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

First-Line Treatment for Male Urinary Tract Infections

Trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 7-14 days is the recommended first-line treatment for male urinary tract infections. 1, 2

Classification and Diagnostic Approach

• Male UTIs are classified as complicated infections due to anatomical considerations, requiring different treatment approaches compared to uncomplicated UTIs in women 1
• Urine culture and susceptibility testing should be obtained before initiating antimicrobial therapy to guide targeted treatment 1, 3
• Common causative pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., and Enterococcus spp. 1
• Evaluation should include assessment for symptoms such as dysuria, frequency, urgency, and suprapubic pain 4

First-Line Treatment Options

• Trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 7-14 days is the first-line treatment option for male UTIs 1, 2
• Nitrofurantoin (100 mg twice daily) for 7 days can also be considered as a first-line option 1, 3
• For epididymitis likely caused by gonococcal or chlamydial infection: Ceftriaxone 250 mg IM in a single dose, PLUS Doxycycline 100 mg orally twice a day for 10 days 4
• For epididymitis likely caused by enteric organisms: Ofloxacin 300 mg orally twice a day for 10 days 4

Treatment Duration Considerations

• Standard recommendation is 7-14 days for male UTIs 1, 3
• Treatment duration should be extended to 14 days when prostatitis cannot be excluded, which is common in male UTIs 1
• Shorter courses (less than 7 days) should be avoided in males unless prostatitis has been definitively excluded 1

Alternative Treatment Options

• Oral cephalosporins such as cefpodoxime 200mg twice daily for 7-14 days can be used as alternative treatment options 1
• Fluoroquinolones should only be used as second-line agents when:
  • Local resistance rates are <10%
  • Patient has no history of fluoroquinolone use in the past 6 months
  • Patient is not from a urology department 1, 5

Antimicrobial Resistance Considerations

• Antibiotic resistance among uropathogens has become increasingly prevalent 1, 6
• Fluoroquinolones and cephalosporins are more likely than other classes of antibiotics to cause collateral damage to gut microbiota 1
• The FDA has issued an advisory warning that fluoroquinolones should not be used for uncomplicated UTIs due to their unfavorable risk-benefit ratio 1
• Knowledge of local susceptibility patterns is essential in determining appropriate empiric therapy 6, 5

Monitoring and Follow-up

• Reassess after 48-72 hours of empiric therapy to evaluate clinical response 1
• Adjust therapy based on culture and susceptibility results 1, 3
• Failure to improve within 3 days requires reevaluation of both the diagnosis and therapy 4
• Swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively 4

Important Pitfalls to Avoid

• Avoid fluoroquinolones as empiric therapy if local resistance rates exceed 10% 1
• Do not use shorter treatment courses (<7 days) in males 1
• Never treat asymptomatic bacteriuria in men without specific indications 1
• Do not neglect evaluation for underlying structural or functional abnormalities that may contribute to infection 1
• Avoid using antibiotics with high rates of resistance in your local community 1, 6

Special Considerations

• For men with epididymitis, bed rest, scrotal elevation, and analgesics are recommended as adjuncts to therapy until fever and local inflammation have subsided 4
• Consider the possibility of urethritis and prostatitis in men with UTI symptoms 3
• Evaluate for anatomical abnormalities or other underlying conditions that may predispose to recurrent infections 1