words

Thanks again for your question and I hope your treatment goes well!

I want to end by saying the antibiotics and the general treatment plan I wrote about above are not applicable to everyone.

There are certainly other antibiotic options, many of them IV (intravenous), and other treatment plans, but it's hard to cover everything as everyone's medical situation is different and unique.

I highly recommend discussing your concerns with your doctor and please feel free to reach out to us with any further questions.

References

  • Prophylactic Lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study, PubMed
  • Lactobacillus GG in the prevention of antibiotic-associated diarrhea in children, PubMed
  • Prostatitis, PubMed
  • Acute Bacterial Prostatitis: Diagnosis and Management, PubMed
  • Antibiotics: past, present and future, PubMed
  • Prostatitis: the role of antibiotic treatment, PubMed

About the Pharmacist

Dr. Brian Staiger, PharmD

Dr. Brian has been practicing pharmacy for over 11 years and has wide-ranging experiences in many different areas of the profession. From retail, clinical and administrative responsibilities, he's your knowledgeable and go-to source for all your pharmacy and medication related questions!

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