Treatment of Urinary Tract Infections in Men
All UTIs in men should be treated as complicated UTIs with a 14-day course of antibiotics when prostatitis cannot be excluded, though a 7-day course may be appropriate in stable patients without complicating factors. 1
Classification and Diagnostic Approach
- All UTIs in men are classified as complicated UTIs according to the European Association of Urology guidelines 2, 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, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 2, 1
Empiric Antibiotic Treatment Options
For Systemic Symptoms/Severe Infection:
- Use one of the following combinations 2, 1:
- Amoxicillin plus an aminoglycoside
- A second-generation cephalosporin plus an aminoglycoside
- An intravenous third-generation cephalosporin
For Oral Therapy:
- Fluoroquinolones (ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg once daily) if local resistance rates are <10% 2, 1, 3
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily 2, 4
- Cephalosporins (cefpodoxime 200 mg twice daily or ceftibuten 400 mg daily) 2
Treatment Duration
- 14 days is generally recommended for men when prostatitis cannot be excluded 2, 1
- A 7-day course may be considered when the patient is hemodynamically stable and has been afebrile for at least 48 hours 2, 1
- Recent evidence suggests that shorter treatment duration (7 days) may be non-inferior to longer courses (14 days) in men without complicating conditions 5
- Treatment duration should be closely related to the treatment of any underlying urological abnormality 2
Special Considerations
Antibiotic Selection Factors:
- Local resistance patterns should guide empiric therapy 1
- Do not use fluoroquinolones for empirical treatment if the patient has used them in the last 6 months 1
- Fluoroquinolones show good penetration into prostatic tissue, making them effective for treating prostatitis 6, 3
- Trimethoprim-sulfamethoxazole is effective against most urinary pathogens but should be used based on local susceptibility patterns 4, 7
Management of Underlying Conditions:
- Appropriate management of any urological abnormality or underlying complicating factor is mandatory alongside antibiotic therapy 2, 1
- For catheter-associated UTIs, remove or change the catheter when possible 1
Follow-up Recommendations
- Tailor therapy based on culture results once available 2, 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%) 2, 1
- Not considering prostatitis as a complication of UTI in men, which requires longer treatment 1, 6
- Treating all male UTIs with prolonged courses when shorter durations may be appropriate for certain patients without complicating factors 5
- Not addressing underlying anatomical or functional abnormalities that may contribute to infection 2, 1