Perletti Gianpaolo, Marras Emanuela, Wagenlehner Florian M E, Magri Vittorio
Laboratory of Toxicology and Pharmacology, Biomedical Research Division, Dept. of Theoretical and Applied Sciences, Università degli Studi dell'Insubria, Via A. da Giussano, 10, Busto A, Province of Varese, Italy, 21052.
Cochrane Database Syst Rev. 2013 Aug 12;2013(8):CD009071. doi: 10.1002/14651858.CD009071.pub2.
Chronic bacterial prostatitis (CBP) is frequently diagnosed in men of fertile age, and is characterized by a disabling array of symptoms, including pain in the pelvic area (for example, perineum, testicles), voiding symptoms (increased frequency and urgency, also at night; pain or discomfort at micturition), and sexual dysfunction. Cure of CBP can be attempted by long-term therapy with antibacterial agents, but relapses are frequent. Few antibacterial agents are able to distribute to the prostatic tissue and achieve sufficient concentrations at the site of infection. These agents include fluoroquinolones, macrolides, tetracyclines and trimethoprim. After the introduction of fluoroquinolones into clinical practice, a number of studies have been performed to optimize the antimicrobial treatment of CBP, and to improve eradication rates and symptom relief.
To assess and compare the efficacy and harm of antimicrobial treatments for chronic bacterial prostatitis.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE, other national or international databases and abstracts from conference proceedings on 8 August 2012.
We included all randomized controlled comparisons of one antimicrobial agent versus placebo or one or more comparator antimicrobial agents, combined or not with non-antimicrobial drugs. We also included trials comparing different doses, treatment durations, dosing frequencies, or routes of administration of antimicrobial agents. We excluded studies in which patients were not diagnosed according to internationally recommended criteria, or were not subjected to lower urinary tract segmented tests.
Study data were extracted independently by two review authors. Study outcomes were microbiological efficacy (pathogen eradication), clinical efficacy (symptom cure or improvement, or symptom scores) at test-of-cure visits or at follow-up, or both, and adverse effects of therapy. Secondary outcomes included microbiological recurrence rates.Statistical analysis was performed using a fixed-effect model for microbiological outcomes and a random-effects model for clinical outcomes and adverse effects. The results were expressed as risk ratios for dichotomous outcomes (with 95% confidence intervals) or as standardized mean differences for continuous or non-dichotomous variables.
We identified 18 studies, enrolling a total of 2196 randomized patients. The oral fluoroquinolones ciprofloxacin, levofloxacin, lomefloxacin, ofloxacin and prulifloxacin were compared. There were no significant differences in clinical or microbiological efficacy or in the rate of adverse effects between these fluoroquinolones. In chlamydial prostatitis, (i) azithromycin showed improved eradication rates and clinical cure rates compared to ciprofloxacin, with no significant differences regarding adverse effects; (ii) azithromycin was equivalent to clarithromycin, both microbiologically and clinically; (iii) prulifloxacin appeared to improve clinical symptoms, but not eradication rates, compared to doxycycline. In ureaplasmal prostatitis, the comparisons ofloxacin versus minocycline and azithromycin versus doxycycline showed similar microbiological, clinical and toxicity profiles.
AUTHORS' CONCLUSIONS: The microbiological and clinical efficacy, as well as the adverse effect profile, of different oral fluoroquinolones are comparable. No conclusions can be drawn regarding the optimal treatment duration of fluoroquinolones in the treatment of CBP caused by traditional pathogens.Alternative antimicrobial agents tested for the treatment of CBP caused by traditional pathogens are co-trimoxazole, beta-lactams and tetracyclines, but no conclusive evidence can be drawn regarding the role of non-fluoroquinolone antibiotics in the treatment of CBP caused by traditional pathogens.In patients with CBP caused by obligate intracellular pathogens, macrolides showed higher microbiological and clinical cure rates compared to fluoroquinolones.
慢性细菌性前列腺炎（CBP）在育龄男性中经常被诊断出来，其特征是一系列使人丧失能力的症状，包括盆腔区域疼痛（例如会阴、睾丸）、排尿症状（频率增加和尿急，夜间也会出现；排尿时疼痛或不适）以及性功能障碍。可以尝试通过长期使用抗菌药物进行治疗来治愈CBP，但复发很常见。很少有抗菌药物能够分布到前列腺组织并在感染部位达到足够的浓度。这些药物包括氟喹诺酮类、大环内酯类、四环素类和甲氧苄啶。在氟喹诺酮类药物引入临床实践后，已经进行了多项研究来优化CBP的抗菌治疗，并提高根除率和缓解症状。
评估和比较慢性细菌性前列腺炎抗菌治疗的疗效和危害。
我们于2012年8月8日检索了Cochrane对照试验中央登记册（CENTRAL）、MEDLINE（PubMed）、EMBASE、其他国家或国际数据库以及会议论文摘要。
我们纳入了所有一种抗菌药物与安慰剂或一种或多种对照抗菌药物的随机对照比较，无论是否与非抗菌药物联合使用。我们还纳入了比较抗菌药物不同剂量、治疗持续时间、给药频率或给药途径的试验。我们排除了患者未根据国际推荐标准进行诊断或未接受下尿路分段检查的研究。
研究数据由两位综述作者独立提取。研究结果包括微生物学疗效（病原体根除）、治愈检查或随访时的临床疗效（症状治愈或改善，或症状评分），或两者兼而有之，以及治疗的不良反应。次要结果包括微生物学复发率。使用固定效应模型对微生物学结果进行统计分析，使用随机效应模型对临床结果和不良反应进行统计分析。结果以二分结果的风险比（95%置信区间）表示，或以连续或非二分变量的标准化均值差表示。
我们确定了18项研究，共纳入2196名随机分组的患者。比较了口服氟喹诺酮类药物环丙沙星、左氧氟沙星、洛美沙星、氧氟沙星和普卢利沙星。这些氟喹诺酮类药物在临床或微生物学疗效以及不良反应发生率方面没有显著差异。在衣原体性前列腺炎中，（i）阿奇霉素与环丙沙星相比，根除率和临床治愈率有所提高，在不良反应方面没有显著差异；（ii）阿奇霉素在微生物学和临床方面与克拉霉素相当；（iii）与多西环素相比，普卢利沙星似乎能改善临床症状，但不能提高根除率。在脲原体性前列腺炎中，氧氟沙星与米诺环素以及阿奇霉素与多西环素的比较显示出相似的微生物学、临床和毒性特征。
不同口服氟喹诺酮类药物的微生物学和临床疗效以及不良反应特征相当。对于传统病原体引起的CBP，关于氟喹诺酮类药物的最佳治疗持续时间无法得出结论。用于治疗传统病原体引起的CBP的其他抗菌药物有复方新诺明、β-内酰胺类和四环素类，但关于非氟喹诺酮类抗生素在治疗传统病原体引起的CBP中的作用，无法得出确凿证据。在由专性细胞内病原体引起的CBP患者中，大环内酯类药物与氟喹诺酮类药物相比，显示出更高的微生物学和临床治愈率。
