What antibiotics should be used to empirically treat a 22-year-old sexually active male with urinary frequency and urgency, but without penile discharge, and a negative urine dipstick (urinalysis) result, while awaiting urine culture results?

Empiric Antibiotic Treatment for Sexually Active Male with Urinary Symptoms

For a 22-year-old sexually active male with urinary frequency and urgency without penile discharge and negative urine dipstick, empiric treatment with doxycycline 100 mg orally twice daily for 7 days is recommended while awaiting urine culture results. 1

Clinical Assessment

• In young sexually active males with urinary symptoms but no penile discharge, non-gonococcal urethritis (NGU) is a common cause, particularly due to Chlamydia trachomatis and Mycoplasma genitalium 1
• Negative urine dipstick does not rule out urethritis or sexually transmitted infections, as these may not cause significant pyuria detectable on dipstick 2, 3
• Male UTIs are considered complicated UTIs by definition, requiring different management than uncomplicated UTIs in women 1

Recommended Empiric Treatment

• First-line therapy: Doxycycline 100 mg orally twice daily for 7 days 1

  • Effective against Chlamydia trachomatis, which is a common cause of urethritis in young sexually active males 1
  • Provides good coverage for Mycoplasma genitalium, another important pathogen in this population 1

• Alternative regimens (if doxycycline contraindicated):

  • Azithromycin 1 g orally in a single dose 1
  • Erythromycin base 500 mg orally four times a day for 7 days 1

Rationale for Treatment Choice

• In young sexually active males with urinary symptoms, sexually transmitted infections are more likely than bacterial UTI, particularly with negative dipstick 1, 2
• Male UTIs are classified as complicated UTIs, with E. coli causing only about 48% of infections (compared to 80-90% in females) 4
• Fluoroquinolones should be avoided for empiric therapy due to:
  • Increasing resistance rates (up to 49.9% for ciprofloxacin) 5
  • EAU guidelines recommend against fluoroquinolones for empiric treatment when patients have used them in the last 6 months 1
  • Risk of adverse effects including tendinopathy 6

Additional Management Considerations

• Obtain urine culture before starting antibiotics whenever possible 1, 7
• Consider testing for gonorrhea and chlamydia with nucleic acid amplification tests 1
• Evaluate and treat sexual partners if STI is confirmed 1
• If symptoms persist after treatment, consider:
  • Resistant organisms
  • Non-infectious causes
  • Need for urologic evaluation 1

Special Considerations

• If the patient has systemic symptoms (fever, flank pain) suggesting pyelonephritis or complicated infection, broader coverage may be needed 1
• For patients with risk factors for complicated UTI (obstruction, recent instrumentation), consider broader spectrum antibiotics 1
• Instruct patient to return if symptoms worsen or fail to improve within 3 days 1