Treatment of Male Urinary Tract Infections
For male urinary tract infections (UTIs), treatment should consist of 14 days of appropriate antibiotics when prostatitis cannot be excluded, with empiric therapy tailored based on local resistance patterns and patient factors. 1
Classification and Diagnostic Considerations
- All UTIs in males are classified as complicated UTIs according to European Association of Urology guidelines 1, 2
- Urine culture and susceptibility testing should always be performed before initiating therapy to guide appropriate antibiotic selection 1, 2
- The microbial spectrum in male UTIs is broader than in uncomplicated UTIs, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1
- Antimicrobial resistance is more likely in male UTIs compared to uncomplicated UTIs 1
Empiric Antibiotic Therapy
First-line options (for systemic symptoms):
- Amoxicillin plus an aminoglycoside 1
- A second-generation cephalosporin plus an aminoglycoside 1
- An intravenous third-generation cephalosporin 1
For oral therapy (when hospitalization not required):
- Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) may be used if local resistance rates are <10% 1, 3
- Trimethoprim-sulfamethoxazole is an alternative option based on local susceptibility patterns 4, 5
Important cautions:
- Do not use fluoroquinolones for empirical treatment if the patient has used them in the last 6 months 1
- Fluoroquinolone use should be restricted due to increasing resistance rates 6
- Consider local resistance patterns when selecting empiric therapy 1, 5
Treatment Duration
- Treatment for 14 days is generally recommended for men when prostatitis cannot be excluded 1
- A 7-day course may be considered when the patient is hemodynamically stable and has been afebrile for at least 48 hours 1
- Recent evidence suggests that shorter treatment duration (7 days) may be non-inferior to longer courses (14 days) in men without complicating conditions 1, 7
- One study found that 7-day treatment with fluoroquinolones or trimethoprim-sulfamethoxazole was non-inferior to 14-day treatment in men with complicated UTIs 1, 8
Management of Special Situations
- For catheter-associated UTIs, remove or change the catheter when possible 1
- For UTIs with systemic symptoms, consider initial parenteral therapy until clinical improvement 1
- In patients with structural abnormalities, management of the underlying urological abnormality is mandatory alongside antibiotic therapy 1, 2
Follow-up Considerations
- Tailor therapy based on culture results once available 1, 2
- Consider imaging studies if recurrent infections occur to rule out anatomical abnormalities 2
- Longer treatment duration is associated with increased recurrence in men without complicating conditions, suggesting that shorter courses may be preferable when appropriate 7
Common Pitfalls to Avoid
- Failing to obtain urine culture before starting antibiotics 1, 2
- Using fluoroquinolones empirically in areas with high resistance rates (>10%) 1, 5
- Not considering prostatitis as a complication of UTI in men, which requires longer treatment 1
- Treating all male UTIs with prolonged courses when shorter durations may be appropriate for certain patients 1, 7
- Not addressing underlying anatomical or functional abnormalities that may contribute to infection 1, 2