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

Treatment of Male Urinary Tract Infections

For male urinary tract infections, a 7-day course of fluoroquinolones or trimethoprim/sulfamethoxazole is recommended as first-line therapy, with treatment extension to 14 days when prostatitis cannot be excluded. 1

Classification and Diagnostic Considerations

• Male UTIs are classified as complicated UTIs due to anatomical and physiological factors, requiring special consideration for treatment duration and antibiotic selection 1
• The microbial spectrum is broader than for uncomplicated UTIs, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 2, 1
• Urine culture and susceptibility testing should be obtained before initiating antimicrobial therapy to guide targeted treatment 1

Empiric Antibiotic Selection

• First-line empiric options include:

  • Fluoroquinolones (when local resistance is <10%) 1
  • Trimethoprim-sulfamethoxazole (standard adult dosage: 1 double-strength tablet every 12 hours) 3
  • Amoxicillin plus an aminoglycoside 1
  • Second or third-generation cephalosporins 1

• Important considerations for antibiotic selection:

  • Fluoroquinolones should be avoided if the patient has used them in the last 6 months or is from a urology department 1
  • Local resistance patterns should guide empiric therapy choices 2, 1
  • For patients requiring hospitalization, initial intravenous therapy may be necessary until clinical improvement 2

Treatment Duration

• Standard treatment duration for male UTIs is 7-14 days 2, 1
• A 7-day course of either fluoroquinolones or trimethoprim/sulfamethoxazole has been shown to be non-inferior to a 14-day course in an adequately powered study specifically in men 2
• Treatment should be extended to 14 days when prostatitis cannot be excluded 1
• Recent evidence suggests that men with UTI without complicating conditions do not need to be treated for longer than 7 days 4

Special Considerations

• Evaluate for and manage any underlying urological abnormalities or complicating factors 2, 1
• For patients with antimicrobial resistance concerns:
  • Consider alternative agents based on local susceptibility patterns 2, 5
  • Reserve carbapenems and novel broad-spectrum antimicrobials for patients with multidrug-resistant organisms 2
• Patients with high fever, chills, or signs of systemic infection may require initial intravenous therapy until symptoms subside 6

Follow-up Recommendations

• Monitor for symptom resolution and consider follow-up urine culture in complicated cases 1
• Address any identified underlying abnormalities to prevent recurrence 1
• Shorter treatment durations (7 days vs. 14 days) have not been associated with increased risk of recurrence in uncomplicated male UTIs 4

Common Pitfalls to Avoid

• Using fluoroquinolones empirically when local resistance rates exceed 10% 1
• Failing to obtain urine culture before initiating antibiotics 1
• Not evaluating for underlying structural or functional abnormalities that may contribute to infection or recurrence 2, 1
• Unnecessarily prolonged antibiotic courses in uncomplicated cases, which may increase risk of resistance and adverse effects 4