What are the best antibiotics for treating urinary tract infections (UTIs) in men?

Best Antibiotics for UTI in Men

For men with urinary tract infections (UTIs), a 14-day course of fluoroquinolones (ciprofloxacin or levofloxacin) is recommended as first-line therapy when local fluoroquinolone resistance is <10%, with trimethoprim-sulfamethoxazole as an alternative option. 1, 2

Classification and Approach

UTIs in men are classified as complicated UTIs according to the European Association of Urology guidelines, which has important implications for treatment 1:

• Male UTIs require longer treatment duration (14 days) compared to uncomplicated UTIs in women
• Broader spectrum antibiotics may be needed due to higher risk of resistant organisms
• Prostatitis should be considered when treating male UTIs, as it cannot be easily excluded

First-line Antibiotic Options

Oral Options for Outpatient Treatment:

• Fluoroquinolones (when local resistance <10%):
  • Ciprofloxacin 500-750 mg twice daily for 14 days
  • Levofloxacin 750 mg once daily for 14 days 1, 2

Alternative Oral Options:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days
• Cephalosporins (e.g., cefpodoxime 200 mg twice daily for 14 days)
• Amoxicillin-clavulanate 500/125 mg twice daily for 14 days 2

Inpatient Treatment for Severe Infections

For severe infections requiring hospitalization, initial IV therapy is recommended with:

• Fluoroquinolones:
  • Ciprofloxacin 400 mg IV twice daily
  • Levofloxacin 750 mg IV once daily
• Extended-spectrum cephalosporins:
  • Ceftriaxone 1-2 g IV once daily
• Aminoglycosides:
  • Gentamicin 5 mg/kg IV once daily
  • Amikacin 15 mg/kg IV once daily 1

Once clinical improvement occurs, transition to oral therapy to complete a 14-day course.

Important Considerations

1. Obtain urine culture before starting antibiotics to guide therapy if empiric treatment fails 2

2. Fluoroquinolone cautions:

   • Despite being first-line for male UTIs, fluoroquinolones carry FDA warnings for serious adverse effects
   • Use with caution in patients with aortic aneurysm risk, history of tendinopathy, or prolonged QT interval 2

3. Treatment duration:

   • 14 days is standard for male UTIs when prostatitis cannot be excluded 1
   • Some evidence suggests 5-day courses of high-dose levofloxacin (750 mg daily) may be effective in certain cases 3, but this remains controversial and the standard recommendation remains 14 days

4. Antibiotic resistance considerations:

   • Local resistance patterns should guide empiric therapy
   • E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., and Enterococcus spp. are common pathogens in male UTIs 1
   • Resistance to fluoroquinolones should be <10% for empiric use 1

5. Special populations:

   • For men with renal impairment, adjust levofloxacin dosing based on creatinine clearance 2
   • For catheter-associated UTIs, consider broader coverage for resistant organisms

Follow-up and Treatment Failure

• Assess clinical response within 48-72 hours of initiating therapy
• If symptoms persist after completing treatment, perform follow-up urine culture
• Consider urological evaluation for structural abnormalities if recurrent infections occur

Common Pitfalls to Avoid

1. Treating too short: Male UTIs require longer treatment (14 days) than female uncomplicated UTIs
2. Not obtaining cultures: Always collect urine culture before starting antibiotics
3. Ignoring local resistance patterns: Empiric therapy should be guided by local antibiotic susceptibility data
4. Overlooking prostatitis: Male UTIs often involve the prostate, requiring longer treatment duration
5. Missing structural abnormalities: Consider urological evaluation in men with recurrent UTIs