A 59-year-old man comes to the emergency department due to lower abdominal pain. The patient has had 2 days of fever, chills, dysuria, and pelvic pain; this morning, he was unable to pass any urine. He has never had similar symptoms before and has no history of chronic urinary or bowel issues. Medical history is significant for hyperlipidemia and coronary artery disease. Temperature is 39 C (102.2 F), blood pressure is 140/90 mm Hg, and pulse is 98/min. Suprapubic fullness and tenderness are present. Digital rectal examination shows an edematous and exquisitely tender prostate. The external genitalia are normal. A suprapubic catheter is placed, which drains 800 mL of urine. Laboratory examination reveals the following: Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 59-year-old man comes to the emergency department due to lower abdominal pain.  The patient has had 2 days of fever, chills, dysuria, and pelvic pain; this morning, he was unable to pass any urine.  He has never had similar symptoms before and has no history of chronic urinary or bowel issues.  Medical history is significant for hyperlipidemia and coronary artery disease.  Temperature is 39 C (102.2 F), blood pressure is 140/90 mm Hg, and pulse is 98/min.  Suprapubic fullness and tenderness are present.  Digital rectal examination shows an edematous and exquisitely tender prostate.  The external genitalia are normal.  A suprapubic catheter is placed, which drains 800 mL of urine.  Laboratory examination reveals the following:  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

This patient's fever, dysuria, leukocytosis, and tender, swollen prostate indicate acute bacterial prostatitis (ABP). In ABP, prostatic swelling can sometimes impinge the urethra and cause difficulty voiding or acute urinary retention (with renal insufficiency). A suprapubic catheter is generally required for decompression because passage of urethral catheters can lead to sepsis (dislodging of bacteria from infected prostate) or prostatic rupture. Most cases of ABP are caused by colonic pathogens (eg, Escherichia coli, Proteus species) that have contaminated the urethra and subsequently enter the prostate via intraprostatic urinary reflux. Urine culture helps define the underlying organism, but prolonged treatment (~6 weeks) with a fluoroquinolone (eg, levofloxacin) or trimethoprim-sulfamethoxazole is generally required to ensure eradication. These agents have excellent coverage against enteric pathogens and achieve high prostatic tissue levels. (Choices A and C) Azithromycin and doxycycline treat genitourinary infections due to Chlamydia trachomatis, which commonly causes acute urethritis (eg, dysuria, urethral discharge) and epididymitis (eg, posterior testicular pain and swelling). However, azithromycin and doxycycline have limited activity against common enteric pathogens (eg, Escherichia coli), so they are not typically used for empiric treatment of ABP. (Choice B) Clindamycin is effective against a number of gram-positive organisms (eg, Staphylococcus aureus) and anaerobes (eg, Bacteroides) but these pathogens are less common causes of ABP. (Choice E) Although nitrofurantoin provides excellent coverage for coliform organisms and is often used for uncomplicated urinary tract infections in women, this medication does not achieve good prostatic tissue concentration and should not be used for ABP. Educational objective: Acute bacterial prostatitis is characterized by fever, dysuria, and a swollen, tender prostate. Most cases are caused by coliform organisms (eg, Escherichia coli) that have contaminated the urethra and entered the prostate via intraprostatic urinary reflux. Urine culture is required to define the underlying pathogen, but 6 weeks of therapy with trimethoprim-sulfamethoxazole or a fluoroquinolone is generally required to ensure eradication. References: Acute bacterial prostatitis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26926407)

A 59-Year-Old Man Comes to the Emergency Department Due to Lower