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Acute bacterial prostatitis — MSRA MCQ

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HardUrinary Tract InfectionsAcute bacterial prostatitisMSRA

A 62-year-old man presents with 36 hours of dysuria, urinary frequency, fever (38.2°C) and deep perineal pain. He is passing urine normally and has no loin pain, vomiting or confusion. BP is 132/76 mmHg, pulse 92 beats/minute and he is drinking adequately. Digital rectal examination shows a diffusely enlarged, markedly tender prostate. He has an eGFR of 74 mL/minute/1.73 m². A previous urine culture 5 months ago grew Escherichia coli susceptible to trimethoprim. Six years ago, ciprofloxacin was stopped because of Achilles tendinopathy requiring physiotherapy. A midstream urine specimen can be obtained before treatment. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Send urine for culture, seek specialist advice, and prescribe trimethoprim 200 mg twice daily for 14 days, then review

Explanation lettering: C = shown as A · E = shown as B · B = shown as C · A = shown as D · D = shown as E

This is acute bacterial prostatitis: fever, lower urinary tract symptoms, perineal pain and a diffusely tender enlarged prostate support prostatic rather than isolated bladder infection. A urine sample should be sent before antibiotics. He is haemodynamically stable, able to take oral treatment and has neither acute urinary retention nor features of sepsis, so initial outpatient oral treatment is appropriate. Fluoroquinolones are usually first-choice oral agents for acute prostatitis because of prostatic penetration. However, previous fluoroquinolone-associated Achilles tendinopathy is a serious adverse reaction; MHRA advice is to avoid fluoroquinolones in patients with such a history. NICE specifies trimethoprim 200 mg twice daily for 14 days then review as the alternative first-choice oral option when a fluoroquinolone is inappropriate, with specialist advice. The prior susceptible E. coli culture supports this empirical choice pending current culture. A is inappropriate because nitrofurantoin does not achieve adequate prostatic concentrations. B would otherwise be a standard regimen, but is unsafe here because of the prior serious fluoroquinolone reaction. D requires bacteriological evidence of susceptibility and specialist discussion. E would be indicated for sepsis, retention, suspected abscess, inability to take oral medication, or deterioration/non-response after 48 hours, none of which is present.

Reference: NICE NG110: Prostatitis (acute): antimicrobial prescribing — Recommendations (Updated September 2024) — https://www.nice.org.uk/guidance/ng110/chapter/Recommendations MHRA Drug Safety Update: Fluoroquinolone antibiotics must now only be prescribed when other commonly recommended antibiotics are inappropriate (22 January 2024) — https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate?es_c=4D8E57EB7462CC94BCC96A821