What is the first-line treatment for urinary tract infections (UTIs) in men?

First-Line Treatment for Urinary Tract Infections in Men

Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 7 days is the first-line treatment for urinary tract infections in men. 1, 2

Classification and Approach to Male UTIs

• Male UTIs are classified as complicated UTIs, requiring special consideration due to anatomical differences and higher likelihood of antimicrobial resistance 3
• Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., and Enterococcus spp. 3
• Urine culture and susceptibility testing should be obtained before initiating antimicrobial therapy to guide targeted treatment 3

First-Line Treatment Options

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is specifically recommended for men with UTIs 1
• Fluoroquinolones can be prescribed as an alternative, but only in accordance with local susceptibility testing 1
• Longer treatment duration (7 days) is required for men compared to the shorter courses (3-5 days) recommended for women 1

Treatment Considerations

• Male gender itself is a complicating factor for UTIs, requiring longer treatment courses and consideration of prostate involvement 3, 4
• A 14-day treatment course is recommended when prostatitis cannot be excluded 3
• Limited evidence is available specifically for male UTIs - one study compared TMP-SMX for 14 days versus 42 days in men, with similar outcomes 4

Antibiotic Resistance Concerns

• Fluoroquinolones should be reserved for cases where first-line agents cannot be used due to resistance or allergies 1
• The FDA has issued an advisory warning against using fluoroquinolones for uncomplicated UTIs due to potential serious adverse effects 1
• E. coli resistance rates to TMP-SMX can be high (46.6% in some studies), so local resistance patterns should be considered 5

Alternative Treatment Options

• If TMP-SMX cannot be used due to resistance or allergies, consider:
  • Nitrofurantoin (if lower UTI only, not for pyelonephritis or prostatitis) 6, 7
  • Cephalosporins such as cefuroxime 5
  • Fosfomycin (though less data exists for its use in men) 6, 5

Monitoring and Follow-up

• Reassess after 48-72 hours of empiric therapy to evaluate clinical response 3
• Adjust therapy based on culture and susceptibility results 3
• Complete the full treatment course even after symptom resolution to prevent relapse and potential prostate involvement 3

Common Pitfalls to Avoid

• Do not use shorter treatment courses (<7 days) in males as this can lead to treatment failure 1, 3
• Avoid fluoroquinolones as empiric therapy if local resistance rates exceed 10% or if the patient has used fluoroquinolones in the past 6 months 3
• Do not neglect evaluation for underlying structural or functional abnormalities that may contribute to infection 3
• Avoid treating asymptomatic bacteriuria in men, as this can increase the risk of antimicrobial resistance 1