Treatment of Male UTI with Fever and Chills
A male patient presenting with fever, chills, and UTI should be treated as a complicated UTI with empiric intravenous combination therapy using either amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin for 14 days (or 7 days minimum if rapidly improving). 1
Key Clinical Principle
All UTIs in males are classified as complicated UTIs by definition, regardless of other factors. 1 The presence of fever and chills indicates systemic involvement, likely representing pyelonephritis or early urosepsis, which mandates aggressive initial therapy.
Initial Empiric Treatment Approach
For Patients Requiring Hospitalization (Systemic Symptoms Present)
Strong recommendation for combination IV therapy: 1
- Amoxicillin plus gentamicin (5 mg/kg daily) or amikacin (15 mg/kg daily)
- Second-generation cephalosporin plus an aminoglycoside
- Third-generation cephalosporin monotherapy (ceftriaxone 1-2g daily or cefotaxime 2g three times daily)
For Stable Outpatients (If Appropriate)
Ciprofloxacin 500-750 mg twice daily orally may be used ONLY if: 1
- Local fluoroquinolone resistance is <10%
- Patient has not used fluoroquinolones in the last 6 months
- Patient is not from a urology department
- No β-lactam allergy requiring alternative therapy
Alternative oral option if susceptibility confirmed: 2, 3, 4
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days
Treatment Duration
14 days is recommended for men when prostatitis cannot be excluded, which is the case in most febrile male UTIs. 1, 5 A shorter 7-day course may be considered only when: 1
- Patient is hemodynamically stable
- Afebrile for at least 48 hours
- Relative contraindications to the prescribed antibiotic exist
Essential Diagnostic Steps
Obtain urine culture and susceptibility testing before initiating antibiotics to guide subsequent therapy adjustment. 1 The microbial spectrum in complicated UTIs includes E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp., with higher antimicrobial resistance rates than uncomplicated UTIs. 1
Critical Pitfalls to Avoid
Do NOT use nitrofurantoin or fosfomycin for febrile UTIs in males, as these agents do not achieve adequate tissue concentrations for pyelonephritis or systemic infection. 1, 4
Do NOT use fluoroquinolones empirically in patients from urology departments or with recent fluoroquinolone exposure (within 6 months), as resistance rates are significantly higher in these populations. 1
Do NOT treat as simple cystitis even if upper tract symptoms are absent—the male gender alone mandates complicated UTI management. 1
Transition to Oral Therapy
Once the patient is clinically stable (afebrile >48 hours, improving symptoms), transition to oral therapy based on culture susceptibility results to complete the full treatment course. 1 Fluoroquinolones (levofloxacin 750 mg daily or ciprofloxacin 500-750 mg twice daily) are preferred for oral step-down if the organism is susceptible. 6, 5, 3
Prostatitis Consideration
Because prostatitis cannot be reliably excluded in febrile male UTIs, the 14-day treatment duration is mandatory. 1, 5 Chronic bacterial prostatitis may require even longer courses (minimum 4 weeks of fluoroquinolones) if recurrent UTIs from the same organism occur. 5, 7