Diagnosis and treatment of patients with prostatic abscess in the post‐antibiotic era

Abstract

We reviewed the pathogenesis, clinical presentation, treatment options and outcomes of prostatic abscess in the post-antibiotic era, focusing on how patient risk factors and the emergence of multidrug-resistant organisms influence management of the condition. A MEDLINE search for "prostate abscess" or "prostatic abscess" was carried out. Prostate abscess is no longer considered a consequence of untreated urinary infection; now, men with prostatic abscess are typically debilitated or immunologically compromised, with >50% of patients having diabetes. In younger men, prostatic abscess can be the initial presentation of such chronic conditions. In older men, prostatic abscess is increasingly a complication of benign prostatic hyperplasia or prostate biopsy. Diagnosis is based on a physical examination, leukocytosis, leukocyturia and transrectal ultrasound, with magnetic resonance imaging serving as the preferred confirmatory imaging modality. Treatment of prostatic abscess is changing as a result of the emergence of atypical and drug-resistant organisms, such as extended-spectrum blactamase-producing enterobacteriaceae and methicillin-resistant Staphylococcus aureus. As many as 75% of infections are resistant to first-generation antibiotics, necessitating aggressive therapy with broad-spectrum parenteral antibiotics, such as third-generation cephalosporins, aztreonam or antibiotic combinations. A total of 80% of patients require early surgical drainage, frequently through a transurethral approach. In the postantibiotic era, prostatic abscess is evolving from an uncommon complication of urinary infection to a consequence of immunodeficiency, growing antibiotic resistance and urological manipulation. This condition, primarily affecting patients with chronic medical conditions rendering them susceptible to atypical, drug-resistant organisms, requires prompt aggressive intervention with contemporary antibiotic therapy and surgical drainage.

Editorial Comment to Diagnosis and treatment of patients with prostatic abscess in the post‐antibiotic era

“…Therefore, from the viewpoint of urologists as well, surgical intervention should definitely be considered for this disease, and Ackerman et al mentioned a diameter of 1 cm of prostatic abscess size needs to be aware for limit of medical therapy indication. 2 It is the present authors' opinion and impression that not all physicians, including urologists, who take care of patients with prostatic abscess recognize it, and so we urologists, especially those specializing in infectious disease, need to educate or inform other department physicians to carry out prompt drainage and, importantly, identify the causative bacteria.…”

“…1 Ackerman et al interestingly focused on imaging diagnosis and surgical interventions as in the post-antibiotic era. 2 These points might be mostly noted by and of interest to urologists. Basically, the prostate is one of the organs that antibiotics cannot easily reach, meaning antibiotics need to overcome the blood-prostate barrier that prevents antibiotics from reaching levels higher than the minimum inhibitory concentration.…”

“…Ackerman et al . interestingly focused on imaging diagnosis and surgical interventions as in the post‐antibiotic era . These points might be mostly noted by and of interest to urologists.…”

Pharmacological Interventions for Bacterial Prostatitis

“…Prostate abscesses less than 1 cm in diameter could be treated conservatively with oral drug. Although no standard of care exists, quinolones (such as ciprofloxacin) are recommended for outpatient and a thirdgeneration cephalosporin, aztreonam, or the combination of an aminoglycoside with ampicillin for those are debilitated or immunocompromised with atypical or-resistant organisms infected (Ackerman et al, 2018). Whereas, larger ones require single aspiration or continuous drainage (Chou et al, 2004).…”

Complement levels in patients with bloodstream infection due to Staphylococcus aureus or Gram-negative bacteria

“…It is estimated that approximately 2 million episodes and 250,000 deaths from bloodstream infections occur annually in Europe and North America combined [2]. A consistent predictor of mortality for patients with S. aureus bacteremia (SAB) [3,4] and Gram-negative bacteremia (GNB) is the presence of septic shock [5]. Septic shock is thought to involve a dysregulated immune response to infection, the mechanisms of which are incompletely understood.…”