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

Treatment of Urinary Tract Infections in Men

For male UTIs, a 7-day course of antibiotics is recommended as first-line therapy for most cases, with 14-day courses reserved for cases where prostatitis cannot be excluded. 1

Classification and Diagnostic Approach

• All UTIs in males are classified as complicated UTIs according to European Association of Urology guidelines 1
• Urine culture and susceptibility testing should always be performed before initiating therapy to guide appropriate antibiotic selection 1
• The microbial spectrum in male UTIs is broader than in uncomplicated UTIs, including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1

Empiric Antibiotic Selection

• First-line empiric 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:

  • Fluoroquinolones may be used if local resistance rates are <10% 1
  • Trimethoprim-sulfamethoxazole is an appropriate option when susceptibility is confirmed 2
  • Avoid fluoroquinolones if the patient has used them in the last 6 months 1

Treatment Duration

• Traditional recommendations suggested 10-14 days of therapy for UTIs in men 2
• Recent evidence supports shorter treatment durations:
  • 7-day course is appropriate for men who are hemodynamically stable and have been afebrile for at least 48 hours 1
  • Drekonja et al. found that 7-day treatment with either fluoroquinolones or trimethoprim/sulfamethoxazole was non-inferior to 14-day treatment in men with UTI 3
  • A 2019 study found no clinical benefit to treating male UTIs longer than 7 days in men without complicating conditions 4
• Extended 14-day therapy is still recommended when prostatitis cannot be excluded 1

Special Considerations

• For catheter-associated UTIs:

  • Remove or change the catheter when possible 1
  • Choose antibiotics based on local resistance patterns 1

• For UTIs with systemic symptoms:

  • Consider initial parenteral therapy until clinical improvement 1
  • Switch to oral therapy once the patient is clinically stable 1

• For patients with structural abnormalities:

  • Management of the underlying urological abnormality is mandatory alongside antibiotic therapy 1
  • Longer treatment courses may be necessary 1

Follow-up Management

• Always tailor therapy based on culture results once available 1
• Consider imaging studies if recurrent infections occur to rule out anatomical abnormalities 1

Common Pitfalls to Avoid

• Failing to obtain urine culture before starting antibiotics 1
• Using fluoroquinolones empirically in areas with high resistance rates (>10%) 1
• 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 many patients 4
• Not addressing underlying anatomical or functional abnormalities that may contribute to infection 1