What is the treatment for a male urinary tract infection (UTI) with intravenous (IV) antibiotics?

Treatment of Male UTI with IV Antibiotics

For male urinary tract infections requiring intravenous therapy, fluoroquinolones (ciprofloxacin 400 mg BID or levofloxacin 750 mg daily), extended-spectrum cephalosporins (ceftriaxone 1-2 g daily), or piperacillin-tazobactam (2.5-4.5 g TID) are recommended as first-line empiric treatments. 1

Classification and Approach

Male UTIs are classified as complicated UTIs according to the European Association of Urology guidelines, requiring special consideration in treatment approach 1. This classification is important because:

• Male UTIs have a broader microbial spectrum than uncomplicated UTIs
• Antimicrobial resistance is more likely
• Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp.

Empiric IV Antibiotic Options

First-line options:

• Fluoroquinolones:

  • Ciprofloxacin 400 mg IV twice daily
  • Levofloxacin 750 mg IV once daily
  • Note: Use only when local fluoroquinolone resistance is <10%

• Extended-spectrum cephalosporins:

  • Ceftriaxone 1-2 g IV once daily (higher dose recommended)
  • Cefotaxime 2 g IV three times daily
  • Cefepime 1-2 g IV twice daily (higher dose recommended)

• Penicillin combinations:

  • Piperacillin-tazobactam 2.5-4.5 g IV three times daily

• Aminoglycosides (with or without ampicillin):

  • Gentamicin 5 mg/kg IV once daily
  • Amikacin 15 mg/kg IV once daily

For suspected multidrug-resistant organisms:

• Carbapenems:

  • Imipenem-cilastatin 0.5 g IV three times daily 1, 2
  • Meropenem 1 g IV three times daily
  • Meropenem-vaborbactam 4 g IV every 8 hours (for CRE) 1
  • Imipenem-cilastatin-relebactam 1.25 g IV every 6 hours (for CRE) 1

• Newer agents:

  • Ceftazidime-avibactam 2.5 g IV every 8 hours (for CRE) 1
  • Ceftolozane-tazobactam 1.5 g IV every 8 hours 1

Treatment Duration

• Standard treatment duration for male UTIs is 7-14 days 1
• Longer duration (14 days) is recommended when prostatitis cannot be excluded 1
• A recent study showed that 7 days of treatment with ciprofloxacin or trimethoprim/sulfamethoxazole was noninferior to 14 days for afebrile men with UTI 3
• When the patient is hemodynamically stable and has been afebrile for at least 48 hours, a shorter treatment duration (7 days) may be considered 1

Important Considerations

1. Obtain cultures before starting antibiotics:

   • Essential for confirming diagnosis and guiding therapy if initial treatment fails 4
   • Particularly important in complicated UTIs where resistance is more common

2. Adjust therapy based on culture results:

   • Tailor treatment once susceptibility results are available
   • Switch to oral therapy when clinically appropriate

3. Address underlying factors:

   • Management of urological abnormalities or underlying complicating factors is mandatory 1
   • Evaluate for obstruction, foreign bodies, incomplete voiding, or immunosuppression

4. Monitor for improvement:

   • If symptoms persist after treatment or recur within 2 weeks, perform a new urine culture with antimicrobial susceptibility testing 4

Special Situations

For carbapenem-resistant Enterobacterales (CRE):

• Ceftazidime-avibactam 2.5 g IV every 8 hours 1
• Meropenem-vaborbactam 4 g IV every 8 hours 1
• Imipenem-cilastatin-relebactam 1.25 g IV every 6 hours 1
• Plazomicin 15 mg/kg IV every 12 hours (for complicated UTI) 1

For multidrug-resistant Pseudomonas:

• Ceftolozane-tazobactam 1.5-3 g IV every 8 hours 1
• Ceftazidime-avibactam 2.5 g IV every 8 hours 1
• Colistin-based therapy (when other options are not available) 1

Pitfalls to Avoid

1. Overuse of carbapenems and novel broad-spectrum agents:

   • Reserve these for patients with early culture results indicating multidrug-resistant organisms 1
   • Inappropriate use contributes to further antimicrobial resistance

2. Inadequate treatment duration:

   • Too short a course may lead to treatment failure
   • Too long a course increases risk of adverse effects and resistance

3. Failure to address underlying abnormalities:

   • UTIs in males often have an anatomic or functional abnormality that requires correction
   • Recurrence is likely if underlying causes are not addressed

4. Neglecting to obtain cultures:

   • Essential for guiding therapy in complicated UTIs
   • Particularly important given the higher likelihood of resistant organisms in male UTIs