Cure of chronic prostatitis presumably due to Enterococcus spp and gram-negative bacteria

Chronic bacterial prostatitis is a therapeutic challenge since even long treatment courses result in clinical and bacteriological cure in only approximately one-third of cases [1]. This is related to the poor diffusion of many antimicrobial agents into the prostate [2], changes in the pH level of prostatic fluid associated with infection, and the presence of infected calculi. The treatment of chronic prostatitis caused by Enterococcus spp is especially difficult, since antibiotics such as amoxicillin and vancomycin do not reach sufficient levels in prostatic fluid. Cure of chronic enterococcal prostatitis has been reported once after treatment with a novel fluoroquinolone [3]. Here, we describe a case of a patient with chronic enterococcal prostatitis who was cured using a combined medical and surgical approach. A 45-year-old man with type I ‘brittle’ diabetes mellitus complicated by severe polyneuropathy had experienced recurrent episodes of prostatitis since 1996. In 1999, he underwent subtotal colectomy for neuropathic bowel motility disorder. Post-surgical complications necessitated a total colectomy with ileorectal anastomosis. The postoperative course was complicated by a severe hernia of the anterior abdominal wall and chronic diarrhea. Since 1999, the patient had suffered from chronic prostatitis presenting with perineal pain, dysuria, and difficulty emptying the bladder. Multiple courses of antibiotics had only a temporary effect. In 2004, surgical repair of the abdominal wall hernia was indicated, but implantation of foreign material was deemed unsafe unless the prostatitis was completely cured in advance. Prostate ultrasonography showed calcifications and minimal bladder residue after voiding. At least six different cultures of urine and ejaculate yielded Enterococcus faecalis (sensitive to amoxicillin, moxifloxacin and linezolid, but resistant to co-trimoxazole), Klebsiella pneumoniae and Proteus mirabilis (both susceptible to moxifloxacin and co-trimoxazole, but only K. pneumoniae sensitive to nitrofurantoin). However, no prostate-specific diagnostic specimens were obtained, so the diagnosis of chronic enterococcal and gram-negative bacterial prostatitis was presumed but not proven. In order to reduce the risk of residual infection associated with prostatic calculi, it was decided that a transurethral resection of the prostate should be performed during prolonged antibiotic treatment. Treatment with moxifloxacin was consequently started, since this agent has good activity against the cultured pathogens [4]. However, within 1 week of treatment initiation the patient developed severe Clostridium difficile-associated diarrhea, which necessitated the discontinuation of moxifloxacin. An alternative antibiotic regimen thus had to be considered. Although we could find no published reports of the use of linezolid for the treatment of chronic prostatitis, data showing that linezolid effectively enters the prostatic parenchyma are available [5, 6]. Treatment was thus restarted with a combination of co-trimoxazole (960 mg bid) plus folic acid (5 mg once daily) for the gram-negative bacteria, and linezolid (600 mg bid) aimed at the enterococci. Both antibiotics had to be administered intraveM. J. H. Pronk . S. M. Arend (*) Department of Infectious Diseases C5P-39, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands e-mail: s.m.arend@lumc.nl Tel.: +31-71-5262620 Fax: +31-71-5266758