What is the management of urinary tract infections (UTIs) in men?

Management of Urinary Tract Infections in Men

The management of UTIs in men should include empiric antibiotic therapy with fluoroquinolones (such as ciprofloxacin or levofloxacin) for 7 days, which has been shown to be as effective as 14-day regimens while minimizing antibiotic resistance risk. 1

Diagnostic Approach

• Obtain urine culture before starting antibiotics to guide targeted therapy
• Evaluate for anatomical abnormalities or complications that may require additional intervention
• Consider imaging if there are signs of obstruction or recurrent infections

Antibiotic Selection

First-line Options:

• Fluoroquinolones (e.g., ciprofloxacin or levofloxacin)
  • Associated with lower antibiotic switch rates compared to other antibiotics 2
  • Levofloxacin is FDA-approved for complicated UTIs and chronic bacterial prostatitis 3
  • Consider local resistance patterns; avoid if local resistance exceeds 10% 4

Alternative Options:

• Trimethoprim-sulfamethoxazole (TMP-SMX)
  • FDA-approved for UTIs due to susceptible organisms 5
  • Effective option if local resistance rates are <10-20% 6
  • 7-day course shown to be noninferior to 14 days in afebrile men 1

Treatment Duration:

• 7 days of antibiotic therapy is generally sufficient for uncomplicated UTIs in men 1
• Consider longer duration (10-14 days) for:
  • Complicated infections
  • Prostatitis
  • Recurrent infections
  • Immunocompromised patients

Special Considerations

Obstructive Uropathy with Infection

• Urgent decompression is lifesaving and should not be delayed 4
• Retrograde ureteral stenting is preferred over percutaneous nephrostomy due to:
  • Better patient comfort
  • Lower rate of subsequent interventions
  • Reduced hospital stay 4

Chronic Bacterial Prostatitis

• Levofloxacin is FDA-approved for chronic bacterial prostatitis due to E. coli, E. faecalis, or methicillin-susceptible S. epidermidis 3
• Longer treatment duration (4-6 weeks) is typically required

Antibiotic Resistance Concerns

• Local resistance patterns should guide empiric therapy
• Avoid TMP-SMX in areas where resistance exceeds 20% 6
• Fluoroquinolones should be used judiciously due to risk of tendinopathy, QT prolongation, and CNS effects 4

Antibiotic Dosing Adjustments

• Adjust dosing based on creatinine clearance:

  Creatinine Clearance	Levofloxacin Dosing
  ≥50 mL/min	Standard dosing
  26-49 mL/min	500 mg once daily
  10-25 mL/min	250 mg once daily
  Hemodialysis	250-500 mg every 48 hours (post-HD on dialysis days) 4

Prevention Strategies

• Increased fluid intake
• Treatment of underlying conditions (e.g., urinary obstruction, stones)
• Avoid treating asymptomatic bacteriuria unless in specific populations (e.g., prior to urological procedures) 4

Follow-up

• Repeat urine culture if symptoms persist after completion of antibiotic course
• Consider urological evaluation for:
  • Recurrent UTIs
  • Failure to respond to appropriate therapy
  • Suspected anatomical abnormalities

The European Association of Urology emphasizes the importance of antimicrobial stewardship to combat rising antibiotic resistance in the management of urological infections 7. A 7-day course of fluoroquinolones or TMP-SMX has been demonstrated to be as effective as a 14-day course for afebrile men with UTI, supporting shorter treatment durations to minimize resistance development 1.