What is the recommended treatment for urinary tract infections (UTIs) in men?

Treatment for UTIs in Men

For urinary tract infections in men, the recommended treatment is a 7-14 day course of antibiotics, with first-line options including trimethoprim-sulfamethoxazole (TMP-SMX), nitrofurantoin, or fluoroquinolones based on local resistance patterns. 1

Diagnostic Approach

• Obtain urinalysis and urine culture before starting antibiotics
• Culture confirmation is essential for tailoring therapy based on bacterial sensitivities
• Treatment may be started empirically while awaiting culture results

Antibiotic Selection for Men with UTIs

First-Line Options

• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 7-14 days
  • Use only if local resistance is <20%
  • Avoid in patients with sulfa allergies
• Nitrofurantoin: 100 mg twice daily for 7 days
  • Contraindicated if CrCl <30 mL/min
  • Highly effective against E. coli (which causes >75% of UTIs)
• Fluoroquinolones (e.g., levofloxacin): While generally reserved as second-line, may be appropriate first-line in men due to concerns about prostate involvement 1, 2
  • Levofloxacin 250-500 mg once daily for 7-14 days
  • Good penetration into prostatic tissue

Alternative Options

• Cephalexin: 500 mg four times daily for 7 days
• Amoxicillin-clavulanate: Based on susceptibility testing
• Fosfomycin: 3 g single dose, may require multiple doses for men

Important Considerations for Men with UTIs

Treatment Duration

• Men typically require longer treatment courses (7-14 days) than women with uncomplicated UTIs 1, 2
• This extended duration is due to the higher likelihood of complicated infection and potential prostatic involvement

Special Considerations

• Prostate Involvement: UTIs in men often involve the prostate, requiring antibiotics with good prostatic penetration 2

  • Fluoroquinolones achieve good prostatic concentrations
  • For bacterial prostatitis, treatment duration may extend to 14-42 days 3

• Renal Function: Adjust dosing based on creatinine clearance 1

  • For levofloxacin:
    • CrCl ≥50 mL/min: 500 mg once daily
    • CrCl 26-49 mL/min: 500 mg once daily
    • CrCl 10-25 mL/min: 250 mg once daily

• Recurrent UTIs: Consider urologic evaluation to identify underlying structural abnormalities

Antibiotic Resistance Considerations

• Local antibiogram patterns should guide empiric therapy 1, 4
• Increasing resistance to TMP-SMX and aminopenicillins has been observed 2, 4
• Fluoroquinolones generally maintain good activity against uropathogens but should be used judiciously due to resistance concerns 4

Follow-up

• Monitor for symptom resolution within 48-72 hours
• If symptoms persist, reassess with repeat culture and consider urologic evaluation
• Consider imaging studies if recurrent infections or concern for anatomic abnormalities

Common Pitfalls

• Undertreating: Men require longer treatment courses than women with uncomplicated UTIs
• Missing prostatitis: Consider prostate involvement in all men with UTIs
• Ignoring resistance patterns: Local antibiograms should guide empiric therapy
• Inadequate follow-up: Men with UTIs may require urologic evaluation, especially with recurrent infections