What is the treatment for urinary tract infections in males?

Treatment of Urinary Tract Infections in Males

All urinary tract infections in males are classified as complicated UTIs and require 14 days of antibiotic therapy when prostatitis cannot be excluded, with empiric treatment consisting of amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin. 1, 2

Why Male UTIs Are Different

• Male UTIs are automatically considered complicated due to the anatomical differences and higher likelihood of prostatic involvement, requiring longer treatment courses than female uncomplicated cystitis 1, 2
• The microbial spectrum is broader than uncomplicated UTIs, with E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. being the most common pathogens 1, 2
• Antimicrobial resistance is significantly more likely in male UTIs compared to uncomplicated female cystitis 1

Essential Diagnostic Steps

• Obtain urine culture and susceptibility testing before starting antibiotics to guide subsequent therapy adjustments 1, 2
• Evaluate for underlying urological abnormalities (obstruction, incomplete voiding, recent instrumentation) or complicating factors (diabetes, immunosuppression) that require concurrent management 1, 2

Empiric Antibiotic Selection

First-Line Regimens (Strong Recommendation)

Use one of the following combinations for empiric therapy: 1, 2

• Amoxicillin plus an aminoglycoside
• Second-generation cephalosporin plus an aminoglycoside
• Intravenous third-generation cephalosporin

Fluoroquinolone Considerations (Use With Caution)

Ciprofloxacin may only be used when ALL of the following criteria are met: 2

• Local resistance rate is <10%
• Entire treatment can be given orally
• Patient does not require hospitalization
• Patient has anaphylaxis to β-lactam antimicrobials

Do NOT use fluoroquinolones empirically if: 2

• Patient is from a urology department
• Patient has used fluoroquinolones in the last 6 months
• Local fluoroquinolone resistance is ≥10%

This restriction is critical because fluoroquinolone resistance has become widespread, and the 2024 EAU guidelines specifically warn against their empiric use in these high-risk scenarios 2. While older literature from 2014 and earlier suggested fluoroquinolones as first-line agents 3, 4, current resistance patterns have changed this recommendation substantially.

Treatment Duration

• Standard duration: 14 days when prostatitis cannot be excluded 1, 2
• Shortened duration: 7 days may be considered only when the patient is hemodynamically stable, has been afebrile for at least 48 hours, and there are relative contraindications to prolonged antibiotic use 1, 2

The 14-day duration is necessary because prostatic involvement is difficult to exclude clinically in male UTIs, and inadequate treatment duration leads to recurrence 1, 4.

Tailoring Therapy After Culture Results

• Switch from empiric IV therapy to oral antibiotics once culture results confirm susceptibility and the patient shows clinical improvement 1
• Adjust the antibiotic regimen based on susceptibility testing to ensure targeted therapy 1, 2

Management of Underlying Conditions

• Address any urological abnormality or complicating factor as this is mandatory for successful treatment 1, 2
• Consider urological evaluation for structural or functional abnormalities, particularly in recurrent infections 2
• Treatment duration should be closely related to management of the underlying abnormality 1

Common Pitfalls to Avoid

• Do not treat male UTIs with 3-day courses like uncomplicated female cystitis—this leads to treatment failure and recurrence 1, 2
• Do not use fluoroquinolones empirically without considering local resistance patterns and patient risk factors 2
• Do not skip urine culture in male patients—susceptibility testing is essential given higher resistance rates 1, 2
• Do not ignore potential prostatic involvement—when in doubt, treat for 14 days rather than 7 days 1, 2