What is the best treatment approach for a man with a urinary tract infection (UTI) caused by bacteria that has failed initial treatment?

Treatment for Failed UTI in Men

For men with a urinary tract infection (UTI) that has failed initial treatment, the recommended approach is to use a combination of antimicrobials such as amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin, based on culture results and local resistance patterns. 1

Understanding UTIs in Men

• UTIs in men are considered complicated UTIs by definition, making them more challenging to eradicate compared to uncomplicated infections 1
• Male UTIs require longer treatment duration (typically 7-14 days) than uncomplicated UTIs in women 1
• The microbial spectrum in complicated UTIs is broader, with higher likelihood of antimicrobial resistance 1

Diagnostic Approach for Treatment Failure

• Obtain a urine culture with antimicrobial susceptibility testing to guide therapy selection 1, 2
• Consider the possibility of underlying anatomical or functional abnormalities that may be contributing to treatment failure 1
• Evaluate for potential complicating factors such as:
  • Obstruction in the urinary tract 1
  • Incomplete voiding 1
  • Recent instrumentation 1
  • Presence of ESBL-producing or multidrug-resistant organisms 1

Treatment Recommendations

First-line Treatment Options

• For empiric treatment while awaiting culture results:
  • Combination therapy with amoxicillin plus an aminoglycoside 1
  • A second-generation cephalosporin plus an aminoglycoside 1
  • An intravenous third-generation cephalosporin 1

Alternative Options Based on Culture Results

• For oral therapy when susceptibility is confirmed:
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days 1, 3
  • Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) in accordance with local susceptibility testing 1, 4

Important Considerations

• Do not use fluoroquinolones empirically if:

  • Local resistance rates are ≥10% 1
  • The patient has used fluoroquinolones in the last 6 months 1
  • The patient is from a urology department 1

• Treatment duration:

  • 7 days for uncomplicated cases after initial treatment failure 1
  • 14 days when prostatitis cannot be excluded 1

Management of Multidrug-Resistant Organisms

• For ESBL-producing organisms:

  • Consider carbapenems (meropenem, imipenem/cilastatin) 1, 5
  • Newer agents like ceftazidime-avibactam or ceftolozane-tazobactam may be appropriate 1, 5

• For severe infections or sepsis:

  • Start with broad-spectrum parenteral therapy 1
  • Adjust based on culture results and clinical response 1

Follow-up Recommendations

• Ensure clinical improvement within 48-72 hours of appropriate therapy 1
• Consider imaging studies (ultrasound, CT) if fever persists beyond 72 hours of treatment or if clinical status deteriorates 1
• Evaluate for underlying urological abnormalities that may require additional management 1

Common Pitfalls to Avoid

• Failing to obtain cultures before initiating new antimicrobial therapy 2
• Not addressing underlying anatomical or functional abnormalities 1
• Using fluoroquinolones empirically in areas with high resistance rates 1
• Inadequate treatment duration, especially when prostatitis cannot be excluded 1
• Not considering the possibility of resistant organisms in treatment failure 5

Remember that UTIs in men are always considered complicated, requiring more aggressive diagnostic evaluation and treatment approaches than uncomplicated UTIs in women 1, 6.