MKSAP: 46-year-old man with fever, dysuria, and urinary frequency

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 46-year-old man is evaluated for fever, dysuria, and urinary frequency of 1 day’s duration. He also notes a sensation of deep pelvic pain near the rectum. He has no urethral discharge or testicular pain. He states that he felt well before the current illness and has no other symptoms. Medical history is unremarkable. He is not sexually active. He takes no medications.

On physical examination, temperature is 38.8 °C (101.8 °F), blood pressure is 130/80 mm Hg, pulse rate is 100/min, and respiration rate is 16/min. Rectal examination reveals a tender and tense prostate.

Blood and urine cultures are pending. Urine dipstick is positive for leukocyte esterase and nitrites.

Which of the following is the most appropriate treatment?

A. Ampicillin
B. Ceftriaxone (single dose) and doxycycline
C. Ciprofloxacin
D. Meropenem

MKSAP Answer and Critique

The correct answer is C. Ciprofloxacin.

This patient with likely acute bacterial prostatitis should begin empiric treatment with a fluoroquinolone, such as ciprofloxacin. Acute prostatitis most commonly results from an ascending urethral infection, although bacterial cystitis or epididymo-orchitis may be an underlying source of infection. Patients most often present with fever, chills, malaise, nausea and vomiting, dysuria, urgency, frequency, and pain in the lower abdomen, perineum, and rectum. The onset of symptoms is typically rapid. On physical examination, the prostate is tender and tense or boggy. Excessive palpation of the prostate should be avoided because it may contribute to bacteremia. As was done with this patient, blood and urine cultures should be obtained, and empiric broad-spectrum antibiotics should be started. Gram-negative bacillary organisms, including Escherichia coli, Serratiaspecies, and Klebsiella species, are the most common causative agents in patients with uncomplicated acute bacterial prostatitis who are at low risk for sexually transmitted infections (STIs). The course of therapy with a fluoroquinolone is at least 14 days and up to 4 weeks. Trimethoprim-sulfamethoxazole is also an appropriate first-line choice if the isolate is known to be susceptible or if the rate of E. coli resistance in the community is less than 20%.

Ampicillin, which had been an alternative therapeutic option for prostatitis, can no longer be recommended as empiric therapy because of the high rate of resistance among community-acquired microorganisms.

A single dose of ceftriaxone, 250 mg intramuscularly, is indicated for uncomplicated acute bacterial prostatitis in patients at risk for STIs with Neisseria gonorrhoeae or Chlamydia trachomatis. Generally, men younger than 35 years are at risk for infection with these organisms. Doxycycline, 100 mg twice daily for 10 days, is also indicated in these patients. This patient is not sexually active and therefore does not require coverage for possible STIs.

Treatment with a carbapenem, such as meropenem, should be reserved for systemically ill patients who require hospitalization or when a fluoroquinolone-resistant organism is a concern. The incidence of fluoroquinolone-resistant E. coli is very high (up to 90%) following prostate biopsy.

Key Point

  • Patients with uncomplicated acute bacterial prostatitis, most commonly caused by Escherichia coli, Serratia species, and Klebsiella species, who are at low risk for sexually transmitted infections should be treated empirically with ciprofloxacin.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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