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The role of antimicrobial therapy in chronic prostatitis

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  • The role of antimicrobial therapy in chronic prostatitis

    Despite reports that fewer than 10% of prostatitis cases are bacterial, a much higher proportion of men diagnosed with prostatitis receive antimicrobials. Antibiotic therapy is recommended for acute bacterial prostatitis and chronic bacterial prostatitis; it is of debatable benefit in patients with inflammatory chronic pelvic pain syndrome.

    The therapeutic problems with antimicrobials are, on one hand, the different biological status of the pathogens (which are often in a biofilm infection) and, on the other hand, the penetration barrier for many agents. Only a few antibiotics are able to penetrate sufficiently well into prostatic secretions. Penetration depends mainly on the degree of ionization of the compound in plasma. In the acidic prostatic secretions, a weak base such as trimethoprim (with a pKa of 7.4) can be expected to be concentrated about four- or five-fold compared with plasma. Clinical studies have shown, however, that the pH of prostatic fluid in patients with chronic prostatitis is often neutral or alkaline. In this case no concentration of trimethroprim could be expected. This may explain why the results obtained with trimethoprim or co-trimoxazole generally did not produce cure rates of >50%.

    Because of their favourable pharmacokinetic properties, the fluoroquinolones may be better options. The quinolones are zwitterions with a different pKa in an acidic and an alkaline milieu. For example, the isoelectric point of ciprofloxacin is at pH 7.4, which corresponds to the pH of plasma. At this pH only 10% of ciprofloxacin is ionized and thus it can penetrate through biological barriers.

    The quinolones penetrated into prostatic fluid to variable degrees. It was lowest for norfloxacin (c. 10%) and highest for lomefloxacin (c. 50%), but none of the concentrations within prostatic fluid exceeded the corresponding plasma concentrations. In contrast, all quinolones were concentrated within seminal fluid: concentration of lomefloxacin exceeded plasma concentrations by 10–20% and those of ciprofloxacin being seven- to nine-fold higher than the plasma concentration. For gatifloxacin, the concentrations in prostatic and seminal fluids were about the same as in plasma. The concentrations of quinolones in prostatic tissue obtained from patients undergoing transurethral resection of the prostate also, in general, exceeded the corresponding plasma concentration, the ratio being lowest for ofloxacin and highest for ciprofloxacin and enoxacin

    The duration of treatment, which should be for a minimum of 2–4 weeks, and the follow-up period also differed tremendously. Only a few studies had a follow-up period of 4 weeks or more. Since, in chronic prostatitis, relapse is the main problem, the follow-up period must be sufficiently long in order to confirm that the patient is cured.

    Recommended Regimens
    Ciprofloxacin 500 mg PO bid x 28d
    Norfloxacin 400 mg PO bid x 28d
    Ofloxacin 200 mg PO bid x 28d
    Some studies have looked at treatment periods of >28 days but there is no evidence that increasing duration is superior to the recommended 28 days.
    Quinolone Allergy Regimens
    Doxycycline 100 mg PO bid x 28d (less toxicity than minocycline
    regimen)
    Minocycline 100 mg PO bid x 28d
    Trimethoprim-Sulfamethoxazole 1 double-strength tablet PO bid x
    28d
    Trimethoprim 200 mg PO bid x 28d
    If minocycline or doxycycline is used, antibiotic testing is very important because many uropathogens are tetracycline resistant. Many reported studies using TMP-SMX have used treatment periods of longer than 90 days.

    Transperineal injections of antibiotics into the prostate.
    In a four week session eight injections are given. The antibiotics are chosen on the basis of the microbiological findings and sensitivity reports. The most frequently used antibiotics are: Gentamicin, Levaquin, Flagyl, Zithromax, and Diflucan. Xylocaine is added to the cocktail to control local discomfort.


    Treatment requires prolonged courses (4-8 weeks) of antibiotics that penetrate the prostate well (β-lactams and nitrofurantoin are ineffective). These include quinolones (ciprofloxacin, levofloxacin), sulfas (Bactrim, Septra) and macrolides (erythromycin, clarithromycin). Persistent infections may be helped in 80% of patients by the use of alpha blockers (tamsulosin (Flomax), alfuzosin), or long term low dose antibiotic therapy.[3] Recurrent infections may be caused by inefficient urination (benign prostatic hypertrophy, neurogenic bladder), prostatic stones or a structural abnormality that acts as a reservoir for infection.


    References
    Naber and Weidner (2000) : Chronic prostatitis—an infectious disease? Journal of Antimicrobial Chemotherapy 46, 157-161
    Shoskes DA, Hakim L, Ghoniem G, Jackson CL (2003): "Long-term results of multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome". J. Urol. 169 (4): 1406–10.


    " و هكذا بعض الأشياء التي نضحك منها في ارتياح
    لأن أعيننا لا تراها كاملة"
    شاعر ألماني

  • #2
    موضوع مهم ومفيد وشكرا للاخ/4micro وكثيرا مانواجه حالات التهاب البروستات وهي غده مهمه وشدني الدوز المستخدم (28)يوم ومن خلال خبرتي المتواضعه اشوف ان السبروفلوكسساسين مع النورفلكس ولمده 5 ايام كافيه للعلاج وبالضافه للالوسبازمين حتي تخف الالم وشكرا
    http://www.arabseyes.com/vb/uploaded...1179182184.gif

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    • #3
      شكرا للزميل عمرو على مروره الكريم
      الواقع اني عرضت الموضوع لأن كثيرا من اطباء المسالك البولية يطلبون من مرضاهم مزرعة بروستاتيك فلويد دون ان يهتموا اذا ما كانت الحالة حادة ام مزمنة و في الحالات المزمنه لا تظهر المزارع العادية شيئا مفيدا لذا اردت طرح الموضوع
      أختكم 4 micro:sm182:
      " و هكذا بعض الأشياء التي نضحك منها في ارتياح
      لأن أعيننا لا تراها كاملة"
      شاعر ألماني

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      • #4
        الاخ/ الكريم ا ن اهم علامه لالتهاب البروستات ان المريض يكون عنده حرقه في البول ويقول لك بعد ما ابول احس اني عادني بغيت ابول واحيانا تفحص البول ويكون كلير ولا فيه اي شى ومرات البول يطلع لك UTI وعند اعطاء العلاجات تخف الحاله ولا تنتهي بل تعود من جديد ---- الموضوع طويل ويحتاج له جلسه اخرى ...............................سلام
        http://www.arabseyes.com/vb/uploaded...1179182184.gif

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