What is the recommended treatment for an uncomplicated urinary tract infection (UTI) in men?

Treatment of Uncomplicated Urinary Tract Infections in Men

In men, urinary tract infections are classified as complicated UTIs and require a 14-day course of antibiotics when prostatitis cannot be excluded, with trimethoprim-sulfamethoxazole (160/800 mg twice daily) being the first-line treatment option. 1

Classification and Diagnostic Approach

• Male UTIs are considered complicated infections due to anatomical and physiological factors, requiring special consideration for treatment duration and antibiotic selection 2, 1
• A urine culture and susceptibility testing should be performed before initiating antimicrobial therapy to guide treatment decisions 1
• The microbial spectrum in male UTIs is broader than in uncomplicated UTIs in women, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 2

First-Line Treatment Options

• Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 7 days) is the recommended first-line treatment for uncomplicated UTIs in men 2
• When prostatitis cannot be excluded, treatment duration should be extended to 14 days 2, 1
• Trimethoprim-sulfamethoxazole is FDA-approved for the treatment of urinary tract infections due to susceptible strains of E. coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 3

Alternative Treatment Options

• Fluoroquinolones (such as ciprofloxacin) can be prescribed as an alternative in accordance with local susceptibility testing 2
• However, fluoroquinolones should only be used when:
  • Local resistance rates are <10% 2, 1
  • The patient has not used fluoroquinolones in the last 6 months 1
  • The patient is not from a urology department 1
  • The patient has anaphylaxis to β-lactam antimicrobials 1

Treatment Duration Considerations

• A 14-day course is recommended for men when prostatitis cannot be excluded 2, 1
• A shorter 7-day course may be considered in specific cases when the patient is hemodynamically stable and has been afebrile for at least 48 hours 2, 1
• Evidence from limited studies shows that for men treated with fluoroquinolones, high rates of bacteriological and clinical cure (97%) have been reported within 2 weeks after treatment 4

Management of Underlying Conditions

• Evaluation for structural or functional abnormalities of the urinary tract is important as these may contribute to infection 1
• Appropriate management of any urological abnormality or underlying complicating factor is mandatory for successful treatment 2
• Common factors associated with complicated UTIs in men include obstruction at any site in the urinary tract, foreign bodies, incomplete voiding, vesicoureteral reflux, and recent history of instrumentation 2

Follow-up Recommendations

• Monitor for resolution of symptoms 1
• Consider follow-up urine culture in complicated cases 1
• For men whose symptoms do not resolve by the end of treatment, or whose symptoms recur shortly after treatment, perform a urine culture and antimicrobial susceptibility testing 2
• If retreatment is necessary, assume the infecting organism is not susceptible to the agent originally used and select an alternative based on susceptibility results 2

Important Cautions and Considerations

• Antimicrobial resistance is more likely in male UTIs compared to uncomplicated UTIs in women 2
• Always obtain a urine culture with susceptibility testing to adjust antibiotic choice after initial empiric treatment, especially in men 65 years and older 5
• Consider the possibility of urethritis and prostatitis in men with UTI symptoms 5
• Limited evidence is available from randomized controlled trials specifically addressing male UTIs, highlighting the need for more research in this area 4