What is the recommended treatment for a urinary tract infection (UTI) in males?

Treatment of Urinary Tract Infections in Males

For male patients with urinary tract infections (UTIs), a 14-day course of antibiotics is strongly recommended when prostatitis cannot be excluded, though a 7-day course may be sufficient for uncomplicated cases with prompt symptom resolution. 1

First-Line Treatment Options

Empiric Therapy for Male UTIs

• For complicated UTI with systemic symptoms:

  • Use one of the following combinations 1:
    • Amoxicillin plus an aminoglycoside
    • A second-generation cephalosporin plus an aminoglycoside
    • An intravenous third-generation cephalosporin

• For outpatient treatment when hospitalization is not required:

  • Trimethoprim-sulfamethoxazole 160/800mg twice daily for 7-14 days (when local resistance is <20%) 2, 3
  • Fluoroquinolones (if local resistance <10% and patient has not used fluoroquinolones in the last 6 months) 1:
    • Ciprofloxacin 500-750mg twice daily
    • Levofloxacin 750mg once daily

Duration of Treatment

• Standard duration: 14 days when prostatitis cannot be excluded 1
• Shorter duration: 7 days may be considered when 1, 4:
  • Patient is hemodynamically stable
  • Patient has been afebrile for at least 48 hours
  • Symptoms resolve promptly
  • No evidence of prostate involvement

Treatment Considerations

Antibiotic Selection Factors

1. Local resistance patterns - Critical for empiric therapy success 1, 2
2. Patient allergies - Consider alternative classes if allergies present 2
3. Recent antibiotic exposure - Avoid fluoroquinolones if used in past 6 months 1
4. Renal function - Dosage adjustments may be required 2:
   • Levofloxacin requires adjustment when creatinine clearance <50 mL/min

Culture and Susceptibility Testing

• Always obtain urine culture before initiating therapy 1
• Adjust empiric therapy based on culture results and susceptibility testing 1

Special Considerations

Catheter-Associated UTIs

• Treat according to recommendations for complicated UTIs 1
• Remove or replace catheter when possible 1
• Higher risk of antimicrobial resistance and treatment failure 1

Prostatitis Considerations

• Male UTIs often involve the prostate, requiring longer treatment duration 1
• For chronic bacterial prostatitis, levofloxacin is indicated for treatment of infections due to E. coli, E. faecalis, or S. epidermidis 5

Evidence for Shorter Treatment Duration

Recent research supports shorter treatment courses in select patients:

• A 2021 randomized clinical trial demonstrated that 7 days of ciprofloxacin or trimethoprim/sulfamethoxazole was noninferior to 14 days for afebrile men with UTI 4
• A post-hoc analysis of a clinical trial showed that males with UTI may be successfully treated with a 5-day course of levofloxacin 750mg daily 6

Important Cautions

• Avoid fluoroquinolones when:

  • Local resistance rates exceed 10% 1
  • Patient has used fluoroquinolones in the past 6 months 1
  • Patient has risk factors for adverse effects (tendon damage, peripheral neuropathy) 2

• Management of underlying factors:

  • Always address any urological abnormalities or complicating factors 1
  • Consider urological evaluation for men with recurrent UTIs 2

Follow-up Recommendations

• Obtain surveillance urine culture 1 week after completing therapy to ensure resolution, particularly for complicated UTIs 2
• Evaluate for symptom resolution within 14 days after completing antibiotics 4
• Consider longer follow-up for patients with risk factors for recurrence or complications 2