Fosfomycin for Chronic Bacterial Prostatitis

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Prostatitis is the inflammation and infection of the

prostate. The bacterial pathogens involved are similar to those involved in

other urologic infections. Although Escherichia coli is

the most common causative pathogen, other etiologies include Pseudomonas aeruginosa, Klebsiella spp.,

Enterococcus spp., Enterobacter spp., Proteus spp., and Serratia spp. In sexually active

men, Neisseria gonorrhoeae and Chlamydia trachomatis should also

be consid­ered.1 Treatment of prostatitis can be difficult, as many

antimicrobials cannot penetrate into the prostate. Current oral treatment

options include fluoroquinolones, tetracyclines, and sulfame­thoxazole/trimethoprim.

However, adverse reac­tions and increasing resistance against these

antimicrobials warrant alternative options for oral therapy.

Fosfomycin is an attractive potential option because it does not cross-react

with other antimicrobials, making it a good choice in patients with extensive

drug allergies. It retains activity against many of the impli­cated organisms,

including multidrug-resistant strains such as extended-spectrum beta-lact­amase

(ESBL)-producing Enterobacteriales and

vancomycin-resistant enterococci. It is also available in an oral dosage form.

However, aside from a few case reports, there are limited data regarding the

dosing, duration, and efficacy of fosfomycin for the treatment of prostatitis.2,3

Karaiskos and colleagues conducted a prospective observation study that set out

to identify the effectiveness and safety of oral fosfomycin in the treatment of

chronic pros­tatitis.⁴ Patients were enrolled if they had more than 3 months of

symptoms consis­tent with prostatitis, positive urine/prostatic secretion

cultures, a negative polymerase chain reaction for sexually transmitted

infections, imaging suggesting prostatic inflammation and did not have other

orally available antimicrobial options (eg, were resistant, had allergies or

adverse reactions). Patients provided consent to participate. Fosfomycin was

dosed at 3 g orally daily for 1 week, then 3 g orally every 48 hours for the

remainder of therapy. Patients were treated for either 6 weeks or 12 weeks, if

they had evidence of prostatic calcifica­tions. Minimum inhibitory concentrations

(MICs) were evaluated via Etest (bioMérieux). Primary outcomes included cure at

end of therapy, defined as resolution or improve­ment of all signs of

infection, and relapse rates, defined as isolation of the same caus­ative

pathogen during treatment or follow-up, at 3 and 6 months of follow-up.

Forty-four male patients were enrolled, ranging in age from 28 to 82 years

(median 54). Most patients had experienced 2 episodes of chronic bacterial

prostatitis. E coli was the most common

causative pathogen (66%), followed by Klebsiella (14%),

and Enterococcus faecalis (14%). Most

isolates were multi­drug-resistant (59%), with 23% displaying evidence of ESBL.

The median fosfomycin MIC was 1.5 mcg/ mL (range, 0.125-32 mcg/ mL) for

gram-negatives and 8 mcg/mL (range 4-24 mcg/ mL) for E faecalis.

Cure was achieved in 82% (36/44 patients) of participants at end of therapy,

with a similar breakdown between the 6- and 12-week groups (Table).

Cure at the 3- and 6-month follow-ups were 80% and 73%, respectively. Fosfomycin

resistance emerged in 5 patients, 2 were in the 6-week group and 3 in the

12-week group. Overall, fosfo­mycin was well tolerated. Eight patients (18%)

reported diarrhea, which resolved in 4 patients by extending the dosing

interval from every 48 hours to every 72 hours. One patient discontinued

treatment due to diarrhea. No patients tested positive for Clostridioides difficile.

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  • Posted

    Continuation of report.

    Although this was a small, single-center study with no comparator arm, the results provide valuable insight into the treatment of chronic bacterial prostatitis. This is the largest study to date of oral fosfomycin for this condition, with positive results. A more concrete dosing regimen was used, and the study provided long-term tolerability infor­mation. Additionally, a significant number of patients presented with resistant organisms.

    In an era of increasing antimicrobial resis­tance, the only option for many patients may be intravenous therapy. Furthermore, many patients may not tolerate the available oral options that can penetrate the prostate. The fluoroquinolones, which have long been considered the gold standard of prostatitis treatment, carry several concerning adverse effects. Additionally, fluoroquinolones, sulfame­thoxazole/trimethoprim, and tetracyclines can interact with many other medications.

    This study’s results provide the proof-of-con­cept for a larger randomized controlled trial of fosfomycin in the treatment of prostatitis. In the meantime, this study may be used to support initiating fosfomycin in a patient with contraindications to one of the available oral alternatives for prostatitis.

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    • Posted

      Interesting, one thing I'd like to know is how does one know if they have Prostatitis vs UTI ? Or maybe you could have both? Or maybe a mild case of prostatitis?

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    • Posted

      That also seems to be your doctors dilemma

      When I've been treated for prosatitis it has never been proved by tests just assumed to be. It's a strangely named disease when there can bacterial and non bacterial versions and Asymptomatic Inflammatory Prostatitis or is that the same as non bacterial?

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    • Posted

      I had a semen test - which I insisted on having - which allegedly found heavy growth of enterococcus faecilis and no fungal overgrowth - so I was prescribed a 6 week course of amoxicillin

      I lasted 7 days on it - gave up because the scrotal inflammation, burning urination and constipation became much worse. So much for their tests; wish to god I had never taken amoxicillin - I'm sure my issues are fungal and taking antibiotics amounts to pouring petrol on the flames

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    • Posted

      Given that I very strongly suspect my issues are fungal in nature - years ago I reacted very adversely to erythromycin and more recently to doxycycline - I believe the anti-fungal diflucan. I managed to obtain some from my GP and I got some from India - ordered online.

      I have been taking the advice of a yeast infection specialist in the US, she's a Phd and has written a book on the subject

      She's advised taking 200mg per day - there is some evidence that this approach can be very successful

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    • Posted

      Thanks - I'm also contemplating the removal of the infected gland - which I feel fell to a deadly combo of prescription antibiotics and too much beer months later down the track

      It was remarkably to get hold of pills from India; here in under a week. I'm not 100% confident on quality no, how can you be! Seems plausible as far as I can tell. This is a major factor in my decision as to whether to take them or not - I've made too many stupid mistakes as it is; though of course one couldn't exactly describe the medical guidance I've had as ideal. GP's I've got couldn't diagnose their way out of a paper bag and they seem very resistant to take on board new info however credible its provenance.

      What your situation Derek? Still sufferering or did you find an answer?

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    • Posted

      Have you discussed the possible surgery with your urologist yet ?

      Fingers crossed I've not had another infection since my last laser surgery in 2012 and my PSA is now 0.70. That part of life is much better but I'm suffering from the prostate infection medications:-) As reported in other posts I was three times prescribed Cipro and Fluoroquinolones that initially caused tendonitis and have caused later long term damage by way of neuropathy in lower left leg and foot causing me walking problems.

      I'll PM you for the name of your Indian pharmacist as I need an expensive item (Metvix) for my keratoses sun damage that the NHS will not prescribe.

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    • Posted

      Going to be discussing possible removal with Consultant on Tuesday - top man in field apparently. Sorry to hear about your collateral damage; I've heard some bad things about Cipro etc - that's shocking

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