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

Treatment of Male Urinary Tract Infections

For male urinary tract infections, treatment should include a 14-day course of antibiotics when prostatitis cannot be excluded, with empiric therapy options including amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin. 1

Classification and Considerations

• UTIs in males are classified as complicated UTIs, requiring special consideration for treatment duration and antibiotic selection 1
• Male UTIs often involve a broader microbial spectrum than uncomplicated UTIs, with higher likelihood of antimicrobial resistance 1
• Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1

Diagnostic Approach

• Obtain urine culture and susceptibility testing before initiating antimicrobial therapy 1
• Evaluate for underlying urological abnormalities or complicating factors that may require management 1
• Consider the possibility of prostatitis, which affects treatment duration and antibiotic selection 1

Empiric Treatment Recommendations

First-line options (with systemic symptoms):

• Combination therapy with one of the following 1:
  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin

Alternative options (specific situations):

• Ciprofloxacin may be used only when 1:
  • Local resistance rate is <10%
  • The entire treatment is given orally
  • The patient does not require hospitalization
  • The patient has anaphylaxis to β-lactam antimicrobials

Important Cautions

• Do not use fluoroquinolones for empiric treatment if 1:
  • The patient is from a urology department
  • The patient has used fluoroquinolones in the last 6 months
• Fluoroquinolone resistance should be <10% for these agents to be effective 1
• Initial empiric therapy should be tailored based on culture results 1

Treatment Duration

• Treatment for 14 days is generally recommended for men when prostatitis cannot be excluded 1, 2
• A recent randomized controlled trial demonstrated that 7-day treatment with ofloxacin was inferior to 14-day treatment for febrile UTI in men 2
• When the patient is hemodynamically stable and has been afebrile for at least 48 hours, a shorter treatment duration (e.g., 7 days) may be considered in specific cases 1

Management of Underlying Conditions

• Appropriate management of any urological abnormality or underlying complicating factor is mandatory 1
• Consider evaluation for structural or functional abnormalities of the urinary tract that may contribute to infection 1

Antibiotic Options Based on Culture Results

• For susceptible organisms, trimethoprim-sulfamethoxazole may be used 3, 4
• Levofloxacin is approved for complicated UTIs due to susceptible organisms 5
• For multidrug-resistant organisms, treatment should be guided by susceptibility testing 6, 7

Follow-up Recommendations

• Monitor for resolution of symptoms and consider follow-up urine culture in complicated cases 1
• Address any identified underlying abnormalities to prevent recurrence 1
• Consider longer-term suppressive therapy for patients with recurrent infections 4