LAUSR

Chronic bacterial prostatitis (CBP) commonly does not respond to the EAU recommended prolonged course of fluoroquinolones, which can lead to ongoing discomfort, lower urinary tract symptoms and dissatisfaction for the patient. Now, a new randomized study published in World Journal of Urology by Manfredi and colleagues evaluates whether probiotics might have a role in the treatment of CBP. Over a period of 22 months, 110 patients with CBP were enrolled and randomly assigned to treatment with the oral fluoroquinolone levofloxacin daily for 4 weeks or daily levofloxacin for 4 weeks plus oral administration of Escherichia coli Nissle 1917 (EcN) twice daily for 4 weeks and then once daily for 8 weeks. EcN is a non-pathogenic, gram-negative bacterial strain that has probiotic properties and can directly compete with the E. coli involved in CBP development. Patients all had symptoms assessed by the validated National Institute of Health-Chronic Prostatitis Symptom index (NIH-CPSI) and had symptoms lasting >3 months. The four-glass Meares–Stamey test was used to diagnose bacterial prostatic infection, and bacteria were sensitive to fluoroquinolones on antibiogram. Baseline characteristics were similar between the two patient cohorts. Both groups had a significant reduction in NIH-CPSI scores after 3 months of treatment (P < 0.001), but patients receiving EcN plus antibiotics reported lower scores than patients receiving antibiotics alone (mean 5.85, s.d. ± 3.07 versus mean 7.64, s.d. ± 3.86, P = 0.009). Bacterial recurrence, as diagnosed by repeat Meares–Stamey test in symptomatic patients, occurred in 11 of 38 patients treated with levofloxacin alone (28.9%) versus 4 of 46 patients in the group treated with dual therapy (8.7%, P = 0.038). No significant differences were found in adverse events between the groups (P = 0.25). Manfredi and colleagues postulate that CBP could be related to an association between urinary and intestinal dysbiosis, or that urethral dysbacteriosis could be an underlying cause. Probiotics might have an indirect effect on urinary microbiota and EcN has antibacterial and anti-inflammatory properties via several potential mechanisms. Although the researchers define limitations of their study, such as the small sample size and non-blinded design, they conclude that compared with fluoroquinolone alone, dual therapy with EcN and levofloxacin “seems to favor better control of symptoms and reduce the risk of biological recurrences”, although larger randomized trials are needed to confirm the results.