What are the recommended antibiotics for treating a urinary tract infection (UTI) in males?

From the Guidelines

The most effective antibiotic for treating a urinary tract infection (UTI) in males is typically trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days, as recommended by the European Association of Urology guidelines 1. When considering treatment options, it's essential to take into account the severity of the illness, local resistance patterns, and specific host factors, such as allergies.

• The treatment duration may vary depending on the underlying abnormality, but generally, a 7-14 day course is recommended, with 14 days being the standard for men when prostatitis cannot be excluded 1.
• Fluoroquinolones, such as ciprofloxacin, can be effective but are usually reserved as second-line agents due to resistance concerns and side effects.
• Nitrofurantoin is another option, but its use may be limited due to the higher likelihood of antimicrobial resistance in complicated UTIs.
• Urine culture and susceptibility testing should be performed to guide the choice of antibiotic and ensure optimal treatment.
• Patients should complete the entire prescribed course, even if symptoms improve quickly, and drink plenty of water to help flush bacteria from the system.
• It's crucial to seek prompt medical attention if symptoms worsen or don't improve within 48 hours of starting antibiotics. The European Association of Urology guidelines emphasize the importance of appropriate management of the urological abnormality or underlying complicating factor, as well as considering local resistance patterns and specific host factors when selecting an antibiotic 1.

From the FDA Drug Label

CLINICAL STUDIES Complicated Urinary Tract Infection and Pyelonephritis – Efficacy in Pediatric Patients

Ciprofloxacin, administered I. V. and/or orally, was compared to a cephalosporin for treatment of complicated urinary tract infections (cUTI) and pyelonephritis in pediatric patients 1 to 17 years of age (mean age of 6 ± 4 years).

The clinical success and bacteriologic eradication rates in the Per Protocol population were similar between ciprofloxacin and the comparator group as shown below

Clinical Success and Bacteriologic Eradication at Test of Cure (5 to 9 Days Post-Therapy) CiprofloxacinComparator

• Patients with baseline pathogen(s) eradicated and no new infections or superinfections/total number of patients. There were 5.5% (6/211) ciprofloxacin and 9. 5% (22/231) comparator patients with superinfections or new infections.

Randomized Patients 337 352 Per Protocol Patients 211 231 Clinical Response at 5 to 9 Days Post-Treatment 95.7% (202/211) 92.6% (214/231) 95% CI [-1.3%, 7.3%] Bacteriologic Eradication by Patient at 5 to 9 Days Post-Treatment* 84.4% (178/211) 78.3% (181/231) 95% CI [-1.3%, 13. 1%]

The recommended antibiotics for treating a urinary tract infection (UTI) in males are ciprofloxacin and amoxicillin-clavulanate.

• Ciprofloxacin has been shown to have a clinical success rate of 95.7% and a bacteriologic eradication rate of 84.4% in the treatment of complicated urinary tract infections and pyelonephritis 2.
• Amoxicillin-clavulanate has been shown to have comparable bacteriological success rates in patients with complicated urinary tract infections, with a success rate of 81% at 2 to 4 days post-therapy 3. Key points:
• The choice of antibiotic should be based on the severity of the infection, the patient's medical history, and the susceptibility of the causative organism.
• It is essential to note that ciprofloxacin is not a drug of first choice in the pediatric population due to an increased incidence of adverse events.
• Amoxicillin-clavulanate is an alternative option for the treatment of UTIs in males, but its effectiveness may vary depending on the specific circumstances of the infection.

From the Research

Recommended Antibiotics for UTI in Males

• The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis is not explicitly stated for males in the provided studies, but for females, it includes a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 4, 5.
• Second-line options for UTIs include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones, and β-lactams, such as amoxicillin-clavulanate 4, 5.
• For males, fluoroquinolones were more often prescribed than for females, while nitrofurantoin was prescribed less often for males than for females 6.
• Amoxicillin-clavulanate may be a useful alternative therapy for the treatment of ceftriaxone non-susceptible Enterobacterales UTIs 7.

Treatment Duration and Outcomes

• The study suggests that male and female UTI patients should initially be treated with first-line antimicrobials (nitrofurantoin) with different durations (50-100 mg four times daily for three days in females and seven days for males) 6.
• Reconsultation was similar for males and females if the antimicrobial prescribed was first-line, but higher for females if the prescribed antimicrobial was not first-line 6.
• Amoxicillin-clavulanate recipients did not have higher failure rates compared to standard of care recipients for ceftriaxone non-susceptible UTIs 7.

Comparative Effectiveness of Antibiotics

• A network meta-analysis of randomized trials compared the efficacies and adverse effects of different antibiotics for uncomplicated UTIs, ranking ciprofloxacin and gatifloxacin as the most effective treatments, and amoxicillin-clavulanate as the least effective treatment 8.
• The analysis found no significant differences in adverse effects between the antibiotic treatments 8.