Treatment of Male Urinary Tract Infections
First-Line Empiric Antibiotic Selection
For men with UTI, start with trimethoprim-sulfamethoxazole (TMP-SMX) for 14 days as first-line therapy, or use fluoroquinolones (ciprofloxacin 500mg twice daily or levofloxacin 750mg once daily) if local resistance rates are below 10% and the patient has not used them in the past 6 months. 1, 2
Oral Antibiotic Options (in order of preference):
Trimethoprim-sulfamethoxazole (TMP-SMX): First-line choice for 14 days, particularly effective against E. coli, Klebsiella, Enterobacter, and Proteus species 2
Fluoroquinolones (if TMP-SMX cannot be used):
Oral cephalosporins (alternative options):
Nitrofurantoin: Consider for 7 days in uncomplicated cases 4
Trimethoprim alone: 7-day course is an option 4
Treatment Duration: The 7-Day vs 14-Day Decision
Treat for 14 days when prostatitis cannot be excluded, which is the default assumption in most male UTI presentations. 1, 2
When to use 14-day treatment:
- Default duration for all male UTIs when prostatitis cannot be ruled out 1, 2
- Presence of systemic symptoms 1
- Structural urinary tract abnormalities 1
When 7-day treatment is acceptable:
- Patient becomes afebrile within 48 hours 1, 2
- Clear clinical improvement and hemodynamic stability 1
- No complicating conditions present 1
- Recent evidence shows 7-day fluoroquinolone or TMP-SMX courses are non-inferior to 14-day treatment in men without complications 1, 5
Pre-Treatment Requirements
Always obtain urine culture and susceptibility testing before starting antibiotics in male UTIs. 1, 2
- All male UTIs are classified as complicated infections by the European Association of Urology, requiring culture-guided therapy 1
- The microbial spectrum is broader than in uncomplicated UTIs, including E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, and Enterococcus species 1, 2
- Antimicrobial resistance is more likely in male UTIs 1
- Tailor therapy based on culture results once available 1
Severe Infections Requiring Parenteral Therapy
For men with systemic symptoms or severe illness, start with intravenous antibiotics until clinical improvement:
- Amoxicillin plus aminoglycoside 1
- Second-generation cephalosporin plus aminoglycoside 1
- Third-generation cephalosporin (IV) 1
- Transition to oral therapy once clinically stable 1
Special Situations
Catheter-Associated UTI:
- Remove or change the catheter when possible alongside antibiotic therapy 1
Recurrent Infections:
- Obtain imaging studies to rule out anatomical abnormalities 1
- Management of underlying urological abnormalities is mandatory 1
Suspected Prostatitis:
- Consider this complication in all male UTIs—it requires the full 14-day treatment course 1, 2
- Ciprofloxacin is the drug of first choice for bacterial prostatitis and febrile UTI in males 6
- Levofloxacin is FDA-approved for chronic bacterial prostatitis due to E. coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis 3
Critical Pitfalls to Avoid
Never start antibiotics without obtaining urine culture first—this is the most common error in male UTI management 1, 2
Do not use fluoroquinolones empirically if:
Do not undertreate with short courses when prostatitis cannot be excluded—this leads to persistent or recurrent infection 2
Do not fail to address underlying anatomical abnormalities that contribute to infection or recurrence 1, 2
Do not assume all male UTIs need 14 days—recent evidence supports 7-day courses in select patients without complications 1, 5
Evidence Quality Note
The recommendation for shorter 7-day courses in uncomplicated male UTIs is supported by high-quality randomized controlled trial data showing non-inferiority to 14-day treatment 1, 5, though guidelines still default to 14 days when prostatitis cannot be excluded 1, 2. In real-world practice, most male UTIs should receive 14 days unless clear criteria for shorter treatment are met.