What is the treatment for male urinary tract infection (UTI) with negative Staphylococcus (Staph) culture?

From the Guidelines

For a male urinary tract infection (UTI) with negative staphylococcus, the recommended treatment is typically an intravenous third-generation cephalosporin as empirical treatment, given the potential for complicated UTI and the need to cover a broad spectrum of pathogens, including E. coli and other gram-negative bacteria, as suggested by the European Association of Urology guidelines 1. Given the complexity of UTIs in men, especially when staphylococcus is negative, indicating another pathogen might be involved, it's crucial to consider the severity of the illness and local resistance patterns when choosing an antibiotic.

• The European Association of Urology guidelines from 2024 1 recommend using a combination of antibiotics for complicated UTIs, including amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin.
• The guidelines also advise against using ciprofloxacin and other fluoroquinolones for empirical treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 1.
• Managing any urological abnormality and/or underlying complicating factors is also strongly recommended 1.
• A study from 2023 1 suggests that short-course antibiotics (5-7 days) can be as effective as long-duration therapy (10-14 days) for complicated UTIs, including in men, but more data are needed to confirm this finding.
• It's essential to complete the full course of antibiotics, even if symptoms improve quickly, and to increase fluid intake to help flush bacteria from the urinary system.
• Over-the-counter pain relievers like ibuprofen can help manage discomfort, and if symptoms persist after treatment, a follow-up urine culture may be necessary to identify the specific pathogen and its antibiotic sensitivities.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

Treatment Options:

• Trimethoprim-sulfamethoxazole (PO) 2 can be used to treat urinary tract infections due to susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris.
• Levofloxacin (PO) 3 can be used to treat uncomplicated urinary tract infections due to Escherichia coli, Klebsiella pneumoniae, or Staphylococcus saprophyticus.

Since the question specifies a negative Staphylococcus, the most suitable option would be to treat with Trimethoprim-sulfamethoxazole (PO) 2 or Levofloxacin (PO) 3 for the coverage of other possible pathogens such as Escherichia coli or Klebsiella species. However, it's crucial to note that the choice of antibiotic should be based on culture and susceptibility results whenever possible.

From the Research

Treatment Options for Male UTI with Negative Staphylococcus

• The treatment of urinary tract infections (UTIs) is a major healthcare concern, with factors such as economic efficiency and emerging resistance becoming increasingly important considerations in providing patient care 4.
• For uncomplicated out-patient UTIs, trimethoprim-sulfamethoxazole has been the preferred first-line agent where local resistance is < 10 - 20% 4.
• However, in areas with increased resistance, fluoroquinolones such as ciprofloxacin and levofloxacin have become common first-line agents 4, 5.
• Ciprofloxacin extended release (ER) is a once-daily formulation that has been shown to be at least as effective as twice-daily ciprofloxacin in achieving clinical cure and bacteriological eradication rates 4.
• Levofloxacin is another fluoroquinolone that has been used to treat complicated UTIs and pyelonephritis, but its use has been limited due to emerging resistance 5.
• A study found that oral antibiotics with comparatively lower resistance rates included amoxicillin/clavulanate, cefdinir, cefuroxime, and nitrofurantoin, while those with high resistance rates included trimethoprim-sulfamethoxazole, tetracycline, ciprofloxacin, levofloxacin, and cephalexin 6.
• Nitrofurantoin was prescribed most frequently for outpatient treatment of UTI/cystitis, while cephalexin was the most commonly prescribed antibiotic for outpatient treatment of pyelonephritis 6.
• A systematic review and meta-analysis found no significant difference between levofloxacin and ciprofloxacin in terms of clinical success rate, microbial eradication rate, and adverse event rate 7.

Considerations for Treatment

• The choice of antibiotic should be based on local resistance patterns and patient-specific factors 4, 6.
• Fluoroquinolones such as ciprofloxacin and levofloxacin may not be ideal empiric antibiotics for treatment of outpatient UTI in areas with high resistance rates 6.
• Nitrofurantoin and other antibiotics with lower resistance rates may be acceptable options for treatment of outpatient UTI 6.
• Further study is needed to determine the efficacy of levofloxacin compared to ciprofloxacin for treatment of E. coli-induced chronic bacterial prostatitis (CBP) 7.