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Acute bacterial prostatitis — MSRA MCQ

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HardInfectious DiseasesAcute bacterial prostatitisMSRA

A 69-year-old man presents with 2 days of dysuria, urinary frequency, fever and severe deep perineal pain. He is passing urine normally and a bladder scan shows a post-void residual of 35 mL. He has no vomiting, rigors, confusion, flank pain or testicular pain. His temperature is 38.1°C, pulse 92 beats/minute, blood pressure 132/76 mmHg and oxygen saturation 97% on air. Digital rectal examination shows a diffusely tender, boggy prostate. He can take oral medication and has an eGFR of 74 mL/minute/1.73 m². He has had no recent antibiotics and no previous urine cultures are available. Four years ago, ciprofloxacin was stopped after he developed Achilles tendinitis; this is documented as a serious fluoroquinolone adverse reaction. He is currently taking prednisolone 30 mg daily for a COPD exacerbation. Which is the most appropriate management today?

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

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Correct answer: D — Obtain a midstream urine sample, seek same-day microbiology advice, and prescribe trimethoprim 200 mg twice daily for 14 days, then review

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

This presentation is acute bacterial prostatitis: fever, urinary symptoms, deep perineal pain and a tender boggy prostate are discriminating features. A urine sample should be obtained before antibiotics. He is haemodynamically stable, has no retention, sepsis features or inability to take oral treatment, so outpatient oral therapy is appropriate with clear safety-netting and review. Fluoroquinolones are usually first-choice oral agents because of prostatic penetration. However, this patient previously had a serious fluoroquinolone adverse reaction and is concurrently taking systemic corticosteroids. MHRA advice is to avoid fluoroquinolones after a previous serious quinolone reaction and to avoid co-administration with corticosteroids because of increased tendon injury risk. NICE identifies trimethoprim as the alternative first-choice oral treatment when a fluoroquinolone is inappropriate, with specialist advice and a 14-day review. A is appropriate for uncomplicated lower UTI but nitrofurantoin does not achieve therapeutic prostatic concentrations. B disregards both the prior serious reaction and current prednisolone exposure. C delays necessary treatment for a potentially serious bacterial infection. D may be considered only after specialist discussion when there is bacteriological evidence of susceptibility and a good reason to prefer it.

Reference: NICE NG110: Prostatitis (acute): antimicrobial prescribing — Recommendations (Published 2018; table 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 NICE NG109: Urinary tract infection (lower): antimicrobial prescribing — Recommendations (Published 2018) — https://www.nice.org.uk/guidance/ng109/chapter/Recommendations