What is the first-line treatment for a male patient with a urinary tract infection (UTI)?

First-Line Treatment for Male Urinary Tract Infections

For male patients with urinary tract infections (UTIs), the first-line treatment should be trimethoprim-sulfamethoxazole or nitrofurantoin for a 7-14 day course, with the treatment duration depending on whether prostatitis can be excluded. 1, 2, 3

Classification and Initial Approach

• Male UTIs are classified as complicated UTIs due to anatomical considerations and require special treatment considerations compared to uncomplicated UTIs in women 1, 2
• Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 2
• Obtain urine culture and susceptibility testing before initiating antimicrobial therapy to guide targeted treatment 1, 2

First-Line Treatment Options

• Trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 7-14 days 2, 4, 3
• Nitrofurantoin (100 mg twice daily) for 7-14 days 2, 3
• Treatment duration should be 14 days when prostatitis cannot be excluded, which is common in male UTIs 1, 2

Alternative Treatment Options

• Oral cephalosporins such as cefpodoxime 200mg twice daily for 7-14 days 2, 5
• Fluoroquinolones (e.g., levofloxacin 500mg once daily) should only be used as second-line agents when:
  • Local resistance rates are <10% 1, 2
  • The patient has no history of fluoroquinolone use in the past 6 months 2
  • The patient is not from a urology department 2
  • The patient has anaphylaxis to β-lactam antimicrobials 1

Treatment Duration Considerations

• Standard recommendation is 14 days for male UTIs when prostatitis cannot be excluded 1, 2
• Recent evidence suggests that a 7-day treatment course of either fluoroquinolones or trimethoprim/sulfamethoxazole may be non-inferior to a 14-day course in men with UTIs 6
• Consider shorter duration (7 days) when the patient is hemodynamically stable and has been afebrile for at least 48 hours 1, 2

Monitoring and Follow-up

• Reassess after 48-72 hours of empiric therapy to evaluate clinical response 2
• Adjust therapy based on culture and susceptibility results 2
• Consider switch to oral therapy when the patient is hemodynamically stable and has been afebrile for at least 48 hours 2

Important Pitfalls to Avoid

• Avoid fluoroquinolones as empiric therapy if local resistance rates exceed 10% or if the patient has used fluoroquinolones in the past 6 months 1, 2
• Do not use shorter treatment courses (<7 days) in males unless prostatitis has been definitively excluded 1, 2
• Do not neglect evaluation for underlying structural or functional abnormalities that may contribute to infection and require management 1, 2
• Avoid using antibiotics with high resistance rates in your local community 6, 5
• Never treat asymptomatic bacteriuria in men without specific indications, as this increases the risk of developing resistant organisms 6

Antimicrobial Resistance Considerations

• Antibiotic resistance among uropathogens has become increasingly prevalent, believed to be the result of overuse, poor selection of antimicrobial agents, and unnecessarily long treatment durations 6, 5, 7
• Fluoroquinolones and cephalosporins are more likely than other classes of antibiotics to alter fecal microbiota and cause collateral damage 6, 5
• The FDA has issued an advisory warning that fluoroquinolones should not be used for uncomplicated UTIs due to their unfavorable risk-benefit ratio 6