What is the treatment for a male urinary tract infection (UTI)?

Treatment of Male Urinary Tract Infections

Male urinary tract infections (UTIs) should be treated as complicated UTIs with trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days, or with fluoroquinolones if local resistance patterns permit. 1

Classification and Diagnosis

Male UTIs are classified as complicated UTIs according to the European Association of Urology (EAU) guidelines, as they typically involve structural or functional abnormalities that make them more challenging to treat than uncomplicated UTIs in women 1.

Key diagnostic steps:

• Obtain urine culture before starting antibiotics to confirm the causative pathogen
• Consider local resistance patterns when selecting empiric therapy
• Evaluate for underlying anatomical or functional abnormalities

Antimicrobial Treatment Options

First-line Treatment

• Trimethoprim-sulfamethoxazole (TMP-SMX): 160/800 mg twice daily for 7-14 days 1, 2
  • Particularly effective when local resistance rates are low
  • Extended duration (14 days) recommended when prostatitis cannot be excluded 1

Alternative Options (if TMP-SMX contraindicated or high local resistance):

• Fluoroquinolones (if local resistance <10%):
  • Ciprofloxacin: 500-750 mg twice daily for 7 days 1, 3
  • Levofloxacin: 750 mg once daily for 5-7 days 1

For Hospitalized Patients with Severe Infection:

Initial IV therapy with:

• Fluoroquinolones (ciprofloxacin 400 mg twice daily or levofloxacin 750 mg daily)
• Extended-spectrum cephalosporins (ceftriaxone 1-2 g daily)
• Aminoglycosides (with or without ampicillin)
• Piperacillin-tazobactam (2.5-4.5 g three times daily) 1

Treatment Duration

• Standard treatment: 7-14 days 1
• Extended treatment (14 days) when prostatitis cannot be excluded 1
• Consider shorter duration (7 days) only when the patient has been afebrile for at least 48 hours and is hemodynamically stable 1

Special Considerations

Microbial Spectrum

Male UTIs typically involve a broader microbial spectrum than uncomplicated UTIs, with higher likelihood of antimicrobial resistance 1. Common pathogens include:

• E. coli
• Proteus species
• Klebsiella species
• Pseudomonas species
• Enterococcus species

Management of Underlying Factors

• Address any urological abnormalities or underlying complicating factors 1
• Consider urological evaluation for structural abnormalities, especially in recurrent cases

Follow-up

• Adjust therapy based on culture results and susceptibility testing
• Consider repeat urine culture after treatment completion to confirm eradication

Pitfalls and Caveats

1. Avoid short-course therapy: Unlike uncomplicated UTIs in women, male UTIs require longer treatment durations (7-14 days) 1, 4

2. Don't overlook prostatitis: Prostate involvement is common in male UTIs and may require extended treatment duration (14 days) 1

3. Consider local resistance patterns: Empiric therapy should be guided by local antibiotic resistance data, particularly for fluoroquinolones 1, 5

4. Tailor therapy based on culture results: Initial empiric therapy should be adjusted once culture and sensitivity results are available 1

5. Evaluate for structural abnormalities: Underlying urological conditions often contribute to male UTIs and may require specific management 1

Male UTIs should be approached systematically with appropriate antimicrobial therapy and evaluation for underlying abnormalities to ensure effective treatment and prevent recurrence or complications.