What is the first-line treatment for urinary tract infections (UTIs) in men?

First-Line Treatment for UTI in Men

Trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 7-14 days is the recommended first-line treatment for urinary tract infections in men, with nitrofurantoin (100 mg twice daily) as an alternative first-line option. 1, 2

Why Male UTIs Require Special Consideration

• All UTIs in men are classified as complicated infections due to anatomical factors, requiring longer treatment courses than uncomplicated UTIs in women 3, 1, 4
• The microbial spectrum is broader than in female UTIs, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 3, 1, 4
• Obtain urine culture and susceptibility testing before initiating therapy to guide targeted treatment 1, 4

First-Line Antibiotic Options

Preferred agents:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days 1, 2
• Nitrofurantoin 100 mg twice daily for 7-14 days 1

Alternative first-line agents:

• Oral cephalosporins such as cefpodoxime 200 mg twice daily for 7-14 days 1

Treatment Duration Algorithm

• Standard duration: 14 days when prostatitis cannot be excluded, which is common in male UTIs 1, 4, 2
• Shorter duration (7 days) may be considered only when:
  • The patient is hemodynamically stable 1, 4
  • The patient has been afebrile for at least 48 hours 1, 4
  • Prostatitis has been definitively excluded 1
• Recent evidence suggests 7-day courses of fluoroquinolones or trimethoprim-sulfamethoxazole may be non-inferior to 14-day courses in select male UTI patients 1, 5

When to Use Fluoroquinolones (Second-Line Only)

Fluoroquinolones should only be used as second-line agents when ALL of the following criteria are met: 1, 4

• Local resistance rates are <10% 3, 1, 4
• The patient has no history of fluoroquinolone use in the past 6 months 1, 4
• The patient is not from a urology department 4
• First-line agents are contraindicated or have failed 1

If fluoroquinolones are used:

• Levofloxacin 500 mg once daily for 7-14 days 1, 2
• Ciprofloxacin 500 mg twice daily for 7-14 days 3

Critical caveat: The FDA has issued an advisory warning that fluoroquinolones should not be used for uncomplicated UTIs due to serious adverse effects and an unfavorable risk-benefit ratio 3. Fluoroquinolones and cephalosporins are more likely than other antibiotic classes to alter fecal microbiota and cause collateral damage, including Clostridium difficile infection 3.

Monitoring and Adjustment

• Reassess after 48-72 hours of empiric therapy to evaluate clinical response 1
• Adjust therapy based on culture and susceptibility results when available 1
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 2
• Consider switch to oral therapy when the patient is hemodynamically stable and afebrile for at least 48 hours 1, 4

Critical Pitfalls to Avoid

• Do not use fluoroquinolones as empiric first-line therapy if local resistance rates exceed 10% or if the patient has used fluoroquinolones in the past 6 months 1, 4
• Do not use treatment courses shorter than 7 days unless prostatitis has been definitively excluded 1
• Do not neglect evaluation for underlying structural or functional abnormalities of the urinary tract that may contribute to infection and require management 1, 4
• Never treat asymptomatic bacteriuria in men without specific indications, as this increases the risk of developing resistant organisms 1
• Do not use antibiotics with high resistance rates in your local community 1

Special Considerations for Epididymitis

If epididymitis is suspected, treatment differs based on likely etiology: 2

For sexually transmitted infections (gonorrhea/chlamydia):

• Ceftriaxone 250 mg IM single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 2

For enteric organisms:

• Ofloxacin 300 mg orally twice daily for 10 days 2

Adjunctive measures:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2