|Dr. Daniel Shoskes comments on the proper role of antibiotics in treatment of prostatitis:
It's no surprise
patients are confused and frustrated. What do we know from the scientific literature?:
- Chronic BACTERIAL prostatitis requires antibiotic therapy for at
least 4-6 weeks and in some cases 12 weeks
- Most urologists don't do cultures for men with chronic prostatitis
because they will treat with antibiotics regardless of the
findings(McNaughton Collins M, Fowler FJ, Jr., Elliott DB, Albertsen
PC, Barry MJ. Diagnosing and treating chronic prostatitis: do
urologists use the four- glass test? Urology 2000;55(3):403-7.). Dr.
Nickel's upcoming article in May 2001 Journal of Urology did show that
57% of men with prostatitis got better with 6 weeks of antibiotics
(Floxin) REGARDLESS of whether the culture was positive or negative.
There was no placebo control group however. This summer the NIH will be
starting a clinical trial which does include placebo and antibiotic
arms that will hopefully answer these questions conclusively.
- Empiric therapy with antibiotics should be for at least 4 weeks.
However, if no improvement is seen by 4 weeks, antibiotics should NOT
be continued (Bjerklund Johansen TE, Gruneberg RN, Guibert J,
Hofstetter A, Lobel B, Naber KG, et al. The role of antibiotics in the
treatment of chronic prostatitis: a consensus statement. Eur Urol
- The fact that you don't feel better after a few days of antibiotics
does not prove you don't have an infection. The fact that you feel
better after antibiotics does not prove that you had an infection. CPPS
waxes and wanes and while nobody wants to believe that they themselves
would ever improve on a placebo, different studies have seen 20-60% of
patients improve on placebo. Furthermore, antibiotics DO have direct
anti-inflammatory effects (Galley HF, Nelson SJ, Dubbels AM, Webster
NR. Effect of ciprofloxacin on the accumulation of interleukin-6,
interleukin-8, and nitrite from a human endothelial cell model of
sepsis. Crit Care Med 1997;25(8):1392-5.). Dr. Dimitrikoff presented a
study last year comparing antibiotics with placebo in men with negative
cultures, no WBC's in the prostate fluid and negative 16S rRNA. There
was no difference between antibiotic and placebo and the side effect
incidence was very high.
- All antibiotics have side effects, most mild and self limited, some
serious and permanent. Quinolones are no exception and patients should
be warned of the more common and serious ones before embarking on
prolonged courses (Harrell RM. Fluoroquinolone-induced tendinopathy:
what do we know? South Med J 1999;92(6):622-5.) However, this
identification of quinolones for particular vilification over other
classes of antibiotics is misguided. I have seen FATAL reactions to
Bactrim. I myself was hospitalized as a teenager for a complication
from tetracyclines taken for acne. The indiscriminate use antibiotics
with no indication of infection other than having the symptoms of CPPS
is ridiculous, harmful and has no basis in scientific evidence. It
exposes patients to uneeded side effects and it often prevents them
from trying other forms of non-antibiotic therapy which may help them
- For antibiotic therapy, I prefer to do a culture and treat according
to the sensitivities I find. All things being equal I prefer to use a
quinolone because of the excellent penetration into the prostate. For
sensitive gram negative bacteria (eg E. coli) I prefer a "first
generation" quinolone (eg Cipro, Levaquin). For gram positive bacteria
(eg Staphylococcus, Corynebacteria) I prefer a "second generation"
quinolone (eg Avelox, Tequin) because of their extended gram positive
coverage. Incidentally, while Staphylococcus often shows up as
sensitive to sulpha drugs on the lab test, sulphas (Bactrim, Septra)
have NO activity against these bacteria in vivo. My second choice for
antibiotic class are erythromycins (Biaxin, Zithromax). There is
evidence that these drugs may have superior penetration into a biofilm
(Yasuda H, Ajiki Y, Koga T, Yokota T. Interaction between
clarithromycin and biofilms formed by Staphylococcus epidermidis.
Antimicrob Agents Chemother 1994;38(1):138-41.). Third choice would be
a tetracycline. I have used Amoxicillin and cephalosporins, however
their penetration into the prostate is questionable.
|SO, if mixing a poultice of antibiotics, roobios tea and silver nitrate
and rubbing it on your forehead while sitting in the tub has cured your
CPPS, I'm thrilled that you are better! But people reading this
newsgroup have to understand that anecdotal advice is exactly that.
Those of us involved with CPPS research are trying to do the proper
scientic studies to prove what works and what doesn't and some of this
evidence based medicine is finally entering the literature. But if you
want to embark on an unproven therapy, don't get harmed in the process.
|Daniel Shoskes MD
Cleveland Clinic Florida
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