Shoskes on Antibiotics

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 1998;34(6):457-66.) 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 (anti-inflammatory, neuromuscular). 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 http://www.dshoskes.com

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