What are the recommended antibiotics for urinary tract infections (UTI) in males?

Antibiotic Treatment for UTI in Males

All UTIs in males are considered complicated by definition and require 7-14 days of treatment (14 days when prostatitis cannot be excluded), with mandatory urine culture and susceptibility testing before initiating empiric therapy. 1

Critical First Step: Obtain Urine Culture

• Urine culture with susceptibility testing is mandatory before starting antibiotics to guide targeted therapy, as male UTIs have a broader microbial spectrum and higher antimicrobial resistance rates than uncomplicated UTIs in women 1
• Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1

First-Line Empiric Oral Antibiotics (Pending Culture Results)

For empiric treatment while awaiting culture results, fluoroquinolones are preferred if local resistance is <10%: 1

• Ciprofloxacin 500-750 mg twice daily for 7 days (minimum duration for males) 1, 2
• Levofloxacin 750 mg once daily for 5-7 days 1, 2

Alternative oral options when fluoroquinolones cannot be used: 1, 3, 4

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days (avoid if local resistance >20%) 1, 5, 4
• Trimethoprim 200 mg twice daily for 7 days 3, 4
• Nitrofurantoin 100 mg twice daily for 7 days (though less studied in males) 3, 4

Treatment Duration Specifics

• Standard duration: 7 days minimum for uncomplicated male UTI 1
• Extended duration: 14 days when prostatitis cannot be excluded (which is common in males with UTI symptoms) 1
• Shorter 7-day courses may be considered only when the patient is hemodynamically stable and afebrile for at least 48 hours 1

Parenteral Options for Severe Presentations

If the patient appears systemically ill or has pyelonephritis, initiate IV therapy: 1

• Ciprofloxacin 400 mg IV twice daily 1
• Levofloxacin 750 mg IV once daily 1
• Ceftriaxone 1-2 g IV once daily (higher dose recommended) 1
• Cefepime 1-2 g IV twice daily 1
• Piperacillin-tazobactam 2.5-4.5 g IV three times daily 1

Step-Down to Oral Therapy

• Transition to oral antibiotics when clinically stable and afebrile for 48 hours 1
• Adjust antibiotic selection based on culture and susceptibility results 1
• Complete the full 7-14 day course (total duration, not just oral portion) 1

Critical Pitfalls to Avoid

• Never use amoxicillin or ampicillin empirically due to very high worldwide resistance rates and poor efficacy 3
• Do not use short 3-5 day courses as recommended for women—males require minimum 7 days 1, 4
• Do not skip urine culture—this is mandatory in all male UTIs to guide therapy 1, 4
• Consider prostatitis in all males with UTI symptoms, as this requires 14 days of treatment and fluoroquinolones have better prostatic penetration 1, 4
• Assess for urethritis as an alternative diagnosis, particularly in younger sexually active males 4

Special Considerations for Multidrug-Resistant Organisms

If patient has risk factors for resistant organisms (recent antibiotics, healthcare exposure, prior resistant isolates): 1, 6

• Consider broader-spectrum parenteral agents: ceftolozane-tazobactam 1.5 g IV three times daily, ceftazidime-avibactam 2.5 g IV three times daily, or meropenem 1 g IV three times daily 1, 6
• Aminoglycosides (gentamicin 5 mg/kg IV once daily or amikacin 15 mg/kg IV once daily) are effective alternatives, especially with prior fluoroquinolone resistance 6

Follow-Up

• Reassess clinical response within 48-72 hours 4
• Adjust antibiotics based on culture results and clinical response 1
• If symptoms persist or recur within 2 weeks, repeat urine culture and consider imaging to evaluate for anatomic abnormalities or prostatic involvement 3, 4